The role of mental health nurses in supporting young people’s mental health: a review of the literature

Jessica Louise Arnold (Department of School Health, Derbyshire Healthcare NHS Foundation Trust, Derby, UK)
Charley Baker (Faculty of Medicine and Health Sciences, School of Health Sciences, University of Nottingham, Nottingham, UK)

Mental Health Review Journal

ISSN: 1361-9322

Publication date: 10 September 2018

Abstract

Purpose

Adolescent mental health issues are on the increase, in particular depression, which is now a major public health concern globally. Mental health education is important and young people’s awareness of mental health is potentially limited. This is one factor that creates barriers to seeking support. School nurses and educational professionals recognise that they do not necessarily have the required skill base to support emotional health concerns with young people. The purpose of this paper is to synthesise qualitative evidence related to the nurse’s role in supporting adolescents.

Design/methodology/approach

A literature review using a systematic approach was undertaken, predominantly through collection of primary qualitative research studies. In total, 22 published studies are included in this review, extracted from four databases – CINAHL, Embase, Medline and Scopus.

Findings

This review shows that awareness of mental health is needed early in adolescence, while at school, to encourage young people to access support and have knowledge of their own emotional health. The need for further mental health education and provision is asserted.

Practical implications

Young people benefit from someone who is accessible and familiar to them in schools so that they can access emotional support as and when needed. Careful involvement of families (including extended families) is noted. It is proposed that this role should be a mental health nurse role, who should be accessible within the school environment.

Originality/value

This paper is original and adds to existing knowledge that mental health challenges are increasing, and more needs to be done in schools to promote mental health and reduce the stigma associated with seeking support.

Keywords

Citation

Arnold, J. and Baker, C. (2018), "The role of mental health nurses in supporting young people’s mental health: a review of the literature", Mental Health Review Journal, Vol. 23 No. 3, pp. 197-220. https://doi.org/10.1108/MHRJ-09-2017-0039

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Publisher

:

Emerald Publishing Limited

Copyright © 2018, Emerald Publishing Limited


Introduction

All types/fields of nurses have a role to play in supporting young people who present with emotional difficulties. Haddad and Gunn (2011) asserted the importance of clinicians’ skills being “robust” and “up to date” with evidence-based practice, and that appropriate clinician knowledge of depression is vital for effective treatment. Merrifield (2015) asserted that every school should have a designated mental health nurse assigned as a point of contact by 2020; yet the RCN (2015) has noted a depletion in school nurses since 2010 in the UK, which might be a barrier to overall holistic nursing provision in school settings. Shocket and Ham (2004, cited in Walsh 2009) raised the importance of mental health promotion within the curriculum in order to reduce stigma, reinforcing the view that a collaborative approach is needed between mental health nurses and schools. This literature review aims to address a gap in knowledge around young people’s mental health help seeking and the role of mental health nurses in this area, through a systematic review and narrative synthesis of existing research.

Background

Mental health conditions – and depression in particular – are common among adolescents yet one of the most overlooked and undertreated areas of mental health (Maurizi et al., 2013). Garmy et al. (2014) stated that depression may not only affect a young person’s mood, but also academic performance and social relationships, potentially causing isolation. The symptoms of depression are broadly defined, consisting of emotional upset and anxiety, both of which may be expected during adolescence; this indicates the difficulty of effectively defining clinical thresholds for diagnosis where there are concerns (National Institute of Clinical Excellence (NICE), 2013; Knapp et al., 2016). McCann et al. (2012) found an absence of information available to adolescents concerning the signs and symptoms of depression and found nurses not effectively responding to adolescents. Similarly, Doyle et al. (2017) identified mental health professionals’ poor understanding of the motivators behind self-harm in adolescence being a concern, they additionally asserted; professionals responding negatively towards young people having a detrimental impact on the engagement process as a result. Furthermore, O’Reilly et al. (2016) identified quality of communication between a practitioner and young people being a complex area to master.

Adolescent depression is a national and global concern (World Health Organization (WHO), 2014; Reeves and Riddle, 2014). Kieling et al. (2011) argued that mental health resources and policies are scarce worldwide and that promotion of mental health is a “worldwide challenge”. Bustreo (2014) further asserted that there has been insufficient investment and attention given to the provision of adolescent health globally. Thornton (2015) stated that 10–20 per cent of young people will experience depression in their youth. This highlights the importance of the need for health education and its provision (WHO, 2014; Kieling et al., 2011; McCann et al., 2012). It is also significant that WHO (2014) recognise that prevention programmes reduce depression in children. An unacceptable 70 per cent of young people with mental health problems are not offered intervention (McDougall, 2011), with potentially serious implications – suicide is the third most common cause of death in adolescents (WHO, 2014; Auerbach et al., 2015; Avenevoli et al., 2015; Bauman et al., 2013).

Early intervention and collaborative working is seen to empower young people’s resilience and maximise their inner resources to prevent problems in later life (McDougall, 2010). This is a view shared by Kieling et al. (2011) who all advocated early intervention and prevention as vital to avoid mental health difficulties progressing into adulthood. Despite this there is still a gap between needs and resources (Belfer, 2008) and limited availability of trained nurses and appropriate services to support adolescents remains an ongoing concern (Kaye et al., 2009).

In America, integration of mental health centres within schools in under-served areas resulted in a reduction of stigma which empowered adolescents to access support earlier (Parasuraman and Shi, 2014). This view from the USA reinforces Merrifield’s (2015) view that UK clinicians need to be “visible” within schools. Hunt (2008) also concluded that a united approach is significant when educating adolescents about the signs and symptoms of depression. Mental health problems during adolescence are an important public health issue. The Chief Nursing Officer’s Professional Leadership Team (2012) recognise that nurses in universal services are crucial to positive mental health, off-setting potential future health inequalities that can stem from poor mental health. Health Education England planned to put a specialist perinatal mental health clinician into every birthing unit by 2017 (PHE, 2015); not only does this confirm key roles for nurses at a universal level, but also the need for coherent services for all to access mental health support (PHE, 2015).

Despite its need, mental health support in schools by specialist mental health nurses is restricted to certain areas and far from a common finding. Historically, the call for closer co-working has been clearly stated – Hunt (2008) outlined the importance of raising awareness of mental health in schools and emphasised collaboration between school professionals and nurses. However, he pointed out that stigma associated with mental health is a factor in adolescents not seeking support. It could be that such stigma reduces the perceived role for (specifically mental health trained) nurses in school settings. As Wolpert et al. (2015) noted, the three-year project Targeted Mental Health in Schools only targeted areas of socio-economic deprivation. McDougall (2011) is emphatic that depression in young people is still not being recognised or treated in the UK until it becomes advanced. While strong local working relationships may be present it may be challenging to work interactively and across disciplines while there are fiscal pressures on both the health and education sectors. Additionally, ambiguity faced by nurses who lack skills or experience in mental health presents barriers to supporting young people emotionally (Giandinoto and Edward, 2014; Arnold and Mitchell, 2008).

Rationale

This review focuses on synthesising what is known about help-seeking behaviour in young people who experience mental health issues and considers the role of nurse to facilitate and support improvement mental health – specifically considering a potentially extended role of mental health nurses with young people.

Aim

The aim of this study is to critically synthesise evidence related to the nurse’s role in supporting adolescents in their mental health, with an overall aim of considering the role of mental health nurse’s in supporting young. The research questions that guided this review were broadly speaking:

RQ1.

How can mental health nurses encourage and support young people to seek support for their mental health in schools?

RQ2.

What might prevent young people from accessing support for their mental health and how might mental health nurses support reducing barriers to help seeking?

