Keywords

Introduction

Mental health nurses are an integral part of the mental health care team. They play a significant role of promoting mental health and caring for service users in both institutional and community care. It is well recognized that effectiveness of the mental healthcare system depends much on both the quantity and quality of mental health nursing service. In Mental Health Atlas 2014, the World Health Organization (WHO) (2015) reported that the median of nurses working in mental health globally has shifted upward by 37%. This positive change in the number of nurses working in mental health is greatest in low-income countries and least in high-income countries. Despite such positive shift, there is a global shortage of appropriately qualified nurses to work effectively in mental health services (World Health Organization 2015). For example, in Australia, it is identified that mental health nursing will be the area of the greatest shortage among healthcare professionals, with a projected shortfall of approximately 17,000 nurses in the year 2030 (Ryan 2015). Education is one of the mental health workforce development strategies to address the issue (Ryan 2015). Such shortage creates an opportunity to review and reflect on current and future mental health nursing education, and how education can promote students’ interest in mental health nursing, and increase the number of new recruits to mental health practice.

The new millennium sees the changing paradigms and views about mental health, mental illness, mental health services, as well as mental health nursing. In many countries, institutional care has been largely replaced by comprehensive, integrated, and community-based mental health services. The recovery approach is replacing the biomedical approach to mental health care. The recovery-based care requires reframing treatment and service provision from the healthcare professionals ’ perspective to service users’ autonomy and emphasis on the individual’s personal strengths. Mental health nurses are expected to work in partnership with individuals who use the mental health services, their families, carers, and their communities (Department of Health 2014a). There is a growing demand for evidence-based nursing practice to provide mental health care which has a sound research base and is continuously refined and improved. Also, an integrated interdisciplinary team approach becomes essential to optimize the use of resources and attain best possible outcomes of mental health care.

This chapter discusses some contemporary issues related to preparing mental health nurses for meeting the rapid developing demand of today’s professional practice, as well as the needs of service users and the healthcare system. The discussion includes the competency-based approach in curriculum development, pedagogical methodology with emphases on students’ active learning, problem-based learning, reflection, digital learning evidence-based practice, and interprofessional education. The recovery model of mental health promotion and maintenance would also be discussed as a recommended theoretical framework for building mental health nursing education programs. The discussion also attempts to highlight issues on the different modes of preregistration education for preparing beginning practitioners.

Competency-Based Mental Health Nursing Education

The Australian College of Mental Health Nursing (ACMHN) published the Standards of Practice for Australian Mental Health Nurses in 2010. These standards (ACMHN 2010) expect the mental health nurse to:

  1. 1.

    acknowledge diversity in culture, values, and belief systems and ensure his/her practice is nondiscriminatory, and promote dignity and self-determination

  2. 2.

    establish collaborative partnerships that facilitate and support people with mental health issues to participate in all aspects of their care

  3. 3.

    develop a therapeutic relationship that is respectful of the individual’s choices, experiences, and circumstances. This involves building on the user’s strengths, holding hope, and enhancing resilience to promote recovery

  4. 4.

    collaboratively plan and provide ethically based care consistent with the mental, physical, spiritual, emotional, social, and cultural needs of the individual

  5. 5.

    value the contributions of other agencies and stakeholders in the collaborative provision of holistic, evidence-based care and in ensuring comprehensive service provision for people with mental health issues

  6. 6.

    actively pursue opportunities to reduce stigma and promote social inclusion and community participation for all people with mental health issues

  7. 7.

    demonstrate evidence-based practice and actively promote practice innovation through lifelong education, research, professional development, clinical supervision, and reflective practice

  8. 8.

    incorporate and reflect common law requirements, relevant statutes, and the nursing profession’s code of conduct and ethics

  9. 9.

    integrate international, national, local, and state policies and guidelines with professional standards and competencies

  10. 10.

    hold specialist qualifications and demonstrate advanced specialist knowledge, skills, and practice, integrating all the standards competently and modeling leadership in the practice setting

The key elements of the ACMHN standards have been used to guide the development of mental health nursing curriculums in Australia. The standards also facilitate an adoption of the competency-based approach by education institutes in organizing their mental health nursing programs. Teaching, learning, and assessment strategies are designed and implemented according to the three areas in the educational taxonomy – attitude, knowledge, and skills.

The ACMHN standards describe that the mental health nurse should accept diversities of individual service users without discrimination, and remove social stigma. A learner in the nursing program could not develop such attitude by just knowing the negative effects of discrimination and social stigma. They need to reflect on own values and feelings toward mental health and the challenges encountered by the service users (Stockhausen 2005).

To reflect, the learner needs to go deeply into the life of the service users and learn through the challenges experienced by them. Reflection exercises during the clinical placement would help the learner develop a sense of the situation where the service users are facing. Direct engagement with the service users will exposure the learner to the emotive element of caring, and hopefully feeling of empathy could be developed (Stockhausen 2005).

