According to the U.S. Department of Health and Human Services (2019), mental health includes one's emotional, psychological, and social well-being. It spans every age, gender, culture, and ethnicity. Holistic nursing care acknowledges the connection between an individual's mental and physical health. Nurse educators are charged with teaching students how to promote and protect the mental health of individuals, as well as caring for clients with mental illnesses. Dynamic changes in mental health care provision, as well as nursing education and pedagogy, require nurse educators to critically examine the context of care when they develop curriculum, education strategies, and learning opportunities.
Historical changes in the provision of mental and behavioral care services include a decrease in the overall number of inpatient beds, a transition to community-based care, and funding cuts for mental health care in the United States. This reduction created additional challenges for the general public and schools of nursing. With a decrease in inpatient mental health facilities, nursing schools lost clinical sites for students' learning opportunities (Lutterman et al., 2017). In addition, the role of the RN in these settings has become more administrative, and students often do not have the opportunity to observe RN role models to learn how to care for mental health clients.
Furthermore, clients with mental health problems are found in other health care settings, not only inpatient psychiatric facilities (Barry & Ward, 2017; Loveland, 2016). Mental health is an integral part of all care provided by nurses to clients regardless of their diagnoses. Generalist nurses who were trained in programs and clinical agencies where clients were siloed based on their physical or mental health needs are not equipped or comfortable addressing clients' mental health needs on top of their physical needs (Kverno, 2016). In addition, nurses may have biases toward clients with mental health conditions and often focus only on their physical concerns (Benjenk et al., 2019).
Due to the decreasing numbers of inpatient psychiatric in-patient beds and the renewed focus on community-based care, nurse educators are challenged to think outside traditional clinical placements to ensure students have opportunities to gain competency in promoting mental health needs of individuals across the life span. Mental health needs often are addressed through community-based nonprofits and programming that provide care and services for vulnerable populations, such as children, immigrants and refugees, and individuals or families experiencing homelessness. Although mental health practitioners, such as psychiatrists, psychiatric nurses, psychologists, and social workers, are in short supply and often are absent from nonpsychiatric settings (Kverno, 2016), learning can still occur for nursing students. When students have the opportunity to participate in nontraditional placements, such as substance abuse, treatment programs, and recovery meetings, as well as homeless shelters and schools, nursing students can learn a great deal about the determinants of health that impact clients and their physical and mental health.
Acknowledging the current shortage of qualified mental health and substance use disorder professionals, the American Psychiatric Nurses Association (2019) recognizes that psychiatric mental health nurses can help to increase access to mental health care. Although research has consistently shown that mental health is not a preferred area for a desired career among nursing graduates, several studies have demonstrated that didactic preparation and clinical experiences in care of these patients positively influence students' attitudes toward mental health nursing (Happell & Gaskins, 2013; Benjenk et al., 2019). In 2019, de Cates et al. compared a traditional psychiatric curriculum with an integrated curriculum in medical students. They found students who were exposed to mental health concepts each year throughout the 4 years had improved attitudes regarding psychiatry. The authors proposed that integration may normalize approaches to mental health and foster more understanding and knowledge.
Although preparation at the undergraduate level prepares generalist nurses rather than specialists, every patient, regardless of age, gender, setting, and health status, requires holistic nursing care that meets their psychiatric and mental health needs. Traditionally, psychiatric and mental health nursing courses focus on diagnoses such as schizophrenia and bipolar disorder and how to care for clients with these severe conditions (Benjenk et al., 2019). In the curriculum, the Mental Health Nursing course was placed in the third of four semesters. It included 35 didactic hours and 56 hours of clinical experiences. These experiences included a supervised clinical rotation, observation experiences, attendance at a community-based support group, and simulation. Faculty identified limitations of the course, including competing priorities in a busy semester that limited student focus and engagement; the need for earlier, wellness-based content in the first semester; and continued reinforcement of concepts throughout the remainder of the program.