Methods

Cochrane’s guidelines were broadly followed by adhering to strict inclusion and exclusion criteria (Table I) while taking a systematic approach when extracting critique and analysis. Structure was also influenced by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009), whose checklist provides a robust protocol for preparation and reporting of findings and ensures methodological rigour: Moher et al. (2015) recommended PRISMA protocol as an essential component of any systematic review in healthcare. The searches and analysis for this paper were carried out in 2016. This review was carried out by the first author (JA) supervised by the second author (CB).

Alternative methods

A critical review (or narrative review) was considered for this paper; however, due to the subjectivity of lack of defined method the research may have been open to bias. A literature review was considered to be the most suitable for this paper as a systematic literature review prevents pieces being viewed in isolation but encouraging comparison (Aveyard, 2014). However, it must be recognised that for this particular review methodology to be accurate, all relevant studies must have been identified; efforts were made to have a clear and transparent selection procedure as reported in this section.

Information and sources section

Inclusion and exclusion criteria were used to manage the volume of literature as well as to strengthen rigour and ensure any bias is reduced (Table I). An initial search was conducted using “Boolean phrasing” involving search terms within the title and combinations of “OR” and “AND” (Appendix 1). Alternatives for each word were included as Aveyard (2014) suggested synonyms increase availability of literature beyond the original search. Four databases (CINAHL, Embase, Medline and Scopus) were searched.

A comprehensive search was carried out to gather articles which matched the search criteria. Both existing literature reviews and empirical research were included in the selection of journal articles due to the limited number of primary research papers on this topic. Even so, Coughlan et al. (2007) warned that secondary sources may be influenced by the author’s opinion and not solely based on the research undertaken. In this respect, careful consideration was given to selection of secondary review articles to analyse their suitability and relevance to the research question.

Study selection

After rejecting studies that did not meet the inclusion criteria (such as duplicates), 22 articles were included for analysis (Table AI). These papers captured a wide range of qualitative material to underpin a mixed methodology approach (Lincoln and Guba, 1985). Siu and Comerasamy (2013) proposed that by using quantitative (positivist) with qualitative (interpretivist) paradigms, “rigour” is firmly established. From 22 articles, the majority of empirical studies (17) were qualitative in their primary research using interviews, focus groups, surveys or a combination of questionnaires and focus groups for their inquiry. The remaining four studies employed a literature review based on primary research; one of the studies reviewed qualitative literature that was both empirical and non-empirical. Combining positivist and interpretivist methodologies allowed “theory triangulation” to occur. Denzin and Lincoln (2005) advocated this concept for social research studies to provide a deeper quality of research. Triangulation has been referred to by Glesne and Peshkin (1992, cited by Kolb, 2012) as use of a range of methods to collect data, and Casey and Murphy (2009) affirmed that this provides a more holistic overview involving comparison of literature from multiple perspectives.

Critical appraisal

Critical appraisal of selected articles is paramount to ensure trustworthiness and assess relevance to a particular research question. Glasper and Rees (2013) argued that healthcare professionals should conduct critical appraisal to evaluate an article’s content as well as quality and they implied that poor research produces unreliable results. For this review, Critical Appraisal Skills Programme (CASP) tools (Singh, 2013) were used as a process of quality appraisal for the publications chosen in this study. CASP is identified as suitable for a range of qualitative and quantitative analysis (Glasper and Rees, 2013). In total, 22 published studies are included in this review, extracted from four databases – CINAHL, Embase, Medline and Scopus. The relevant CASP tool was applied to every article. Table AI shows the comparative considerations of the quality of the different studies.

Thematic synthesis of results

Familiarity with the studies allowed a summary of findings to be written up while identifying relevant themes. Aveyard (2014) recognised that this is achieved through re-reading to ensure familiarity with content. This is similar to the “constant comparative method” supported by Strauss and Corbin (1998), which enables the researcher to go “back and forth”. Braun and Clarke’s (2006) coding system was used once familiarity with the material was achieved, as a more structured approach, ensuring no key concepts were overlooked. This is considered most appropriate for those seeking to interpret qualitative data (Ibrahim, 2012). Braun and Clarke (2006) stated that thematic analysis ensures an extraction of themes whilst systematic analysis allows comparison of similarities and differences within journal articles. Focusing on uncovering themes using Braun and Clarke’s method, a colour coding system was adopted to select themes across the papers. Coding can be a manual or computerised process, as both Kelle (2004) and Seale (2000) noted. In this case, coding was undertaken manually. Immersion and repeated reading lead to identification of meanings and patterns within the data. The spread of these themes across the articles was diverse, and published researchers gave greater attention to Themes 1 and 2, and to a lesser extent, Theme 4, making these stronger themes. A matrix was constructed to compare key themes during analysis (Table AI). Four overarching themes were identified (Table AII): “Young People’s help-seeking behaviours”, “The appropriateness of school as a setting for mental health support”, “Working in partnership with parents/guardians” and “Barriers to help seeking”.

Synthesis of studies

Theme 1: young people’s help-seeking behaviours

This theme encapsulates what is known both from and about adolescents when they seek support from adults. Rickwood et al. (2005, p. 4) defined “help seeking” as actively seeking assistance from others through effective communication in response to a current problem. This is reliant on the presence of significant and trustworthy people within the young person’s social or family network (Rickwood et al., 2005). For some, help seeking may be sought from familiar professionals – young people referred mostly to teachers or youth workers (Rickwood et al., 2005). Peer support is regarded as the preferred source for help with personal difficulties; as this study confirms, few young people seek professional advice in the first instance (Rickwood et al., 2005). However, it is within the presence of a skilled adult that they are most likely to disclose their feelings and receive the help they need. Oliver et al. (2008) also emphasised the importance of family relationships and social support as a protective factor for help-seeking behaviour during adolescence.

From a young person’s perspective, McCann et al. (2012) observed that trusting relationships with significant family members empowers open conversation, while experience of conflict or unsupportive family structures compromises their ability to cope – an absence of communication can contribute to long-term internalising of emotion and exacerbation of symptoms (McCann et al., 2012). Young people expressed how they were emotionally affected by fragmented relationships which caused anger and blame towards family members; in turn, their own emotional state began to deteriorate rapidly (McCann et al., 2012).

Adolescents described in the most recently published study by Martínez-Hernáez et al. (2014) are similar to those by Rickwood et al. (2005); both find self-reliance and social support important when resolving emotional distress. For some young people, denial of their emotional state (especially depression) is a prime obstacle to seeking help (Martínez-Hernáez et al., 2014). Issakainen and Hanninen (2016) showed that avoidance of issues and not wishing to burden others can also be a coping strategy that prevents help seeking. Some young people express lack of confidence to ask for assistance from professionals (Martinez-Hernaez et al., 2014), and risk not being attended to.

O’Connor et al. (2014) noted that mental health issues emerge at high levels during adolescence: however, this age group is least likely to seek support. Surprisingly, within this research, adolescents identified in surveys as “health-conscious” did seek help (O’Connor et al., 2014). It is worrying to see in Fleming et al.’s (2012) study the measures some young people may resort to if referred prematurely to a health professional; for some it is said that the distress could exacerbate self-harm or suicidal thoughts.

Social support from friends and peers is identified as a strong motivator for actively seeking help. This is enforced by McCann et al. (2012), Martínez-Hernáez et al. (2014) and Rickwood et al. (2005). However, it is important to note that help seeking may only occur if family and peers are educated about mental health symptoms and know of available services (Kelly et al., 2007).

Pryjmachuk et al. (2011) found that young people seek assistance from school nurses because they are less stigmatising and part of normal school life. With that said, nurses were found to lack confidence in their skills to give appropriate support (Pryjmachuk et al., 2011). However, as Spratt et al. (2010) asserted, through trust and by listening to young people nurses allowed them to re-regain control of their emotions with an enhanced resilience.

