Psychiatric and Mental Health Nursing in China: Past, Present and Future

Psychiatric and Mental Health Nursing in China: Past, Present and Future

YAPNU-50962; No of Pages 7 Archives of Psychiatric Nursing xxx (2017) xxx–xxx Contents lists available at ScienceDirect Archives of Psychiatric Nurs...

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YAPNU-50962; No of Pages 7 Archives of Psychiatric Nursing xxx (2017) xxx–xxx

Contents lists available at ScienceDirect

Archives of Psychiatric Nursing journal homepage: www.elsevier.com/locate/apnu

Psychiatric and mental health nursing in China: Past, present and future Xiuying Xu a, Xin-Min Li b, Dongmei Xu c, Wenqiang Wang a,⁎ a b c

Xiamen Xianyue Hospital, Xiamen Mental Health Center, Fujian, China Department of Psychiatry, University of Alberta, Edmonton, Canada Beijing Huilongguan Hospital, Beijing, China

a r t i c l e

i n f o

Article history: Received 17 February 2017 Accepted 4 June 2017 Available online xxxx Keywords: Psychiatric and mental health nursing China Service Development Past Present Future

a b s t r a c t The mental health service model and policy have undergone dramatic changes and are moving toward the establishment of integrated service network-based community mental health services in China. But there are still some issues, such as shortage of resources, a relatively low rate of psychiatric treatment, lack of the knowledge about mental health in the general population, and stigma associated with mental disorders. This paper summarizes the history of psychiatric and mental health nursing in China and analyzes the characteristics of the current situation. There are healthcare challenges for psychiatric and mental health nurses with the mental health services reform by government, and in this paper we discuss future trends and provide suggestions for development of the psychiatric nursing profession, and mental health services reform. © 2017 Elsevier Inc. All rights reserved.

INTRODUCTION

Past

Whiteford et al. (2013) reported that the global burden of mental and substance use disorders increased by 37.6% from 1990 to 2010. The WHO World Mental Health Survey Consortium reported that 35.5% to 50.3% of people with serious mental illness (SMI) in developed countries and 76.3% to 85.4% in less-developed countries have never sought any professional treatment. In China, the costs of mental disorders in 2013 accounted for over 15% of the total health expenditure and 1.1% of gross domestic product (Xu, Wang, Anders, & Qiu, 2016). A study conducted in four provinces in China with a sample of 63,004 size showed that mental illness affected 17.5% of adults and that N173 million individuals suffer from mental illness; 24% of them were moderately or severely disabled by their illness; but only 8% of them had sought professional help (Phillips et al., 2009). The huge burden of mental disorders highlights the pressing need for improved mental health services. The psychiatric and mental health (PMH) nurse is an essential team member in health promotion, illness prevention, and rehabilitation in all mental health areas. This paper discusses the past, present and future of PMH nurses working in the mental health services field across China.

The first officially documented institution administered for the mentally ill by government in China was in the Tang Dynasty (895 CE), where homeless widows, orphans and the mentally ill were cared for; this concept originated from the Beitian Bingfang, a type of charity facility administrated by monks (Lan, 1994). John Kerr, an American missionary, set up the first western style psychiatric hospital for the homeless mentally ill; it was established and funded in 1897 (Chen, 2015). There were 200 psychiatric beds in it, and it is now the Guangzhou Brain Hospital. The American psychiatrist A.H. Woods was invited to teach neuropsychiatry courses in Peking Union Medical College Hospital as an associate professor in 1922 and the first department of neuropsychiatry was established in 1928 (Chen, 2015). In the next 20 years, psychiatric hospitals were built very slowly in large cities. After the People's Republic of China was founded in 1949, there was a rapid development of mental health services and psychiatric hospitals were gradually built in every province. In the 1950s, treatment of mental illness saw the inclusion of the use of psychotropic drugs such as chlorpromazine and lithium, insulin shock, electroconvulsive therapy (ECT), and psychiatric rehabilitation in the community. A striking feature of the mental health service model was the requirement of forced restriction of patients for long periods of time in hospital (Table 1). In the 1960s and 1970s, the mental health service almost stagnated during the Cultural Revolution (1966–1976), but worker rehabilitation centers for people with mental illness and caring networks were provided by neighborhood committees in Shanghai (Zhang & Yan, 1990), and the primary treatment model for people with mental illness was in a

⁎ Corresponding author. E-mail address: [email protected] (W. Wang).

http://dx.doi.org/10.1016/j.apnu.2017.06.009 0883-9417/© 2017 Elsevier Inc. All rights reserved.

