Abstract
Background
Mental health nurses represent only 1.03% of the global nursing workforce, contributing to persistent workforce shortages. Undergraduate nursing students demonstrate limited interest in mental health nursing (MHN), often associated with negative attitudes toward MHN and individuals with mental illness. Understanding factors influencing these attitudes and career intentions is essential to inform targeted educational interventions.
Objectives
This integrative review aimed to identify factors influencing undergraduate nursing students’ attitudes and career interest in MHN and evaluate the impact of MHN education on these outcomes.
Methods
Guided by Whittemore and Knafl's framework, a rapid integrative review was conducted across CINAHL, EMBASE, ScienceDirect, PubMed, and PsycINFO for English-language studies published between 2000 and October 2025. Of 362 records identified, 113 underwent screening, and 22 met inclusion criteria following full-text review. Quality appraisal employed CASP and JBI tools. Data were analyzed using constant comparison, with findings organized into structured matrices.
Results
Four themes emerged: (1) attitudes toward MHN varied widely, with more negative perceptions among first-year students; (2) overall career interest in MHN remained low to neutral; (3) influencing factors included attitudes toward mental illness, clinical exposure, and perceived preparedness; (4) MHN education improved attitudes but did not significantly increase career interest.
Conclusions
Although MHN education enhances attitudes, it does not translate into increased career interest. Strategies such as extended clinical placements, lived-experience education, problem-based learning, and simulation may improve interest. Further rigorous research, including randomized controlled trials, is required to establish causality and inform workforce development strategies.
Keywords
Introduction
Canada has experienced a substantial rise in the prevalence of people living with mental disorders over the past decade, with rates of generalized anxiety disorder and major depressive disorder approximately doubling during this period (Statistics Canada, 2023). In Canada, mental illnesses and substance use disorders are among the leading causes of disability and impose a substantial economic burden on the health system and society, imposing an estimated 51 billion dollars in annual costs through lost productivity, healthcare utilization, and reduced health-related quality of life (Centre for Addiction and Mental Health (CAMH), n.d.). Despite this growing burden, service provision has not kept pace with need. Data from the 2022 Mental Health and Access to Care Survey indicate that only 48.8% of individuals reporting a mental illness had consulted a healthcare professional, and although 58.8% expressed a need for counselling, just 43.8% received such services (Statistics Canada, 2023). These gaps highlight a critical mismatch between population mental health needs and the available workforce and services.
Within this context, nurses hold key positions in the mental healthcare system. They provide comprehensive mental health assessments, deliver psychoeducation, establish and sustain therapeutic relationships, and offer ongoing counselling and support to individuals and families (Connell et al., 2022; Graham et al., 2020; Nsatimba et al., 2025). Through close and sustained contact with service users, nurses are uniquely placed to advocate for equitable access to care and to challenge stigma and discriminatory practices within healthcare settings and the wider community (Connell et al., 2022; Graham et al., 2020; Elmadani et al., 2025). However, the potential of nursing to respond to escalating mental health needs is constrained by significant workforce shortages. Globally, mental health nurses represent only 1.03% of the nursing workforce, with an average of 3.8 mental health nurses per 100,000 population, underscoring a substantial shortfall in specialist provision (International Council of Nurses (ICN), 2022).
A key driver of this shortage is the persistent lack of interest among undergraduate nursing students in pursuing careers in mental health nursing (MHN), with multiple studies reporting MHN as one of the least preferred specialties at graduation (Chmielewski et al., 2025; Hunt et al., 2020; Matarese et al., 2019; Njaka et al., 2024; Ong et al., 2017). This pattern has frequently been linked to negative or ambivalent attitudes toward MHN and toward people living with mental illness, including stereotypical views, fear, and discomfort (Rice et al., 2019; Warrender et al., 2024). These attitudes are shaped by a complex interplay of personal beliefs, societal stigma, and the nature and quality of mental health content and clinical experiences within undergraduate curricula. Understanding the factors that influence nursing students’ attitudes and career intentions in relation to MHN is therefore crucial to informing educational strategies and workforce planning aimed at strengthening the future MHN workforce.