Reflection would be more effective when it is guided by the clinical mentor who works with the student to review and discuss the student’s reflective journals (Chien 2012). Attitude development takes time and cannot be assessed by scores or grades. When the clinical mentor reviews student’s reflective journals together with the student, issues with the students’ values and views toward mental health and promoting the service user’s well-being could be identified and guidance could be continuously offered.

Build Knowledge Base by Problem-Based Learning

Learning is a life-long process. Continuing professional development is a common requirement by professional regulation bodies globally as well as healthcare employers. In preregistration nursing programs, students should be guided to develop both an inquiring mind and skills to search for answer to problems.

Problem-based learning (PBL) is a commonly employed strategy to drive students to work in groups to learn the knowledge about a problem. Each PBL group member is responsible for finding the answer to a designated problem, and then sharing and discussing in the group. In this process, learners would develop multiple skills, including skills of identifying the knowledge gap, searching and scrutinizing the information collected, and collating the information for sharing and discussing in the group. This is a process to develop inquisitive and autonomous learning. It is also a way to collaborate with others to learn effectively (Cooper and Carver 2012).

In mental health nursing education, the PBL questions are usually constructed around the competencies expected by the regulatory body of the nursing profession, which could include specialized knowledge in mental health, local and international issues and policies on mental health care, standards and guidelines of practice, legal requirements and professional codes, and contributions of the healthcare system and other stakeholders. Learning outcomes could be assessed in formal examinations as well as by rating performances in the PBL process (Roh et al. 2013).

PBL has been used for many decades by various professional programs and is not confined to classroom learning. PBL could be facilitated by academics in the school, and supervisors during clinical placements. Many innovative strategies have been developed to enhance learning by PBL, for example, integrating PBL with simulation learning activities. This is found to be effective in promoting students’ interest and motivation in solving problems (Roh et al. 2013).

Develop Clinical Competency Through Practice

In their daily work, mental health nurses employ communication skills to engage the service users and their families. For a student with no experience of interacting with an individual with mental health issues, practical guidance is needed. The guidance may include the very basic skills like what to say and how to start a conversation to attain therapeutic outcomes. Students often experience anxiety when they fail to start an engagement or are rejected by the service user. It is useful to learn from demonstration of communication and listening skills by experienced clinicians both in simulation environment and clinical settings. Sharing experiences among students is often helpful to broaden the scope and increase the depth of understanding of a specific topic as well as to build effective skills (Bronwyn 2014).

For example, Bronwyn (2014) had effectively used student-generated podcast to facilitate student sharing in learning therapeutic communication skills. Students were asked to produce and upload audio files of 3–5-min communication activities as podcast. Through self-reflection, sharing views on others work, and writing reflective essays, students effectively mastered the communication skills with facilitation by the teacher. Students were motivated by such peer learning experience.

Mental health nurses use many therapeutic intervention skills in practice, like cognitive behavioral therapy. All such specific skills, like learning the basic communication skills, need to be learned first in a safe and simulated learning environment. Repeated rehearsals with facilitation by academic and clinical mentor are the key to clinical skill mastery.

Integrate Digital Technology in Healthcare and Nursing Education

Today’s rapid advances in digital technology have great impacts on healthcare, including those addressing mental health issues. Digital technology offer opportunities for service users to access therapeutic and supportive services conveniently. There has been fast development in e-mental health services. For example, innovative mobile apps using smartphone have been developed for supporting caregivers and service users (Zhang et al. 2016, 2017).

The use of digital technology often involves interdisciplinary efforts. Mental health nurses could be an active member in the production and implementation team of e-mental health services. They could be directly involved in the development of apps or other e-mental health programs, and supporting the service users in the use of these programs. Given its easy access and effectiveness, especially for those service users living in remote areas, e-mental health services are now an essential part of regular services (Zhang et al. 2016, 2017). It is thus essential that mental health nursing programs equip the graduates with skills in digital technology.

Apart from applications in healthcare, digital technology can be a powerful enabler of learning which goes beyond knowledge transfer. Technology enables students to learn at anytime, anyplace, anywhere, and any pace which is convenient to them. Digital technology such as e-learning, serious games, virtual reality, and augmented reality have increasing been used in healthcare professional education. It can be applied in a broad spectrum of education practices including classroom learning, blended learning, and virtual learning. Evidence supported that digital technology can enhance flexible learning, interactive learning, real-time feedback, networking, and overall student performance (Kowitlawakul et al. 2017; Johnston et al. 2013).

Enhance Evidence-Based Practice

During the Crimean War in the 1850s, Florence Nightingale applied evidence in food and environmental hygiene, and patient outcome to enhance patient care. Members of the nursing profession proudly regarded this as the first documented attempt of evidence-based practice (EBP) in nursing (Chan 2013). EBP in health care is generally referred to integrating the best research with clinical expertise and patient values to achieve optimal health outcomes. Research evidence support that EBP could lead to safer care, better care outcomes, and lower health care costs (Winters and Echeverri 2012). EBP has become a core competency of all healthcare clinicians. Nurses are expected to access and appraise evidence before integrating it into clinical practice.