Please cite this article as: Xu, X., et al., Psychiatric and mental health nursing in China: Past, present and future, Archives of Psychiatric Nursing (2017), http://dx.doi.org/10.1016/j.apnu.2017.06.009

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Table 1 Mental health facilities and resources in China, 1949–2010.

Psychiatric hospitals Psychiatric beds Psychiatric beds/10,000 population Psychiatrists Psychiatrists/100,000 population Psychiatric nurses Psychiatric nurses/100,000 population Median length of stay in psychiatric hospitals (days) Median bed utilization ratio (%)

1949

1961

1965

1978

2005

2008

2010

2012

9 1142 – 100 – – – – –

139 22,000 – 1228 – – – 120 84.7

76 18,000 – 1404 – – – 105 97.2

219 42,000 2.30 3128 3.30 – – 103 N91.0

557 109,961 0.84 13,122 1.00 23,636 1.81 48 85.2

598 171,752 1.29 15,882 1.20 29,125 2.19 49 90.9

657 207,372 1.55 18,040 1.35 35,337 2.61 53.90 96.4

728 246,392 1.82 20,655 1.53 43,788 3.23 48.8 97.4

“–” means there are no available statistics. Sources: Liu, Chen, Xie, et al., 2013; Li, Sun, Zhang, et al., 2012; Ma, Yan, Ma, et al., 2012; Ministry of Health, 2006, 2009, 2011, 2013.

hospital-based care. In the 1980s and 1990s, the Ministry of Health, Civil Affairs and Public Security in China set up a three-tier network (city, district/county and street/town levels) to deal with psychosis. Treatment models, such as use of antipsychotics, work-rehabilitation centers and family-based therapy were extended (Liu, Ma, He, et al., 2011). In 2002, the first National Mental Health Plan (2002 − 2010) was signed by the Ministries of Health, Public Security and Civil Affairs and the China Disabled Persons' Federation. Targets and guidelines were established to achieve the following goals: a) establish a governmentled mental health services system that collaborated with several sectors; b) facilitate implementation of mental health legislation; c) heighten awareness of mental health in the general population; d) enhance mental health services to reduce burden and disability; and e) develop more mental health services and increase the capacity of current psychiatric hospitals (Liu et al., 2011; Ministries of Health, Public Security, Civil Affairs and CDPF, 2002). In 2004, the National Continuing Management and Intervention Program for Psychoses (686 Program), after its initial funding of CNY 6.86 million, was implemented in China and was consistent with policy recommendations issued by the WHO and supported by other recognized international organizations (Ma, Liu, He, et al., 2011). The aim of this program was to consolidate the reform and to found a patient-centered and recovery-oriented public health services model through the key provisions of continuum of care based on community, accessibility and equality of treatment for people with mental illness. The Chinese Psychiatric-Mental Health Nursing Association was founded in 1990. The Nurse Ordinance that provided the legal basis to protect the legitimate rights and interests of registered nurses was implemented in 2008. In addition, the National Mental Health Law that protects legal rights of people with mental disorders was formally promulgated in 2013. With mental health services reform developing rapidly and making significant progress, that put higher requirements on psychiatric and mental health nurses in China. Present Resources and workforce of PMH nurses Most mental health professionals in China are psychiatrists or psychiatric nurses, and there is a paucity of clinical psychologists and social workers and virtually no occupational therapists (Liu et al., 2011). According to the 2010 Statistical Report on Development of Medical Services of China, the total number of mental health professionals per 100,000 population in 2010 was 5.16, including 1.54 physicians, 2.65 nurses, and 0.97 other types of mental health professionals in 2010 (Liu et al., 2013). There were 2,048,000 registered nurses (RNs) working in all kinds of medical institutions in 2010 (Ministry of Health, 2011), and RNs working in mental health facilities only accounted for 1.73% (35,337) of all RNs in the country. However, in the USA the number of licensed RNs was estimated at 4.1 million, and 4% (164,000) of these RNs were working in psychiatric/mental health or substance abuse settings, with half of them practicing in the community, and about half in inpatient settings in the USA (Budden, Zhong, Moulton, & Cimiotti,