Methods and Materials
Design
An integrative review approach, informed by Whittemore and Knafl's framework, was adopted to synthesize heterogeneous empirical evidence on nursing students’ attitudes and career interests in mental health nursing (MHN) (Whittemore & Knafl, 2005). In addition, the review examined the influence of MHN education on these outcomes (Whittemore & Knafl, 2005). This approach enabled us to synthesise a heterogeneous body of evidence on nursing students’ attitudes and career interests in MHN and to integrate findings from diverse study designs into a coherent, narrative account.
Studies were selected through staged title, abstract, and full-text screening against predefined inclusion and exclusion criteria, and reasons for full-text exclusion were documented to ensure transparency. Data from the included studies were then extracted into standardized tables and analysed using Whittemore and Knafl's constant comparison approach, involving iterative data reduction, coding, comparison across studies, and synthesis into overarching themes aligned with the review objectives. In this review, we use the term ‘foundational literature’ to refer to earlier theoretical, conceptual, or policy works that have underpinned the development of mental health nursing education and research on student attitudes, and which we cite to contextualize the empirical studies rather than as part of the primary evidence base.
Aim and Problem Identification
This review aims to synthesise empirical evidence on nursing students’ attitudes towards mental health nursing and their career interests in this field. It also seeks to identify key influencing factors and to highlight implications for education and workforce planning. Specifically, this review addressed four objectives: (1) to describe nursing students’ attitudes towards people with mental illness and mental health nursing; (2) to examine their career intentions regarding mental health nursing; (3) to identify factors that influence these attitudes and intentions; and (4) to explore the effects of mental health nursing education on these outcomes. These issues were framed to inform educational and workforce strategies to strengthen the MHN pipeline, and aligned with Whittemore and Knafl's problem identification phase clarifying the focus on determinants of attitudes and career choice in MHN and the role of educational experiences in shaping these outcomes (Whittemore & Knafl, 2005).
Search of the Literature
The databases searched were CINAHL, EMBASE, ScienceDirect, PubMed, and PsycINFO (see Supplemental Appendix A for the full search strategy) using a librarian-assisted strategy combining controlled vocabulary and keywords related to mental health, nursing students, education, attitudes, intention, and career choice. The key search terms included “mental health education”, “nursing students”, and “career choices”, with additional synonyms such as “mental health training”; Boolean operators and database-specific subject headings refined retrieval, and limits were applied to peer-reviewed studies published in English between 2000 and October 2025. We limited the review to peer-reviewed journal publications and excluded theses and dissertations because time and resource constraints did not allow for a comprehensive search and appraisal of these sources.
Study Selection
The flow of studies through the identification, screening, eligibility, and inclusion stages is summarized in a PRISMA flow diagram (Figure 1). Three reviewers were involved in the review process. All titles and abstracts were screened independently by two reviewers, with potentially eligible articles progressing to full-text review by the same two reviewers. Any disagreements at either stage were discussed and resolved by consensus, with the third reviewer available to adjudicate when consensus could not be reached. Data extraction and coding were also conducted independently by two reviewers using a standardized template and an a priori coding framework; discrepancies in extracted data or assigned codes were identified through comparison and resolved through discussion among all three reviewers until agreement was achieved. Titles clearly unrelated to MHN or nursing students were removed, followed by abstract screening to assess relevance to attitudes, career interests, and MHN education, after which full texts were appraised for eligibility; the process followed PRISMA guidance to support transparent documentation of identification, screening, eligibility, and inclusion steps (Page et al., 2021), and a reference management program (Zotero, version 7.0.11) was used to organize citations, remove duplicates, and support data extraction. All records were imported into EndNote which was used to remove duplicates and manage the screening process. The database search identified 362 records. After removal of duplicates and clearly irrelevant records, 113 records remained for title and abstract screening. Of these, 51 were excluded as clearly not meeting the inclusion criteria. The full texts of the remaining 62 studies were then assessed for eligibility based on the predefined criteria, and reasons for exclusion at this stage were documented. In total, 22 studies were included in the final synthesis, as summarized in the flow diagram (Figure 1). Reasons for full-text exclusion (n = 40) included: lack of data on intentions or desire to enter a career in mental health nursing (n = 12); absence of outcomes related to student attitudes towards people with mental illness or mental health nursing (n = 20); non-primary research designs (e.g., reviews, commentaries; n = 4); focus on career intentions in non-mental health nursing specialties (n = 1); exclusive inclusion of students in certificate/diploma programs (n = 1); exploration of attitudes towards entities other than mental health or mental health nursing (n = 1); and full text unavailable despite reasonable efforts to obtain it (n = 1).