Core issues identified within this theme show that help-seeking behaviours are influenced if young people have significant trusting adults around them. This empowers young people to access help from professionals (McCann et al., 2012). Oliver et al. (2008) and Rickwood et al. (2005) suggested that within the presence of an adult, young people are more likely to discuss their inner emotions and access help.

Theme 2: the appropriateness of school as a setting for mental health support

Sakellari et al. (2014) hold the view that mental health should be a subject that is taught early before young people create pre-conceived ideas of depression and associated stigma. Their experimental group uncovers negative perceptions from adolescents who have had no education around mental illness. This is reinforced by Lovett et al. (2011) who noted that negative views towards mental illness can prevent or delay seeking help. Furthermore, Woolfson et al. (2008) observed that focus groups are important for teaching health issues to peers within a school setting. For this to be effective, it must be taught through each year to progress and consolidate mental health literacy for each age group. Kelly et al. (2007) and Woodhouse (2010) claimed that school is the most universal and convenient setting for young people to access mental health support. However, ongoing consultation with young people should take place to ensure content remains relevant and accommodates need (Woolfson et al., 2008).

Onnela et al. (2014) shared the opinion of Kelly et al. (2007) and Woodhouse (2010), recommending that mental health promotion should be prominent in schools. Risk factors for young people with a family history of mental health problems can be reduced by empowering them to seek assistance at school where rapid support can be delivered. With this in mind, the school ethos must enhance wellbeing for its students within an appropriate environment – arguably, schools are the only universal setting for delivery of metal health promotion (Onnela et al., 2014). Spratt et al. (2010) highlighted two advantages in having schools as the central location to access support: first, accessibility of nurses enhances young people’s autonomy allowing them to seek advice without the knowledge of others (especially their parents). Second, in rural areas young people can be isolated from access to other health services.

Pryjmachuk et al. (2011) proposed that teaching mental health should be delivered by someone who is familiar to the children or young people. Woolfson et al. (2008) raised the importance of young people’s views and stressed that teachers should have a “thorough knowledge of the subject” (p. 796). Puolakka et al. (2011) echoed this in a study which sees mental health as multi-disciplinary, requiring skilled professionals such as a Personal Social Educational teacher who carries substantial experience of mental health (Woolfson et al., 2008). Those without a mental health specialism can raise uncertainty about their delivery (Puolakka et al., 2011), and teachers who have a robust knowledge base are essential for effective teaching (Puolakka et al., 2011). This is evident within Puolakka et al.’s (2011) research where they extract information from focus groups conducted with school professionals.

Although mental health promotion is happening in schools, Pryjmachuk et al. (2011) reminded us of the limitation of school nurses’ knowledge and skills. Even though mental health is becoming a considerable part of their role, many nurses are not adequately trained: this was a common theme in Pryjuachuk’s (2011) focus groups involving four school nursing teams. Bartlett’s (2015) study also empathises the importance of specialist mental health provision to support school nurses. Spratt et al. (2010) confirmed an absence of inter-agency work across these interfaces noting that quality is not always evident or even sustained. As this implies, effective communication and partnership across universal services and specialist services is of paramount importance. The absence of specialist mental health services such as Child Adolescent Mental Health Service (CAMHS) is reflected in studies by Pryjmachuk et al. (2011) and Bartlett (2015). It seems collaborative working with CAMHS is always reflective of particular individuals within the service and staffing changes inevitably affect partnerships with schools (Pryjmachuk et al., 2011).

“Togetherness” is young people and professionals working in collaboration – mental health is understood to be everyone’s business (Woodhouse, 2010). Even though Woodhouse (2010) suggested mental health nurses are ideally placed to promote health literacy, Pryjmachuk et al. (2011) thought this may not be ideal because young people express a preference to talk with a familiar person. Consultation allows mental health nurses to contribute to young people’s wellbeing together with professionals already involved (such as teachers) – professionals to support those who need it (Woodhouse, 2010). Even so, Onnela et al. (2014) stressed that young people need to know how to access such advice if required. Both Oliver et al. (2008) and Puolakka et al. (2011) argued the need for mental health professionals to be known to young people and have a physical presence within the school setting.

Within the universal school setting, Kelly et al. (2007) stated the need for peer support training. They illustrated how young people would be willing to access peers rather than a health professional. Furthermore, Burns and Rapee (2006) valued the importance influential peers.

In summary, Sakellari et al. (2014) and Woolfson et al. (2008) indicated the need for mental health to be promoted early to adolescents and at regular periods throughout their schooling. Importantly, it seems teachers are influential in delivery of this subject, but require professional support from nurses through consultation. Pryjamachuk (2011), Bartlett (2015) and Spratt et al., (2010) shared the opinion that school nurses are in a pivotal position to support young people. However, the studies suggest they do not have the necessary skills base or knowledge to effectively support young people with mental health issues. This requires support from specialist health professionals and further training for school nurses to instil confidence in their role. The role of school nurse is often complimented or can be complimented by involvement of parents.

Theme 3: working in partnership with parents/guardians

This theme examines professionals working in partnership with parents and the challenges placed upon professional boundaries when young people do not want inclusion of their parents. Puolakka et al. (2011) reminded us that young people should not be seen in isolation from parental involvement. He argued that families are central to young people’s emotional wellbeing. Working with parents is core to strengthening the relationship between professionals, young people and families. By establishing this triangulated approach, young people’s resilience can encompass healthier coping strategies. Communication and co-operation with parents aids the process of acquiring appropriate specialist mental health involvement (Puolakka et al., 2011). Puolakka et al. (2011) outlined the extent of their data analysis using the “grounded theory”, showing rigour within this particular study.

Bartlett (2015), whose study analysed only primary research in their literature review, recognised the importance of moving beyond the nuclear family. The extended family, including grandparents and others of significance, can be involved. However, Bartlett (2015) warned that family involvement can lead to unrealistic pressures placed upon professionals, creating conflict within supporting the relationship (Bartlett, 2015). Despite this, Sawyer et al. (2012) whose research is strengthened by its choice of the Randomised Control Trial (RCT) method, argued the need for professionals to bridge communication gaps in families – they identify this as central to young people’s emotional health. Yap et al. (2012) asserted that regular contact between young people and their parents is paramount within the therapeutic relationship.

Some attention must be given to difficulties faced by parents through their involvement. Coverdale’s (2015) study describes the stigma encountered by some parents when asking for support, seen as a sign of failure in their parenting. For others, not knowing which services to access causes some difficulty (Coverdale, 2015). McCann’s study emphasises the need to increase families’ understanding of mental health, in particular depression. McCann et al. (2012) showed that family members can strengthen resilience in adolescents enabling them to seek support from professionals. Moreover, Burns and Rapee (2006) argued for a community approach to reduce misconceptions and misunderstandings about this condition.

Overall, building trusting relationships is central for nurses in supporting young people’s mental health. However, a dilemma comes when parental involvement causes conflict and tests professional boundaries, as Bartlett (2015) identified. Nevertheless, certainty around professional boundaries is somewhat unclear, leaving nurses in a problematic position (Puolakka et al., 2011). Given that evidence suggests inclusion of parents is paramount in contributing to a child’s positive emotional growth, it is important to remember that this may not always be possible, especially if young people themselves do not understand the “norm” for emotional wellbeing or when to seek help.

Theme 4: barriers to help seeking

Barriers to help seeking and access of services was a common theme across articles, with many young people and parents making explicit reference to the obstacles they faced. Key issues in Gulliver et al.’s (2010) study involved worries relating to accessing services, particularly if a past negative or “bad” experience had occurred. For some participants within Martínez-Hernáez et al.’s (2014) study, a lack of knowledge of available services and their accessibility were prime barriers to young people getting the right treatment. Martínez-Hernáez et al.’s (2014) research demonstrates minimal flaws as they sought collection of information through focus groups, ensuring all relevant information was rigorously gathered.