2013). Compared with the 12.97 PMH nurses per 100,000 population in average global workforces in 2004 (WHO, 2011), mental health human resources in China are quite limited. Table 2 shows characteristics for PMH nurses. Education and licensing In China, nursing education is divided into technical secondary schools, college undergraduates, and postgraduates in master's and doctoral programs. The vast majority of schools put psychiatric nursing into a clinical nursing education curriculum, such as Medical Nursing, Surgical Nursing, Pediatric Nursing, Obstetrics and Gynecology Nursing, or Community Nursing (Li & Li, 2010). After finishing school requirements, all levels of nursing graduates need to participate in and pass the National Qualification Examination for Nurse Practitioners jointly organized by the Chinese Ministry of Personnel and the Ministry of Health, get the nurse practical certification, and work in a variety of nursing practices, such as medical, surgery nursing practice and so on, including psychiatric nursing practices. Mental health facilities will provide the training in psychiatric nursing knowledge and skills for those nursing students who choose to work there (Wang, 2008). Since 2011, psychiatric nursing content has been part of the National Qualification Examination for Nurse Practitioners, and the proportion of psychiatric nursing questions in the examination will increase year by year. The government of China has been devoted to developing higher education in Table 2 Characteristics of PMH registered nurses in China in 2010 (n = 35,337). N

%

Gender Female Male Nurse age groups 18–25 25–44 N45

30,842 4495 N 4670 22,398 8269

87.3 12.7 % 13.3 63.3 23.4

Education status Postgraduate degree Bachelor's degree Technical college High school and below

17 3756 15,496 16,068

0.05 10.63 43.85 45.47

Years of work experience b5 years 5–9 years 10–19 years 20–29 years ≥30 years

7795 5447 8367 9002 4726

22.06 15.41 23.68 25.47 13.37

Professional level Senior nurse Associate-level nurse Intermediate-level nurse Assistant-level nurse Entry-level nurse Nurse not yet classified

32 837 8486 11,013 13,690 1279

0.09 2.37 24.01 31.17 38.74 3.62

Sources: Ministry of Health (2011); Liu et al., 2013.

Please cite this article as: Xu, X., et al., Psychiatric and mental health nursing in China: Past, present and future, Archives of Psychiatric Nursing (2017), http://dx.doi.org/10.1016/j.apnu.2017.06.009

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nursing in recent years; bachelor's degree education programs in nursing were offered again in 1983 and master's degree education programs have been offered since 1992, but the nursing graduates with master's degrees and doctorates tend to work in educational institutions instead of clinical settings, and few of them choose to engage in psychiatric and mental health care. The Ministry of Education Committee on Institutions of Higher Nursing Professional Teaching published the Educational Standard of Undergraduate Nursing Students in 2010 (Su & Chen, 2014). The academic learning time of a Psychiatric Nursing curriculum by the standard required is 24 to 42 h for nursing undergraduate students, including theory classes of at least 20 h, clinical observation at least 4 h and a clinical practicum of 2 to 4 weeks in psychiatric hospitals (Li & Yao, 2012). There are established minimum academic requirements for a psychiatric nursing curriculum for undergraduate nursing students. In 2011, the Development Outline of a Chinese Nursing Career (2011–2015) mentioned that China would train 25,000 specialist nurses (SNs), and five national training bases for psychiatric-mental SNs were founded by 2015 (Ministry of Health, 2012). Thus SN training programs were established rapidly across China, with training areas focused on ICU, diabetes, operating rooms, emergency care, tumor care, and wound and enterostomal care. Most SN training programs lasted 2–6 months. Cao et al. investigated 50 third-grade class-A hospitals, and found that the number of SNs accounted for 10.10% of the nurse team (Cao, Li, He, et al., 2015). The Chinese Psychiatric-Mental Health Nursing Association began to organize the SN program; the first phase for the psychiatric program was conducted jointly by the Beijing Huilongguan Hospital, the Sixth Hospital of Peking University, and Beijing Anding Hospital in 2010. The candidates in training were required to have clinical practical experience and a college diploma. Training content focused on theory and skills of psychiatric and mental health nursing and lasted two months. Participants who finished the training course and passed the examination could get a psychiatric specialist nurse certification. Subsequently, the mental health institutions and medical administrators in some provinces have been holding corresponding training programs. But wide variation exists among the provinces in the regulation of all SNs; Fairman, Rowe, Hassmiller, et al. (2011) cautioned that inconsistent province-to-province regulatory oversight of psychiatric SNs may lead to poor access to safe and effective mental health care services. It is necessary to solve existing problems such as lower skills of teachers without uniform pre-training, different levels of students using the same training plan, lack of formal certification and standards, and overlapping roles of SNs and head nurses (Zhang, Zhao, & Zhang, 2012). Clinical practice With “deinstitutionalization”, the pursuit of human freedoms and rights, and improvements of community health service systems, western nations completed the transition from closed to open management patterns in psychiatric wards in the 20th century. However, mental health service provision is still primarily hospital-based in China, and patients can bypass primary and secondary health care levels and have direct access tertiary psychiatric hospitals (Liu et al., 2011). The majority of psychiatric hospitals retain a restrictive environment management pattern, because: (a) a wide disparity exists among provinces and cities in terms of social and economic development; (b) psychosis treatment and management is still the top priority of the government from the social stability point of view; (c) there is an unequal allocation of health resources between the community and psychiatric hospitals; (d) the psychiatric profession is becoming less attractive, with fewer medical school graduates willing to be trained as psychiatrists (Liu et al., 2011). Inpatient psychiatric care involves intensive treatment for most acute and emergency patients and provides confined units by a psychiatric hospital or psychiatric unit within a general hospital. PMHregistered nurses can practice in a variety of clinical settings in the

