mental health nursing scholarly articles

• Research article
• Open access
• Published: 26 April 2019

Mental health nurses’ attitudes, experience, and knowledge regarding routine physical healthcare: systematic, integrative review of studies involving 7,549 nurses working in mental health settings

• Geoffrey L. Dickens   ORCID: orcid.org/0000-0002-8862-1527 1 , 2 ,
• Robin Ion 3 ,
• Cheryl Waters 1 ,
• Evan Atlantis 1 &
• Bronwyn Everett 1  

BMC Nursing volume  18 , Article number:  16 ( 2019 ) Cite this article

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There has been a recent growth in research addressing mental health nurses’ routine physical healthcare knowledge and attitudes. We aimed to systematically review the empirical evidence about i) mental health nurses’ knowledge, attitudes, and experiences of physical healthcare for mental health patients, and ii) the effectiveness of any interventions to improve these aspects of their work.

Systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Multiple electronic databases were searched using comprehensive terms. Inclusion criteria: English language papers recounting empirical studies about: i) mental health nurses’ routine physical healthcare-related knowledge, skills, experience, attitudes, or training needs; and ii) the effectiveness of interventions to improve any outcome related to mental health nurses’ delivery of routine physical health care for mental health patients. Effect sizes from intervention studies were extracted or calculated where there was sufficient information. An integrative, narrative synthesis of study findings was conducted.

Fifty-one papers covering studies from 41 unique samples including 7549 mental health nurses in 14 countries met inclusion criteria. Forty-two (82.4%) papers were published since 2010. Eleven were intervention studies; 40 were cross-sectional. Observational and qualitative studies were generally of good quality and establish a baseline picture of the issue. Intervention studies were prone to bias due to lack of randomisation and control groups but produced some large effect sizes for targeted education innovations. Comparisons of international data from studies using the Physical Health Attitudes Scale for Mental Health Nursing revealed differences across the world which may have implications for different models of student nurse preparation.

Conclusions

Mental health nurses’ ability and increasing enthusiasm for routine physical healthcare has been highlighted in recent years. Contemporary literature provides a base for future research which must now concentrate on determining the effectiveness of nurse preparation for providing physical health care for people with mental disorder, determining the appropriate content for such preparation, and evaluating the effectiveness both in terms of nurse and patient- related outcomes. At the same time, developments are needed which are congruent with the needs and wants of patients.

Peer Review reports

People with a mental disorder diagnosis are at more than double the risk of all-cause mortality than the general population. Most at risk are those with psychosis, mood disorder and anxiety diagnoses. Median length of life lost by this group is 10.1 years greater for people with a diagnosis of mental disorder than for general population controls, but mortality rates are significantly higher in studies which include inpatients [ 1 ]. While risk of unnatural causes of death, notably suicide, are greatly increased in this group, it is death from natural causes that remains responsible for the vast majority of mortality. In people with schizophrenia, for example, cardiovascular disease accounts for about one third of all deaths and cancer for one in six, while other common causes are diabetes mellitus, COPD, influenza, and pneumonia [ 2 ]. A relatively high rate of tobacco smoking in this group is implicated in significant increased mortality [ 3 ], as is obesity [ 4 ], exposure to high levels of antipsychotic pharmacological treatment [ 5 ], and mental disorder itself [ 1 ].

Accordingly, the physical health of patients with mental disorder has been prioritised, becoming the focus of guidelines for practitioners in general [ 6 ] and for mental health nurses and other clinical professionals specifically [ 7 , 8 , 9 ]. However, while policies and guidelines are necessary prerequisites of change they must also be implemented in practice if they are to have a positive effect; one of the key barriers to change implementation for mental health nurses has been identified as lack of confidence, skills, and knowledge [ 10 ]. Robson and Haddad ([ 11 ]: p.74) identified that surprisingly ‘modest attention’ had been paid to the issue of such attitudes and knowledge among nurses related to their role in physical health care provision, and developed the Physical Health Assessment Scale for mental health nurses (PHASe) in order to further investigate the phenomenon. Since then, there has been a tangible and growing response among mental health nursing academics and practitioners. In recent years, published literature reviews have covered a decade of UK-only research on the role of mental health nurses in physical health care [ 12 ], patients’ and professionals’ perceptions of barriers to physical health care for people with serious mental illness [ 13 ], the focus and content of nurse-provided physical healthcare for mental health patients [ 14 ], and the physical health of people with severe mental illness [ 15 ]. There has also been an upsurge in the amount of related empirical research. However, to date, no one has systematically reviewed this growing literature about mental health nurses’ attitudes towards, or their related knowledge and experience about providing routine physical healthcare. Further, studies about the effectiveness of interventions designed to improve their delivery of or attitudes to routine physical healthcare have not been systematically appraised. This is surprising given the known links between nurses’ attitudes and their implementation of evidence-based practice [ 16 , 17 , 18 ] and the centrality of measuring nurses’ attitudes to physical health care delivery in recent mental health nursing research on the topic [ 11 , 19 , 20 ].

In this context we have conducted a systematic review to identify, appraise, and synthesise existing evidence from empirical research literature about i) mental health nurses’ experience of providing physical healthcare for patients and about their related knowledge, skills, educational preparation, and attitudes; ii) the effectiveness of any interventions aimed at improving or changing mental health nurse-related outcomes; and iii) to identify implications for the future provision of relevant training and education, for policy, research, and practice. The specific review question being addressed therefore is: what is known from the international, English language, empirical literature about mental health nurses’ skills, knowledge, attitudes, and experiences regarding provision of physical healthcare.

A systematic review of the literature following the relevant points of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses [ 21 ].

Search strategy

Since the review scope encompassed questions about experience and effectiveness a dual literature search strategy was developed. For studies about mental health nurses’ experience of delivering physical healthcare a Population Exposure Outcome (PEO) format review question was developed (Population: mental health nurses; Exposure: physical healthcare provision for patients or related training; Outcomes: experiential, social, educational, knowledge, or attitudinal terms, see Additional file  1 : Table S1). For studies of the effectiveness of interventions to improve or change mental health nurse-related outcomes a Population Intervention Comparator Outcome (PICO) structure was implemented (Population: mental health nurses; Intervention: any intervention including physical health-related education, policy or guideline change; Comparator: any or none; Outcome: any) [ 22 ]. We searched five electronic databases: i) CINAHL, ii) PubMed, iii) MedLine, iv) Scopus, and v) ProQuest Dissertations and Theses using text words and MeSH terms. The references list of all included studies, together with those of relevant literature reviews, and the tables of contents of selected mental health nursing journals were hand searched. The search terms were informed by previous literature reviews on the subject of physical healthcare in mental health. The initial search was conducted in April 2018 and re-run in September 2018.

Inclusion and exclusion criteria

Inclusion criteria for studies were English language accounts of empirical research which investigated mental health nurses’ experience of providing physical health care or examined the effectiveness of any intervention that aimed to improve outcomes related to the provision of physical healthcare. Thus, studies of interventions aimed at changing nursing practice, behaviour, knowledge, attitudes, or experiences were eligible, but not those which solely attempted to determine the effect of an intervention on nurses in terms of patient outcomes. While improvement in patient care and outcomes is clearly the desirable endpoint of any intervention on nurses, previous reviews have indicated that no good quality studies exist [ 23 ]. Additionally, studies were only eligible for inclusion where the practitioners involved comprised or included mental health or psychiatric nurses or mental health nursing students, or registered nurses whose practice was within mental health services. Included studies could have used any design or methodological approach. As in previous reviews, studies solely about mental health nurses providing care for people with alcohol/ drug misuse, or mental disorder/substance misuse dual diagnosis were not eligible. Studies about mental health nurses and the provision of emergency physical care or of their experience of providing care for the seriously deteriorating physical health of a patient were omitted as this is the subject of a separate review (Dickens et al. submitted).

Data extraction

Information about the study title, author, publication year, data collection years, location (country), research objectives, aims or hypotheses, design, population, sample details and size, data sources, study variables (i.e. details of intervention) or other exposure, unit of analysis, and study findings were extracted from full text papers. Corresponding authors of included studies were contacted regarding any issues where clarification or additional data could aid the review.

Studies were categorised as interventional or observational. Intervention studies investigated the impact of an educational, policy, or practice intervention in terms of any mental health nurse- or nursing- related outcome, e.g., knowledge, attitudes, behaviour. Intervention studies were further sub-classified as simulation studies (as defined by Bland et al. ([ 24 ]: p.668) “a dynamic process involving the creation of a hypothetical opportunity that incorporates an authentic representation of reality, facilitates active student engagement and integrates the complexities of practical and theoretical learning with opportunity for repetition, feedback, evaluation and reflection”), traditional educational interventions (e.g., lectures, workshops, workbooks), or policy-level interventions (e.g., requiring nurses to follow some new policy or implement some new practice). Observational studies either described mental health nurse- or nursing- related outcomes and/or utilised case control designs to compare them with those of other occupational or professional groups and/or used qualitative methods.