Screening was conducted by two reviewers (Wahid, Rasha and Cearns, Katrina) who independently screened all titles and abstracts against the inclusion and exclusion criteria, followed by independent full-text review of potentially eligible articles. Discrepancies at any stage were discussed and resolved by consensus, with a third reviewer (Lazarus, Eilean) available to arbitrate when agreement could not be reached, although this was not ultimately required. For data extraction and coding, two reviewers independently extracted study characteristics and findings into a standardized matrix and applied an a priori coding framework aligned with the review objectives (attitudes, career intentions, influencing factors, and educational effects). Coding disagreements were identified through comparison of matrices and resolved through discussion, with refinements to code definitions made iteratively to ensure a shared understanding before final synthesis.
Inclusion and Exclusion Criteria
Inclusion criteria were: empirical studies addressing mental health education within nursing curricula or practice; samples comprising undergraduate nursing students, with or without licensed mental health professionals; primary research (qualitative, quantitative, or mixed methods), including evaluations of innovative educational interventions; studies published in peer-reviewed journals; publications from 2000 onwards; and English language studies. We restricted the search to studies published from 2000 onwards because mental health nursing education and discourse around stigma and career choice have changed substantially over the past two decades, and earlier studies were considered less comparable to contemporary curricula and practice contexts. Only studies published in English were included due to limited resources for translation and full-text appraisal in other languages, which would not have allowed for consistent quality assessment across non-English reports. Exclusion criteria were: non–peer-reviewed publications (including opinion pieces, editorials, and grey literature) and secondary research that did not contribute new empirical data.
Quality Appraisal
Methodological quality was appraised using the appropriate Critical Appraisal Skills Programme (CASP) checklists according to study design (CASP, 2023). Quasi-experimental studies were appraised using the Joanna Briggs Institute critical appraisal tool for quasi-experimental designs (Barker et al., 2024); most studies were rated as fair quality, typically limited by sample size and generalizability, while two were rated poor due to multiple methodological concerns such as uncontrolled confounding, although no studies were excluded on the basis of quality in order to preserve breadth and maximize inclusivity of findings.
Data Analysis
Data were analyzed using the constant comparison method described by Whittemore and Knafl (2005). In the data reduction phase, we organized and condensed the extracted information by grouping studies according to methodology and relevance to the review objectives, and by summarizing key variables (e.g., setting, participants, measures, and main findings) to create a manageable dataset for in-depth analysis. In the data display phase, extracted data were manually coded and organized into matrices for each design type (Tables 1–3), with categories aligned to attitudes, career intentions, influencing factors, and educational effects. In the comparison phase, we systematically examined patterns, similarities, and differences within and across methodological groups to identify recurring themes and relationships. In the final conclusion and verification phase, we refined our interpretations by cross-checking them against the original reports and by considering study quality and context when weighting the findings.
Data Matrix for Qualitative Studies.
Data Matrix for Observational Studies.
Data Matrix for Quasi-Experimental Studies.
Results
The search strategy yielded 362 studies from databases, of which 249 duplicates and irrelevant studies were immediately excluded (Supplemental Appendix C). From the remaining 113 studies, 51 were excluded based on title and abstract screening. After reading the full text of the 62 studies that had passed the screening, a further 40 were excluded, yielding 22 studies for analysis. Key characteristics of the included studies and their main findings related to attitudes and career intentions are summarized in Tables 1 and 2. Where available, we also describe the country and broad program type (e.g., generic undergraduate vs specialized psychiatric nursing) to provide contextual information about the educational settings.