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care continuum, including provision of therapeutic and safe environments, ongoing assessment, symptom management, crisis intervention and stabilization, promotion of self-care activities and recovery, medication administration and monitoring of efficacy and side effects for patients who are at high risk for harming themselves or are unable to care for their basic needs (Xu, Shao, & Wu, 2012). According to the National Mental Health Law, when treating aggressive or violent patients, the PMH-registered nurses can monitor appropriate use of seclusion and restraints under the supervision of psychiatrist (Chen et al., 2012). Despite the current emphasis on decreased hospital stays, long-stay patients with severe and persistent mental disorders continue to require acute care services, with institutions providing food, clothing, pleasant environment, and perhaps some means of exercise (Xu et al., 2012). So thousands of patients with severe mental illness (SMI) have been socially isolated from their families and normal community life and restricted within the walls of hospitals for months and years with little hope of being integrated into society. Community nursing services In recent years, patients, families, providers, and advocacy groups involved in mental health care no longer accept long-term institutionalization. Instead, they advocate for short-term treatment in an environment that promotes dignity and well-being while meeting the patient's biologic, psychological, and social needs. The continuum of care that supports recovery in mental health services can be viewed from various perspectives and ranges from intensive treatment (hospitalization) to supportive interventions (outpatient therapy). By implementing continually the 686 Program, patients can get a continuum of treatment, management and equitable mental health services. Patients at risk for aggression and violence are provided with free medication, laboratory tests, a subsidy for hospitalization and followup if they have poor socio-economical support. Should psychiatric emergencies or severe cases of medication side effects occur, the program provides free crisis management. If patients lack finances to pay for continued treatment after they are discharged from a hospital, the program includes the free services mentioned above. With a new hospital-community integrated service model, this program covers 0.33 billion of the general population in 680 districts/counties, and 160 cities. N280,000 patients suffering from psychiatric disorders have been registered and about 382,000 practitioners were trained as members of inter-professional teams by 2011 (Liu et al., 2011). Psychiatric nurses serve in various pivotal functions across the 686 Program to provide a continuum of care for people with mental disorders, which involve both direct care and coordination of the care delivered by other practitioners. In addition, case management service, partial hospitalization programs, and mental rehabilitation clubhouses have been established in some areas of China (Feng & Liu, 2014). Nurses play an important role in the care of people who have severe and persistent mental illnesses and who require long-time stays in the community. Nurses provide basic psychiatric nursing care, such as social skills training, living skills training, education regarding illness and symptom identification and relapse prevention, aggression management, relaxation training, utilization of community resources, and other forms of expressive therapy (Happell, Hoey, & Gaskin, 2012). Future The evolution of mental health resources and service in the past 60 years went through three phases, namely rapid growth, steady development, and the reform period (Li et al., 2012). The mental health service policy has also undergone dramatic changes, and is moving toward the establishment of integrated service network-based community mental health services (Ma et al., 2011). Nurses function as members of a multidisciplinary team and assume responsibility for assessment and selection of level of care, education, evaluation of response to

Please cite this article as: Xu, X., et al., Psychiatric and mental health nursing in China: Past, present and future, Archives of Psychiatric Nursing (2017), http://dx.doi.org/10.1016/j.apnu.2017.06.009