Study quality appraisal

The likelihood of bias in intervention studies was assessed against criteria described by Thomas et al. [ 25 ] and encompassed assessment of the likelihood of selection bias in the obtained sample, study design, potential confounders, blinding, potential for bias in data collection from invalid instrumentation, and participant retention (see Additional file  2 : Table S2). Relevant items from the US Department of Health & Human Sciences NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies [ 26 ] were used to assess cross-sectional observational studies (see Additional file  3 : Table S3). Qualitative descriptive studies were assessed using the Critical Appraisal Skills Programme [ 27 ] tool (See Additional file  4 : Table S4). Multiple papers arising from single studies were quality assessed as a single entity. Study quality was initially undertaken independently by at least two of the team. A good level of inter-rater agreement was achieved (Cohen’s Kappa = 0.742 between pairs of raters). Disputed items were discussed by GD and CW and consensus achieved.

Study synthesis

The available total and subscale data from those studies that conducted data collection via the Physical Healthcare Attitude Scale for mental health nurses (PHASe [ 11 ]), the only scale used across more than two studies, was tabulated and compared across studies using unpaired t-tests in QuickCalcs GraphPad software. Where individual item mean and dispersion scores were unavailable estimates were calculated as follows: the mean mean (i.e., Σ means / n means) and the estimated standard deviation (the square root of the average of the variances [ 28 ]). Also, and where available, dichotomised data (‘Strongly agree’ or ‘agree’ responses versus all other responses) from the multiple studies using the 14-item PHASe scale investigating self-reported current involvement in aspects of physical healthcare was tabulated and subjected to Chi-squared analysis. Significant cross-study differences of means and proportions involved all subscale or item data for each study being compared with the corresponding subscale or item from the original study development sample, ‘the reference group’ [ 11 ].

Where available, effect sizes for correlational, interventional, or difference-related outcomes from studies were extracted or, where sufficient information presented, calculated. Where sufficient information was not presented we attempted to contact the corresponding author for clarification. Appropriate effect size statistics were calculated using an online resource [ 29 ]. All other information from study results was subject to a qualitative synthesis conducted by author 1 and subsequently refined and agreed by all of the authors.

Study settings and participants

The search strategy resulted in the inclusion of 41 study samples published in 51 papers (see Fig.  1 ) involving 7549 ( M [ SD ] = 200.5[374.1], Mdn =  47, range 2 to 1899) mental health nurses and n  = 213 mental health nursing students ( Mdn  = 33). Thirty-three samples included only nurses, of which 20 drew specifically on mental health nurses or nurses working in mental health settings only; eight samples were multidisciplinary. Four papers drew on two samples (i.e., two papers per study) while one sample featured in nine separate papers [ 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 ]. Studies were conducted in the UK ( k  = 17), Australia ( k  = 9), US ( k  = 4), Canada ( k  = 2), Qatar, Hong Kong, Japan, Jordan, Belgium, Norway, Israel, Turkey, India, and Taiwan (all k  = 1); two studies were conducted internationally; first, in Qatar, Hong Kong, and Japan [ 19 ], and the US and Canada [ 39 ]. Studies were published between 1994 and 2018 ( Mdn year of publication 2016, only n  = 9 before 2010 and n  = 1 before 2000).

PRISMA study inclusion flowchart

Study design

Eleven studies evaluated an intervention; of these, 10 utilised pre- post AB designs and one adopted a randomised controlled trial design. Other studies used cross-sectional survey or qualitative designs. Intervention studies sometimes incorporated additional qualitative or descriptive elements.

Outcome measures

The most commonly used measure employed was the PHASe or some adaptation of it [ 11 ] in seven studies reported across eight papers [ 11 , 19 , 20 , 40 , 41 , 42 , 43 , 44 ]. The PHASe comprises four factors: 1. Nurses’ attitudes to physical health care; 2. Nurses’ confidence to provide physical health care; 3. Nurses’ perceived barriers in providing physical health care; and 4. Nurses’ attitude towards smoking. Contact with study corresponding authors (Bressington, Chee, Haddad) resulted in acquisition of additional PHASe total and subscale information that was not included in the respective published study papers. Two other outcomes tools were used in two studies each, these being the purpose-designed survey measure of Howard and Gamble [ 45 ] subsequently used by Terry and Cutter [ 46 ], and Happell’s [ 33 ] own questionnaire adapted for use by Clancy et al. [ 40 ]. Most studies used purpose-designed tools. Many reported sufficient information to allow confidence about their internal reliability and face/content validity but there was little information about their measurement reliability, criterion validity, or sensitivity to change (see Additional file  5 : Table S5). A small number of papers used existing validated measures [ 47 , 48 , 49 , 50 , 51 , 52 ] and these were generally the most robust tools (see Additional file  6 : Table S6).

Study quality

All K  = 7 qualitative studies were rated very highly in terms of their quality on a 10-point assessment ( Mdn  = 9, range 9–10). Cross-sectional observational studies met a median of four of seven quality criteria (range two to six; mean[SD] 4.43[1.33]). Four of these provided an a priori sample size calculation and there was a lack of valid outcome measures in nine of the 21 studies. Overall risk of bias for cross-sectional studies was judged to be low for nine studies, unclear for six and high for six. The quality of interventional studies was generally the poorest ( Mdn  = 5, range 2 to 7 of 10 indicators). Only two were judged to be at low risk of bias (see Additional file 2 : Tables S2, Additional file 3 : Table S3, Additional file 4 : Table S4, Additional file 5 : Table S5 and Additional file 6 : Table S6 for further details). Common omissions were, again, sample size justification, lack of repeat pre-baseline and follow up measures, and information about the representativeness of included samples.

Non-intervention studies

Studies examined physical healthcare in general ( k  = 24), sexual health ( k  = 4), smoking ( k  = 6), physical activity and healthy eating, nutrition - in particular the role of Omega-3 in diet, mild brain injury, and breastfeeding (all k  = 1; see Table  1 ).

With regards to studies using the PHASe, of all possible comparisons across studies (see Tables 2 and 3 ), the mean score of the study sample differed significantly from the reference sample [ 11 ] on 13 out of 21 (61.9%) subscale and three of four total score combinations (75.0%). Analysis revealed poorer attitudes compared to the reference sample on all three of the significantly poorer attitude scores on 10/17 (58.9%) subscale comparisons, and better attitudes on three (14.3%). However, the reference group only outperformed the other studies on two of the eight possible comparisons on the subscales ‘Physical Healthcare’ and ‘Confidence in Providing Physical Healthcare’ and was poorer for three comparisons. The PHASe total score difference was greatest (large effect size) between the reference sample and Chee et al’s [ 41 ] Australian sample (Cohens d  = 1.13) followed by Bressington et al’s [ 19 ] Japanese mental health nurse sub-sample ( d  = 0.72). For subscale scores, effect sizes for differences were also largest between the reference sample and that of Chee et al. [ 41 ]. Effect sizes were in favour of the reference sample on the attitudes to smoking and barriers to physical healthcare subscales ( d  = 1.48 and 1.78 respectively). Next largest were differences between Haddad et al’s [ 43 ] sample also on the barriers to healthcare ( d  = 0.93) and attitudes to smoking subscales ( d  = 1.01). On this occasion differences were in favour of Haddad et al’s [ 43 ] sample. Attitudes to smoking were more favourable than the reference sample in two studies, comparable in one and poorer in two.

Regarding the level of self-reported involvement in aspects of physical healthcare the proportion of respondents in PHASe-studies answering ‘strongly agree’ or ‘agree’ to 14 items revealed considerable cross-sample differences. Of 95 possible comparisons between the reference study and others, 70 (73.7%) differed significantly. Of these, 86.7% compared unfavourably with the UK reference study, 13.3% favourably). The number of items per sample differing from the reference sample ranged from 7 to 13 ( Mdn =  10). Japan [ 19 ] provided the only sample of mental health nurses whose responses compared favourably with the reference sample (7/10 significantly differing responses being more favourable in the Japanese sub-sample), while Ganiah et al’s [ 42 ] sample (0/11 favourable comparisons among significantly differing responses), Happell et al’s [ 30 ] (0/14 favourable comparisons), Chee et al’s [ 41 ] Australian sample (1/11 favourable comparisons), Haddad et al’s [ 43 ] UK sample (1/10 favourable comparisons) and Bressington et al’s [ 19 ] Hong Kong sample (2/12 favourable comparisons) all fared poorly. Items relating to checking GP-status, advising on exercise, weight management, healthy eating, contraception, and eyesight checks were all rated less favourably by at least two other samples (range 2 to 6, Mdn  = 4) and more favourably by none compared with the reference sample. Only the item about ensuring patients have had their general physical health assessed on first contact with mental health services was rated more favourably by two samples and less favourably by none compared with the reference sample. For all other items there were item-level variations with no clear pattern.