Through constant comparison analysis, four themes were identified:
On average, nursing student attitudes towards MHN and people with mental illness ranged from negative to neutral to positive across the included studies. For the purposes of this synthesis, we use these terms to denote the overall direction of attitudes as reported in each study (e.g., mean scores below, around, or above the mid-point of validated attitude scales, or qualitative descriptions indicating predominantly unfavourable, ambivalent, or favourable views). Negative and neutral attitudes appeared to be more prevalent among first-year nursing student populations, while students in later academic years typically demonstrated more positive attitudes towards people with mental illness (e.g., Alexander et al., 2023; Gyaltshen et al., 2022; Richards et al., 2023). Attitudes regarding the valuable contributions of mental health nurses tended to be positive amongst nursing students, but negative attitudes—such as viewing people with mental illness as aggressive, dangerous, or unpredictable—were also common (e.g., Happell and Gough Nee Hayman-White, 2007; Hoekstra et al., 2010; Thongpriwan et al., 2015). Undergraduate nursing students also frequently reported anxiety about working with people with mental illness, which was more common amongst first-year students and less prevalent amongst students in their third and fourth years of the nursing program.
Mental Health Nursing Career Interests
Across the included studies, nursing students generally expressed low interest in pursuing a career in MHN, with career intention scores most often falling in the neutral to negative range. However, four studies reported comparatively higher levels of interest in MHN as a career (Alsolais et al., 2023; Duman et al., 2017; Lim et al., 2020; Poreddi et al., 2015). Notably, three of these studies focused primarily on students in the later years of their programmes (third or fourth year), suggesting that greater exposure to MHN theory and clinical experiences may be associated with increased career interest (Duman et al., 2017; Lim et al., 2020; Poreddi et al., 2015).
Influencing Factors
Several factors were identified that influenced nursing students’ attitudes towards MHN, their interest in an MHN career, or both, including prior exposure to people with mental illness, feelings of preparedness, and features of MHN education. In addition to these quantitative associations, two qualitative studies provided further insight into students’ sense of readiness for MHN practice. In these studies, undergraduate nursing students explicitly reported feeling underprepared for a career in MHN and described their mental health education as insufficient for working confidently in this field (Hoekstra et al., 2010; Zhang et al., 2021). Students highlighted gaps in practical skills, limited and sometimes poorly structured clinical exposure, and a lack of emphasis on MHN within the broader curriculum, which they perceived as discouraging them from choosing MHN as a career option.
Overall, the included studies indicated that more positive attitudes towards people with mental illness and MHN were associated with increased interest in a career in MHN. Negative stereotypes were associated with decreased career interest in MHN; however, these correlations were generally weak and may be indirect (Ben Natan et al., 2024; Happell et al., 2014b; Hoekstra et al., 2010; Itzhaki et al., 2017; Poreddi et al., 2015). Positive attitudes towards the valuable contributions of mental health nurses showed weak to moderate positive correlations with MHN career interest (Happell and Gough Nee Hayman-White, 2007; Happell et al., 2008a; Happell et al., 2008b). Anxiety about working with people with mental illness was consistently negatively associated with MHN career interest (Happell and Gough Nee Hayman-White, 2007; Happell et al., 2008a). Across the quantitative studies that examined these associations, several reported statistically significant relationships between more favourable attitudes and greater MHN career interest, but effect sizes were typically small (e.g., low positive or negative correlation coefficients), indicating that attitudes explained only a limited proportion of the variance in students’ career preferences. This pattern suggests that, although attitudes are related to MHN career interest, their practical influence on specialty choice is modest and likely overshadowed by other contextual, personal, or structural factors.
Students commonly perceived working in MHN as challenging and, at times, less prestigious than other specialties, but these views varied according to the nature of their prior exposure to people with mental illness. Simple contact or personal exposure (for example, knowing someone with a mental illness in one's social network) had mixed effects on attitudes, and only one study found a clear association between such contact and interest in an MHN career (Ben Natan et al., 2024). In contrast, previous experience providing care for people with mental illness, whether in a nursing role or in non-nursing support roles, was consistently associated with more positive attitudes, lower anxiety towards people with mental illness and MHN, and higher levels of interest in an MHN career (Alsolais et al., 2023; Ben Natan et al., 2024; Surgenor et al., 2005; Thongpriwan et al., 2015).