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treatment, referral or transfer to a more appropriate level of care (Feng & Liu, 2014). But present situations, such as the shortage of health resources, reducing the rate of psychiatric treatment, lack of knowledge of mental health, social prejudices and discrimination toward SMI still exist. Psychiatric nurses face the challenge of providing mental health care within a complex system that is designed for effective delivery of mental health services in spite of expanding service needs and limited resources. So we suggest the following strategies to meet the needs of society and promote psychiatric nursing profession development. Increasing the relevance, effectiveness, and accessibility of education and training Availability of a mental health workforce with the appropriate knowledge and skills to implement necessary changes in the healthcare system is crucial to improving access and quality. There is an obvious need for educational programs and initiatives in China to draw more on major theories of learning and effective education strategies (ACMHA, 2011). On the academic education stage of psychiatric nursing, accessibility to undergraduate, master's, and doctorate nursing education programs should be expanded. Although there have been over 200 universities offering undergraduate nursing programs in China, the nurse workforce is very low compared to other countries (Budden et al., 2013). Table 2 shows that very few of the registered nurses working in mental health facilities have post-graduate degrees and only 11% have bachelor's degrees; 44% of registered nurses had completed a two or three-year degree at a technical college, while 45% had no academic qualification (Liu et al., 2011). We must expand the dialogue from “evidence-based clinical practice” to “evidence-based teaching practice.” Such practice would build on adult learning theory, address all three domains of learning (knowledge, attitudes and skills), and measure discrete and concrete competencies and educational outcomes. Teaching content must be more effective, efficient, timely, standard, patient-centered and research-based, and prepare nursing students to practice in the environment of reformed mental health services. Measurement should focus on developing skill sets and assuring that undergraduate nursing students have obtained the requisite proficiencies. Psychiatric nursing graduate programs should modify their curricula to include emphasis on comprehensive health assessment, referral, and management of common physical health problems, and provide a continued focus on educational preparation to meet national criteria and professional competencies. On the practical side of psychiatric nursing, we propose all of PMHregistered nurses take formal educational programs to learn about psychiatric and mental health knowledge and skills. Motivation systems must be put in place that encourage more clinical nurses to specialize in mental health, standardizing the professional training of nurses who work in mental health facilities (ACMHA, 2011). National psychiatric associations must offer more and higher quality courses, conferences and other educational forums to help nurses to update professional knowledge and skills. Hospital leaders should strongly encourage and support clinical nurses to go on for in higher degrees of education programs in psychiatric mental health nursing because the programs are often expensive and time consuming. Expanding the role and capacity of community nursing The primary goal of a continuum of care is to provide treatment that allows patients to achieve the highest level of functioning in the least restrictive environment. It is more beneficial and certainly more cost-effective for people with mental disorders to stay in the community and receive outpatient treatment whenever possible. The patients can often keep working, stay with their family members and friends, and get other support from mental health services system. So community support service programs should deal with rehabilitation, vocational needs, education, and socialization, in addition to management of symptoms and medication. In addition, we should consider a person's

personality and behavior patterns, so that coping skills, ways of communication, and level of self-esteem and insight gradually develop over the lifetime (Videbeck, 2014). Case management in community mental health has emerged since the 1960s following the wide deinstitutionalization of people with mental illness (Hamden, Newton, McCauley-Elsom, & Cross, 2011). Various models of case management have evolved over time. Prominent models include broker case management, clinical case management, strengths management, rehabilitation, assertive community treatment (ACT), and intensive case management (ICM). Both ACT and ICM were designed for people with SMI who have complex service needs. Compared with broker and clinical case management models, ACT and ICM models require smaller caseloads, greater outreach to patients, staff with psychotherapeutic skills, more frequent contacts with clients, the movement of the location of contacts from the clinic to the community, and higher levels of direct service provision (Happell et al., 2012). Nurses have been at the forefront of providing case management. In China, psychiatric hospitals not only bear the brunt of acute and emergency inpatient care, but also undertake rehabilitation service for a large number of chronic psychiatric inpatients. The patients have to stay in psychiatric hospitals longer, which brings a heavy economic burden to individuals, families and society. Inpatient psychiatric treatment still accounts for most of expenditure on mental health, community health services having not been given the financial base it needs to be effective. Just like most low- and middle-income countries (LMICs), China has a long way to go to meet the goal of provision of adequate mental health care in the community (Liu et al., 2011). Promoting community mental health services, changing of the focus from hospital to community, and providing more individualized mental health services are important.