A more recent trend in nursing education is the focus on concept-based curricula instead of the traditional, systems-based coverage. This initiative to integrate content by concepts began to encourage deeper learning instead of memorization as well as, decrease the gap between theory and practice through enabling just in time cognitive connection making for students (Brussow, Roberts, Scaruto, Sommer, & Mills, 2019). The World Health Organization (n.d) advocates that mental health concepts be introduced early in nursing education and be ongoing throughout the curriculum. Teaching mental health concepts across the nursing curriculum prepares students for meeting the mental health needs of clients from all populations and developmental levels. Nurse educators are also aware of the reduction of psychiatric-mental health content on the NCLEX-RN® (National Council of State Boards of Nursing, 2012). This reduction does not reflect the importance of mental health inpatient populations that all nurses will care for, regardless of setting.
This article describes the integration of mental health concepts throughout an accelerated bachelor of science in nursing (BSN) program and the process of developing the curriculum. This innovative curriculum design increases focus on mental health and wellness, retains the content on caring for mental health illness across the life span, and provides clinical opportunities in a variety of settings to help support student learning of this vital content.
Faculty in the school of nursing were charged with reenvisioning the curriculum to ensure they were preparing nurses to meet the needs of patients, communities, and health care systems in the future. The end result of this effort was the development of a four-semester sequence of courses that begins with wellness across the life span in the first semester and concludes with complex nursing care of clients, families, and communities. Faculty developed an innovative approach to integrate mental health throughout the curriculum in lieu of a stand-alone course. Student representatives were active in the curriculum revision process, participating in discussions and giving their feedback about critical components of the curricular changes including integration of mental health across the curriculum. The goal was to prepare learners to appreciate the mental health and wellness needs of all patients across the life span rather than for students to view mental health and psychiatric nursing as a specialty that they may not encounter in their future nursing careers.
In preparation for integrating mental health concepts and content throughout the curriculum, the faculty examined key documents, such as the American Association of Colleges of Nursing (AACN) Baccalaureate Essentials (AACN, 2008), NCLEX-RN Test Plan (National Council of State Boards of Nursing, 2012), and Essentials of Psychiatric Mental Health Nursing in the BSN Curriculum (American Psychiatric Nurses Association & International Society of Psychiatric-Mental Health Nurses, 2008), to identify mental health concepts that should be included in the curriculum. Faculty who taught the previous stand-alone psychiatric and mental health course developed a detailed curricular map of how mental health concepts could be introduced in the beginning of the curriculum and where psychiatric specific concepts and content could be integrated in the remaining semesters. Pertinent mental health objectives were added to all of the clinical courses, and competencies related to mental health care were included in their associated clinical evaluation tool and nursing care plan template. Expert guest lectures, simulations, case studies, and inpatient and outpatient clinical activities were developed to ensure students learned about relevant concepts and had an opportunity to develop their clinical knowledge and competencies.
The first-semester courses focus on assessment, wellness, and health promotion; mental health content in this semester includes mental health screening and health promotion across the life span, therapeutic communication, and motivational interviewing. The negative health outcomes related to the stress response are discussed in homeostasis and directly linked to the concept of resilience in the wellness course. Mental health and wellness content that is foundational to nursing practice (e.g., therapeutic communication) is routinely taught by general nursing faculty.
The foundational material then is applied to the care of specific populations across the life span throughout the remaining three semesters. Mental health content that is specialized (e.g., substance use and bipolar disorder) is taught by nurse educators and advanced practice nurses with specialized training in mental and psychiatric health content. Relevant mental health content covered during the second semester includes depression, anxiety, eating disorders, and mental health conditions seen more frequently in childbearing women, children, and adolescents. For example, depression was integrated in courses in this semester because students provide care for childbearing women at risk for postpartum depression. In the community health course, classroom activities focus on the mental health needs of vulnerable populations, such as the incarcerated, refugees, and persons experiencing homelessness. Substance use disorders, psychiatric illnesses such as bipolar disorder and schizophrenia, and cognitive impairment are covered in the third semester when students are learning to care for adults and an aging population. During the fourth semester, mental health is integrated into the care of patients and communities with complex health needs. For example, students are asked to consider the mental health needs of both responders and community members who are affected by disasters.
Similarly, mental health concepts and learning are integrated throughout clinical experiences as well. In the first semester, students attend a community-based support group and complete a motivational interview with a standardized patient. In the third semester, students complete a 6-hour inpatient mental health clinical experience during which they are introduced to inpatient mental health care settings and the role of the RN in mental health. Laboratory and simulation activities during this semester also include a “Hearing Voices” session and dementia care training where students learn evidenced-based strategies for providing care to individuals experiencing cognitive decline.