Several studies reported associations between students’ feelings of preparedness and their attitudes towards people with mental illness. In particular, moderate to strong negative correlations were found between preparedness and anxiety about working with people with mental illness, indicating that students who felt more prepared tended to report lower anxiety (Happell and Gough Nee Hayman-White, 2007; Happell et al., 2008a; Happell et al., 2008b; Happell et al., 2014b; Lim et al., 2020; Poreddi et al., 2015). Two studies also suggested that greater feelings of preparedness were positively correlated with more favourable views of the valuable contributions made by mental health nurses (Happell and Gough Nee Hayman-White, 2007; Poreddi et al., 2015). In addition, several studies identified positive correlations between preparedness and interest in an MHN career, although the strength of these associations varied from relatively strong direct relationships to weaker, more indirect links (Happell and Gough Nee Hayman-White, 2007; Happell et al., 2014b; Happell et al., 2008a; Happell et al., 2008b; Poreddi et al., 2015).
Impact of Mental Health Nursing Education
Several studies discussed the effects of MHN education on nursing student attitudes and their interests in a career in MHN. This will be discussed in the following subcategories:
Studies examining the impact of MHN courses within general undergraduate nursing programmes consistently found significant improvements in attitudes towards people with mental illness and MHN following education, but no corresponding significant changes in students’ interest in an MHN career (Hastings et al., 2017; Surgenor et al., 2005). Similar patterns were observed in studies that specifically evaluated combinations of MHN theory and clinical education, where enhanced attitudes and reduced anxiety did not reliably translate into stronger MHN career intentions (Alsolais et al., 2023; Ben Natan et al., 2024; Hoekstra et al., 2010; Thongpriwan et al., 2015; Zhang et al., 2021). One study identified an association between clinical placement and interest in an MHN career, but clinical placement was not a significant independent predictor of career intention in multivariable analysis (Ben Natan et al., 2024). Together, these findings suggest that standard MHN content embedded in general nursing programmes may be effective for improving attitudes and reducing stigma, but is insufficient on its own to meaningfully shift career preferences towards MHN.
Two studies examined the effects of a problem-based learning (PBL) format in MHN education (Çetinkaya Duman et al., 2017; Duman et al., 2017). In PBL, students work in small groups to solve clinical problems with the educator acting as a facilitator rather than a didactic lecturer. Both studies found that PBL was associated with reductions in negative attitudes towards people with mental illness, although findings for attitudes towards MHN were mixed. In both studies, preference for a career in MHN increased following PBL education, but this change reached statistical significance in only one study (Çetinkaya Duman et al., 2017).
Two further studies investigated the effects of standardised patient (SP) simulations on nursing students’ attitudes and MHN career preferences (Itzhaki et al., 2017; Kameg et al., 2021). In these interventions, actors portrayed patients with mental illness, providing students with opportunities to practise assessment and therapeutic communication in a controlled environment. The findings were inconsistent: one study reported improved attitudes towards people with mental illness following SP simulation (Itzhaki et al., 2017), whereas the other found no significant attitudinal change (Kameg et al., 2021). Both studies observed increases in interest in an MHN career; this increase was statistically significant in one study (Kameg et al., 2021), and in the other, SP simulation showed a significant association with career preferences when examined using correlation analyses (Itzhaki et al., 2017). Taken together, these findings suggest that innovative educational formats such as PBL and SP simulation may enhance attitudes and, in some cases, modestly strengthen MHN career interest, although effects are not uniform across studies.
One study compared the effects of a non-traditional placement in a recovery camp with a traditional placement in inpatient mental health facilities (Patterson et al., 2018). Students in the recovery-camp group showed greater improvements in attitudes and reduced anxiety towards people with mental illness and MHN than those in traditional placements. However, there were no significant differences between the groups in their interest in an MHN career. This suggests that, while innovative recovery-oriented placements may be particularly effective for enhancing attitudes and confidence, they do not necessarily translate into stronger preferences for MHN as a career.