There has been progressive development in the past decades on EBP in mental health nursing. Innovative research has been conducted in many areas with evidence translated into clinical practice. Some examples include intervention at psychological emergency (Callaghan and Waldock 2012), psychoeducation (Chan et al. 2009; Chien et al. 2012), management of behavioral and psychological symptoms of dementia (Kales et al. 2015), service users peer support (Landers and Zhou 2011), and promotion of mental health in perinatal care (Shorey et al. 2015).

Despite the progress, challenges remain in applying EBP to nursing practice. Evidence suggested that nurses generally have positive attitude toward implementing EBP. Lack of skills in literature search, evidence synthesis, and the lack of organizational resources for research utilization have been frequently reported by nurses as the biggest barriers that impeded EBP (Chan 2013). For example, a descriptive survey of 1015 nurses in USA showed that nurses were willing to implement EBP, but most nurses suggested a need for educational opportunities and access to knowledgeable mentors, resources, and tools needed to use EBP. Another big barrier was an organizational culture that did not support EBP implementation. Staff nurses encountered resistance from nurse managers (Melnyk et al. 2012). Some nurse managers were critical for providing the support needed for implementing EBP and for providing role models. Such resistance and barriers could be related to the lack of education (Wallis 2012).

Further, there are many knowledge gaps in mental health nursing practice. Zauszniewski et al. (2007) pointed out that some practice remained grounded in tradition, and trial-and-error approach. Areas such as effects of seclusion, employment of chemical restraint, and titration of depot tranquillizer still need further studies to have conclusive evidence. Many “traditional practice” could have been developed by nurse leaders with their practical wisdom. These practices are sometimes being formalized as clinical guidelines. Practices backed up by authority are seldom being challenged by practicing nurses.

The Institute of Medicine (2010) Interdisciplinary Health Professions Education Summit noted that EBP had not been incorporated into the basic fabric of the education of healthcare providers (Winters and Echeverri 2012). The outcome was that healthcare students may not be fully prepared for EBP practice.

Continuing efforts are required to integrate best available evidence in mental health nursing practice. There is a need to build EBP culture in practice. Education could be one of the ways to build such culture. EBP competencies can be developed at different levels of mental health nursing education.

The American Association of Colleges of Nursing identified “scholarship for evidence-based practice” as an essential of preregistration bachelor degree nursing education. Preregistration education could prepare students with competencies in searching, reading, evaluating, and applying evidence to nursing practice (Winters and Echeverri 2012). Students should gain knowledge and skills in various research designs, including quantitative, qualitative, and mixed method, so that they can use the best deigns to answer different research questions. At the undergraduate level, EBP concepts can be integrated into both theoretical and clinical courses, instead of a standalone subject.

It is essential that academics and clinical mentors act as role models of these skills. Role modeling can help students developing positive attitudes toward evidence-based practice which is an essential first step to EBP. Academics can teach by incorporating best evidence and practice into their teaching. A clinical learning environment which encourages changes and students receiving support from mentors on how to apply evidence to improve care can play an important role in promoting EBP culture among students. Students can engage in evidence-based projects, which require them to observe practice, collect and synthesize research evidence, and implement recommendations to improve practice and evaluation of outcome. It can help students to build competency in integrating EBP in nursing practice (Chan 2013).

At the postgraduate levels, masters programs are commonly used to prepare advanced nursing practitioners who will be clinical leaders to implement care practice change to improve outcomes. It is essential that such programs prepare graduates with proficiency in conducting research and use evidence effectively. The graduates should be able to translate best available evidence to improve practice (Winters and Echeverri 2012). Doctoral programs should prepare graduates to take the leadership role in using advanced analytic method to appraise, synthesize evidence, dissemination of evidence, make practice recommendations, and translate evidence to improve practice (Chan 2013).

In the clinical setting, organized educational support should be given to the nurse managers and leaders to promote the use of EBP. Specifically designed professional development programs can be offered to develop their competency for completing EBP projects and building organizational capacity for implementing EBP. The program contents could include finding and synthesizing evidence, learning effective strategies for implementation and evaluation, and discussing techniques for building an EBP program. The healthcare institute should ensure there are incentives for these clinical leaders to learn and implement EBP. They should be made responsible for supporting and guiding EBP in their areas and be the role model for nursing students (Cullen et al. 2011).

Implement Interprofessional Education

Within the healthcare team for mental health care, mental health nurses are often recognized as the professional who have the closest engagement with the service user. It is not only due to the nurses’ nonstop support for the service user, especially the round-the-clock care in the in-hospital setting, but also the intense therapeutic relationship with the service users. In community and home settings, mental health nurses often act as service users’ case manager who coordinates the use of professional, social, and community resources for promoting well-being of the user. It is therefore significant for the nurse to be effectively working with all members of the healthcare team.

