Marketing Strategies to Reposition Psychiatric-Mental Health Nursing Specialty in Student Nurse Education Programs in the United States and China

Background: The scarcity of psychiatric nurses is an increasing problem in both the United States and China. Without a systematic effort for the increased recruitment of students into the behavioral health field, the scarcity of psychiatric nurses will persist. To address this problem, three professors in the United States and a visiting international scholar of psychiatry from China joined forces to examine the issues related to the recruitment of student nurses into the mental health nursing specialty in their respective countries. The need for psychiatricmental health nursing (PMHN) practitioners is increasing internationally as more individuals are diagnosed with mental illnesses, and millions of youth and adults aged 14–24 years are at high risk. There has been considerable discussion about contributing factors associated with a decrease in the PMHN specialty. One issue is whether or not educational institutions are effectively marketing PMHN programs and providing their students with the proper curriculum and training. Materials and Methods: Literatures published within the past 10 years were reviewed in combination with the collaborative face-to-face discussions. Results: Psychiatric nursing shortage has caused concerns considering the increasing demand of patients with mental illnesses. Contributing factors were identified including aging workforce, de-emphasis of the PMHN courses in nursing education, and stigma associated with working with psychotic patients. Conclusions: Marketing strategies for repositioning PMHN programs were proposed to eliminate the shortage of PMHN nurses in both China and the United States. Marketing Strategies to Reposition Psychiatric-Mental Health Nursing Specialty in Student Nurse Education Programs in the United States and China Publication History: Received: August 01, 2016 Accepted: November 24, 2016 Published: November 26, 2016


Research Article
Open Access

Background
Mental illnesses not only lead to more disability than any other chronic illnesses, but also extensively contribute to the burden of diseases worldwide; moreover, the number of patients with mental illnesses and co-occurring physical illnesses are on the rise throughout the world [1,2]. However, the number of nursing students both undergraduate and graduate choosing mental health nursing as a career has decreased in the United States and China among other countries. To meet this challenge, more psychiatric nurses with adequate mental health training are needed especially in the United States and China, with their unmet treatment needs and limited capacity vis-à-vis mental illness.
Psychiatric-mental health nurses work with patients and families to assess their needs, diagnose mental disorders, and offer a range of treatment plans and services. The misconceptions about and neglect of psychiatric mental health nursing (PMHN) in curricula of schools of nursing in the United States and China seriously hinders the recruitment of nurses into the area of mental health. The number of undergraduate nursing students who choose to pursue PMHN as a profession has remained low over the past years in the United States and China. From the point of view of nursing students, there are several reasons for this: nursing students (1) fail to understand the multiple roles of PMHN, (2) have negative attitudes toward mental illness [3], (3) view psychiatric placements less favorably that other placements [4], and (5) regard the PMHN specialty as being unappealing and stressful [5]. PMHN specialty. After these first 20 face-to-face sessions, further communication about the topics was facilitated via email over 6 months. Simultaneously, the participants conducted a literature search in both Chinese and English publications using PubMed. The following search terms were used: psychiatric mental health nursing, 精 神科心理健康护理 (jingshengkexinlijiankanghuli [psychiatric mental health nursing]), United States, China, recruiting, and 招生(zhaosheng [student recruitment]). Articles containing one or more of these terms published over the past 10 years were retrieved. Based on the literature and our structured discussion sessions, we (1) identified themes in the articles that reflect the shortcomings of PMHN capacity and then (2) adapted four marketing strategies from business literature to address these themes.