Two studies examined the effects of education delivered by people with lived experience of mental illness (Happell et al., 2014a; Itzhaki et al., 2017). Both studies found that lived-experience-led education significantly improved students’ attitudes towards people with mental illness, and one reported a significant increase in interest in an MHN career following the lived-experience-led course (Happell et al., 2014a). Interestingly, in Happell et al. (2014a) there was a significant increase in positive attitudes towards MHN among students in the nurse-led education group that was not observed in the lived-experience-led group, suggesting complementary benefits of both educational approaches. Taken together, these findings indicate that involving people with lived experience, alongside expert nurse educators, can be a powerful strategy for improving attitudes and, in some cases, enhancing interest in MHN as a career.
A two-part study examined the effects of increasing the length of MHN theoretical and clinical education (Happell et al., 2008a; Happell et al., 2008b). In the first part, conducted after completion of the theoretical course, students who received a longer period of MHN theory reported greater interest in an MHN career than those who received fewer theory hours, although there were no differences in attitudes towards people with mental illness or MHN between the groups (Happell et al., 2008a). In the second part, conducted following clinical placements, students who completed a longer MHN placement demonstrated more positive attitudes, lower anxiety, and higher career interest in MHN than those with a shorter placement (Happell et al., 2008b).
Across studies, reporting of the specific structure and intensity of MHN curricula was heterogeneous, with many articles providing only limited detail on theory hours or placement duration; where such information was clearly described, we note these features in the narrative to aid interpretation of findings. Most included studies were conducted in generic undergraduate nursing programmes with mental health content embedded within a broader curriculum, while a small number drew on settings with more specialised psychiatric or mental health nursing pathways where available. This context is important when considering how far the observed effects of curriculum length and placement design may generalise to dedicated psychiatric nursing programmes.
Discussion
Overall, nursing students’ career interests in MHN were generally neutral to negative across the included studies, mirroring previous reports that consistently rank MHN among the least preferred specialties at graduation (Hunt et al., 2020; Matarese et al., 2019; Njaka et al., 2024; Ong et al., 2017; Shabat & Itzhaki, 2024). Within this review, attitudes towards people with mental illness and MHN ranged from negative to positive, with negative or ambivalent views more common among first-year students and more positive attitudes typically observed in students in their third and fourth years of the nursing program. Attitudes became more positive in later years of study, as reported in several studies of students in their third and fourth years of the nursing program (Alexander et al., 2023; Gyaltshen et al., 2022; Richards et al., 2023; Roach & Tadesse, 2023), which underscores the likely contribution of education to attitudinal change. One possible explanation for the more positive attitudes observed among later-year students is their increased exposure to MHN content and clinical experiences, which may normalize contact with people living with mental illness and reduce anxiety.
These findings should also be interpreted in light of differences between generic undergraduate nursing curricula and specialised psychiatric nursing programs. In several countries, including parts of Canada and other jurisdictions, dedicated psychiatric nursing education prepares Registered Psychiatric Nurses through distinct diploma or degree pathways, with a stronger mental health focus than is typically available in generic programs. As such, the patterns we observed may not fully generalise to settings where students enrol in specialised psychiatric nursing programmes from the outset.
Addressing the first objective, the studies included in this review reported statistically significant, but generally weak, associations between nursing students’ interest in a career in MHN and their attitudes towards both people with mental illness and MHN (e.g., Ben Natan et al., 2024; Happell and Gough Nee Hayman-White, 2007; Happell et al., 2008a; Happell et al., 2008b; Poreddi et al., 2015). The apparent weakness and potential indirect nature of these associations, as reported in the primary studies, offers a plausible explanation for why substantial improvements in attitudes following MHN education did not consistently translate into increased career interest. This suggests that while attitudes are relevant, they may not be the primary driver of specialty choice, and that other contextual, personal, or structural factors exert a stronger influence on students’ decisions regarding MHN careers.
Exposure to people with mental illness emerged as another important factor associated with improved attitudes and greater interest in MHN, particularly when this exposure occurred in caring roles, either within or outside nursing. These findings imply that clinical placement ought to be a key mechanism for enhancing both attitudes and career intentions. However, the evidence in this review indicated that, although clinical placements were significantly associated with more positive attitudes, they were not consistently associated with greater preference for MHN as a career. Notably, one study demonstrated that extending the duration of clinical placement was associated with increased interest in MHN (Happell et al., 2008b), suggesting that current placements may be too brief or insufficiently structured to maximise their impact on career intentions. Further research is needed to examine optimal duration, setting, and pedagogical design of MHN placements.