Defining the standards and scope of practice for psychiatric and mental health nursing Along with the rapid economic progress and the development of medical and health care, the environment of nursing practice and working content is undergoing changes. In terms of practice, psychiatric nursing practice has expanded from the hospital to the community and is now viewed as a core mental health discipline; in terms of job content, it has transformed from diseases nursing to holistic nursing services that focus on meeting people's physical, psychological, cultural, spiritual, and environmental requirements. The Nurses Ordinance was implemented in 2008 in China to protect the legal rights of the nurses, to standardize nurse practice registration, to regulate the behavior of nurses, and strengthen the responsibility of government and the medical institutions. It helps to ensure nurse manpower resources and promotes the importance of nurse specialties. However, the implementing of the Nurses Ordinance in medical and health institutions is at various levels. A questionnaire survey to comprehensively understand the situation of actual execution of Nurses Ordinance included a total of 61,424 nursing staff across the country and indicated inconsistencies among different classes of hospitals and medical institutions regarding health protection measures, opportunities for sharing academic communications, and attending professional nursing groups; there was also an imbalance in the nursing staff allocation (Li, Huang, & Liu, 2015). Scope and Standards of Psychiatric-Mental Health Nursing Practice (2nd Edition) was published by the American Nurses Association in 2014 (ANA, APNA, & ISPN, 2014) and describes the responsibilities for which nurses are accountable. The professional standards are used to decide safe and acceptable practice and to assess the quality of care when legal issues or lawsuits arise. This document also outlines the scope of practice and phenomena of concern for PMH nurses. Canadian Standards for Psychiatric-Mental Health Nursing (4th Edition) was also published by Canadian Federation of Mental Health Nurses in 2014. However, professional standards and scope about psychiatric and

Please cite this article as: Xu, X., et al., Psychiatric and mental health nursing in China: Past, present and future, Archives of Psychiatric Nursing (2017), http://dx.doi.org/10.1016/j.apnu.2017.06.009

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mental health practice have not been defined in such a formal way so far in China. It is important to define clearly the standards and scope of PMH nursing practice, in order to protect the public and provide legal protection for nurses; such definitions would promote the development of the nursing profession and discipline, and it would be beneficial for the profession to meet the growing demands of society and to provide higher quality nursing services to Chinese people.

Standardizing the training of the Psychiatric-Mental Health Specialist Nurse (PMH-SN) and developing a Psychiatric-Mental Health Advanced Practice Registered Nurse (PMH-APRN) program The concept of specialist nurses came from abroad, but it was translated differently and there is not a uniform definition of SN and standards for educating and credentialing that are consistent across SN groups in China (Gao & Xu, 2013). In the absence of a consistent definition and educational credentials for practice, the instability of the health care system and increased competition among providers pose a threat to the legitimacy of all SNs as providers. Commonly, SN refers to a special position in which the person has strong nursing knowledge and skills, has completed the required SN education course, and is a qualified registered nurse (Li & Gao, 2005). Compared with the APRN of the western countries, there is a wide gap in selection of participants, verification of licensure, involvement of professionals, qualification requirements, professional standards and scope (Gao & Xu, 2013; Zhang et al., 2012). To improve the authority and credibility of SNs, who must be titled clearly, licensed and regulated at the national level, they should be certified by the Chinese Ministry of Personnel and the Ministry of Health. APRNs play a pivotal role in future of health care. APRNs are often primary care providers and are at the forefront of providing preventive care to the public (ANA, APNA, & ISPN, 2014). PMH-APRNs are registered nurses, educated at the masters or doctoral level, having graduated from intensive accredited graduate nursing programs. They pass a specialized psychiatric certification examination and maintain national certification after fulfilling rigorous requirements of direct patient care (Delaney, 2013). The education of a PMH-APRN builds on years of clinical experience throughout the health care system, working as an interdisciplinary team member and providing health delivery solutions to underserved patients and their families in community settings (Hanrahan & Hartley, 2008). PMH-APRNs provide the full spectrum of mental health services and cover prescribing medications; they include both clinical nurse specialists (PMH-CNSs) and nurse practitioners (PMH-NPs). It has been reported that approximately 6577 Master'sprepared PMH nurses hold a Clinical Specialist certification (adult and child combined) and an additional 7816 Master's-prepared nurses hold a PMH-NP certification (adult and lifespan) in the USA (American Nursing Credentialing Center, 2014). PMH-APRNs are allowed to prescribe medication under the supervision of a psychiatrist in many states of the USA (Rosedale & Knight, 2015). There are over 10,000 nurses across the UK qualified to prescribe both as independent and supplementary prescribers (Earle, Taylor, Peet, et al., 2011). PMH-APRNs act as clinicians, educators, consultants, and researchers who are involved in the assessment, diagnosis, and treatment of clients with behavioral disorders or who have the potential to develop such disorders (ANA, APNA, & ISPN, 2014). Evidence shows that PMH-APRNs can be excellent providers who deliver comprehensive mental health services, particularly in symptom remission, function improvement and hospital readmissions reduction (Hanrahan & Hartley, 2008). A clinical research study reported that PMH-APRNs improved health outcomes in people with serious and persistent mental illness living in underserved areas (Delaney, 2013). With more nurses with a baccalaureate, master's degree or doctorate engaged in Chinese psychiatric mental health facilities, the nation increasingly will call upon PMH-APRNs to meet these needs and participate as key members of health care teams.

