The integration and associated challenges of Mental Health Competencies in Undergraduate Nursing Education: a scoping review

The librarian contributed to identifying the appropriate databases, keywords, and search strings to ensure a comprehensive search. Constant communication was maintained with the librarian to ensure that the search process went smoothly. The literature search was conducted in October 2023 after several piloting searches. The piloting searches allowed for refinement to suit the scoping review. The following databases were searched: CINAHL, MedLine “PubMed”, Scopus, Emerald Insight, and Science Direct for peer-reviewed articles related to the subject. The search strategy used keywords such as (‘integration’) AND (‘mental health competencies’ OR ‘psychiatric competencies’ OR ‘mental health skills’) AND (‘undergraduate education programs’ OR ‘undergraduate nursing education curriculum’) AND (‘challenges’ OR ‘barriers’). Table 1 shows the inclusion and exclusion criteria for article selection.

Two reviewers independently screened the titles and abstracts of the identified articles to ensure rigor and reduce potential bias. Each reviewer assessed the articles using the predefined inclusion and exclusion criteria to ensure consistency and reduce bias. Any disagreements that arose during this process, were resolved through discussion and consensus among the reviewers. In a situation where a consensus was not reached, a third reviewer was consulted to make the final decision. The screening and selection process was conducted in the following phases: firstly, the search results were imported into EPPI reviewer software. Duplicates were removed using the software’s built-in function. Secondly, carefully screening all imported studies’ titles and abstracts based on the inclusion criteria. Thirdly, the reference list of the identified articles was screened to foster a comprehensive coverage of evidence, i.e. backward snowballing [45, 48]. The titles and abstracts of the identified articles were screened for relevance by the researchers. Any discrepancies were duly resolved. Full-text screening was conducted for all the identified articles (See Fig. 1 for the review screening process flow chart). The research team scrutinized this process.

The following basic information regarding the eligible studies was systematically extracted and tabulated to ensure consistency: authors and publication year, title, journal, location, study design or method, data source, data analysis, and key findings (See Table 2 below for the basic information on eligible studies). The data extraction process was carried out systematically by two reviewers who collaborated to ensure consistency and accuracy. Prior to the review, the reviewers jointly developed and finalized the data extraction table, agreeing on its contents to standardize the process (See Table 2 below for basic information on the eligible studies). A third reviewer critically assessed and validated the data extraction table. In conducting scoping reviews, authors should extract only the data items that align with the scoping review questions [49]. Given the heterogeneity of the included studies, a narrative synthesis approach was used to compile, summarize, and organize the data [45, 50]. This process converted quantitative data into qualitative descriptions, identifying patterns and recurring themes [50]. A narrative synthesis typically provides a broad overview of the existing literature, identifies vital concepts, and highlights research gaps; hence best for this scoping review. The data analysis process was validated through multiple rounds of review by the research team to ensure consistency and alignment with the research objectives. Furthermore, a thematic analysis was conducted [45]. A thematic analysis used deductive coding to group findings into themes and subthemes. An iterative approach ensured thorough data exploration through repeated readings [51].

Seventeen studies met the inclusion and exclusion criteria, representing diverse geographic regions and research designs (Table 1). A quantitative description of these studies, including publication years and research methods, is provided under “Quantitative description of eligible articles”, above. The scoping review findings were grouped into two main themes: (1) Strategies and Pedagogical Approaches for Integrating Mental Health Competencies in Undergraduate Nursing Education and (2) Challenges to Integrating Mental Health Competencies in Undergraduate Nursing Education.