The remaining non-intervention studies provide a mixed and sometimes contradictory picture. First, in terms of reported use of physical health care skills, Osborn et al’s [ 47 ] study revealed that nurses working in mental health settings in one large hospital were less likely to use physical healthcare skills than colleagues in medical, oncology, maternity and surgical settings. Further, they reported using a smaller range of relevant skills. In Howard and Gamble’s [ 45 ] survey, nurses’ responses indicated a gap between their perceived responsibilities for physical healthcare and their practice. Elsewhere, compared with those responding on behalf of healthcare and educational organisations, nurses were less likely to endorse their role in physical healthcare provision [ 53 ] and they reported very low levels of endorsement of related skills training need [ 54 ]. However, for others in more recent studies, they displayed a clear commitment to the physical healthcare role [ 55 ], and said they want more training [ 31 , 56 ]. Further, nurses strongly endorsed their own role in physical health, sexual health, and substance abuse related care and were supported strongly by other healthcare professionals [ 40 ]. Across a series of linked surveys and qualitative studies, Happell et al. [ 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 57 ] reported associations between nurses’ positive evaluation of the physical healthcare role and practicing aspects of it more commonly. In studies of nurses and specific physical healthcare-related activities there was a suggestion that respondents’ own values or beliefs might be more influential in determining their health-giving or advising behaviour in relation to smoking cessation [ 50 , 58 ]. In relation to sexual health, both Dorsay and Forchuk [ 59 ] and Quinn et al. [ 60 ] have reported that nurses cite patient embarrassment as a reason for not asking patients about sexual side effects of antipsychotic medications. Lack of time, resources and knowledge were reported as barriers to providing advice and interventions regarding exercise and physical activity [ 61 ], Omega-3 [ 62 ]. Knowledge and attitudes to HIV/AIDS were generally good [ 63 ]. Finally, smoking-cessation training was associated with more smoking-cessation helping behaviour [ 64 ] though, counter-inuitively, training was negatively associated with attitudes to smoking cessation in a single study [ 65 ]. Further, Sharma et al’s [ 64 ] study compared the attitudes of mental health trained nurses and comprehensive/ generalist trained nurses working in mental health services: the most marked differences between the groups were on the smoking-related items with the former group expressing significantly more liberal views about smoking restrictions, more worrying attitudes about the benefits and utility of cigarette use as a therapeutic tool, and less confidence in the ability of mental health patients to quit smoking. This was particularly concerning in the study context which was about attitudes to physical healthcare with younger, first episode psychosis patients.

Intervention studies

Five studies focused on physical healthcare in general and six on specific issues (diabetes n =  3; sexual health, cardiometabolic health, obesity all n =  1). Ten evaluated an educational innovation, the exception being Happell et al. [ 35 ], who examined attitudes among nurses to the introduction of a specialist cardiometabolic health nurse role. Haddad et al. [ 43 ] examined the impact of the introduction of personal physical health care plans for patients on nurses’ physical healthcare attitudes alongside the delivery of a single educational session on physical healthcare assessment. The remaining nine studies evaluated educational interventions including three involving simulation and six involving didactic teaching, workshop-format or blended-learning approaches.

Simulation studies

Duration of interventions was 30 min [ 49 ] and1-day [ 66 ], while information was not provided by Wynn [ 52 ]. The mode of simulation delivery involved manikins [ 66 ], human actor as patient [ 66 ], software-based Human Person Simulator [ 52 ], and participant as ‘patient’ in which student participants wore a 15 kg bariatric empathy suit while undertaking everyday tasks in order to help them appreciate the experience of obesity [ 49 ]. Other simulations involved diabetes care [ 52 ], fractured leg in the context of a jump or fall in a patient with first episode psychosis, medical deterioration in the same patient following transfer to a psychiatric ward, and delirium [ 66 ]. Results indicated improved clinical judgement and reduced diabetes-related medical emergency reports [ 52 ], improved knowledge, attitudes, and confidence about physical healthcare [ 66 ], improved response to obese patients, characteristics of obese patients and supportive roles in caring for obese patients [ 49 ].

Non-simulation studie

Study duration ranged from a 2.5-h workshop on physical health [ 67 ] to a 20-credit bachelor’s degree level (equivalent to 200-h of taught and self-directed study and assessment completion) module on physical healthcare in mental health [ 46 ]. Non-simulation studies evaluated the introduction of personal health plans for patients in a low secure forensic unit together with a single educational session on physical health care for nursing staff [ 43 ]. Specific topics addressed included diabetes [ 68 , 69 ], health assessment [ 46 , 67 ], oral health, IM injectables [ 68 ], vital signs, blood readings, BMI measurement [ 46 ], and cardio-metabolic health [ 35 , 57 ].

In Sung et al’s [ 51 ] RCT, nurses were allocated in a random stratified design to attend 8 × 2-h session about sexual healthcare over a period of 4-w or no intervention. Significant effects were detected in the experimental group relative to the control group for improvements in related knowledge and in attitudes, but not in self-efficacy. The study involved nurses employed both in medical and psychiatric wards (stratified allocation from both) and there was no reported effect of ward-type on outcomes. Pretest- posttest design intervention studies targeted at diabetes found greatly improved clinical judgment in relation to diabetes care and reduced diabetes-related emergency referrals [ 52 ] and similarly impressive improved diabetes-related knowledge [ 69 , 70 ]. Improved attitudes to obesity, obese patients, and supportive roles in caring for obese individuals have been reported across a mixed group of participants and did not differ between mental health and other nurses [ 49 ]. and physical healthcare in general. Happell et al. [ 57 ] reported improved support for a specialist cardiometabolic nurse role following its introduction, however we find this conclusion is unwarranted since it is derived from statistical testing of 14-questionnaire items only one of which was found significant. Interventions aimed at physical healthcare in general found some impressive post- group improvements in knowledge [ 66 , 67 , 68 ], attitudes [ 66 ], and confidence [ 46 , 66 ].

We have conducted a systematic review of the empirical literature about mental health nurses and their attitudes towards, knowledge about, and experiences of physical health care for patients. We took a broad approach to searching the literature and included interventional and observational studies involving real or simulated situations. We included studies involving mental health nursing students and multidisciplinary professional groups in addition to those including only mental health nurses. We contacted study authors to gain additional information and, for the studies using the PHASe [ 11 ] and this elicited significant, previously unpublished information. While we applied no time limits to our comprehensive search we found studies only from as early as 1994, only nine from before 2000, and the median year of publication was 2016. This means that there has been a welcome increase, which we described as a ‘mini-explosion’ in the Introduction, in related empirical work in recent years. The total number of nurses involved in studies, 7549, makes this to our knowledge one of the largest amalgamations of evidence gathered directly from mental health nurses.

However, the overall methodological quality of studies was somewhat limited, particularly interventional studies to improve mental health nurses’ physical healthcare assessment practices and skills. Nevertheless, while many of the included studies examine mental health nurses, and nurses working in mental health settings, this group comprises a heterogeneous collection of individuals of vastly differing experience, preparation, knowledge, and roles. As a result, it is not too surprising that some less well-researched areas have thrown up starkly different results. However, there is consistent evidence that there is a strong association between mental health nurses’ reported attitudes and their reported involvement in physical health care [ 19 , 20 , 42 ]. Similarly, that the nurses who value physical health care also report that they deliver more of it [ 30 ] and those who talk to at least one other discipline about their patients’ physical health do so with multiple professional groups [ 33 ]. Accordingly, fewer resources could be expended on answering these sorts of associational questions in the future.

Our conclusion is that it is now time for a new phase for mental health nursing research related to physical healthcare: efforts must be redoubled to focus on developing and testing interventions to improve nurses’ attitudes, knowledge, and skills. We must ensure that new studies are well-designed and rigorously conducted. More specifically, further research is required to build knowledge about whether the supposed benefits arising from this relationship translate into objectively better practice and indeed better patient outcomes. This would strengthen the case for training to improve attitudes and provide some urgency to better understand what interventions might deliver that outcome. Further, it appears that mental health nurses well-recognise that they require further skills and knowledge related to physical health care across a wide range of areas [ 19 , 30 , 31 , 57 , 71 ]. However, ambivalence and reluctance remains about embracing the change needed to achieve this [ 61 ].