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Enhancing interprofessional collaboration The Institute of Medicine (IOM) has provided considerable evidence that interprofessional collaboration and teamwork have a positive impact on organizational performance (IOM, 2010). Interprofessional team models are increasing in western countries, particularly for teams working with patients with chronic diseases and/or mental health needs. Such mental health teams typically comprise psychiatrists, pharmacists, psychologists, psychiatric nurses, psychiatric social workers, occupational and recreation therapists, and vocational rehabilitation specialists (Videbeck, 2014). PMH nurses play an important role in multidisciplinary teamwork. Based on the American Scope and Standards for Psychiatric-Mental Health Nursing, the PMH-registered nurses would also collaborate with consumers, health care providers, and community members to coordinate resources and seek feedback regarding interventions (ANA, APNA, & ISPN, 2014). PMH nurses share knowledge and skills and must maintain compassionate and caring relationships with their co-workers. With consumers' demands becoming more varied and complex, the PMH nurse is in the ideal position to be a case manager in the collaborative teamwork. The case manager should take a leading role in coordinating activities to help attain patient goals such as reducing readmission, decreasing length of hospital stays and remaining in the community for as long as is feasible. Effective case managers need to have clinical skills, relationship skills, and liaison and advocacy skills to be most successful with their clients. Clinical skills include treatment planning, symptom and functional assessment, and skills training for patients. With regard to relationship skills, they must be able to establish and maintain productive and respectful relationship with clients. Liaison and advocacy skills refer to developing and maintaining effective contacts for financial entitlements and vocational rehabilitation. The American Nurses Association stated that the roles of the PMH nurse as a case manager could include assessment and monitoring of consumers and referring them for general medical problems and psychiatric problems; such case managers could also administer drugs and monitor their side effects, as well as provide health education to the consumer and family (Videbeck, 2014). Implementing Evidence-based Practice (EBP) in the PMHN field In 2012, the International Council of Nurses (ICN) published a report entitled “Closing the gap: from evidence to action”. The ICN encouraged nurses to use EBP which enables them to constantly review their practice and to seek new and more effective and efficient ways of doing things (ICN, 2012). Then The Lancet published an editorial titled “The state of nursing and evidence-based practice” which encouraged nurses to use evidence and enhance the level of nursing service through EBP. EBP is an approach to clinical decision making in health care delivery that takes the best evidence from well-designed studies and integrates it with clinicians' expertise and patients' preferences and values (Melnyk, Gallagher-Ford, & Fineout-Overholt, 2014). The American IOM recommended that all health professional educational programs should include five competencies, including: (a) providing patientcentered care, (b) applying quality improvement principles, (c) working in interprofessional teams, (d) using EBPs, and (e) using health information technologies (IOM, 2003). Using EBP in the clinical setting should result in enhanced quality of care and patient outcomes, provide new opportunities for professional development, help in recruitment and retention of nursing staff, and save money for the health care system (Wallin, Ewald, Wikblad, Scott-Findlay, & Arnetz, 2006). However, EBP is barely implemented in the PMH nursing specialty in China. There are several barriers to the implementation of EBP in PMH nursing environment globally, and these can be classified into four major categories: the nature of the evidence, contribution of the PMH nursing researchers to EBP, personal characteristics of PMH nurses, and organizational factors (Alzayyat, 2014; Yadav & Fealy, 2011a). The