The active involvement of nursing educators in implementing diverse pedagogical approaches, such as person-centred methods and reflective practices, was highlighted across multiple institutions. Educators play a key role in emotionally, ethically, and cognitively supporting students, shaping their attitudes and empathy toward mental health. These efforts indicate that integrating mental health competencies is a critical focus in undergraduate nursing education. Educators ensure that students acquire factual knowledge about mental health and understand its relevance in nursing practice. This scoping review underscores the importance of integrating mental health competencies into undergraduate nursing education to equip students with the necessary skills and knowledge for future practice. Various strategies were adopted for this integration, with one paper emphasizing the active engagement of educators in using approaches such as person-centred care and reflective learning. These methods help students better understand and incorporate mental health knowledge into their clinical practice, with educators striving to foster empathy, critical thinking, and positive attitudes toward mental health care [59]. These educators are committed to ensuring that students develop factual knowledge about mental health and an understanding of the scope of nursing in the mental health context [59]. They are creative and responsive in addressing students’ learning needs. They are dedicated to preparing students to achieve mental health care competence, which implies that integrating mental health competencies is a significant focus in undergraduate nursing education [59]. Several reviewed articles reported the use of strategies such as simulation, PBL, TBL, clinical immersion, and critical reflective journaling. These approaches enhanced students’ confidence, knowledge, understanding, critical thinking, engagement, motivation, teamwork, and communication skills in dealing with patients with mental health conditions [31]. For example, Harmon and Hills [56], reported significant improvements in Psychiatric-Mental Health (PMH) exit examination scores over four semesters following the implementation of a TBL instructional approach in an undergraduate PMH course. This score increase suggests a positive impact on students’ acquisition of PMH content. In another reviewed study student participants reported that the simulation experience was relevant to their nursing practice and significantly impacted their confidence, clinical skills, and communication skills [54]. Providing simulation to enhance students’ understanding of mental health provides them with practical, real-world scenarios that enhance students’ readiness for clinical practice. Students perceived the simulation scenarios as reflective of real-life situations encountered in mental health settings [54]. Another study indicated simulation increased students’ feelings of preparedness for complex clinical situations and enhanced their coping abilities [16, 31]. Similarly, Jacobs’ [58] highlighted how service-learning experiences allow nursing students to apply theoretical knowledge in real-world community contexts. By engaging in community service, students can holistically address specific needs of the community, including mental health needs. Integrating theory into practice fosters a deeper understanding of mental health concepts and promotes the development of mental health competencies among nursing students.

Specific mental health nursing modules and interventions, such as anti-stigma programs, were also effective in integrating mental health competencies into the nursing curriculum. These modules enhanced students’ knowledge and positively shifted their perceptions of mental illness, illustrating how competencies are integrated into undergraduate nursing education. This approach links the pedagogical strategies to the broader concept of integration, emphasizing that the strategy employed reflects a deep and wide-ranging incorporation of mental health competencies into the nursing curriculum. İnan et al. [57] shed light on how mental health nursing competence is integrated into undergraduate curricula through the mental health nursing module and the integration of an anti-stigma program in the module in clinical practice. The study reported a positive change in nursing student’s perception of dangerousness after the model. Through an analysis of how these interventions alter students’ attitudes and lessen stigma, the study advances our knowledge of how mental health competencies are incorporated into undergraduate nursing education. It further emphasizes how crucial nursing students are to have good attitudes fostered by exposure to patient viewpoints, practical experiences, and effective teaching approaches. Similarly, Rodríguez-Almagro et al. [61] evaluated the level of stigma toward people with mental health problems among nursing students. They found out that stigma decreases as students advance in their degrees, particularly after theoretical psychiatry and mental health training. Another study revealed the effectiveness of interventions like peer education (PE) programs in changing negative beliefs and increasing interest in psychiatric nursing as a career choice among nursing students [63]. This was used in integrating mental health competencies into undergraduate nursing education. The findings of the reviewed literature suggest that incorporating such programs into the nursing curriculum helps combat stigma and foster a positive attitude toward working in psychiatric nursing.

A significant improvement in the nursing students’ clinical competency level was reported when the “mental health nursing students’ clinical competence model” was implemented [15]. This shows that certain treatments can improve when mental health competencies are included in nursing education. Another study by Choi et al. [53] demonstrated the extent of integrating mental health competence into undergraduate nursing education by introducing a curriculum for an undergraduate mental health nursing clinical practicum. According to the reviewed article, evaluating nursing students’ learning outcomes from the introduced curriculum and exploring nursing students’ perceptions of the clinical practice revealed a significant improvement in students’ level of empathy [53]. Significantly, undergraduate students’ level of empathy may be increased due to teaching strategies such as adopting critical reflecting journalism, self-understanding activities, experimental learning, and other clinical settings, as reported by the researchers. Choi et al. [53] additionally observed that undergraduate nursing students gained an understanding that not all individuals with psychiatric conditions exhibit aggression and that these patients are capable of socializing with others. Furthermore, Graham et al. [55] identified essential competencies integrated into undergraduate nursing education for mental health assessment, health promotion, therapeutic relationship building, counselling, and behaviour management. These include the foundational values, beliefs, and attitudes that shape psychiatric nursing practice, including empathy, compassion, and person-centered care. The study by Shen et al. [62] indicated that psychiatric placements served to reduce stigmatizing attitudes among nursing students, emphasizing the importance of direct engagement with individuals with mental illness in changing perceptions.