The PHASe was used across multiple studies which allowed for some international and setting-specific comparison of nurses’ attitudes. We found that nurses’ self-perceived practices and attitudes differed significantly between samples from across the world. This, of course, may well reflect different approaches to mental health nurse preparation; for example, in Australia, all pre-registration nurses undergo the same core programme whereas in the UK mental health nursing is a specialist branch of pre-registration training. Therefore, results from Chee et al’s [ 41 ] recent study are enlightening since they reveal equivalent attitudes to physical healthcare specifically, more confidence in delivering physical healthcare but poorer scores in relation to barriers to physical healthcare delivery and smoking cessation. Given the non-equivalence of results on the attitudes to smoking subscale between Chee et al. [ 41 ] and Wynaden et al. [ 44 ], both conducted in Western Australia by related research teams, there are questions about the extent to which results are sample specific. Larger scale, representative data collection in Australia and New Zealand could therefore add significantly to the debate about nurses’ preparation for physical healthcare skills under different preparation regimes. As the PHASe authors’ note, the tool has not been subjected to tests of its stability or criterion validity and improvements in evidence for this would add significantly to the ability to draw sound conclusions from research using the tool. Findings from Osborne et al’s [ 47 ] large hospital-wide survey indicate that the gap in the physical health-related skills addressed by the PHASe is real and of concern.

Apart from the PHASe the literature is peppered with outcomes tools designed for single studies and with little evidence of anything other than face validity and internal consistency. Is it possible, we must ask, that this reflects that researchers are asking the wrong questions i.e., focusing overly on mental health nurses’ attitudes and self-proclaimed knowledge and efficacy when what is now required is a more robust approach to examining their actual knowledge and performance and, crucially, their impact on patient outcomes. Little seems to have been added to the literature on this since Hardy et al. [ 23 ] found no studies to include in their systematic review. Further, Haddad et al’s [ 43 ] study in a low secure forensic setting found nurses scoring favourably on PHASe subscales about attitudes to physical healthcare and to smoking compared with non-forensic nurses in the reference sample, suggesting perhaps that in a setting where length of stay is considerably longer then nurses have more opportunity to engage with patients in this aspect of care. Notably, however, nurses in the same sample compared unfavourably with the reference sample in terms of perceived involvement in actual physical healthcare, a somewhat contradictory finding.

For intervention studies, effect sizes were generally largest, and were in fact sometimes startlingly large, where interventions were targeted and outcomes were knowledge based (e.g., educational studies). This is unsurprising since educational interventions are generally evaluated against criteria that are specifically and directly addressed in the intervention. Outcomes tended to be measured immediately following the training [ 46 , 52 ], but their long term retention is generally not known and neither is any practical beneficial change to practice. The apparent potency of these interventions requires further testing in randomized designs with appropriate follow-up periods.

Some study samples in the current review included non-nursing staff; though their occurrence and representativeness was too limited to allow robust conclusions to be drawn about the relative state of nurses’ knowledge and attitudes within the multidisciplinary team context. Given the current review explicitly focused on mental health nurses then further research exploring the multidisciplinary aspects of physical health care provision is warranted.

Mental health nurses’ ability to provide routine physical healthcare has been highlighted in recent years. Recent literature provides a starting point for future research which must now concentrate on determining the effectiveness of nurse preparation for providing physical health care for people with mental disorder, determining the appropriate content for such preparation, and evaluating the effectiveness both in terms of nurse and patient- related outcomes. At the same time, developments are needed which are congruent with the needs and wants of patients. Perhaps what the included studies best demonstrate is that mental health nurses seem to realise that physical health care is part of their role.

Abbreviations

Medical Subject Headings

Physical Health Attitudes Scale for mental health nurses

Population Intervention Comparator Outcome

Preferred Reporting Items for Systematic Reviews and Meta Analyses

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Acknowledgements

The study was partly funded as part of the CUBIC Capability, Capacity and Cultural Change project funded by Nursing and Midwifery Office (NaMO) New South Wales

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Geoffrey L. Dickens, Cheryl Waters, Evan Atlantis & Bronwyn Everett

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GLD conceived of and designed the study. GLD, RI, CW, EA, BE contributed to acquisition of data, analysis and interpretation of data. GLD, RI, CW, EA, BE contributed to drafting the manuscript or revising it critically for important intellectual content. GLD, RI, CW, EA, BE gave final approval of the version to be published. GLD, RI, CW, EA, BE agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Additional files

Additional file 1:.

Table S1. Example PICO-style electronic literature search. Example literature search (DOCX 13 kb)

Additional file 2:

Table S2. Controlled intervention evaluation study quality assessment. Study Quality Assessment (controlled intervention study) (DOCX 13 kb)

Additional file 3:

Table S3. Cross-sectional, observational studies quality assessment (adapted from National Heart, Lung, and Blood Institute [ 26 ]. Study Quality Assessment (Cross-sectional and observational studies) (DOCX 16 kb)

Additional file 4:

Table S4. Longitudinal uncontrolled intervention study quality assessment. Study Quality Assessment (uncontrolled intervention studies) (DOCX 14 kb)

Additional file 5:

Table S5. Qualitative study quality assessment. Study Quality Assessment. (Qualitative studies) (DOCX 14 kb)

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Table S6. Outcome measure content and quality assessment. Quality assessment of outcomes measures used in studies. (DOCX 25 kb)

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Dickens, G.L., Ion, R., Waters, C. et al. Mental health nurses’ attitudes, experience, and knowledge regarding routine physical healthcare: systematic, integrative review of studies involving 7,549 nurses working in mental health settings. BMC Nurs 18 , 16 (2019). https://doi.org/10.1186/s12912-019-0339-x

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What are the core competencies of a mental health nurse? A concept mapping study involving five stakeholder groups

Nompilo moyo , bscn, mph, mha, martin jones , msc, dprof, richard gray , bsc (hons), msc, phd.

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Correspondence: Nompilo Moyo, School of Nursing and Midwifery, La Trobe University, Bundoora, Victoria 3086, Australia. Email: [email protected]

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Accepted 2022 Mar 10; Issue date 2022 Aug.

This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

Mental health nurses aim to provide high‐quality care that is safe and person‐centred. Service users require individualized care, responsive to their preferences, needs, and values. The views of service users, mental health nurses, nurse academics, psychiatrists, and nurse managers about the core competencies of mental health nurses have not been explored. Our study aimed to describe and contrast the views of multiple stakeholder groups on the core competencies of mental health nurses. Concept mapping is a six‐step mixed‐methods study design that combines qualitative data with principal component analysis to produce a two‐dimensional concept map. Forty‐eight people participated in the study from five stakeholder groups that included service users and clinicians. The final concept map had eight clusters: assessment and management of risk; understanding recovery principles; person‐ and family‐centred care; good communication skills; knowledge about mental disorders and treatment; evaluating research and promoting physical health; a sense of humour; and physical and psychological interventions. There were important differences in how service users and health professionals ranked the relative importance of the clusters. Service users reported the understanding recovery principles cluster as the most important, whilst health professionals ranked the assessment and management of risk group the most important. There may be a disconnect between what service users and other stakeholders perceive to be the core competencies of mental health nurses. There is a need for more research to examine the differing perspectives of service users and health professionals on the core competencies of mental health nurses.

Keywords: core competencies, concept mapping, mental health nurse, service user, knowledge

INTRODUCTION

Defined as a combination of knowledge, professional skills, and attitudes, competencies ensure that a nurse can safely and effectively complete a task or activity within the context of a specific job (Hayes, 2020 ). Competencies enable an organization's workforce to understand the behaviours that must be demonstrated and the levels of performance that are expected to achieve organizational goals. They inform the nurse about the actions and behaviours that will be valued, recognized, and rewarded (Hayes, 2020 ).

The scope of practice of nurses working in mental health requires a broad set of clinical competencies to address the care needs of service users. Authors have described a broad range of competencies that include communication, management of risk, medication knowledge, and administration (Comiskey et al . 2019 ; Santangelo et al . 2018 ; Ward & Gwinner, 2015 ). The Australian College of Mental Health Nurses ( 2013 ) has described mental health nurses' scope of practice as comprising a variety of nursing roles, duties, obligations, accountabilities, activities, creativity, modalities, and innovations and is based on ethical decision‐making.

The impact of mental health nursing care on clinical outcomes for service users

There is no evidence from clinical trials or high‐quality observational studies that shows mental health nursing care as an exposure improves service user clinical outcomes compared to no specialist psychiatric nursing care. For example, Moyo, et al . ( 2020 ) reported a systematic review that examined the association between mental nursing skill mix and patient outcomes in adult mental health inpatient units and identified no studies that met inclusion criteria.