There are many factors influencing a person’s mental health. An individual’s mental function is recognized as associated with a wide range of nonhealth and social issues, which goes beyond the healthcare perspective. Mental healthcare is moving toward integrated care systems where collaborative practice between different disciplines has become increasing vital. Thus, mental health nurses need to work with a complex interdisciplinary team that include not just medicine and allied health professionals, but also other disciplines such as like education, legal, spiritual support, employment, financial, and housing services (Stanton and Tooth 2013).

It is now well accepted that a formally organized component in the undergraduate curriculum that enable students from different disciplines to learn together would effectively facilitate the students to develop the competency needed to work in an interdisciplinary team. Thus, there is increasing emphasis on interprofessional education (IPE) in healthcare education.

After almost 50 years of enquiry, WHO (2010) acknowledges that IPE enables effective interprofessional collaborative practice, and most importantly, improved patients’ health outcomes. WHO describes that IPE occurs when students from two or more professions learn about, from, and with each other to enable effective collaboration. IPE aims to help students from different disciplines understand the roles and responsibilities of each other, develop skills in team communication, team work, conflict resolution, and reflect and learn from each other’s experiences. The ultimate goal is to make the future health worker collaborative practice-ready (Jacobs et al. 2013).

Healthcare students’ attitude and understanding of their own and other healthcare disciplines may affect their willingness to collaborate. A study on first year dentistry, medical, nursing, pharmacy students in their attitude toward IPE found that medical and nursing students had the most positive attitudes toward IPE followed by pharmacy, and lastly dentistry students. Public perceptions may explain this result. The public is more likely to associate pharmacists as working behind the counter of a pharmacy, while dentists are more commonly associated with working in an independent dental clinic. Those entering pharmacy or dentistry studies may hold such misconceptions and do not see a strong need to collaborate with other healthcare professionals (Ahmad et al. 2013).

To help changing such misperceptions, IPE should occur early in healthcare education. IPE could highlight the respective professional roles and introduce ways how best various disciplines work together to achieve effective and efficient operation of the healthcare system. For example, in an introductory IPE session, the link between the roles of various health professionals with the roles of players of a football team could effectively help students realize the importance of teamwork and collaboration (Stephens et al. 2007). In mental health nursing education, IPE needs to expand beyond health boundaries. Mental health nursing students need to be given opportunities to interact with students inside and outside health disciplines to develop competency working in an integrated mental health care system.

First year mental health nursing students could involve with students from other disciplines, such as medical and social work students in interdisciplinary projects that are relevant to their needs. Students can gain insight into roles of different healthcare disciplines before stereotypes set in. For senior students, their professional identity may be more established. They could work together to develop care plans and solve clinical problems (Sanson-Fisher et al. 2005).

Different models of conducting IPEs have been employed with different outcomes. Common practices involve students from multiple health disciplines attending lectures together, such as in anatomy and physiology classes. Though the students may have the opportunity to interact in the lectures, it might not facilitate team work and understand each other’s discipline role (Sanson-Fisher et al. 2005). It could be regarded as interprofessional teaching, but not IPE per se.

Students from multiples disciplines attending tutorials on clinical cases can facilitate interactions and collaboration. Students from these disciplines are involved in identifying patient’s problem and developing care plans. Such activities can help to enhance communication skills and understand team roles. Experiential learning in simulation learning environment could also create opportunities for students from different disciplines to interact, communicate, and manage clinical scenarios in a safe environment. IPE could have some limitations. While the IPE group tutorials usually focus on team work and collaboration, some of the discipline-specific learning needs, for example, learning clinical pathology by medical students or devising rehabilitation plan by nursing students, may not been met in these IPE activities. There may also be logistic problems such as timetabling (Jacobs et al. 2013; Sanson-Fisher et al. 2005).

IPE can also be effectively implemented in the clinical settings. In clinical placement, students in the interdisciplinary team all have direct and individual responsibilities toward care of real patients. They could learn from each other under supervision of an interdisciplinary clinical teaching team. Members of the student can work together as a team to conduct patient assessment, care planning, care implementation, and evaluation. They participate in interdisciplinary case conference to reach care management decisions.

Such approach can help students understand the roles and functions of other team members, participate in a collaborative environment, communicate with team members, resolve conflicts, and reach a team decision in the real life clinical setting. However, like IPE classroom learning, IPE in the clinical setting could have similar challenges of timetabling and limitations to discipline-specific learning (Sanson-Fisher et al. 2005). Most health professional accreditation requirements currently do not highlight IPE learning and it may cause additional difficulties for organizing IPE activities.