Feelings of fear (such as shame) further prevented adolescents accessing services and professionals (Gulliver et al., 2010). Coverdale (2015) highlighted stigma as a barrier faced by parents seeking advice for their child. The parents in this study perceived accessing help as a reflection of their parenting. For many parents identified by Coverdale (2015), they did not feel knowledgeable about services available for emotional health support. A lack of understanding from both young people and their parents about emotional wellbeing can manifest itself in certain ways, one being avoidance of services and professionals. This can have implications for the young person (Issakainen and Hanninen, 2016) and Burns and Rapee (2006) recognised the need to raise mental health literacy in order to improve rates of access.

A sense of failure or being different from others has also been raised as creating barriers; exacerbation of negative feelings can manifest progressively over years (Issakainen and Hanninen, 2016). The strengths of Issakainen and Hanninen’s (2016) study lie in selection of participants through collection of their narratives which provide a first-hand account. As these narratives come directly from young people, they have not been interpreted per se, making them vital evidence for future research. However, Issakainen and Hanninen’s (2016) study does not explicitly define the three-stage analysis process which has been applied, therefore as a consequence it could be considered weaker evidence.

Sakellari et al. (2014) are keen to show that adolescents who have had no prior involvement with mental health professionals tended to portray professionals as different in appearance from others. Likewise, in their illustrations they drew children suffering from a mental illness with no recognisable gender characteristics and with bright red eyes. These were in contrast to the focus group who were educated around mental illness prior to being asked to draw pictures of individuals who may be suffering from a mental illness. Representations of mental illness can create many misconceptions when adolescents have not encountered an individual with an illness nor had prior understanding of illness (Sakellari et al. 2014). Lovett et al. (2011) provided ample evidence that young people do consider mental illness stigmatising. Lovett et al.’s (2011) focus groups provide inclusion of children and young people’s perspectives combined with a well-founded discourse analysis, which is highly regarded and reliable. However, young people’s views could be influenced by peers within the focus group which meant they did not challenge other opinions (Lovett et al., 2011). Sakellari et al. (2014) and Woolfson et al. (2008) both recommended educating children at a young age before they develop constructed and fixed views of mental health. While this may assist help seeking, success ultimately depends on forming a united approach between health professionals and schools.

Burns and Rapee (2006) revealed gender dynamics relating to emotional competence in depression. Girls demonstrate a much higher level of mental health literacy than boys. Girls are able to distinguish between acute emotional upset in everyday life and depressive symptoms which require professional support. In consideration of Burns and Rapee’s (2006) findings, a wide range of participants were included which shows a diverse range of adolescent behaviour. However, it must be recognised that questionnaires may not capture all significant data. Furthermore, data were primarily collected from young people of higher socio-economic background as opposed to children from a variety of economic contexts. This could be a disadvantage, which Burns and Rapee (2006) recognised.

Considering the whole issue of perception of barriers, it is clear that education around mental health is a necessity to avoid misconceptions and instil knowledge of accessible services. This demonstrates the importance of healthy emotional regulation and development and knowing when to seek support if things extend beyond normality for a particular person.

Discussion

Summary of evidence

As identified in the background of this paper, adolescent mental health problems are now categorised as a public health issue, not only nationally but globally (WHO, 2014; Reeves and Riddle, 2014). Early intervention with all adolescents is identified as being a need to strengthen their knowledge of mental health – health literacy – and also resilience and inner resources before the symptoms or experiences develop or advance (McDougall, 2010). However as Kieling et al. (2011) and Belfer (2008) asserted, early intervention can only be achieved with more mental health nurses within the school setting to address this worldwide challenge and concern. A wide range of considerations around the involvement of peers and also extended family is required, specific to each young person.

This analysis shows that all professionals can support young people when they are experiencing mental health problems by using interpersonal skills to listen and provide empathetic responses in a non-judgemental way. It does appear, however, that young people who have had a negative experience when reaching out for help may not seek help again. Barriers can be formed against peers and adults as a sign of weakness in a person’s ability to access support. Stigmatised perceptions about mental health may be held by young people and the adults around them, which prevents them from accessing support and leads to suppression of emotions. As discussed in the background, this again raises the importance of adolescents being identified and supported before mental health symptoms become too advanced. Three broad areas from this analysis can be synthesised as requiring discussion: nurses’ own skills and knowledge, communication between professionals, and health education promotion to young people.

Nurses’ skills and knowledge

The skill and knowledge base of nurses was a potential area that crossed a number of the research studies, as acknowledged by Giandinoto and Edward (2014) and Haddad and Gunn (2011). It is argued that nurses have responsibility to acquire and develop skills and knowledge to effectively support young people. Even so, Ruddick (2008) and Kenny (2014) declined to place sole responsibility on nurses who have specialised in mental health – they recognised the necessity of including all nurses of any specialism. They argued that all nurses possess interpersonal skills, such as effective communication and active listening, to be able to empower positive mental health. Ruddick (2008) and Bowers et al. (2009) shared the same view emphasising how nurses can undertake active listening and convey empathy through effective communication – these are core for any nurse practitioner. This is in line with NICE’s (2011) guidelines, which recognise the importance of clinicians building trusting, empathic and non-judgemental relationships.

These findings contribute to ways of solving the problem by emphasising the importance of nurses, particularly school nurses, being trained in mental health practice. PHE (2015) reminded us that not every adult who works with children and young people can be a mental health expert and schools continue to raise problems about access to support when their provision reaches its limit. Nurses need to share their knowledge with one another through effective liaison and consultation (Woodhouse, 2010) so that they are able to support any young person who needs support emotionally. Inter-agency working is key here. As raised in the background literature, not only is it significant for nurses to respond positively to disclosures of depression and self-harm from young people as Doyle et al. (2017) pointed out, but McCann et al. (2012) stated this is essential for engagement. This positive interaction needs to happen to improve healthcare experience for young people (Doyle et al. 2017). Given that it is of high importance to master, effective, empathetic healthcare interactions remain to be one of the most complex areas to perfect for some clinicians (O’Reilly et al. 2016).

Communication between professionals and multi-agency working

Quality provision is pivotal to supporting young people’s emotional health and wellbeing. Oliver et al. (2008) and Puolakka et al. (2011) see the need to have a health professional who has a physical presence within school. Communication between school and health professionals is an issue as the absence of specialist mental health professionals, such as CAMHS, is significant (Pryjmachuk et al., 2011; Bartlett, 2015). This is also evident in the work of Wolpert et al. (2015) who showed that mental health services are targeted to specific areas in UK schools. School nurses are relied on to form a collaborative approach with teachers and individual schools as they appear to be the only potential support accessible to teachers. However, a depletion of school nurses is not advantageous to schools or to their pupils (RCN, 2015) and findings here strongly suggest health professionals have a presence in schools (Oliver et al., 2008; Puolakka, 2011). Merrifield (2015) also emphasised the need for clinicians in the UK to be “visible” and Puolakka et al.’s (2011) study is of the same opinion. Overall, this seems to be a long-standing issue which is yet to be resolved for young people. We make further recommendations below.

Importance of health promotion and emotional literacy with young people

In planning mental health promotion, young people’s views should be included before delivery is started as findings do show what young people would like to gain. Differences which arose during teaching were clear within the findings, and most people want teaching to be done by a familiar adult with thorough subject knowledge; others noted that health professionals would be suitable for their needs (Woolfson et al., 2008). However, both Pryjmachuk et al. (2011) and Woolfson et al. (2008) stated the importance of delivery by someone with good understanding of the subject. What is clear through this review is that young people would like teaching to take place with peers in the school setting.