Person‐centred care

Person‐centred care is defined as reintroducing the service user into care, reinforcing the ever‐present ethical need to protect dignity, provide autonomy, choose, control, respect decision‐making, and do good (Edvardsson, 2015 ). Whilst we note that there is no strong evidence from systematic reviews that person‐centred care improves clinical outcomes (Barnett et al . 2019 ; Bee et al . 2015 ; Gondek et al . 2017 ), there is a strong policy emphasis for mental health services in Australia to adopt this approach (Australian Commission on Safety & Quality in Health Care, 2019 ; Australian Department of Health Victoria, 2021 ). As a consequence, we have located this study within a person‐centred practice framework.

Mental health nursing in an Australian context

In Victoria, the Nurses Act of 1993 removed the requirement for mental health nurses to be registered separately for new nurses, instead requiring future nursing graduates to be included on a single registry (Division 1) (Happell, 2009 ; Victorian Government, 1993 ). The implementation of a new Nurses Act in Victoria in 1993 resulted in the abrupt cessation of direct‐entry mental nursing training programmes (Happell, 2009 ). The Nurse Act 1993 allowed a registered nurse with no specialist training in mental health to perform the duties previously could only be undertaken by a mental health nurse (Victorian Government, 1993 ). In 2012, the Nursing and Midwifery Board of Australia changed the registration status of nurses with a sole qualification in mental health to general registration with the condition that they could only practice in psychiatric settings (Nursing & Midwifery Board of Australia, 2012 ). The ACMHN defines a mental health nurse – in an Australian context – as a registered nurse with a formal specialist qualification in mental health (Australian College of Mental Health Nurses, 2010 ). The college does not recognize nurses working in mental health settings who do not possess speciality postgraduate qualifications in the discipline as mental health nurses. Mental health nurses can be credentialled by the ACMHN, but it has no regulatory standing (Australian College of Mental Health Nurses, 2010 ).

We note that other countries offer different pathways to mental health nursing. For example, in the United Kingdom, there is a direct pathway to mental health nursing without the need to complete a comprehensive nursing program (Nursing & Midwifery Council United Kingdom, 2018 ).

In 2007, the ACMHN conducted a mixed‐method study to review and update the 1995 Australian mental health nurses' standards of practice (Australian College of Mental Health Nurses, 2010 ). A total of 229 mental health nurses and key stakeholders were involved in the study. Based on this work, the ACMHN published the revised Australian mental health nurses' standards of practice (Australian College of Mental Health Nurses, 2010 ). Given that there has been important development in mental health services over the past decade, it is, perhaps, worthy to investigate if these competencies are still relevant to contemporary practice.

Stakeholder perspectives on mental health nursing competencies

We searched five databases and identified 80 papers published between July 2006 and 31 December 2021 that explored the perspectives of service users and nurses on the competencies of mental health nurses. Out of 80 studies, we identified six (Askey et al . 2009 ; Biringer et al . 2021 ; Jones et al . 2007 ; McAllister et al . 2021 ; Santangelo et al . 2018 ; Sinclair et al . 2006 ) where service users, nurses, and other health‐care professionals’ views of the competencies of mental health nurses were compared and contrasted. One of these six studies examined the competencies of a nurse prescriber (Jones et al . 2007 ). Arguably, more research contrasting stakeholder perspectives is warranted. The aim of this study is to use concept mapping to understand and contrast the core competencies of mental health nurses from multiple stakeholder perspectives.

Protocol and registrations

Our reporting followed the Good Reporting of A Mixed Methods Study (GRAMMS) (O’Cathain et al . 2008 ) reporting guidelines. The protocol for this study was submitted for publication prior to commencing data collection but was published after the fieldwork had started (Moyo, et al . 2020 ).

Study design

We considered two mixed methods for this research: concept mapping and the Delphi technique. These are two discrete and different methods used to examine the perceptions of a group of people about a phenomenon. The Delphi method requires experts to answer complex research questions (Grisham, 2009 ). Although the Delphi technique is intended to elicit expert opinions, it ultimately results in consensus among respondents and is not helpful in contrasting differences between groups (Lund, 2020 ). Concept mapping affords the advantage of enabling the views of different stakeholder groups to be compared and contrasted and was consequently considered to be a preferable methodology to achieving the aim of this study.

Theoretical position of concept mapping

Concept mapping is situated between post‐positivist and constructivist paradigms (Ponterotto, 2005 ). The quantitative (multivariate statistical analysis) part of concept mapping fits with the positivist paradigm, whilst the qualitative part aligns with constructivism. Concept mapping uses standardized procedures to collect data, and the participants entirely determine the content of the map (post‐positivist; Ponterotto, 2005 ). Constructivism conforms to a relativist viewpoint that implies many tangible and equally valid realities (Schwandt, 1994 ), consistent with our goal of comparing and contrasting the participants' perceptions.

Concept mapping

We used a concept mapping method originally developed by Trochim ( 1989 ). Concept mapping is a mixed‐method participatory research design that combines qualitative approaches with quantitative analytical tools to produce visual displays of the relationships between concepts (Burke et al . 2005 ). The final output is a concept map which is a geographical representation of stakeholder views of a particular concept. Our study followed the six stages of concept mapping. We have published a protocol (Moyo, et al . 2020 ) for this study previously.

Recruitment of participants

We sought expertise in addressing this question from the perspective of multiple stakeholders:

Service users aged 18 years or over who had experienced mental illness;

Mental health nurses, nurse managers, and psychiatrists, who were licensed to practice in Australia and were currently working in mental health settings;

Nurse academics working in an Australian University who indicated that they contributed to providing mental health education.

All participants needed to indicate that they had basic computer skills and were able to speak and read English.

Mental health nurses self‐identified, we did not verify their accreditation status with ACMHN as we considered this might negatively impact participation in the study.

We selected the stakeholder groups as we considered that each has a different baring on the work of mental health nurses (Bee et al . 2008 ; Cowman et al . 2001 ). For example, nurse academics design the mental health curriculums and educate nurses, and psychiatrists work closely with mental health nurses as part of the multidisciplinary team.

We used newsletters of advocacy organizations and snowballing methods to recruit service users. Professional groups were recruited through social media, newsletters, and snowballing techniques that are described in detail in the study protocol (Moyo, et al . 2020 ).

Phase 1: Preparation

Stage one involved deciding on the focus question for the study, ‘what are the core competencies (knowledge, clinical skills, and attitudes) of a mental health nurse?’

Phase 2: Generation of statements (Brainstorming)

Participants were interviewed individually by a researcher (who was a mental health nurse). Interviews were conducted using a video conferencing platform. Participants were invited to respond to the question, ‘what are the core competencies (knowledge, clinical skills, and attitudes) of a mental health nurse?’ The interviewer asked participants to elaborate on vague statements and asked follow‐up questions. Interviews were audio‐recorded. We generated more than enough statements for the Adriane software, and we reduced the number of statements by combining repetitive and overlapping concepts into single statements. Following that, the statements were entered into Ariadne.

Phase 3: Structuring of statements

The structuring of statements was conducted online using the Ariadne software package (Ariadne, 2015 ) and involves two tasks: prioritization and clustering. First, participants were asked to prioritize (rate) competencies in order of importance on a scale of one to five (one being the most important and five the least important). Participants were to ensure that there were an equal number of statements on each of the five points on the scale. Next participants were asked to group statements that seemed to belong together into clusters. Both tasks were completed online by ‘dragging and dropping’ virtual cards on the screen.

Phase 4: Representation

Data from the prioritization and clustering tasks were analysed using the Ariadne software package (Ariadne, 2015 ). Ariadne produced a matrix of zeros and ones representing the likeness between the statements for each participant. All the individual matrices were changed into one matrix representing all the individuals. The matrix was used as the input for a principal component analysis (PCA). PCA is a method for translating the distances (or the correlation) between statements or other entities into coordinates in a multidimensional space (Ariadne, 2015 ). The first two dimensions of the PCA solution were presented in the Concept Map. Ariadne then categorized the statements further by completing a cluster analysis with the coordinates of the statements (Ariadne, 2015 ). Ariadne also calculated the correlation between the priority of each statement and its position on the Concept Map for the individual and groups of participants (Ariadne, 2015 ).

Determining the best cluster solution

Concept mapping produces multiple (up to 17) cluster solutions. The research team reviewed each cluster to determine which cluster solution best represented the data.