Despite the evidence demonstrating the positive impacts of IPE, its use is still not widespread. Literature suggests that barriers to IPE implementation could be related to operational difficulties aligning curricula of different professional programs and logistics of bringing different groups of students and teachers together. Programs for training health care professionals are highly demanding in terms of width and depth of knowledge and challenging training of clinical competencies. Adding new elements in the already demanding programs would require thorough consideration and careful planning (Jacobs et al. 2013). Attitudinal barriers such as negative stereotypes and prejudices among health academics may also discourage team members to have frank discussion and collaboration. Workload is an issue for academic staff (Sanson-Fisher et al. 2005). IPE may be perceived as an additional burden to the already packed curriculum and demanding academic requirements.

To overcome barriers, a framework for IPE needs to be set up and agreed by different disciplines in education institutions. Shared leadership, such as co-chairing of IPE committee may avoid being dominated by any one discipline. Each discipline needs to continuously review its curriculum to free up time and resources for IPE components. Developing course contents that are appropriate for IPE is an essential step. A formal group, like an IPE steering committee, can be set up to determine IPE educational outcomes in terms of interprofessional competency, identify materials common to health disciplines, and explore workable strategies to implement IPE (Jacobs et al. 2013; Sanson-Fisher et al. 2005).

Apart from formal curriculum, student-led extracurricular activities, such as public mental health screenings or overseas community trips involving multidisciplinary students, could be incorporated as part of the IPE initiatives (Ahmad et al. 2013). Students are in a good position to initiate IPE activities. The IPE activities suggested by the students could provide valuable information for the academics to plan appropriate activities that will appeal to the students. Taking into account of students’ suggestions to improve IPE activities will also provide students with a sense of ownership of the IPE experience, and this will hopefully elicit greater participation from students (Ahmad et al. 2013).

There need to be adequate time, development, and training provided to faculty to develop IPE concept and learn how to deliver IPE. Recognition of staff member’s participation and achievements is important for the success of IPE. Staff members who spend time developing IPE with colleagues from other disciplines can be recognized for their efforts in their annual staff appraisal. As IPE involves collaboration among different schools within the university and healthcare agencies, commitment by senior management in education institutions, practice, and work settings is essential (Jacobs et al. 2013).

It is important to obtain ongoing feedback from students and teachers and longitudinal studies on IPE outcomes to improve IPE implementation. At present, majority of the evidences related to IPE are related to student satisfaction and attitude change. Apart from whether the IPE activities have positive impact on the attitudes of the healthcare students who are involved in them, there is a need for ongoing evaluation to assess the longer-term benefits of IPE (Jacobs et al. 2013), particularly whether students can transfer learning in the IPE to clinical practice settings with improved patient outcomes.

Incorporating “Recovery Model” in Mental Health Nursing Education Curriculum

With advances of technology, there has been progressive development in the biological explanations of many mental disorders, neuropathology, diagnostics and symptomatology, and psychopharmacology. The medical model had been dominating the mental health care practice for the past few decades. In contemporary mental health care, attention has been redirect to the individual, the service user as a person, and not the illness. The individual’s recovery from the disabilities associated with the illness becomes the center of attention. It is a major shift in the beliefs about mental health care – from medical model to recovery model.

The “recovery model” focuses on empowerment, collaboration, resilience, and hope (Stanton and Tooth 2013). For many individuals having mental health problems, recovery is about staying in control of their life despite the existing mental health problem. The emphasis is on the long-term health and well-being of the individual, but not absence of the mental health problem (Department of Health 2014b; SANE Australia 2014). The recovery-centered approach has been adopted in Australia, the UK, the United States of America (USA), and many other countries as the key component in a fair and progressive system of mental health care. Governmental policy and plans of allocating resource for mental health service are moving toward such a direction. Mental health nurses are to be well prepared for such trend of practice.

To keep abreast with the current development, there is a need to update mental health nursing education curriculum with a new set of learning objective and expected outcomes of the graduates. Students need to be facilitated to develop a strength-based focus in nursing care. The aim of mental health nursing is to promote a person’s aspirations, talents, and uniqueness. Nursing interventions are focusing on supporting recovery and building the resilience of the individuals with mental health problems while helping these individuals manage their symptoms (Department of Health 2014b).

The mental health nurse would need the knowledge about fundamentals of mental health problems including the pathology of mental disorders and treatment modalities, and more importantly, an understanding of how the individuals are affected by the mental disorder and the treatment process. Mental health nursing education is to prepare graduates who have the competency to recognize specific needs of the individual with mental health issues, to develop a therapeutic relationship that is respectful of the individual’s choices, experiences, and circumstances, and to establish partnership with the service users to develop plans to overcome challenges in their life. This involves students knowing how to build on service users’ strengths, hold hope, and enhance resilience to promote recovery (Stanton and Tooth 2013; Gilburt et al. 2013).

In many countries, both developed and developing, the majority of individuals with mental health issues are cared for in the community at their home. Many service users are living with their families or significant others who are their major carer. Families are often a significant part of the mental health care system. Family members play an important and ever-expanding role in the promoting well-being of the service user.