State of mental health nursing in the United States and China
In the United States, mental disorders are prevalent, often serious; and yet, are treatable disorders that have a significant impact on the entire population. Mental disorders are prevalent among one in four Americans and follow cardiovascular diseases as the leading disease burden in the United States [6]. According to the Substance Abuse and Mental Health Services Administration (SAMHSA) (2009), almost 20% of the U.S. adult population experienced acute mental illnesses (excluding substance use disorders), and 4.8% of adults had serious mental illnesses, which affects nearly 11 American million adults [1]. The WHO reports that the United States possesses 3.1 advanced practice psychiatric nurses per 100,000 people; globally, 7.7 nurses work in this area per 100,000 people [7]. With this low nurseto-patient ratio, serving mental health needs clearly is a challenge worldwide. In China, the situation surrounding mental health also demonstrates a compelling need for enhanced mental health services.
In China, as of 2009, the prevalence of mental disorders was15% among the total population, with 16 million adults having severe psychosis, 30 million having depression, 6 million suffering from dementia, and 30 million children and adolescents 17 years or younger disturbed by emotional and behavioral problems [8]. A more recent study in China indicate the proportion of people in China who suffer from mental disorders ranges from 4.3% to 17.3%; moreover, the lifetime prevalence of these disorders ranges from 11.3% to 15.8%, with a 12-month prevalence of 6.4% to 6.7% among those aged 15 years or older [9]. As of the end of 2005, nearly 24,100 psychiatric nurses were reported to be working in psychiatric-mental health institutions in China [9]. Additionally, psychiatrists and psychiatric nurses are the major mental health professional groups in China because China has a limited number of clinical psychologists and social workers and no occupational therapists. Compared to the United States, there only are 2.6 psychiatric nurses per 100,000 people in China [10], and a large proportion of these psychiatric nurses have minimal training one reason for this is that there are no master's degree Qing and Xiao assert that psychiatric nurses in China receive inadequate education in nursing, especially in mental health nursing, which limits their ability to deliver necessary mental health care [11]. Moreover, the available mental health resources in China are insufficient to meet the needs of those affected, and the resources that are available are not evenly distributed across China [12].
The shortage of human resources for mental health is a worldwide problem, especiallyin low-income and middle-income countries [13]. A mismatch exists between the burden of mental health disorders and the supporting resources that are utilized to prevent and treat them. In this regard, both the United States and China are not exceptions, and both countries face the challenge of providing adequate human resources for the delivery of necessary mental health care to those in need. With a large proportion of those who have mental disorders living in rural areas in the United States, some states are facing severe shortages of mental health professionals compared to other states with a large proportion of the population living in urban areas [1]. Meanwhile, despite steady urbanization in China, 44% of the Chinese population still resides in rural areasin 2015, which exacerbates the problem of providing adequate mental health care. Phillips and colleagues report that almost one in five adults in China suffer from a mental illness, which occurs at a higher prevalence in rural areas compared to urban communities [14]. Increasing the number of mental health nurses to deliver adequate mental health care services in China has the potential to close the gap between the need and available service to reduce the burden of mental disorders.