Phase 5: Interpretation of concept maps

We organized a focus group that comprised at least one participant from each stakeholder group to review and interpret the final concept map. First, we calculated the mean rating of the total statements in each cluster to determine the average rating of each cluster. Then, the clusters were presented in a table in order of their relative importance. We used this table to interpret the concept map. Furthermore, the distance between clusters and the location of the clusters were used to interpret the clusters.

Phase 6: Utilization of concept maps

During this stage, the authors had a meeting to discuss how the concept map study results will be used.

Changes to the protocol

Initially, we did not intend to reimburse service users for taking part in the study. In response to feedback from service user advocacy groups, we amended the protocol so that participants were reimbursed $50 for their time. An amendment was submitted and approved by the University human research ethics committee.

Participants were not involved in determining the best cluster solution as proposed in the protocol because we did not want to burden them. We omitted to include a statement about service users and public involvement in our protocol.

Ethical considerations

Ethical approval was granted by the La Trobe University human research ethics committee before commencing the study (Approval No. HEC20257). Written informed consent was obtained from people who had expressed an interest in participating. Participants were informed that they could withdraw from the study at any phase of the concept mapping process. At each stage of the concept mapping, participants were asked if they were still interested in completing the task. We provided a list of addresses and online psychosocial support and counselling services to participants for help and advice in the event of emotional distress during the interview process because of previous experiences of distress and trauma.

Patient and public involvement in the research project

Participants were not involved in developing the focus question or the design of the study. Instead, service users and mental health professionals helped in recruiting other people through the snowball technique. One service user and six mental health professionals, together with the authors, interpreted the final concept map.

The flow of participants through the study is shown in Fig.  1 . A total of 48 people participated in the brainstorming and 43 in prioritizing and clustering tasks. There were broadly equal numbers of participants across the five stakeholder groups.

A diagram showing the flow of participants.

Demographic characteristics of participants

The demographic characteristics of the stakeholder groups and the duration of the interviews are shown in Table  1 . Most participants identified as female and were in their mid‐40s. The majority of service users reported that they had a diagnosis of depression and/or anxiety. Across the four professional groups most held a postgraduate qualification, had around 20 years of mental health experience, and had trained in Australia. Seven (78%) of the nine nurse academics worked as casual or part‐time mental health nurses in the clinical setting.

Participant characteristics

Generation of statements (brainstorming)

All participants took part in the brainstorming phase of concept mapping. The mean duration of interviews was 21 minutes ( SD = 4.41). There were no important differences in the duration of interviews between stakeholder groups. A total of 409 individual statements were identified.

Statement reduction

The researcher retrieved information from the interview by listening back to it and entering it on an Excel spreadsheet. The number of statements exceeded the maximum (98) that can be entered into the concept mapping software package. Therefore, we followed the procedures set out in the study protocol (Moyo, et al . 2020 ) to reduce statements. Statement reduction was undertaken by NM and RG. We combined repetitive or overlapping statements into single concepts. The final list included 60 understandable, singular, and specific statements (Kikkert et al . 2006 ). A complete list of statement is shown in Table  2 .

Comparing mean importance of statements generated by stakeholder groups

Each statement was rated regarding its perceived importance as a competence of a mental health nurse using a scale from 1 to 5, with one being the most important. Statements are arranged according to their importance, that is, statements on top were highly rated. The letters (a–h) on each statement represents the eight clusters.

Statement in cluster one, assessment and management of risk.

Statement in cluster two, understanding recovery principles.

Statement in cluster three, family‐ and patient‐centred care.

Statement in cluster four, good communication skills.

Statement in cluster five, knowledge about mental disorders and treatment.

Statement in cluster six, evaluating Research and promoting physical health.

Statement in cluster seven, a sense of humour.

Statement in cluster eight, physical and psychological interventions.

No confidence interval since SD is 0.00.

The final list of statements ranked from most through least important for all participants and by stakeholder group is reported in Table  2 . Ariadne combined the ratings of all statements by all individuals and calculated the mean score of each statement. 'Skilled in engaging people when they are distressed' was ranked as most important statement overall.

The Ariadne software package produced a point map that shows the position of each statement (see Fig.  2 ). Ariadne also generated 17 candidate concept maps. Candidate concept maps had between two and 18 clusters (all candidate concept maps are available in File S1 ). Two members of the research team (NM, RG) reviewed each concept map to determine which best conceptually represented the views of participants. Initially, we eliminated concept maps with two through six clusters as the clusters were large and contained statements that clearly did not relate to each other. Next, we eliminated nine maps with small clusters because they only contained single statements and statements that seemed to relate to each other were not placed within the same cluster. From a final shortlist of three: seven cluster, eight cluster, and nine cluster solutions, we considered that the eight‐cluster solution best represented the data (Fig.  3 and Table  3 ).

A point map showing the position of each statement.

The final eight‐cluster concept map solution showing stakeholder perceptions of the core competencies of a mental health nurse.

Comparing mean importance of eight‐cluster solution of the five stakeholder groups

Clusters were ranked on a 1–5 scale, with one being the most important. The Lower the mean score, the more important the cluster.

The concept map is divided into four large areas (north, south, east, and west). The statements located in the same area are related and those in different regions are contrasting, for example, statements in the west contrast those in the east.

Ariadne produces three cluster formats: (a) rectangle with a single line border, (b) rectangle with a border made of multiple lines, (c) a shape that traces the position of the statements that form the boundary of the cluster. We initially selected the rectangle format because they are more straightforward to interpret. However, after reviewing map formats, we concluded that the cluster format that traces the position of statement was a more informative visual representation of the cluster.

Phase 5: Interpretation of concept map

Seven participants (Fig.  1 ) – at least one from each stakeholder group – and three members of the research team (NM, RG, MJ) agreed to take part in a focus group meeting to review and interpret the final concept map. The focus group was held via video conferencing and lasted 70 min. At the start of the focus group, RG showed participants the concept map, a list of statements in each cluster and asked them to generate labels for each grouping. Possible labels were discussed by the group and were either eliminated or retained. For clusters one, two, three, five, to eight, the consensus was straightforward. However, there was disagreement in the group around the label for cluster four (good communication skills). The debate centred on the inclusion of ‘good’ as an unnecessary adjective to describe communication skills. The majority view was that communication skills can be bad as well as good and it was important to emphasize that the statements in this cluster represented skills that participants valued.

Labelling the x ‐ and y ‐axes of the concept map

The x ‐ and y ‐axes on the map are viewed as themes that participants used to sort the statements (Brown, 2018 ; Rudawska, 2020 ). The axes can be interpreted based on these themes and labelled to improve the data's visual representation (Brown, 2018 ). NM proposed candidate names for the x ‐axis and y ‐axis by examining the statements (competencies) in the four quadrants of the map. The statements on the 'west' end of the x ‐axis were related to patient care and communication skills. Therefore, the west end was labelled ‘interpersonal relationships’. The competencies in the extreme 'east' were about knowledge of mental disorders and treatment, and hence, the far east of the x ‐axis was labelled ‘medical construction of mental experiences’.

The 'northern' end of the y ‐axis was named ‘principles of care’ because the statements on the north of the y ‐axis were linked to recovery principles and person‐centred care. The competencies towards the extreme 'southern' of the y ‐axis were related to health assessments and communication skills and the 'southern' end was labelled ‘health assessment’.

There was general agreement among the participants about the axis labels. The labelled clusters and axis are shown in Fig.  3 .

In the final part of the interpretation phase, participants considered the location and distance between the clusters to interpret the concept map. Participants were also asked to consider the thickness of the line surrounding each cluster as a visual cue to indicate the relative importance of the cluster; the thinner the line, the more important the cluster.

Description of eight clusters

Clusters were ranked according to their relative importance from one (most important) to eight (least important). Figure  3 is the final concept map showing the eight clusters. Table  3 shows the importance ranking of the eight clusters, by stakeholder group.

Cluster one, assessment and management of risk

There are six statements in cluster one, ‘assessment and management of risk’. Statements include ‘can undertake a risk assessment (harm to self)’, ‘conduct a mental state examination’, and ‘are able to handover patients accurately’. Cluster one is in the southeast quadrant of the concept map. The cluster's position on the x‐ and y‐axes indicates that it is related to health assessment (south of the y‐axis) and knowledge of mental disorders (east of the x‐axis). Cluster one is also located on the border of the y ‐axis between cluster four, ‘good communication skills’ and cluster eight, ‘physical and psychological intervention’. Clusters four and eight are in different quadrants, suggesting that cluster one is related to these two concepts.

Cluster two, understanding recovery principles

Cluster two, ‘understanding recovery principles’, has one statement, ‘knowledge about the principles of recovery’, and is located on the far northeast of the map. The location suggests that the cluster is related to principles of care (north of the y‐axis). In addition, the positioning close to cluster five, ‘knowledge of mental health disorders and treatment’, also suggests that the two clusters are linked.