Mental health nurses are often in the best position to assist family carers at critical times. Thus, mental health nursing education needs to prepare graduates who have the knowledge and competency to work with these carers, understand carers’ burden, coping, and resilience. They need skills to develop innovative programs for empowering the carers to manage their caregiving challenges. Students should be equipped with skills to involve the carers effectively so that they become active and contributing members of the healthcare team. This is an essential part of the recovery model. It is critical that mental health nursing students know how to identify available resources for the carers and facilitates access to the resources needed to provide care to service users, for example, involve in planning the care program, and working actively with the service users to achieve their life aims.

With the move toward the recovery model of care, mental health nurses would need a specific set of competencies. The mental health nursing program would need to be designed to prepare graduates who will value the active participation of the service user as well as contributions by the significant others. The graduates need to appreciate service users’ individual choice and caregivers’ specific circumstances. To enable person-centred care, mental health nurses need to have essential skills in collaborating with service users, caregivers, and other healthcare team members (Chan 2011).

Transitioning to a recovery approach in mental health nursing education would require substantive changes in the curriculum content, delivery, as well as fostering a new culture of service user participation throughout the nursing program. The contents in the preregistration curriculum need to include the concepts of recovery and elements of recovery model, assessment and care planning from service users’ perspectives, and social inclusion/vocational activities from a social work perspective. There is also a need to include carers’ perspective on recovery; involve carers in care provision; and spirituality and reflection on fundamental issues around personal values and beliefs, strength-based approaches, and the role of hope (Gilburt et al. 2013). With the recovery model, it does not mean symptomatology, pathology, and medical and other treatment modalities would be ignored, but these subjects would not be the sole focus (Stanton and Tooth 2013).

In the preregistration mental health nursing program, students can have a brief experience in the acute care settings, and more substantial experience on community, primary healthcare, and home settings where the majority of the service users are being cared for. Students need to have first-hand experience of interacting with the service users in their own living environment to understand their lived experiences, and learn from them. Evidence suggested that health discipline students generally perceived service users’ involvement in education as positive and interesting (Byrne et al. 2013).

For example, a recovery camp where students gained understanding about the lived experience of a person with mental illness facilitated the development of in-depth knowledge of recovery (Patternson et al. 2016). Such involvement could be effective in influencing more positive attitudes, an understanding of a collaborative environment, as well as enhancing a more holistic approach to practice (Happell et al., 2015a, b). In some universities, trials have been conducted to involve service users in mental health nursing education, with substantive academic positions established for them. There were positive impacts but there were funding issue and negative attitudes of other faculty members. To overcome these barriers, the commitment of schools of nursing is essential. On-going research and evaluation are needed on the longer term outcomes, like graduates employment in mental health services (Byrne et al. 2013; Happell 2014; Happell et al. 2015a, b).

Modes of Mental Health Nursing Education at Preregistration Level

Internationally, there are, in general, two modes of preregistration education and training for nurses working in mental health settings – direct entry to the specialist study of mental health nursing, or starting with a generic study of comprehensive nursing program of which mental health nursing would either be an integral part or an optional specialist component. These two modes of education are stipulated by the regulatory bodies in individual countries. Mental health nursing is generally regarded as a specialist qualification in most developed countries. The preparation of mental health nurses and practice are regulated accordingly. There are different ways of organizing the way to prepare mental health nurses and how their practices are regulated. In the following discussion, the different systems of preregistration mental health nursing education in the United Kingdom for (UK) and Australia are used to illustrate the two modes of education preparation.

Mental Health Nursing Education in the UK

In the UK, the Nursing and Midwifery Council (NMC 2018) maintain registers for two main categories of professionals – nurses and midwives. In the nurse register, there are different levels of registration, each with many sub types. At Level One (the beginning level to practice), there are four main sub types of Registered Nurse (RN), namely RNA (Adult Nurse), RNMH (Mental Health Nurse), RNLD (Learning Disabilities Nurse), and RNC (Children’s Nurse).

Both the RNLD and RNC qualifications could also be obtained by the RNA or RNMH completing an advanced program in Learning Disabilities or Child care, respectively, that is, at a postregistration level. RNAs are to practice in “physical” care facilities and RNMH in “mental health” care. This is very similar to the old ways of classifying RNs as “Registered General Nurse – RGN” and “Registered Mental Nurse – RMN.”

Given the different foci of education requirements in the basic RNA and RNMH programs, career choices for the graduates from these programs are different. In general, RNAs practice in all clinical areas except those highly specialized mental health facilities, whereas RNMH practice in mental health facilities. Both can practice in community and home settings.

In the UK nurse education system, nursing student can complete a direct-entry specialist program and become an RNMH. With this single registration, one can only practice in the mental health care field. By further study and training, the RNMH could advance into specialties such as child and adolescent psychiatric nursing, psychogeriatric nursing, or substance-abuse nursing. If the RNMHs wish to shift to practice in “physical” care area like the medical, surgical, or emergency care, they must complete a “postbasic” training to gain the RNA qualification. The UK mental health nursing education system is designed to “channel” the RNMHs to become members of the mental health workforce right from the very beginning of training.