During the final semester, students complete a series of simulations that incorporate the mental health needs of both complex patients and their caregivers, including a simulation on de-escalating a patient in acute emotional distress. A mental health nurse was recruited to supervise students in the mental health observational clinical and to contribute to simulation experiences in the third and fourth semesters. Although mental health specific clinical hours decreased after the integration, additional focus was placed on recognizing and addressing the mental health needs of patients that students were caring for in their clinical courses across the life span. In addition, clinical evaluation tools for every clinical course were updated to include an outcome measure specific to mental health.
To ensure that relevant content on mental health was retained and related learning outcomes did not decline, a formal evaluation plan was established. Components of the evaluation plan included comprehensive tracking and review of mental health concepts in the curriculum, as well as summative and formative course and programmatic evaluation measures. Students continued to take the standardized mental health assessment so that faculty could ensure students retained mastery of this content after integration in real time. NCLEX-RN pass rates also were monitored closely after the curriculum revision.
Quantitative metrics remained consistent in a comparision of four cohorts before and four cohorts after the integration of mental health in the curriculum; approximately 72 students were in each cohort. Prior to integration, students completed the mental health standardized (and nationally normed) assessment at the conclusion of the freestanding mental health course in the third semester of the program. After integration, this same assessment continued to be administered at the conclusion of the third semester. There was no significant difference in student scores between the last four cohorts of the old curriculum and the first four cohorts of the integrated curriculum (mean percentile prior to integration, 71.08 and mean percentile after integration, 71.46 [t = .38, p = .71]). The 3-year average NCLEX-RN first-time testing pass rates have remained constant at 97% for the 4 years encompassing the curricular change.
Summative feedback from students collected through end-of-program surveys and focus groups from two cohorts of accelerated BSN students for the 2 years after the curricular change did not include any comments regarding the integration of mental health content. More recent survey results, however, have indicated a lack of awareness of what mental health concepts were taught in the curriculum. Students often failed to recognize broader concepts as part of mental health, such as therapeutic communication and grief, because the faculty did not explicitly name each concept as mental health. Student comments included “psych/mental health content was very limited” and “we need more mental health, [like an] actual class.” Feedback from students also included they did not have adequate opportunities to apply the knowledge learned in clinical practice or simulation. The students expressed dissatisfaction with the limited clinical practice caring for patients in inpatient mental health care settings; one student stated that “only having one clinical experience does not give us a good view of what it's like.”
Overall, the curricular integration of mental health nursing content across the curriculum has been successful. Integrating mental health concepts in the prelicensure nursing curriculum enables students to learn and understand how to care for clients with mental health concerns throughout the program. Changing the curriculum from a stand-alone mental health course to an integrated curriculum had no effects on standardized assessments or NCLEX-RN pass rates.
Although a comprehensive curricular evaluation highlights that mental health concepts are adequately threaded through the curriculum, the students' perception was in contrast. Without the structure afforded by a separate mental health course, the students perceived that this material had not been covered adequately. Several strategies could assist in increasing students' awareness of the breadth and depth of integration. First, faculty should be explicit in their definition of mental health and wellness to increase students' understanding that it is inclusive of more than acute psychiatric mental health conditions. Second, faculty must clearly communicate where mental health objectives, concepts, and learning opportunities occur so that students can recognize these across the curriculum. Each course should highlight the content covered on the first day when reviewing the overall course. In addition, mental health and wellness objectives should be added to simulations so that students can identify activities that provided opportunities to learn how to care for patients' mental health in simulation.
Integrating mental health concepts across the curriculum may positively impact nursing education and patient outcomes. Interweaving these concepts throughout nursing clinical courses across the life span prepare nursing students to recognize the mental health and wellness needs of all their patients, not just those in acute psychiatric care settings. With the decreasing number of inpatient hospital beds, integration across the curriculum expands learning experiences in a variety of nontraditional clinical settings, including simulation and community-based organizations. In addition, repeated exposure to this content has the potential to positively influence nursing students' attitudes about mental health and illness. Further study will allow faculty and clinicians to better understand the impact of integration of mental health concepts on patient outcomes.
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