Cluster three, person‐ and family‐centred care

The statements in cluster three, ‘person‐ and family‐centred care’, are closely grouped together; consequently, the cluster is relatively small, suggesting an important relationship between statements. Cluster three also has the largest number ( n  = 17) of statements of all the clusters. Statements in the ‘person‐ and family‐centred care’ cluster include ‘are able to engage with consumers’, ‘works in a patient centred way’, and ‘skilled at talking to patients, families, and friends’. Cluster three is the only cluster positioned in the northwest quadrant of the map, suggesting that the concept is discreet.

Cluster four, good communication skills

‘Skilled in engaging people when they are distressed’, ‘skilled at working as part of a team’, and ‘clinical documentation is respectful’ are examples of the six statements that are included in cluster four, ‘good communication skills’. Cluster four is in the southwest of the map, in the same quadrant as clusters seven and one, suggesting they are related.

Cluster five, knowledge about mental disorders and treatment

Twelve statements are included in the ‘knowledge of different mental disorders and treatment’ cluster and include ‘knowledgeable about the use of Pro Re Nata (PRN) medication’, ‘are knowledgeable about risk factors for mental illness’, and ‘knowledgeable about different psychotherapeutic techniques’. Cluster five is situated between clusters two and six, ‘evaluating research and promoting physical health’ and in the same quadrant, suggesting that these three clusters may be related.

Cluster six, evaluating research and promoting physical health

Cluster six, ‘evaluating research and promoting physical health’, is located just above the x ‐axis line towards the east of the map. The cluster has two statements: ‘Skilled in being able to critically evaluate new research’ and ‘are skilled in promoting physical health’. The two statements in cluster six are diagonally opposite, suggesting that they may not be closely related.

Cluster seven, a sense of humour

Located just below the x ‐axis and to the west of the map is cluster seven, ‘a sense of humour’. The cluster has a single statement, ‘have a good sense of humour’. Cluster seven is positioned close to cluster three but is in a different quadrant, suggesting they are not related.

Cluster eight, physical and psychological interventions

Cluster eight, ‘physical and psychological interventions’, is made up of eight statements that include ‘can undertake a physical health assessment’, ‘competent in taking blood’, and ‘competent in delivering different psychotherapeutic techniques’. The cluster is located in the southeast quadrant of the map.

Comparisons between stakeholder groups

Table  3 shows the mean, standard deviation, and 95% confidence intervals for each cluster by stakeholder groups and for all participants.

There were notable discrepancies in how different stakeholder groups perceived the relative importance of clusters. For example, service users rated cluster one, ‘assessment and management of risk’, as less important, whilst the other four groups ranked it as the most important. The ‘understanding recovery principles’ cluster was highly ranked by service users, mental health nurses, and managers. Conversely, psychiatrists and academics put this cluster towards the middling of the ranking. There was a marked difference in the rating of cluster three, ‘person‐ and family‐centred care’. It was highly ranked by service users, nurse academics, and psychiatrists, and lowly by mental health nurses and managers. Clusters four and five were ranked similarly by the stakeholder groups. ‘Evaluating research and promoting physical health’ cluster was ranked fourth by nurse academics and low by other groups. All participating groups gave the ‘sense of humour’ cluster a low ranking except for psychiatrists, who ranked the cluster as third most important. Physical and psychological interventions cluster was rated less important by all participant groups.

We report a concept mapping study to describe and contrast the core competencies of mental health nurses from the perspective of five stakeholder groups. Our final concept map had eight clusters: Assessment and management of risk, understanding recovery principles, person‐ and family‐centred care, good communication skills, knowledge about mental disorders and treatment, evaluating research and promoting physical health, a sense of humour, physical and psychological interventions.

Broadly, the eight clusters are consistent with those reported in previous systematic reviews (Bee et al . 2008 ; Delaney & Johnson, 2014 ) and primary studies (King et al . 2019 ; Moll et al . 2018 ; Stewart et al . 2015 ). For example, assessment and management of risk, person‐centred care, and good communication skills are consistently identified as important competencies of mental health nurses (Gunasekara et al . 2014 ; Testerink et al . 2019 ; Ward & Gwinner, 2015 ).

Our study extends knowledge by enabling us to consider differences between stakeholder groups. The most notable differences we observed were between service users and other groups. For example, professionals rated the 'assessment and management of risk' cluster as the most important whilst service users ranked this cluster as less important. Service users, mental health nurses and managers rated understanding recovery principles as most important, whilst psychiatrists and nurse academics indicated these were less important. The discrepancy between groups has not been previously reported and provides some limited evidence of a disconnect between service users and professionals view about the core work of mental health nurses.

Despite the importance of physical health in mental health, all stakeholder groups ranked the ‘physical and psychological interventions’ cluster as less important. Competencies in physical health interventions benefit service users physically and aid in the development of therapeutic relationships between the service user and the nurse (Hawamdeh & Fakhry, 2014 ). However, some mental health nurses perceive they are less competent to provide physical care than expected of them (Celik Ince et al . 2018 ), whilst others believe it falls beyond their scope of practice (Gray & Brown, 2017 ).

The competencies identified by participants in our study tended to be brief and highly specific (e.g. ‘spending time with consumers’, ‘able to express empathy’) and are seemingly discrepant to how competencies are described in health policy documents that tend to involve multiple elements. For example, in the Australian College of Mental Health Nursing, standard 3 of practice policy states that ‘mental health nurse develops a therapeutic relationship that is respectful of the individual’s choices, experiences and circumstances, this involves building on strengths, holding hope, and enhancing resilience to promote recovery’. Our observation may suggest that stakeholders do not conceptualize – in clinical practice – competencies in the way they are described in policy documents. Rather, stakeholders tend to fracture complex ideas into component concepts that they can interpret and process. The concise descriptions of competency statements in other studies are consistent with our findings. For example, 52 nurses working in mental health intensive care units identified empathy, active listening, and appropriate body language as core nursing competencies (Ward & Gwinner, 2015 ).

We also observed that some of the competencies identified in our study are not reported in the Standards of Practice for Australian Mental Health Nurses 2010, for example, ‘knowledge about Safewards interventions’ and ‘work in a trauma‐informed way’. Competencies in trauma‐informed care were also noted as important in the Royal Commission into Victoria’s Mental Health System ( 2021 ). The Royal Commission into Victoria’s Mental Health System ( 2021 ) examined the views of service users, families, carers and supporters, nurses, and other mental health professionals about the competencies of mental health professionals. The Royal Commission identified that mental health professionals (including nurses) lacked competency in promoting personal recovery and helping service users who have been traumatized (Royal Commission into Victoria’s Mental Health System, 2021 ). Wilson et al . ( 2017 ) included 11 studies in the literature review to examine the challenges mental health nurses face in integrating trauma‐informed care into acute inpatient settings in Australia. The authors report that trauma‐informed care can promote a positive organizational culture and improve the care provided to service users (Wilson et al . 2017 ).

In our study, participants reflected on interventions they had exposure to through their clinical experience. There is a need to consider how the scope of practice of mental health nurses evolves as new evidence emerges. For example, participants noted ‘trauma‐informed care’ as a candidate way of working for the revised scope of mental health nursing practice. The ACMHN needs to consider the quality of evidence that underpins emerging interventions and whether they should be included as a core competency for mental health nurses.

Person‐ and family‐centred care is a method of health‐care planning, delivery, and assessment based on mutually beneficial collaborations between health‐care professionals, service users, and families (Johnson & Abraham, 2012 ). It is sometimes challenging to collaborate with service users and their families, particularly when they have conflicting agendas (Goodwin & Happell, 2006 ). Many mental health services claim that person‐centred care is a core value of the service. We observed that the positioning of the person‐ and‐family‐centred care cluster on the concept map was distant from other clusters (the only cluster in the top left‐hand quadrant of the map). This observation perhaps suggests that the concept of person‐centred care has not been meaningfully integrated into practice in a meaningful way.

The ‘understanding recovery principles’ cluster was also a discrete concept – with a single statement – that, although located on the map close to the ‘knowledge about mental disorders and treatment’ and ‘evaluating research and promoting physical health’ clusters was not part of a broader cluster that integrated the multidimensional construct of recovery‐focused working. A single statement has been classified as a cluster in previous studies (see, e.g. Brown et al . 2019 ; Cardwell et al . 2021 ).

