ICN mental health guidelines map out a clear path toward the provision of high-quality mental health care for all

The International Council of Nurses (ICN) held an online seminar on 6 March 2024 to launch its new Mental Health Nursing Guidelines.

The guidelines represent ICN’s commitment to helping nurses deliver high-quality, ethical and compassionate nursing care for people with mental health conditions everywhere.

They are designed to improve the consistency and quality of care delivered, and to provide a road map so that nurses can advocate for best practice and robust policies, and for better access for nurses to appropriate self-care, professional development and educational opportunities.

The webinar was chaired by ICN President Dr Pamela Cipriano, who said the guidelines are a major step forward for nursing’s collective mission to improve mental health care globally. Dr Cipriano placed the guidelines in the context of the World Health Organization’s (WHO) definition of health as a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity, and its definition of mental health as a state of wellbeing, in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.

Mental health is a human right

Dr Cipriano said mental health is a universal human right and that people who live with mental health conditions “…have the same rights as anyone else to live free of discrimination, violence and stigma.”

She said that nurses’ mental health is also vitally important and that the pandemic and the associated deaths, stress, fear, fatigue and moral injury that nurses had suffered has taken its toll on individual nurses and the profession.

“The pandemic sounded the alarm, and we all know all too well that the world has woken up to the dramatic need for mental health services. The recovery and healing from those unprecedented experiences is only just beginning, and the slow progress is really a threat to the entire nursing workforce and the patients and communities that we serve.”

Dr Cipriano set out the challenges nurses face in providing mental health care, including that while half the people in the world will have a mental health condition at some point in their lives, more than 70% of people who develop a severe mental health condition or substance use disorders receive no treatment at all, with access to services being especially difficult in low- and middle-income countries, where very few people get the treatment they need.

She said nurses are at the forefront of providing compassionate care and that the challenge, which the guidelines address, is to lead a transformation of mental health care and overcome the problems of not enough services and not enough nurses.

Dr Cipriano ended her introduction by saying: “As you learn more about the mental health guidelines from ICN, this is also an opportunity to hear from and engage with the panel of world renowned mental health experts who will focus on advocacy for a rights-based, ethical and compassionate approach to care, as well as the urgency to take action for the health of all people.”

There is no parity between mental and physical health

ICN Deputy Chief Nursing Officer David Stewart, who oversaw the production of the guidelines, spoke about their long gestation and thanked the many nursing experts from nearly 60 countries around the world who contributed to them.

Mr Stewart said: “We recognize that nowhere in the world does mental health enjoy parity with physical health in national policies, budgets, or in education and practice. It is indefensible that people cannot access good quality care because it is a human right to have the highest attainable standard of mental and physical health.”

One of the co-authors of the guidelines Dr Madeline Naegle, who is a Professor Emerita at the Rory Meyers College of Nursing and a Global Mental Health Consultant, highlighted the applicability of the guidelines in countries with very different cultures and educational and financial resources.

Dr Naegle said: “We as nurses, know that it's the interpersonal work, interpersonal therapies, the efforts to manage care and the efforts to get patients to the right resources, that really take us forward. One of the points we make very strongly in this document is that we want our nurses to be well prepared, to do what they can in interpersonal ways, and to use the systems that they have, whether they're very complex or whether they're very basic, to get people the care they need.”

Consensus on practice standards

She said the main purpose of the guidelines is to promote a consensus on practice standards: “We have a great vision before us. We're not all in the same place, but what brings quality consistently to the recipients of our care is that we've agreed on certain practice standards and that we will teach our students to reach those practice standards on graduation. We want to urge more nurses in their communities, no matter how small, to raise a voice when plans are being made about health care delivery.”

Charlene Sunkel, a global health lived experience mental health advocate and the Founder and Chief Executive Officer of the Global Mental Health Peer Network, congratulated ICN on the guidelines. She spoke about the importance of having people with lived experience of mental health conditions represented wherever decisions about mental health care and the education of health care professionals are made.

Reducing the mental health gap

Sir Graham Thornicroft, Chair of the Lancet Commission, Professor of Community Psychiatry, King’s College London, spoke about opportunities for nurses to contribute towards mental health and help to reduce the so-called mental health gap.

Professor Thornicroft said: “Mental health conditions are enormously common and about one quarter of us every year have such difficulties and three quarters of us know somebody who will have a mental difficulty this year. But the large majority of people with such difficulties receive no care or treatment. People with severe depression, even in the rich countries, only about a quarter receive treatment, and in low- and middle-income countries worldwide it is less than 5%. Nursing is one of the most important sectors of person power to deliver mental health. But there are relatively few specialist mental health nurses - between 1 and 3% of the world’s nurses.