Feelings of preparedness were also identified as having a significant positive association with both attitudes towards people with mental illness and MHN and with career interest in MHN. In the context of the limited effects of standard MHN education on career choice, this may indicate that existing curricula do not adequately foster students’ sense of readiness for practice in MHN. This interpretation is supported by the two qualitative studies in which students explicitly reported feeling underprepared for a career in MHN and described their education as insufficient for working in this field (Hoekstra et al., 2010; Zhang et al., 2021). Although several included studies measured preparedness and its relationship with education, this construct was not a primary focus of the present review and therefore was not analysed in depth. A dedicated review examining how educational content, pedagogy, and practice exposure shape preparedness and, in turn, influence MHN career intentions would be a valuable next step.
Addressing the second objective, MHN education embedded within general nursing programs was consistently associated with more positive attitudes towards people with mental illness and MHN but not with significant changes in students’ interest in pursuing MHN as a career (Alsolais et al., 2023; Ben Natan et al., 2024; Hastings et al., 2017; Hoekstra et al., 2010; Surgenor et al., 2005; Thongpriwan et al., 2015; Zhang et al., 2021). This disconnect suggests that the current model of MHN education, while effective for stigma reduction and attitudinal improvement, may not adequately address factors that shape career decision-making. Several studies in this review, however, highlighted specific educational strategies with potential to enhance MHN career interest, including extending the duration of theoretical and clinical MHN education, integrating teaching by people with lived experience of mental illness, incorporating standardised patient (SP) simulations, and using problem-based learning (PBL) formats. Given the limited number of studies, methodological concerns in some quasi-experimental evaluations, and the absence of randomised controlled trials, these strategies should be considered promising but preliminary, warranting further rigorous evaluation before widespread adoption.
Beyond the studies included in this review, a broader body of work on psychiatric nursing education highlights similar tensions between improving attitudes and attracting students into MHN careers (Alshammari et al., 2025). International literature suggests that shifts from specialist to generic nurse education models can dilute mental health content and may undermine the preparation and identity of mental health nurses, with concerns raised about reduced quality of MHN education and its implications for workforce supply (Hazelton et al., 2024). Reviews and commentaries on psychiatric nursing education argue for curricula that provide sustained, high-quality mental health content, diverse clinical placements, and pedagogies that explicitly foster interest in MHN as a distinct and valued specialty, rather than treating it as a marginal component of generalist training (O'Brien et al., 2025).
Our findings also align with wider literature on stigma within and towards the psychiatric nursing profession. Recent syntheses indicate that psychiatric nursing is often perceived as a less prestigious specialty and that associative stigma—stemming from working with a highly stigmatized population—can negatively affect both practising nurses and students’ perceptions of MHN as a career choice. These studies emphasize that insufficient mental health training and limited meaningful contact are consistently linked with higher levels of stigma, whereas specialization and positive, recovery-oriented experiences are associated with more favourable attitudes and stronger professional identity among mental health nurses. Taken together, this broader literature reinforces the interpretation that enhancing MHN education is necessary but not sufficient; efforts must also address structural and cultural factors that devalue MHN within nursing.
Implications for Nursing Researchers and Educators
The findings of this review carry important implications for researchers and educators concerned with the MHN workforce. For researchers, there is a need to move beyond documenting low interest in MHN and to systematically investigate determinants of negative attitudes and active de-selection of MHN as a career option. This includes examining individual factors (e.g., beliefs, fears, personal values), educational influences (e.g., quality, timing, and integration of MHN content), and broader structural and professional issues such as role visibility, working conditions, and career progression opportunities. Longitudinal and mixed-methods designs are particularly needed to capture how attitudes and intentions evolve over time and how educational innovations—such as problem-solving oriented approaches, PBL, SP simulations, and structured contact with people with mental illness—shape longer-term career trajectories.