Based on the findings of Burns and Rapee (2006), Sakellari et al. (2014) and Lovett et al. (2011), it is clear that lack of emotional literacy risks creating pre-conceived ideas about mental illness. As Sakellari et al. (2014) noted, discussions between peers and family who have minimal experience of mental health can cause problems and prevent seeking of help leading to deterioration of health. Having knowledge around mental wellbeing is significant in preventing misconceptions and Sakellari et al.’s (2014) work proved to be a significant insight into how young people spoke about mental illness.

The need for this to happen at a much younger age is clear so that young people can consolidate their later learning. The Children’s Society (2015) note that depression is now occurring in younger children. Finding an appropriate health professional who is confident with their knowledge and who is accessible is strongly recommended by Pryjmachuk et al. (2011). Whilst recognising mental health illness occurs in adolescence, as stated earlier by PHE (2015), it is crucial to have early intervention. Moreover, recognition of the significant need to educate and support young people is also necessary. Peer support is valued as a strong motivator towards help-seeking behaviours; however, help seeking will only occur if family and/or young people are educated about mental health and symptoms of deterioration (Kelly et al., 2007). McCann et al. (2012) proposed the need for education within this area. However, with limited professionals available, confirmed by the RCN (2015) and Wolpert et al. (2015), this proposal may not be achievable.

Implications for mental health nursing

Overall, it is clear that these three areas of concern outline opportunities to improve and support young people’s emotional health. The findings contribute towards ways of improving this problem. It has been shown that if conditions are created for young people to seek assistance in an environment that is accessible and comfortable, emotional problems might not manifest which prevents mental illness in adulthood – a concern in the British population today (Wanless, 2016). Reflecting on the three areas addressed in the discussion, it is clear that multi-agency working between nurses of different disciplines is needed. Furthermore, seamless communication between mental health nurses, school nurses and educational professionals must be upheld for adolescents to be supported with immediate effect. Nurses acquiring the necessary skills and knowledge are central to adolescents receiving information and support they need as Ruddick (2008) and Kenny (2014) clearly identified.

Mental health nurses then need to be aware that school nurses may well not be able to provide the level of support needed. Their expertise is valuable and a necessity in schools. Mental health nurses need to be actively sharing their skills with teachers and school nurses. It has been pointed out that school nurses cannot provide the level of support needed and mental health nurse would be best placed within schools to provide immediate support (Puolakka et al., 2011; Pryjmachuk et al., 2011; Bartlett, 2015). Even though it has been argued that all nurses do possess the core interpersonal qualities within their role to listen and convey empathy, it is important that young people identified as needing further support can be accessed readily by a mental health nurse in a school setting. Being familiar and accessible were the two key qualities identified as being important for young people to seek support (Rickwood et al., 2005). A school nurse has been part of a young person’s experience of growing up in school (RCN, 2014) and therefore to reduce stigma, a mental health nurse should equally be readily available for their emotional health too, in the same way that a school nurse assists with physical health needs.

Mental health promotion could further be delivered by mental health nurses via outreach to young people in schools throughout their primary and secondary years. It needs to be appropriate to the child or young person’s level of understanding – and, vitally, informed by what young people say they would find helpful alongside core programmes of information and support. Additionally, educating parents and guardians about mental health is required to reduce stigma and pre-conceived ideas about mental illness (Coverdale, 2015). This reiterates the need for collaborative working between education and healthcare to be united in their approach.

Strengths and limitations

PRISMA guidelines (Moher et al., 2009) offered a robust structure for the methodology, again minimising the risk of bias. Use of the critical appraisal tool CASP ensured that the journal articles selected were credible and valid for inclusion with strengths and weaknesses identified. Aveyard (2014) described how influential a review of a spread of research pieces can be in forming a consistent picture, rather than analysing one piece of research alone. Analysis of a range of research articles can lead to new discoveries. However, the restrictions imposed by such a robust methodology meant that only peer-reviewed articles were included within the literature review – “grey” research, for example, was eliminated from the analysis. This meant young people’s perspectives from other forums were not included, which may limit the generalisability of the themes to young people who were involved with research. Additionally, the research was carried out by a master’s level student with supervision, meaning a full meta-synthesis was not reasonable – however, the search and analytic approach has been clearly described above.

Conclusion

This review shows the importance of mental health promotion by mental health nurses to adolescents. While reviewing current nursing practice and suggesting implications for future practice, it is strongly suggested that mental health awareness and presence in schools is consistent throughout all levels of school provision, and that mental health nurses to take an active role in this through their visibility to young people, who are clear that a having trusted adults in school is essential in offering support which young people will feel comfortable to access. Young people’s views are important to shaping future health awareness and promotion, and their changing opinions need to be captured through ongoing research. The principal findings of the research have exposed that there is a need for mental health nurses to be predominately employed and/or based within schools. This study recommends that priority is given to such provision.

Figures

Flow diagram of Embase, Medline, CINAHL, Scopus

Figure A1

Flow diagram of Embase, Medline, CINAHL, Scopus

Eligibility criteria

Inclusion criteria Exclusion criteria Justification
English language Studies not written in English Language
Time frame – literature published 2005-2016 Time frame – literature published before 2005 To ensure research is contemporary
Age range – adolescents 13–18 years Age range below 13 and above 19 Population under study
Quantitative methodology, e.g. Randomised controlled Trials (RCTs)
Qualitative research, e.g. focus groups, interviews, observations
Literature reviews/systematic reviews
Thesis or dissertations To include the broadest range of studies and published literature
Peer-reviewed journals Non-peer-reviewed journals Ensuring quality of research