Contributing factors related to shortages in PMHN programs
The shortage of psychiatric nursing programs in China and the United States are likely associated with factors such as an aging workforce, stigmas related to mental disorders, and the de-emphasis of psychiatric mental health in nursing education systems. As many healthcare systems in many countries are experiencing nursing shortages and struggling to recruit new nurses and retain those who are already in the systems, the unpopularity of PMHN compared with other nursing specialties is documented in literature [15]. In addition, few nurses specialize in substance use disorders; furthermore, the Pew Charitable Trust notes a major shortage in the number of professionals practicing with patients diagnosed with substance abuse in the United States [16]. An understanding of factors contributing to this unpopularity is important to the development of effective marketing strategies to increase student enrollment in PMHN in the United States, China, and other countries.
The aging of the nursing workforce is a factor contributing to the low number of students interested in PMHN. In 2009, the number of psychiatric registered nurses 50 years of age or older in the United States was 59% (compared to the non-psychiatric nurse population of 42%), and only 4.2% of psychiatric nurses were under 30 years of age [17]. The Annapolis Coalition provides a workforce development blueprint and advocates for more advanced practitioner (AP) psychiatric-mental health nurses. Although the Health Resources and Services Administration (HRSA) recognized it as one of the central mental health professions, the advanced practice registered nurse in psychiatric-mental health (APRN-PMH) workforce is still small compared to other core professions such as psychiatry, psychology, social work, and counseling. There are about 15,973 APRN-PMHs in the United States with a mean age of 51.4 years old (8% below 35 years of age). Approximately half of the APRN-PMH workforce will be retired in 10 years, which will lead to a huge decrease in an already small workforce [18].
Data from countries, including China, indicate the difficulty of recruiting nurses to provide mental health services, which is attributable to a lack of interest in the field among nursing students and inadequate incentives for mental health nurses [19]. For example, in mental health facilities throughout China, Liu and colleagues report that the number of mental health nurses per 100,000 population was 2.6 in 2010; moreover, among these registered nurses, 13.3% were Page 3 of 6 under 25, 63.2% were 25 to 44, and 23.4% were 45 or older [20]. As can be seen, the low proportion of younger nurses under 25 reflects challenges of having new nurses or nursing students specializedto enter mental health nursing.
Stigma about mental illnesses contributes to the low interest in PMHN among nursing students in the United States and China. Media outlets frequently misrepresent psychiatric patients by associating them with aggressive behaviors [21]. Individuals with apparent and severe psychiatric disorders may be considered the only ones to have a "real" mental problem. Depressed, anxious, stressed individuals are not seen as having mental disorders but rather problems of living [22]. In China, an investigation of 267 psychiatric professional practitioners from 30 provinces revealed that most psychiatric practitioners consider stigma a major problem among patients with severe psychosis, and this stigma remains even after the recovery of these patients [23]. Moreover, this stigma is associated with mental health care providers, including nurses in other words, average people have a prejudice against mental health care providers because they are associated with patients with severe psychosis. Furthermore, nursing students in the United States often connect negative connotations with mental health hospitals and think the field of psychiatric nursing lacks prestige [21].
The de-emphasis of mental health among nursing school curriculam has contributed to the lack of interest in PMHN in the United States and China. PMHN is a major but easily neglected issue in healthcare worldwide. Mental health nursing is not considered as a priority by decision-makers in education systemsin several countries; consequently, mental health training for students in both undergraduate and graduate nursing programs is insufficient in many countries including China and the United States [19]. Moreover, PMHN has not been emphasized as an integral part of the nursing curricula [24]. For example, in China, as of 2013, few nurses working in mental health facilities had post-graduate degrees, and only 11% had bachelor's degrees, which reflects a low level of training [20]. As can be seen, (1) the de-emphasis of PMHN in nursing schools, (2) the low proportion of course content related to mental health, and (3) insufficient clinical exposure all contribute to negative attitudes towards patients with mental health illnesses and PMHN among nursing students.
The time dedicated to psychiatric nursing lectures and psychiatric clinical rotations has been reduced in many nursing programs including in the United States and China. Moreover, schools of nursing may expose students to only one setting in which psychiatric services are provided, and this is most often an institution in which patients with chronic mental illnesses are treated. Furthermore, nursing students may regard PMHN as not being knowledge and skills based. The reason for this perception may be that the body of knowledge on which PMHN is built (i.e., psychopharmacology, neuroscience, molecular biology, and genetics) simply is not recognized by nursing students. In terms of strategies and skills, PMHN encompasses behavioral, cognitive, interpersonal, and psychological specialty skills that nursing students also may not appreciate [18]. This lack of recognition and appreciation for the knowledge and skills inherent in the PMHN role likely stems from its low visibility in the curriculum. For example, Happell reports that a lack of mental health training contributes to a perceived lack of readiness for nursing graduates to work with patient who experience mental illness [25,26]. The table 1 below provides a detailed description of typical BSN PMHN courses in the nursing curricula in the United States and China. Major topic areas that typically are covered in these courses comprise therapeutic communication with patients, mental disorders (e.g., schizophrenia, anxiety disorders, stress-related disorders, eating disorders, and personality disorders), nursing assessment, and nursing care.While this variety of topics is comprehensive, the amount of time devoted to them in the total BSN curriculum is limited.

Marketing strategies to reposition PMHN
Nurses take on complex roles and responsibilities when attending to mental health patients. For example, PMHNs take part in providing direct care to patients, prescribing and managing medication, managing patient wards, and delivering follow-up care in communities [27]. These roles may not be identified and understood by nursing students, which may influence their understanding about PMHN when making career decisions. Addressing this lack of understanding through a more active promotion of the PMHN role using a marketing type approach, as demonstrated in studies from other disciplines [28,29], could help nursing students identify with the importance and rigor of the PMHN role. Without a systematic plan of marketing strategies to enhance the recruitment and retention of the psychiatric nursing workforce, limited numbers of PMHN practitioners and an uneven geographic distribution of PMHN practitioners will persist.