Among the significant challenges highlighted in this scoping review was the absence of standardized frameworks for mental health nursing education. In the absence of consistent guidelines or frameworks, ensuring that comprehensive mental health competencies are integrated into undergraduate nursing education, becomes challenging.Atashzadeh-Shoorideh et al. [15] highlighted variability in clinical mental health competence among undergraduate nursing students. This variability could be attributed to differences in educational approaches, clinical experiences, and levels of exposure to mental health settings. Furthermore, Terry [52, 64] reported negative public attitudes (stigma) associated with mental health nursing not only affect nurses’ morale but may also influence nursing students’ perceptions and interest in pursuing careers in mental health nursing. Additionally, concerns over patient behaviour, such as fear of patient assault and aggression, further escalate these challenges, reflecting a lack of confidence and preparedness among students. This fear may be rooted in a lack of exposure to mental health settings during their education or insufficient training in managing challenging behaviours. Furthermore, the study reported that unequal student contributions in group work activities, difficulties in understanding patients’ symptoms, and negative attitudes toward mental health consumers limit the effectiveness of specific pedagogical approaches. These challenges indicate potential gaps in nursing education programs regarding developing mental health competencies and cultivating positive attitudes toward mental health care [52].

The persistence of prejudice, stigma, and misconceptions about mental illness among nursing students, even after practicum experiences, was a recurring challenge [26, 53]. Shen et al. [62] revealed that issues such as stereotypical impressions of mental illness, communication difficulties, emotional challenges, and safety concerns are identified as hurdles that students encounter during their placements. These challenges pose obstacles to integrating mental health competencies in nursing education. Additionally, Terry [64] reported how mental health nurses perceive their roles as being in the middle, with a lack of clarity in their professional identity. This uncertainty may affect the teaching and learning of mental health competencies in nursing education, as students may struggle to understand the role and contribution of mental health nursing within the broader healthcare context. This suggests that while integration exists to some degree, these challenges must be addressed while incorporating mental health competencies into nursing education. Jacobs’ [58] reported that challenges such as intercultural communication and collaboration are identified, suggesting that nursing students may face difficulties integrating mental health competencies into their education. A study by Alexander et al. [52] also identified challenges in teaching mental health nursing, such as the need for nontraditional teaching methods and difficulty bridging theory and practice.

Overall, this scoping review demonstrated that, to an extent, Mental health competencies are integrated into nursing education through various approaches, including teaching pedagogies, simulation, problem-based learning, and mental health nursing modules. Despite efforts, challenges such as lack of standardized frameworks, public stigmatization, faculty shortages, and fear of patient behaviours hinder integration. It is recommended that a standardized framework be developed for integrating mental health nursing competencies into undergraduate nursing curricula. This framework should encompass all life and clinical practicum stages, address faculty shortages in specialized fields, and streamline clinical placements. Furthermore, nursing education institutions should endeavour to provide educators with training and resources to enhance their awareness and knowledge of mental health illnesses, focusing on competency development and the integration of innovative teaching pedagogies. Additionally, nursing education institutions should encourage the development of empathetic skills among students through clinical practicum experiences and educational interventions. They should also promote diversity and inclusion in undergraduate nursing education to address challenges such as communication difficulties, intercultural communication, and stereotypical impressions of mental illness, encourage equal participation in group work activities, and foster an inclusive learning environment. Future research should focus on developing standardized frameworks for integrating mental health nursing into undergraduate nursing education addressing public stigmatization, and on effective educational interventions and strategies to overcome challenges in integrating mental health competencies is necessary.

This scoping review has several limitations. Most of the identified studies were from developed countries, which may limit the application of findings to nursing education contexts in developing or underdeveloped regions. Furthermore, the inclusion of grey literature or unpublished studies may have provided additional perspectives and insights. The inclusion of only English-language published research may have overlooked relevant research published in other languages. Additionally, the lack of inclusion of review articles may have hindered a comprehensive understanding of the research landscape, existing knowledge, and research gaps. Also, the restricting of the scoping review article to articles published between 2013–2023 may have excluded more recent studies published outside of the selected timeframe. This limitation should be considered when interpreting the findings, as this scoping review may not have captured all trends on the topic.

This scoping review provides valuable insights into the extent to which mental health competencies are integrated into undergraduate nursing education and the associated challenges. By synthesizing findings from various studies, new insights are provided into key themes, trends, and challenges in this area. The findings revealed that diverse teaching approaches, such as trauma-informed education practices, problem-based learning, and reflection simulation are adopted to integrate mental health nursing into undergraduate nursing education. These educational approaches are directly linked to practical skills necessary for effective mental health nursing practice. Mandatory interventions such as structured clinical practicums and anti-stigma campaigns and optional components that amongst others, include virtual simulations and peer education are necessary for practice. However, these efforts are constantly challenged by societal stigma, patient behaviours, unequal student contributions in group work activities, and difficulties in understanding patients’ symptoms. Effective strategies for integrating mental health competencies into undergraduate nursing education identified in this scoping review are simulation techniques, problem-based learning, critical reflective journalism, clinical immersion, and the use of virtual experiences. Overall, this scoping review contributes to the growing body of knowledge on mental health education in nursing and provides a foundation, and directions, for further research and practice in this important area.