Data extraction

Author and origin of study and year of publication Title Keywords/Search terms used and database Methodology and analysis used Sample Themes Conclusions CASP strengths and weaknesses
Pryjmachuk et al. (2011)
UK study
School nurses’ perspectives on managing mental health problems In young people Health promotion OR mental health awareness AND nurses’ role
Medline Databases
Qualitative primary research:
 Focus group
Analysis used:
 Five stages of Framework
33 school nurses from 4 school nursing teams in UK Main themes emerged from data:
 1. Recognised mental health as an important part of their work
 2. Limited education and specialised training in MH
3. Support from local CAMHS teams needed
School nurses should be involved in mental health work, their role should focus on health promotion, assessment, signposting and early intervention Strengths:
 Qualitative focus group gathered professional views from school nursing teams. Clear structure of focus, strong focus of themes and analysis employed
Weaknesses:
 Limited number of participants took part in the study. Difficulty generalising findings outside of the local areas
Bartlett (2015)
UK study
Can school nurses identify mental health needs early and provide effective advice and support? Health promotion OR mental health awareness AND nurses’ role
CINAHL database
Literature review – analysing primary research in UK regarding the role of the school nurse providing care to YP MH needs
Thematic analysis undertaken
8 UK primary research papers analysed 1. Help-seeking preferences of children and Young People
2. Training and support needs of school nurses
3. Service provision and capacity, wider socio-economic determinants
The need for school nurses to have post graduate training in mental health and supervisor with a mental health specialism
More visible and accessible in school
Strengths:
 Analysed only primary research in their literature. Amplifies the rigour and validity of the research papers included and analysed
Weaknesses:
 Conclusions may only be drawn from a second person’s interpretation of findings
Puolakka et al. (2011)
Finland study
Mental health promotion in the upper level of comprehensive school from the viewpoint of school personnel and mental health workers Mental health promotion for adolescents
Mental health promotion FOR young people
CINAHL database
Primary qualitative research
Data analysis:
 Grounded theory method applied in the data analysis
Interviews with nine people working with secondary school Children 1. Resources
2. School children and their families
3. Work to promote mental health
School environment seen as being the ideal place to promote mental health
Co-operation needed between the family, school and community was a significant factor in the promotion of YP mental health
Strengths:
 Conceptual model adopted throughout this study. Data analysis underpinned by the grounded theory which shows rigour within this particular study
 Clear outline of four key concepts uncovered from the research data
Weaknesses:
 Limited information gathered from the chosen research method employed
 Small scale research-limiting the data collated
Woodhouse (2010)
Australian study
Is there a future in mental health promotion and consultation for nurses? CINAHL database Journal article review – researcher draws on published literature
Data analysis:
 Not stated
Journal article review – researcher draws on published literature New practice roles and challenges
MH promotion and consultation roles for nurses?
Mental health nurses to form effective partnership with other professionals to construct new ways of promoting mental health to communities and young people
Mental health promotion and consultation roles to be considered in the future to help educate professionals and young people around mental health
Strengths:
 Clearly focused question applied to research
Weaknesses:
 Research is restricted in its choice of method
 No clear pre-determined strategy identified to apply to the papers discussed
 Conclusions may only be drawn from a second person’s interpretation of findings
Spratt et al. (2010)
UK study
We are the ones that talk about difficult subjects
Nurses in schools working to support young people’s mental health
Mental health nurses AND promotion for adolescents
Scopus database
Primary research and national survey/interviews
Data analysis:
 Software package NVivo7 and coding into themes
Twenty-five interviews with school nurses and managers 1. School and mental health
2. Public health model
3. Training( mental health)
School nursing service in schools
Role for nurses building trust
Strengths:
 Minimised bias by inclusion of all 14 Scottish health boards invited to participate within the study. Strength of study with including a larger population. Ethics clearly addressed to all participants involved
Weaknesses:
 Rejection of one of the Scottish boards into the research and restricting of school nursing underway when research was collated from health boards
Onnela et al. (2014)
Finland study
Mental health promotion in comprehensive schools CINAHL database
Mental health nurses AND promotion for adolescents
Qualitative primary research: six school workshops
Data analysis:
 Action research methods
Workshops delivered at six different schools
Nine sessions altogether. Mental health nurses at each of the nine sessions along with parents, children and teachers
1. Collaboration between MH nurses and school staff
2. Universal delivery to the whole school setting
3. Quicker and earlier intervention and referral to appropriate MH services
Mental health kiosks/resources near school cafeteria and MH nurse to give out leaflets to students and test their knowledge
Reduces stigma, shift from terminology of illness to empowerment
Classroom interventions are taught by MH nurses
Strengths:
 Vigorous triangulation of parents, professionals and young people resulting in their research to be robust from all perspectives. Ethics clearly addressed to all participants
Weaknesses:
 Small scale study employed within one school
Coverdale (2015)
UK study
Emotional wellbeing (EWB) and mental health: an exploration into health promotion in young people and families CINAHL database
Health promotion OR emotional health
Qualitative primary research – focus groups
Small scale qualitative study with YP and their parents, exploring the meaning of EWB and how it could be promoted
Data Analysis:
 Collaizzi’s seven-step data analysis framework was utilised, then coded into themes using thematic content analysis
Data collected by three focus groups with fifteen YP and fifteen interviews with parents of a different YP 1. Support for YP
2.Awareness of emotional wellbeing
The need for integration of healthcare practitioners, public health and education to promote EWB activities, delivery of services to support YP and their families
Mental health services available for Young people to access and self-refer
Addressing stigma identified with getting support
Emphasis on raising awareness of YP EWB in their parents. Parenting support
Identifying with emotions-emotional literacy
Strengths:
 Analytical frameworks applied within this study ensuring no concepts were missed when drawing up results
Weaknesses:
 Small sample study. Difficulty generalising findings on a national level
Burns and Rapee (2006)
Australia study
Adolescent mental health literacy: young people’s knowledge of depression and help seeking Depression OR mental health promotion AND adolescents
Embase database
Quantitative primary research:
 Questionnaires assessing YP’s mental health literacy
Data analysis:
 Not stated
202 (122 males and 80 females) aged 15–17 took part in the study 1. Misconceptions about mental health conditions, symptoms
2. Help-seeking support
YP did recognise symptoms of depression
YP recognised first step would be to get professional help
Needs to be a consistent approach in the community, e.g. terminology – mental health literacy
Strengths:
 Large data collection through the use of questionnaires
Weaknesses:
 Data analysis not stated
 Questionnaires have pre-determined criteria which do not always allow for elaboration on potential issues
McCann et al. (2012)
Australia study
Views of young people with depression about family and significant other support: interpretative phenomenological analysis study Depression OR mental health promotion
CINAHL database
Qualitative primary research
Data analysis:
 Interpretative phenomenological analysis (IPA) – gathering YP views
Young people’s views gathered about their experience of support when dealing with depression Two themes identified:
 1. YP views about the influence of families/significant others helping them through with patience and encouragement – this strengthened YP resilience to cope with depression
 2. Being in an unsupportive environment compromised YP ability to cope
Mental health nurses need to increase families’ and significant others’ understanding of depression
Mental health nurses’ capacity to support YP and families to raise awareness of depression
Strengths:
 Qualitative primary research collates in-depth information from young people directly
Weaknesses:
 Potential bias of participants due to them being selected by clinicians
Martínez-Hernáez et al. (2014)
Spanish study
Non-professional help-seeking among young people with depression: a qualitative study Young people’s views AND depression OR nurses
Medline database
Primary research – interviews with young people
Interviewed in depth about their reasons for avoiding professional mental healthcare services
Data analysis:
 Software programmes used to analyse data. Grounded theory and ethnographic method used to code themes
105 young people selected who had participated in a national survey on adolescents. Thirty-seven people with a previous diagnosis of depression, thirty-three who had emotional distress and thirty-five controls 1. Normalisation of the problem and they relied on social network opposed to MH professional support
2. Mental health literacy. YP referring to the terminology “depression”
3. Problems, e.g. denial, lack of knowledge of MH services available to them, accessibility
4. Consequences attached to support, e.g. shame, protocol-driven treatment
Avoidance varied by gender and prior experience of mental health services
Some young people understood depressive symptoms as normal and not seeking professional support
Females who had been diagnosed with depression expressed lack of trust and fear of social consequences of help seeking
Strengths:
 Rich, in-depth data with participants interviewed thoroughly. These data are valid as these offer first-hand responses gathered in a phenomenological way
Weaknesses:
 Small sample study of participants
Woolfson et al. (2008)
UK study
Young people’s views of mental health education in secondary schools: a Scottish study Young people OR depression OR mental health
Scopus database
Mixed methods:
 Qualitative primary research
 Nine Focus groups
Quantitative questionnaires
Data analysis:  Two members of the research team modified each focus group by recording the discussion and transcribing this. Discussion transcripts were analysed independently by two members of the team and key themes identified
Nine focus groups to identify key themes which led to questionnaires given out to 773 pupils YP’s views on mental health education to be delivered by someone they are familiar with and who has personal experience of?
Wanted to learn with peers about MH
YP wanted to learn about mental illness and prevention and coping strategies
Gender differences between boys and girls
Mental health programme in school would be beneficial
Professionals should take into account the young people’s ages and gender
Listening to YP views seen as a starting point for improvements to emotional literacy regarding MH
Delivery in class groups and during different phases, e.g. primary and secondary
MH should reflect the needs of the YP
Strengths:
 Clear, pre-determined strategy was used to determine which studies would be included. Exclusion category explicitly stated to reduce bias and enhance validity. Cross-study synthesis outlined