In the UK, there has been discussion on changing the present pre-entry in the specialization program to a comprehensive program to prepare a generic nurse (McKeown and White 2015). It was argued that with the aging population and related chronic health problems, the present pre-entry specialization might not be able to prepare nurses to provide comprehensive care to patients with increasing complex needs.

Holistic Person-Centered Care

In the past, the biomedical model which focused on mental illness significantly limited healthcare professionals’ perspective of health. There was insufficient awareness of the link between the mental and physical health. Nursing profession globally has now recognized that nursing practice should adopt a health-oriented model. Health is perceived from a holistic view with emphasis on interconnectedness of various aspects of health including the biological, psychological, social, cultural, and spiritual parts. All these individual characteristics determine the health status and how the individual reacts to health issues.

To support individuals to manage their health problems, nurses need to address the issue holistically and in collaboration with the service user – a holistic person-centered approach. Nursing education programs need to provide students with knowledge and skill foundation which is built around the concept of holistic health and person-centered care. Nursing students need to know that the mind cannot be separated from the body, as well as all other aspects of life, e.g., culture, beliefs, etc.

Independent Role and Responsibilities of Today’s Mental Health Nurse

Nurses have traditionally been taken as physician’s assistants. The dependent role of nurses has been reinforced by the specialization of nursing practice which basically follows the medical model. For example, the traditional psychiatric nurses had been expected to assist the psychiatrist to keep the “patients” and others safe through custody care, enforcing psychiatric medications and other treatments.

Today’s mental health nurses are expected to embrace the holistic and person-centered ideology. They are taking up advanced practice role, such as providing psychotherapeutic intervention; and/or extended practice, such as prescribing medication. They collaborate with members of the interdisciplinary healthcare team and the “service-users” or “consumers.”

The new roles and responsibilities of the mental health nurse require a comprehensive set of professional nursing competencies. Such specialist competencies would best be built on a broad-base foundation of nursing competencies. A comprehensive baccalaureate program plus the initial experience as a beginning nurse would adequately prepare the nurse to move into any specialties, like mental health nursing.

Mental Health Nursing Education in Australia

Australia has moved away from the multiple discipline nursing registers since 1990s. The Nursing and Midwifery Board of Australia (NMBA), the national regulatory body, closed off the separate register for mental health nurses in 2010 (Hemingway et al. 2016). A single registration of nurses is now maintained by the NMBA.

All nursing programs within the country provide comprehensive nondiscipline-specific training. Graduates are prepared to practice in various settings, such as medical, surgical, mental health, and age care, as beginning nurses. Beginning registered nurses working in the mental health care setting have gone through the same education as other beginning nurses in a medical or surgical setting. Individual nurses could move on to advanced practice in any nursing specialties after further study.

The nationally accredited comprehensive program to prepare a registered nurse is a 3-year full-time bachelor’s degree of nursing. Comprehensive education enables nursing graduates having generic skills to work in diverse settings and to address all clinical possibilities. Such approach is based on the belief of holistic health. The individual’s health status is an outcome of interaction of all the various systems, including biological, psychological, social, cultural, spiritual, and economical elements. The comprehensive program equips students with the holistic view of health, and the knowledge and skills to meet health needs of service users (Hemingway et al. 2016).

Advanced studies in mental health nursing are offered by many tertiary institutes at postgraduate certificate/diploma/master level which can be 1 or 2 years of study specialized in mental health. Such specialized study is not a compulsory requirement for nurses to work in the mental health setting. The Australian College of Mental Health Nurses, a national professional group of mental health nurses, developed a credentialing program in 2004 as a professional self-regulation for mental health nurses (Hemingway et al. 2016). However, it is not a legal requirement for RNs to have such credentialing before they can practice in mental health settings.

Considerations and Evolvement in the Mode of Mental Health Nursing Education

On the contrary, in the mental health sector in Australia, there are recent concerns about the professional competencies of the graduate nurses from the comprehensive program. There are queries if the “comprehensive” nurse has been adequately prepared to take care of mental health service users. There are suggestions to consider an undergraduate direct entry mental health program similar to that of the UK. One of the major issues underlying such suggestions is that there have been severe shortages of nurses in the mental health setting. There is substantial evidence showing that, after the move to comprehensive nursing education, there has been increasing difficulty recruiting and retaining nurses in mental health settings. It appears that the majority of graduates from the comprehensive nursing program do not take mental health nursing as a career choice. Some nurses joining the mental health service do not stay long. When compared with the UK situation, Australia has a more recognized shortage of mental health nurses (Happell and McAllister 2015).