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Therefore, nursing programs could use marketing strategies to reposition the PMHN specialty to address the shortage of psychiatric nurses. For example, media resources such as TV, radio, newspaper, periodicals, the Internet, and social networking sites can be deployed in courses throughout the curriculum to realistically and positively depict PMHN to dispel the misconceptions about psychiatric nursing that nursing students may have. Pamphlets, journals, publications, training materials, and course websites can not only increase access to existing and new materials on mental health nursing [19], but also reposition and promote the uniqueness of PMHN. Repositioning is synonymous with "systematic plan"and involves how one revises perceptions whether those perceptions are about oneself or about one's competition. Repositioning involves revising perceptions about PMHN. In business and marketing, repositioning is foundational and helps to differentiate value in the mind of the customer [30]. We assert that repositioning can be adapted from the business and marketing fields because concepts from these fields address the perceptions and thoughts of the customer or prospect. Applied to PMHN, repositioning provides innovative thinking about ways to adjust the perceptions of PMHN among nursing students in the United States and China. We recommend four repositioning marketing strategies derived from the business and marketing literature forthe use of nursing faculty involved with training nursing students in PMHN. In business and marketing, repositioning is foundational and helps to differentiate value in the mind of the customer [30]. We assert that repositioning can be adapted from the business and marketing fields because concepts from these fields address the perceptions and thoughts of the customer or prospect. Applied to PMHN, repositioning provides innovative thinking about ways to adjust the perceptions of PMHN among nursing students in the United States and China. We recommend four repositioning marketing strategies strategies derived from the business and marketing literature forthe use of nursing faculty involved with training nursing students in PMHN.
Repositioning Marketing Strategy #1: Market the PMHN as a unique role with a comprehensive knowledge base. As one of the oldest nursing specialties, PMHN is a discipline that was the first specialty to offer an advanced practice graduate degree in nursing [31]. This should be marketed (i.e., emphasized) to nursing students. Today, PMHN practitioners master a body of knowledge that comprises medications, molecular biology, genetics, neuroscience, psychiatry, psychology, sociology, the recovery model, and community-based care [18]. The inclusion of neurobiology, psychology, pharmacology, and therapeutic skills makes PMHN aunique, rigorous, and evidencebased discipline. Indeed, emphasizing the uniqueness of a particular service and differentiating it from others is an important marketing strategy in repositioning [30]. Building upon this concept can help nursing students develop a new and more accurate perception of PMHN, which espouses a biopsychosocial, behavioral view of patients.
Repositioning Marketing Strategy #2: Market PMHN through the inclusion of positive clinical placements in the curricula. Happell and colleagues indicate that positive clinical placements are an essential factor that positively influences nursing students' attitudes about and interest in the field of psychiatric nursing [32]. Moreover, this strategy can address misconceptions about PMHN among nursing students [30]. For example, studies have shown that the exposure gained from curriculum and practicum improves the attitudes of student nurses about mental health nursing [25,26,33]. These studies emphasize the importance of establishing closer working relationships between schools of nursing and clinical settings to ensure that nursing students have opportunities to: (1) be actively involved in patient care, (2) be exposed to a positive clinical environment, and (3) have a more comprehensive understanding about PMHN and patients with mental disorders [34]. Anxiety is a strong factor negatively affecting a student nurse's likelihood of entering PMHN, and a sense of preparedness diminishes this anxiety [35], which can be accomplished through arranging positive clinical placements for the students throughout the educational experience.
Repositioning Marketing Strategy #3: Market PMHN education by including patients in the classroom. Learning from service users (i.e., patients) in the classroom provides a different experience for students compared to learning in clinical sites, and involving patients in the classroom might accelerate transformative learning and results in positive actions among students. Inviting psychiatric patients to the classroom and allowing students to hear about the lived experiences of the patients will allow the students to not only understand the challenges faced by mental health patients, but also conceive of them as people with the potential to recover. The involvement of mental health patients in the classroom could provide a foundation to promoting the "recovery approach, values, and principles" that encourages nursing students to "be optimistic about the possibility of positive individual change" [36].
Repositioning Marketing Strategy #4: Market PMHN with a value added perception. Nursing educators need to shift the perception of PMHN and give student nurses a reason to believe that PMHN is a valuable and viable career to pursue. Nursing educators can apply the marketing principle to repositioning PMHN and emphasize the value of choosing a PMHN career. In particular, in this repositioning effort, lever aging integrated marketing communication (IMC) relies on two major themes: the value-added role of PMHN vis-à-vis consumer behavior and in media communication [37]. Through an IMC approach to repositioning PMHN, communicating with and managing new nursing students, keeping an ongoing dialogue with PMHN graduates, and utilizing feedback from PMHN students to shape the nursing specialty are the main efforts to emphasize. These efforts can be accomplished by PMHN faculty members who intend to increase the number of students choosing PMHN as a career. In addition, the way we deliver mental health service is steadily shifting from traditional face-to-face approaches to technologically-driven approaches (e.g., mobile technologies and telehealth to deliver care). As this trend continues, more student nurses interested in PMHN will be trained to understand the value of, promote, and practice the use of such technologies.

Conclusions
Today's marketplace presents an overwhelming need to utilize both traditional means of media and new interactive marketing communication. The key to accomplishing dual utilization is through the convergence of the relevance, benefit, and overall value of the marketing message. This same approach can be utilized in a school of nursing. For example, nursing faculty and administration can rely on marketing techniques to highlight (1) the uniqueness and comprehensive body of knowledge implicit in PMHN, and (2) the positive clinical and the value-added perception offered by PMHN.
Nurses not only are the largest workforce category in the mental health system in both the United States and China, but also play a critical role in providing services to persons with mental disorders. However, in both the United States and China, PMHN is not a priority