 Bias reduced further with two researchers analysing the transcripts gathered from the study
 Application of mixed methods provides capture of rich data from a variety of sources
Weaknesses:
 Small number of participants included into the focus groups compared to the questionnaires distributed. Qualitative data limited by the inclusion of a small number of participants
Rickwood et al. (2005)
Australian study
Young people’s help seeking for mental health problems Young people OR mental health promotion
CINAHL database
Qualitative primary research: questionnaires
Data analysis:
 Not stated
Data from a total of 2,721 young people aged 14–24 years was gathered 1. Barriers to seeking help-seeking behaviours for YP
2. Young people’s mental health literacy/awareness
Lack of emotional competence noted as a barrier to getting help
Having supportive social influences around YP enables them to seek help
Stigma surrounding mental health and professionals results in YP not seeking help
Strengths:
 Primary research undertaken with a large sample of participants of young people directly
 Weaknesses:
No clear pre-determined strategy outlined. Data analysis not explicitly explained to justify the rigour of this research
Lovett et al. (2011)
UK study
Children’s views on mental illness Health promotion
CINAHL database
Qualitative primary research – focus group
Data analysis:
 Discourse analysis
Focus group included children/Young people aged 10–18 years 1. Mental health/mental illness
2. Understanding of the terminology associated with emotional health/mental health
YP have poor understanding of mental health/awareness
Misconceptions of mental illness/mental health. There needs to be mental health promotion aimed at children and young people in schools
Strengths:
 Exhibit a clear data analysis undertaken which improves the validity of the results outlines from the research
 Well-founded discourse analysis which is highly regarded and reliable
Weaknesses
 Small sample group
Fleming et al. (2012)
New Zealand study
It is mean! The views of young people alienated from mainstream education on depression, help seeking, and computerised therapy Young people OR mental health promotion
CINAHL database
Qualitative primary research – focus group
Data analysis:
 Audio recordings were transcribed by a professional transcriber using a general inductive approach to analysis the data. Coded the findings – looked for commonalities
Focus group included children/young people aged 13–16 years 1. Dealing with depression/YP’s coping strategies
2. Reluctant to see mental health service/professional
YP reluctant to talk to health professionals
Some YP stated they would harm themselves if referred to a health professional.
Lack of understanding what mental health services could offer YP
Stigma associated with accessing support and surrounding the word “mental”
Strengths:
 Research gathered through structured focus groups with pre-determined criteria and questions
 Weaknesses:
 Due to the pre-determined criteria of the focus groups the methods are focused on the interviewer’s agenda as opposed to an open forum where participants can freely reflect on their experiences
Gulliver et al. (2010)
Australia study
Perceived barriers or facilitators to mental health help seeking in young people – a systematic review Young people OR mental health promotion
Medline database
Literature review journal
Data analysis:
 Thematic analysis undertaken on the qualitative and quantitative literature
Reviewed twenty-two published studies of perceived barriers or facilitators in adolescents or young adults 1. Stigma
2. Confidentiality and trust
3. Lack of knowledge about mental health services
4. Difficulty/awareness of identifying symptoms
At least five or more barriers identified for YP not wanting to access help
Both stigma and embarrassment emerged as the prominent barriers to help seeking for mental health problems
Strengths:
 Clear thematic analysis undertaken to reduce bias and enhance validity and rigour of results
Weaknesses:
 Secondary sources may be influenced by original researcher/author views creating potential basis
O’Connor et al.
(2014) Australia study
Factors that influence young people’s mental health help-seeking behaviour: a study based on the Health Belief Model Mental health nurses AND promotion for adolescents
CINAHL database
Primary research- survey/questionnaires
Data analysis:
 IBM SPSS Statistics used to analyse the data
180 volunteers took part in the survey 1. Barriers to help-seeking behaviour
2. Support networks
Attitudes can influence help-seeking behaviour
Future messages need to be delivered through promoting mental health to YP that health services are effective and can improve functioning
Strengths:
 Mixed methods enhance the methodological rigour. A more holistic overview of results with inclusion and comparison from two methods
Weaknesses:
 Small scale research
Yap et al.
(2012) Australia study
Young people’s beliefs about preventative strategies for mental disorders: findings from two Australian national surveys of youth
Yap et al.
(2012)
Depression OR mental health promotion
Embase database
Primary research- survey
Data analysis:
 Using per cent frequencies
3,746 youths 12–25 years assessed by a national telephone survey. Youths’ beliefs about preventative strategies, e.g. depression 1. Gender differences in males and females – females seeking support
2. Preventative/intervention programmes
Gender differences in seeking help and support
Mental illness in YP remains high
Gap between YP’s knowledge and behaviour
Highlights the need for mental health promotion with YP
Strengths:
 Large sample influences the reliability of the results
Weaknesses:
 Limited information informs this study due to questionnaires and surveys have pre-determined criteria which do not always allow for elaboration on potential issues
Sakellari et al. (2014)
Greek study
Greek adolescents’ views of people with mental illness through drawings: mental health educators’ impact Young people’s views AND depression OR nurses
CINAHL database
Experimental group with twenty-eight participants received health promotion whilst the other thirty-one participants did not receive this
Data analysis:
 Content analysis of the drawings
Fifty-nine young people aged 13–16 (mean age was 14) 1. STIGMA associated with mental illness
2. Difficulty/awareness of identifying symptoms
3. Beliefs and attitudes towards people with emotional difficulties/mental illness
YP’s views about mental illness – stigmatising perceptions of people.
This study highlights the need for health professionals to use this research as a baseline/guide to implement health promotion in the future with YP
Strengths:
 Participants chosen by random selection – no pre-determined strategy involved resulting bias into the sampling
Weaknesses:
 Participants outcomes varied due to four declining to be involved in the outcome stages of the research
Sawyer et al. (2012)
Australia study
Do help-seeking intentions during early adolescence vary for adolescents experiencing different levels of depressive symptoms? Embase
database
Young people’s views AND depression OR nurses
RCT
Questionnaire booklet with “yes” or “no” answers
Data analysis:
 Bivariate and multivariate logistic regression analysis used
5, 362 participants aged 12–14 completed a baseline assessment for a RCT evaluating the effectiveness of a universal intervention designed to reduce depressive symptoms in high school students 1. Gender differences (females more likely to seek help from nurses, family and friends than males)
2. Help-seeking behaviours
Those with high levels of depressive symptoms reported to not seek help from family or friend
29% said they would seek help from nurse 80% from family members
This study highlights the need for targeted and universal interventions (mental health promotion and education) to encourage peers and family to engage with young people experiencing depressive symptoms
Strengths:
 Research gathered through structured questionnaires
 Clear focus for the intended study
Weaknesses:
 Reduced bias by using a Randomised Control Trial (RCT)
Kelly et al. (2007)
Australian study
Improving mental health literacy as a strategy to facilitate early intervention for mental disorder Medline database
Depression OR mental health promotion AND adolescents
Literature review based on primary research studies
Data analysis:
 Analysis not stated clearly in this study
Twelve primary research studies analysed.
All studies involved direct intervention with young people
1. Mental health literacy programmes for young people
2. Peer support groups
3. School-based interventions
4. Outreach community interventions
Good mental health literacy in young people empowers them to identify early signs of mental health disorders and seek support early
Information to adults/care givers in young people’s lives about mental health can also help them identify deterioration of mental health early
Further research to focus on the most effective intervention for improving young people’s knowledge about mental health
Strengths:
 A systematic approach provides a clear structure for this research
Weaknesses:
 Restricted in choice of method
 Conclusions may only be drawn from a second person’s interpretation of findings
Issakainen and Hanninen (2016)
Finland study
Young people’s narratives of depression Scopus database
Depression OR mental health promotion
Empirical research analysing eighty-one narrative accounts from young people
Data analysis:
 3 stage process:
  1. Researcher read through the data and wrote down phrases summarising young people’s accounts
  2. A coding frame was applied to extract the key themes, e.g. family, school and work
  3. Chronological order of events was identified in each of the narratives to see which event contributed to the young person’s mood
Eighty-one young people’s written accounts of being depressed
Narratives gathered from group discussions and individual interviews with young people
1. Family
2. School
3. Work
Biographical events and social conditions can profoundly influence the course of young people’s life and mental health
Contributors to lowering a young person’s mood emerged from the three themes, these being family, school and work. Bullying had an impact on how the young people viewed themselves which lowered their self-esteem
Youth friendly health services help young people recover from adversities
Media coverage of depression and mental health has been suggested by the authors of this research to help other young be aware of the signs and symptoms and services to support them
Strengths:
 Selection of participants through collection of their narratives which provides a first-hand account. Narratives come directly from young people, they have not been interpreted by anyone else
Weaknesses:
 Does not state explicitly analysis which has been has been applied
Oliver et al. (2008)
UK study
Young people and mental health: novel methods for systematic review of research on barriers and facilitators Medline Database
Young people AND mental health
Systematic review based on twelve primary research studies with young people
Data analysis:
 Coding strategy – coding scheme adopted by two reviewers
Systematic review based on twelve primary research studies with young people in school settings 1. Intervening at the level of the individual
2. Intervening at the level of community
3. Intervening at the level of society
Young people did not see “mental health” and “mental illness” relevant to their own lives, but instead related better to terminology such as feeling sad, lonely and depressed
More research to guide mental health promotion for young people needed in the UK
Better provision of information to young people about mental health and services to support them
Strengths:
 Identifies in detail the inclusion of included studies. Bibliographic databases sought. Only relevant studies are used by applying a sensitive search strategy to ensure reliability of selected papers
 Studies combined in depth and cross-study synthesis of studies
Weaknesses:
 Conclusions may only be drawn from a second person’s interpretation of findings from primary research studies chosen