Please cite this article as: Xu, X., et al., Psychiatric and mental health nursing in China: Past, present and future, Archives of Psychiatric Nursing (2017), http://dx.doi.org/10.1016/j.apnu.2017.06.009

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advantages of EBP for enhancing patient care are well documented, so there is no longer an excuse for psychiatric nurses to be lacking in knowledge and skills (Alzayyat, 2014). Achieving higher implementation of EBP among allied mental health professionals requires a cultural shift, placing higher value on these activities despite the challenging context of constant pressures to increase patient flow. Addressing EBP through small group projects, increasing the number of PMH nursing researchers, conducting clinical research projects, training PMH nurses about computer skills, integrating EBP principles into nursing curricula, choosing suitable journals for publication, and offering organizational facilitators are essential prerequisites for the achievement of EBP in the PMH nursing field (Melnyk et al., 2014).

Reducing stigma and promoting psychiatric rehabilitation One of major problems facing individuals with mental illness and their families is stigma. Public stigma occurs after individuals are publicly “marked” as being mentally ill. The common stereotypes and media associate mental illness with negative images, and people with mental illness are thought to be or are portrayed often as aggressive, dangerous, unpredictable, and incapable of functioning independently. Patients are aware of the public's negative view of mental illness and often agree with the public's perception. They may begin to believe that they are unpredictable, cannot become productive members of society, or will become a burden on the family. In order not to be labeled as being mentally ill, they may ignore their symptoms or refuse to seek treatment. Stigma can result in misunderstanding, prejudice, and discrimination in the community. A study in Hong Kong indicated that over 40% of hospitalized patients with schizophrenia experienced negative attitudes and excessive restrictions by mental health professionals (Lee, Chiu, Tsang, Chui, & Kleinman, 2006). These results reflect the fact that Chinese mental health professionals work mainly in inpatient psychiatric hospital settings where the patients are likely to be the more severely ill, generating increasing social distance among providers. To reduce the stigma associated with mental disorders and improve access to seek professional help, PMH nurses should educate individuals, family, groups, and the general population about the etiology, symptoms, treatment and prevention of mental illness. The goals of psychiatric rehabilitation are promoting recovery, providing community integration, and enhancing the quality of life for individuals with mental disorders. The recovery process includes helping and encouraging the individual to do something that he/she has to accomplish on his or her own. Community integration involves three interrelated domains: a) physical integration entails residing in the community and utilizing its resources; b) social integration means interacting with a variety of people in one's community; and c) psychological integration involves perceived community membership or a sense of belonging (Pratt, Gill, Barrett, & Roberts, 2014). Present attitudes should not detract from helping individuals have a reasonable quality of life, with social support, companionship, employment, recreation, and adequate food, housing and clothing. The role of the PMH nurses is to not only to provide care and treatment for the healthcare consumer, but also to develop partnerships with them to assist them with their individual recovery goals. The American National Consensus Statement on Mental Health Recovery stated that recovery is guided by ten fundamental components, including self-direction, individualized and person-centered, empowerment, holistic, nonlinear, strengths-based, peer support, responsibility, and hope (U.S. DHHS, 2006). To achieve psychiatric rehabilitation goals, PMH nurses should be involved in influencing, self-determination and empowerment, recognizing dignity and worth of every individual, having the optimism that everyone has the capacity to recover, learn, and grow, and valuing the importance of cultural diversity and normalizing environments.

CONCLUSION In the 21st century, advances in neurosciences, genomics, and psychopharmacology, as well as evidenced-based practice and cost-effective treatment enable the majority of individuals, families, and groups in need of mental health services to be cared for in a community setting. Acute, intermediate, and long-term care settings still admit and care for people with severe and permanent mental disorders. Our government should continue to learn from the advanced experience, domestic and abroad, aiming at the situation psychiatric care, developing and establishing the characteristics within China of a systematic and comprehensive, high quality of psychiatric and mental health nursing service system. We should broaden the PMH service through improving health legislation and policies, service modes and continuing educational programs. It is evident from this review that PMH nurses need contemporary knowledge and skills but more importantly are essential to the future nursing organizations of change and to advancing mental health reforms locally and nationally. This will require a rigorous postgraduate curriculum that is regularly updated to include emerging EBP; activism to address regulatory barriers to the full scope of practice; and a systematic plan to increase and strengthen the PMH nurse workforce. That would prepare them to contribute to contemporary systems of mental health care, but more importantly to help provide a better future for our consumers, families, communities, and society at large.

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