A ‘sense of humour’ was a discrete cluster, and its location on the map made it distinct from other groups. On the map, it is closely related to ‘good communication skills’. Psychiatrists viewed ‘sense of humour’ as an important competence, but other groups did not. A sense of humour has been identified previously as an important part of mental health nursing practice in previous systematic reviews of qualitative studies (e.g. Cleary et al . 2012 ).

Limitations

There are several important limitations that need to be considered when interpreting the findings of our study. We used social media and snowballing techniques to recruit participants, this may have introduced selection bias. It is likely that people who actively use social media are systematically different to those who do not. A computer software package was used to undertake prioritization and clustering tasks, this may have discouraged people who did not have good computer skills from participating. Our study did not involve carers, or other professional groups working in mental health settings. These groups may have provided different views and they should be considered in future studies. Nurses working in mental health are not required to have a postgraduate qualification; this may impact the insights that they are able to share about the competencies of mental health nurses. It may be that we should only have included nurses who had evidence that they had completed postgraduate training in mental health, and this is an acknowledged limitation of our study.

On reflection, participants seemly reported an inclusive definition of what a mental health nurse is, which contrasts with the explicit definition used by the ACMHN. In our study, stakeholders were situated within a specific time and place and socio‐political context. Inevitably this will have impacted the competencies that were generated and the relative importance that participants ascribed to them.

The study used convenience sampling, and therefore, the results cannot be generalized beyond the views of the participants. There is no agreed‐upon number of people needed for the concept mapping (Ariadne, 2015 ; Rosas & Kane, 2012 ; Trochim, 1989 ). The sample size in our study is consistent with previous studies that have used a concept mapping methodology (Iris et al . 2010 ; Johnson et al . 2014 ; Kabukye et al . 2020 ; Niemeijer et al . 2011 ; Robinson & Trochim, 2007 ). Our aim was not to have a representative sample but rather to inform our understanding of complex phenomena. A final limitation of our study was the decision to have researchers and not stakeholder make the decision about which cluster map solution to use. The researchers may have unknowingly chosen the cluster map solution that had clusters with clinically related statements but not conceptually representing the views of participants.

Service users and mental health professionals have conflicting perspectives about the relative importance, particularly the ‘assessment and management of risk’. Further research is needed to test these ideas in representative samples of service users and mental health workers.

RELEVANCE TO CLINICAL PRACTICE

We observed a potential disconnect between service users and professional stakeholder groups about the core work of mental health nurses. A further study examining the differing perspectives of service users and health professionals on the core competencies of mental health nurses is required. The ACMHN should consider reviewing the existing competencies of mental health nurses, particularly in light of emerging evidence about the effectiveness of different interventions.

Supporting information

File S1 Seventeen candidate concept maps produced by Ariadne concept mapping software.

ACKNOWLEDGEMENT

We would like to express our appreciation to the participants who took part in this study. Open access funding provided by La Trobe University.

Authorship statement: All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors. All authors contributed to the conception and design of the study. NM collected, and analysed the data. All authors interpreted the study results. NM wrote the initial draft. NM, MJ and RG reviewed and edited the manuscript. All authors read and approved the final manuscript.

Declaration of conflict of interest: The authors declare no conflicts of interest.

Open Science Framework Registration: https://doi.org/10.17605/OSF.IO/9XJNH.

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Mental Health Nursing

June andrews horowitz.

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Received 2020 May 6; Accepted 2020 May 7; Issue date 2020 May.

Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/ ).

This Special Issue, Mental Health Nursing , provides transdisciplinary readers with a glimpse into the varied interests among researchers in nursing. By design, the articles and subjects featured in this issue were self-selected through submissions and accepted via rigorous peer review. Therefore, these topics do not and are not intended to comprise a representative sample of current mental health nursing research studies. Nonetheless, I anticipate that readers will appreciate the interesting and diverse foci of the featured papers.

The articles reflect multifaceted interests. Notably, topics span the life course from mental health during childhood to older age, although extensive nursing research concerning perinatal, infant and early childhood mental health is not represented. Studies also address a variety of mental health indicators such as depressive symptoms, aggression, and anxiety. Investigations concerning interventions and care plans are featured. Articles also feature experiences and perspectives of healthcare providers and caregivers. Environments include treatment facilities, emergency services, and community settings. Moreover, studies cut across what might be considered traditional specialties in the medical model of health care. Mental health needs and issues are ubiquitous and are not restricted to psychiatric diagnoses or treatment settings, as reflected in the variety of topics found in this Special Issue.

The breadth and scope of these topics also recall a longstanding nursing framework known as the nursing metaparadigm comprised of four intersecting domains: nursing, person, environment, and health [ 1 ]. During more than four decades, this ontology has undergone critique and re-conceptualization. Nevertheless, the interrelations among the domains of nursing, person, environment, and health endure as a guiding framework for nursing practice and research [ 2 ].

The grouping of articles in this Special Issue reflects this framework. For example, the article, Identifying the Factors Related to Depressive Symptoms amongst Community Dwelling Older Adults with Mild Cognitive Impairment , illustrates nursing’s concern with factors and experiences associated with identified symptoms and conditions in a specific context, i.e., community. Another paper, Encounters with Persons Who Frequently Use Psychiatric Emergency Services: Healthcare Professionals’ Views , also examines the intersection of the nurses’ (and other providers’) clinical interactions with those persons who repeatedly use mental health emergency services. The study’s focus is situated at the juncture of nurse/person/environment/and health. In addition, the transdisciplinary focus on nurses, assistant nurses or certified nursing assistants, and physicians also speaks to nursing’s longstanding role as core health care team members in collaborative practice with other clinicians.

The issue’s transdisciplinary relevance also extends its value. The topics and methods are highly accessible to many health care and public health readers. Additionally, submissions came from authors from a variety of countries. Thus, the accepted papers reflect diverse perspectives and health care systems globally. Grouping papers under a broad umbrella such as Mental Health Nursing is challenging. Yet, regardless of the country of origin, each article addressed one or more aspects and/or intersections of the nursing metaparadigm components of nurse/person/environment/and health. Moreover, when nursing practice was not considered specifically, relevance to clinical nursing practice is clearly evident in the implications. Finally, it is my hope, along with the journal’s editorial staff, that our readers will enjoy this this Special Issue as an accessible window into the diversity of current nursing research internationally, and will spark interest into nursing’s perspective going forward.

This work received no external funding.

Conflicts of Interest

The author declares no conflict of interest.

• 1. Fawcett J. The metaparadigm of nursing: Present status and future refinements. Image J. Nurs. Scholarsh. 1984;16:84–87. doi: 10.1111/j.1547-5069.1984.tb01393.x. [ DOI ] [ PubMed ] [ Google Scholar ]
• 2. Bender M. Re-conceptualizing the nursing metaparadigm: Articulating the philosophical ontology of the nursing discipline that orients inquiry and practice. Nurs. Inq. 2018;25:e12243. doi: 10.1111/nin.12243. [ DOI ] [ PubMed ] [ Google Scholar ]
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Nursing care in mental health: Human rights and ethical issues

Affiliations.

• 1 67816University of São Paulo at Ribeirão Preto College of Nursing, Brazil.
• 2 3158University of Alberta, Canada.
• PMID: 33111635
• DOI: 10.1177/0969733020952102

People with mental illness are subjected to stigma and discrimination and constantly face restrictions in the exercise of their political, civil and social rights. Considering this scenario, mental health, ethics and human rights are key approaches to advance the well-being of persons with mental illnesses. The study was conducted to review the scope of the empirical literature available to answer the research question: What evidence is available regarding human rights and ethical issues regarding nursing care to persons with mental illnesses? A scoping review methodology guided by Arksey and O'Malley was used. Studies were identified by conducting electronic searches on CINAHL, PubMed, SCOPUS and Hein databases. Of 312 citations, 26 articles matched the inclusion criteria. The central theme which emerged from the literature was "Ethics and Human Rights Boundaries to Mental Health Nursing practice". Mental health nurses play a key and valuable role in ensuring that their interventions are based on ethical and human rights principles. Mental health nurses seem to have difficulty engaging with the ethical issues in mental health, and generally are dealing with acts of paternalism and with the common justification for those acts. It is important to open a debate regarding possible solutions for this ethical dilemma, with the purpose to enable nurses to function in a way that is morally acceptable to the profession, patients and members of the public. This review may serve as an instrument for healthcare professionals, especially nurses, to reflect about how to fulfil their ethical responsibilities towards persons with mental illnesses, protecting them from discrimination and safeguarding their human rights, respecting their autonomy, and as a value, keeping the individual at the centre of ethical discourse.

Keywords: Ethics; human rights; nursing care; persons with mental illness.

Publication types

• Human Rights
• Mental Health
• Nursing Care*
• Paternalism
• Psychiatric Nursing*