Themes

Overarching themes Journal articles which relate to the subtheme Subthemes
Theme 1: young people’s help-seeking behaviours Fleming et al. (2012), Issakainen and Hanninen (2016), Kelly et al. (2007), Martínez-Hernáez et al. (2014), McCann et al. (2012), O’Connor et al. (2014), Oliver et al. (2008), Pryjmachuk et al. (2011), Rickwood et al. (2005), Spratt et al. (2010) Young people seeking support from peers
Young people more likely to seek help if they have supportive family structures in place
Friendly and welcoming professionals and services empower young people to seek support
Fear of school nurses lacking in specialised skills to support young people with emotional difficulties
Theme 2: the appropriateness of school as a setting for mental health support Bartlett (2015), Burns and Rapee (2006), Kelly et al. (2007), Lovett et al. (2011), Pryjmachuk et al. (2011), Onnela et al. (2014), Puolakka et al. (2011), Sakellari et al. (2014), Spratt et al. (2010), Woodhouse (2010), Woolfson et al. (2008) Misconceptions of mental illness
Early identification of mental health problems – mental health literacy needed early
School as a convenient and accessible setting for young people to access
Young people stating school as accessible to them
Ethos of school has to reflect mental health promotion and awareness for this to be appropriate
Nurses working collaboratively and directly with school professionals and school nurses
Mental health should be taught by a familiar adult in young people’s lives at school
Lack of training offered to school nurses in mental health
School nurses not being trained in the skills needed to support young people who have emotional difficulties
Limited support in school by specialised mental health services such as Child Adolescent Mental Health Services (CAMHS)
Mental health nurses and CAMHS sharing of knowledge through consultation with teacher and school nurses
Theme 3: working in partnership with parents/guardians Bartlett (2015), Burns and Rapee (2006), Coverdale (2015), McCann et al. (2012), Puolakka et al. (2011), Sawyer et al. (2012), Yap et al. (2012) Healthcare professionals working in partnership with young people’s parents/families
Conflict between professionals and young people’s families/guardians (professional boundaries and confidentiality)
Educating families and communities about mental illness
Theme 4: barriers to help seeking Burns and Rapee (2006), Coverdale (2015), Gulliver et al. (2010), Issakainen and Hanninen (2016), Lovett et al. (2011), Martínez-Hernáez et al. (2014), Sakellari et al. (2014) Barriers to accessing services
Negative past experiences of health professionals and health services
Stigma surrounding mental illness (fear of seeking help and the consequences of doing so)
Young people not understanding the terminology of mental illness causing fear to speak out
Emotional literacy skills poor in recognising symptoms

Appendix 1. Search terms

Search terms using Boolean phrasing

Health promotion OR mental health awareness AND nurses role

Mental Health promotion for adolescents

Mental health promotion OR young people

Health promotion OR Emotional Health

Mental health nurses AND promotion for adolescents

Depression OR mental health promotion AND adolescents

Depression OR depression OR mental health promotion

Young people views AND depression OR nurses

Young People OR depression OR mental health

Young people OR mental health promotion

Mental health nurses AND promotion for adolescents

Young people AND Mental Health

Depression OR mental Health Promotion

Depression OR Mental health promotion AND adolescents

Keywords

Adolescents, young people, young people’s views, depression, mental health awareness, mental health promotion, nurses’ role

Databases/search engines

CINAHL

SCOPUS

Medline

Embase

Appendix 2

Figure A1

Appendix 3

Table AI

Appendix 4

Table AII

References

Arnold, M. and Mitchell, T. (2008), “Nurses’ perceptions of care received by older people with mental health issues in acute hospital environment”, Nursing Older People, Vol. 20 No. 10, pp. 28-34.

Auerbach, R., Millner, A., Stewart, J. and Esposito, E. (2015), “Identifying differences between depressed adolescent suicide ideators and attempters”, Journal of Affective Disorders, Vol. 186, pp. 127-33.

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Further reading

Briggs, S., Slater, T. and Bowlby, J. (2017), “Practitioners’ experiences of adolescent suicidal behaviour in peer groups”, Journal of Psychiatric and Mental Health Nursing, Vol. 24 No. 5, pp. 293-301.

CRD (2008), “Systematic reviews: CRD’s guidance for undertaking reviews in healthcare”, Centre for Reviews and Dissemination, York, available at: www.york.ac.uk/media/crd/SystematicReviews.pdf (accessed 15 August 2015).

Glasziou, P., Irwig, L., Bain, C. and Colditz, G. (2001), Systematic Reviews in Health Care: A Practical Guide, Cambridge University Press, Cambridge.

Sawyer, M.G., Pfeiffer, S., Spence, S.H., Bond, L., Graetz, B., Kay, D., Patton, G. and Sheffield, J. (2010), “School-based prevention of depression: a randomised controlled study of the beyondblue schools research initiative”, Journal of Child Psychology and Psychiatry, Vol. 51 No. 2, pp. 199-209.

Acknowledgements

There was no funding in the undertaking of this study.

Corresponding author

Jessica Louise Arnold is the corresponding author and can be contacted at: jessicalouisearnold@hotmail.com

About the authors

Jessica Louise Arnold is MSc Graduate Mental Health Nurse, RCN Margaret Parkinson Scholar, Professional Graduate Certificate in Education (ProfGCE) with Qualified Teacher Status (QTS), BA (Hons) Childhood Studies.

Dr Charley Baker (BA, MA, PhD, PGCHE, FHEA) is Lecturer in Mental Health and Lead for Safeguarding, School of Health Sciences at University of Nottingham, and Editor in Journal of Psychiatric and Mental Health Nursing