For educators, the challenge is to design and implement curricula that go beyond knowledge transmission to actively cultivate empathy, reduce stigma, and build confidence for practice in MHN. This may involve integrating MHN content across the curriculum, embedding sustained and well-supervised experiential learning opportunities, and deliberately showcasing MHN as a valued and viable career path. Prolonged and diverse clinical placements in community, in-patient, and recovery-oriented settings may foster greater readiness and self-efficacy, especially when paired with reflective debriefing and role-modelling by enthusiastic MHN practitioners. Aligning educational strategies with the factors identified in this review—particularly exposure, preparedness, and meaningful contact—may help to narrow the gap between societal mental health needs and the capacity of the nursing workforce to respond. More broadly, this review underscores the need for research examining how different models and experiences of nursing education influence students’ subsequent specialty choices and long-term practice trajectories.
Limitations
This review has several limitations that should be considered when interpreting the findings. Because of time and resource constraints, the search was not exhaustive and was limited to a subset of databases and to English-language, published studies, which may have led to the exclusion of relevant international or non-English studies and introduced publication bias. The inclusion criteria, which required studies to address both attitudes towards MHN and career preferences for MHN, may have been overly restrictive and could have excluded work focusing on only one of these domains. Screening, quality appraisal, and data extraction were conducted by a single reviewer, increasing the risk of selection and appraisal bias. Two included studies were rated as poor quality, potentially influencing the synthesis, although they were retained to maximize inclusivity. Finally, the absence of randomized controlled trials and the predominance of cross-sectional and quasi-experimental designs mean that causal inferences about the effects of specific educational approaches on career interests cannot be made. Two included studies were rated as poor quality because of multiple methodological concerns (e.g., uncontrolled confounding, small samples). These studies were retained to preserve the breadth of available evidence on MHN attitudes and career intentions; however, their findings were interpreted cautiously and given less weight in the synthesis, consistent with recommendations for inclusive yet quality-sensitive integrative reviews (Whittemore & Knafl, 2005).
Conclusion
This integrative review demonstrated that nursing students’ attitudes towards MHN are significantly, but only weakly, correlated with their interest in pursuing MHN as a career. This weak association helps explain why substantial improvements in attitudes following MHN education do not reliably result in increased career interest. Instead, factors such as contact with people with mental illness—particularly in caring roles—and students’ feelings of preparedness appear to exert a more substantial influence on MHN career intentions. The review also identified several educational strategies with potential to enhance the attractiveness of MHN, including extended theoretical and clinical exposure, involvement of educators with lived experience of mental illness, integration of SP simulations, and the use of PBL approaches. To address the persistent limited appeal of MHN, these educational innovations must be explicitly aligned with the drivers of student attitudes and career choice. Additional, methodologically robust studies are needed to confirm the feasibility and effectiveness of these approaches in strengthening nursing students’ interest in MHN and ultimately contributing to a more sustainable specialist workforce.
Supplemental Material
sj-docx-1-cjn-10.1177_08445621261447369 - Supplemental material for Factors Influencing Nursing Students’ Attitudes and Career Interests in Mental Health Nursing - An Integrative Review
Supplemental material, sj-docx-1-cjn-10.1177_08445621261447369 for Factors Influencing Nursing Students’ Attitudes and Career Interests in Mental Health Nursing - An Integrative Review by Katrina Cearns, Eilean Rathinasamy Lazarus and Rasha Wahid in Canadian Journal of Nursing Research
Footnotes
Acknowledgements
The authors would like to thank the Librarian, Trent University, Canada for his valuable assistance in developing and refining the literature search strategy for this review.
Ethics Approval and Consent to Participate
Ethics approval and consent to participate were not required for this review because it synthesizes data from previously published studies and does not involve primary data collection from human participants.
Consent for Publication
Not applicable.
Authors’ Contributions
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability
Data sharing is not applicable to this article as no new primary data were generated or analyzed in this scoping review.
AI Declaration
This article involved the use of generative artificial intelligence tools to support language editing and formatting of the manuscript. The authors reviewed and take full responsibility for all content. No AI tools were used for data collection, data analysis, or interpretation of results.
Supplemental Material
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References
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