Studies related to the shortage of mental health nurses in Australia have been conducted. Happell and McAllister (2015) suggest that there has been underrepresentation of mental health contents in the undergraduate curricula since the introduction of comprehensive nursing education. Some nursing graduates express that they are not adequately prepared for the knowledge, skills, and professional competency for mental health practice, though practicing at the beginning level. Thus, working in mental health settings would not be their choice. When comparing the “direct entry mental health nursing” program with the comprehensive program, it is apparent that the learners from the comprehensive programs have much less exposure to both the theory and clinical input than the single discipline program. There is limited coverage of mental health nursing in the very packed comprehensive curriculum (Happell and McAllister 2015).

Given the persistent social stigma toward mental illness, it requires sound personal determination for a newly graduate nurse to choose mental health as a career choice. It is suggested that career immersion in mental health, including clinical exposure and career mentoring, is of utmost importance. Lengthy clinical placement in mental health settings is not possible in the comprehensive nursing program. Usually a 3-year curriculum can afford a 2-week mental health placement. Such a brief encounter could hardly allow the student to demystify mental health, reduce stigma related to mental illness, and reduce uncertainty about the role of the mental health nurses. Consequently, it may not be able to develop students’ interest and desire to work in mental health (Hemingway et al. 2016).

The comprehensive nursing program and registration system do allow more career choices for the graduates than the direct entry single discipline program. If the new graduates find the encounter in mental health settings not favorable, it is easy for them to move to other areas to pursue the nursing career. Furthermore, mental health is one of many disciplines that could be limited in terms of geographical location and few career choices in a particular region. There is high tendency for new graduates moving away from mental health practice.

Factors Influencing Nurses’ Career Choice

The changing economic and financial context also influences the nursing job market and has a direct impact on nursing graduates’ career choice. The mode of mental health nursing education, either comprehensive or “direct entry into mental health discipline,” may not be the sole determining factor causing shortage of mental health nursing workforce. Instead of looking at the mode of nursing education program, it is more important to examine how effective the comprehensive nursing program is to help the graduate build a holistic concept of health, and develop the competency to meet individual needs of the service user, and not the narrow focus of a certain health problem.

To help promoting students’ interest in mental health nursing and increasing new recruits to mental health practice, there are suggestions to review the present bachelor degree nursing curriculum in Australia. Strategies to improve the comprehensive curriculum could include increasing the mental health content, implementing a reinforced module of transition-to-practice in mental health nursing for those students selecting the option of mental health practice. Another suggestion is to introduce a major stream in mental health nursing in the current comprehensive program (Hemingway et al. 2016; Happell and McAllister 2015). Such strategies could improve the comprehensive curriculum while retaining its strengths of a holistic approach in nursing practice. There is a need to conduct systematic evaluations to determine the effectiveness of these strategies (Hemingway et al. 2016, Happell and McAllister 2015).

The decision on whether mental health nursing should be part of a comprehensive program or standalone direct entry single discipline program is not merely a professional decision. There are economic considerations. Many governments and healthcare systems may consider it easier in nurses’ deployment if nurses are graduated from comprehensive programs. The Australian experience could provide very helpful hints and insight for the UK and the global community on the future direction of mental health nursing education.

Outcomes of the Mental Health Education in Nursing Graduates

The mental health nursing graduates are expected to be competent, safe, and committed mental health nurses who can meet the contemporary and changing demands of global mental health services. Pedagogically, emphases are put on developing the required competencies through active, experiential, and reflective learning experiences. Students are encouraged to take active parts in the teaching and learning process to develop independent and life-long learning skills. Different education institutes may have different foci in their curricula design. It would be most effective if they work closely with the local community and healthcare system to develop appropriate curriculum and provide appropriate clinical experiences to students. The ultimate goal is to produce graduates who can serve the needs of the local community.

Conclusion

This chapter highlighted some important issues in contemporary mental health nursing education. Most discussions and examples provided were within the context of developed countries. With fundamental changes in the concept of health and service users’ participation in care, as well as the modes of mental health service, the new generation of mental health nurses would need a new set of competency for meeting contemporary needs.

The national mental health policy, organization and delivery of service, relationships among professional disciplines, would all have an impact on the development of mental health nursing education. To produce graduates who can meet the needs of service users as well as needs of the community, education providers need to work very closely with the various stakeholders. Stakeholders include but not limited to government, policy makers, healthcare administrators, frontline mental health nurses, regulatory bodies, community leaders, multidisciplinary team including health and nonhealth disciplines, and very importantly the service user groups.

Innovations in curriculum design and delivery need to be grounded on the model of care accepted by all stakeholders, and continuing improvements must be supported by evidence. The education system needs to be organised in the way that can facilitate growth of mental health nurses along the journey of professional practice. Well-established education principles with innovations in teaching and learning technology are to be applied upon a framework of contemporary practice of mental health nursing. The nursing education system needs to support service development in different societies so that the adequate number of mental health nurses with the appropriate competency is available to meet the service needs. Finally, leaders in mental health nursing education from different countries should make efforts to promote international collaborations for improving the quality of mental health nursing education.