“Who should supply mental health care, assessment treatment and sometimes referral? In the large majority of countries, because specialists, such as psychiatrists and psychologists, and indeed mental health nurses are so few on the ground, it is those nurses and general nurses who are in the poll position to provide mental health care. In fact it is the only group in sufficient numbers to provide care in relation to the scale of need.”

Professor Thornicroft said stigma and discrimination are significant barriers stopping people getting the care they need. It infringes human rights, it is toxic upon people and there are a whole range of types of social exclusion stemming from stigma.

He said that social contact between people with mental health conditions and those who do not have them is the primary active ingredient for stigma reduction. He emphasized the importance of using language that does not objectify the person with lived experience. So for example, saying someone is a ‘person with schizophrenia,’ rather than a ‘schizophrenic.’

He also spoke about the terrible toll on nurses during the pandemic, with about half of all health and social care staff having anxiety or depression, a quarter having post-traumatic stress disorder, and more than half having at least one of these conditions.

Professor Thornicroft said: “We have to pay attention to our own needs as health care practitioners and look after ourselves carefully so that we are a sustainable resource.”

A human rights-based approach

Dr Michelle Funk, Head of Policy, Law and Human Rights Unit, Department of Mental Health & Substance Use, WHO, congratulated ICN on the guidelines and said they were comprehensive and that it was good to see they had such a strong grounding in a human rights-based approach.

She spoke about the general renewed awareness of mental health issues and their importance which means more people are speaking about mental health now than used to be the case.

But she said there are many challenges to be overcome, including institutionalization, the lack of access to community services, large scale use of coercive practices, including violence, abuse and neglect associated with mental health services, the systematic denial of people’s right to determine their own treatment and other areas of their lives, stigma, discrimination and disempowerment that many people experience within mental health services.

Dr Funk said: “These are all areas that we are working on through WHO’s quality rights initiative, which aims to produce a transformative change in the mental health field that we have been talking about. However, if we are truly to make progress, we really need, as a first and urgent step to promote the widescale mindset change in line with a human rights-based approach and reduce stigma and discrimination. If we don’t there’s a real risk that any new policy, law or services that are developed might be a slight advance on previous ones, but without any fundamental change in the paradigm.”

She said a new, free, WHO online training program on the human rights-based model of mental health care is expected to reach up to five million nurses affecting the care of up to 50 million people experiencing mental health challenges.

Nurses will be called upon to provide additional care

Howard Catton, ICN Chief Executive Officer, spoke about the global mental health workforce. He said data are limited because many countries and organizations are not focusing sufficiently on mental health nurses, who he emphasized are a vitally important part of the overall global nursing workforce.

Mr Catton spoke about ICN’s 2022 report The Global Mental Health Nursing Workforce: Time to Prioritize and Invest in Mental Health and Wellbeing. It highlighted the discrepancy between the small size of the mental health nursing workforce and the huge and growing demand for mental health care.

Mr Catton said: “Over the course of their lifetimes one in every two people in the world will develop a mental health disorder, which is about the same proportion as the numbers who will develop cancer. 71% of people with severe mental health and substance abuse disorders receive no treatment. Can you imagine the outcry, the reaction, the response if 71% of people with stage 3 or 4 cancer received no treatment whatsoever?

‘There is a huge discrepancy in equality in terms of access to health care, which costs us, estimated to be up to 16 trillion Dollars. Given that there is value for money from the investment, still countries are spending less than two Dollars per person, even though we know that there is a positive return on investment. The consequence of these unmet needs is a huge impact on individuals, but families and close friends carry a huge supporting role as well.”

Mr Catton said the first State of the World’s Nursing (SOWN) report identified a critical shortage of nurses of at least six million. But he said a more ambitious estimate of what Universal Health Coverage would mean the shortfall in nurse numbers could be as high as 30 million. Mr Catton said: “The increase in the health care we want to provide will overwhelmingly be provided by nurses who will be at the forefront and who we need to deliver. All nurses are educated to provide physical and mental health care and practice holistically, but there is a disparity: overwhelmingly, specialist mental health nurses are working in high income countries.”

He said that general pre-registration nursing courses should include at least 80 hours of education on mental health, and experience should be gained in a range of placement settings, including in communities, rather than just in acute settings. He said next year’s second SOWN report would include a deeper dive into the true state of the global mental health nursing workforce.

Mr Catton then chaired a panel, which included the previous speakers, plus Dr Emma Wadey Deputy Director of Mental Nursing at NHS England, and Sheryl Garriques-Lloyd, Lecturer at the University of the West Indies School of Nursing and Regional Coordinator the Latin America and Caribbean Region of Sigma Theta Tau.

To watch the webinar, including the panel discussion click here