ABSTRACT
Background
Intensive Care Unit (ICU) nurses frequently care for patients with mental illness, yet many report feeling insufficiently prepared to address mental health needs in critical care settings. Understanding nurses' knowledge, skills and attitudes toward mental health care is essential to improving the quality and safety of care.
Aim
This study assessed Jordanian ICU nurses' self‐reported knowledge, skills and attitudes regarding the care of patients with mental illness and examined factors associated with their perceived competence in managing mental health conditions in critical care settings.
Methods
A cross‐sectional descriptive design was used, involving 502 ICU nurses from 20 public, private and university hospitals in Jordan. The primary outcomes were nurses' self‐reported perceived knowledge and preparedness, self‐reported skills and attitudes toward caring for patients with mental illness. The questionnaire also assessed previous experience and receipt of formal training specifically related to mental health care for critically ill patients. Data were analysed using descriptive statistics, Kruskal–Wallis test, Pearson correlations and multiple regression. Instrument reliability was acceptable (Cronbach's α = 0.81–0.92).
Results
Nurses reported moderate self‐reported perceived knowledge and beliefs (mean = 3.19 ± 0.70), self‐reported skills (mean = 3.20 ± 0.51) and attitudes (mean = 3.28 ± 0.44). Important gaps were identified in knowledge of psychotropic medication use, clinical assessment tools and legal aspects of mental health care, as well as confidence in managing suicidal behaviour, psychotic symptoms and mental status assessment. Only 32% of nurses had received formal training specifically in mental health care for critically ill patients, whereas 79% reported that they could be better prepared to manage such situations with additional education. Perceived knowledge‐and‐beliefs scores, skills and attitudes were strongly and positively correlated (r = 0.606–0.790, p < 0.001). Higher educational qualification (β = 0.129, p = 0.011) and longer professional nursing experience (β = 0.229, p = 0.005) were associated with higher self‐reported skills. More positive attitudes were associated with educational qualification (β = 0.174, p < 0.001), years as a qualified nurse (β = 0.362, p < 0.001) and ICU experience (β = 0.211, p < 0.001).
Conclusion
Jordanian ICU nurses reported moderate perceived competence in mental health care, alongside important gaps in perceived knowledge, perceived preparedness, self‐reported clinical assessment skills and confidence in managing complex mental health situations. Some responses also indicated potentially stigmatizing beliefs that require attention in future education. The strong associations among knowledge, skills and attitudes suggest that these domains should be addressed together through structured mental health education, practical skills training and organizational support. Objective assessment of clinical competence is warranted to complement self‐reported preparedness.
Keywords: attitudes, ICU nurses, intensive care unit, knowledge, mental health care, mental illness, skills
1. Introduction
Mental Health Disorders (MHD) are characterized by a clinically significant disturbance in a person's behaviour, emotional control or cognition, according to the World Health Organization (WHO). In 2023, nearly 1 in 7 people worldwide—approximately 1.2 billion individuals—were living with a mental disorder, with anxiety and depressive disorders being the most common. Despite the availability of effective prevention and treatment options, many people with mental disorders do not have access to effective care and may experience stigma and discrimination (World Health Organization 2026).
The global burden of mental disorders is also relevant to acute and critical care because people living with mental health conditions may develop or present with serious physical illness requiring hospitalization and, in some cases, intensive care. Mental disorders frequently coexist with chronic physical conditions and may be associated with delayed help‐seeking, barriers to accessing preventive and routine health services, medication‐related adverse effects, substance use, self‐harm and increased vulnerability to physical illness. When admitted to the ICU, these patients may require care that addresses acute physiological instability alongside psychiatric symptoms, cognitive disturbance, communication difficulties, behavioural distress and psychosocial needs. Consequently, critical care teams require the knowledge, skills, confidence and organizational support needed to provide safe, person‐centred and non‐stigmatizing care to patients with coexisting mental and physical health needs (World Health Organization 2026; Lawrence et al. 2013; Plana‐Ripoll et al. 2019; Wilson et al. 2025).
International evidence suggests that pre‐existing mental health disorders are common among adult ICU patients. A systematic review and meta‐analysis estimated a pooled prevalence of 19.4% (95% CI: 8.9%–32.6%), although reported estimates ranged from 6.2% to 28.0% across studies, reflecting differences in clinical settings, patient populations and methods used to identify mental health disorders. Depression was the most frequently reported pre‐existing disorder. However, comparable data on the prevalence of documented pre‐existing mental health disorders among general adult ICU admissions in Jordan are limited. In a Jordanian study of 108 patients admitted to ICUs in seven governmental hospitals, 84.3% screened positive for anxiety symptoms and 79.6% for depressive symptoms; these findings indicate a substantial psychological symptom burden among ICU patients but should not be interpreted as the prevalence of pre‐existing diagnosed mental disorders. Together, these findings support the relevance of mental‐health‐informed care in Jordanian ICUs (Pilowsky et al. 2021; Shdaifat and Al Qadire 2022).
Negative attitudes toward mental illness might prolong stigma and hinder patient healing. Research suggests that even medical professionals may have negative attitudes about mental illness, which may limit the amount of care that is recovery‐oriented (Sreeram et al. 2021, 2022). Nurses' unfavourable perceptions of mental health issues and the process of recovery may hinder the delivery of effective care for individuals dealing with mental illness. Additionally, there is a lack of research investigating nurses' views on mental health disorders and recovery‐focused approaches, especially among those employed in acute psychiatric settings (Hsiao et al. 2015; Waldemar et al. 2019). Nurses play an important role in providing treatment for those with mental diseases, especially those confined to critical care units. To provide safe, efficient and patient‐centred care, it is crucial to assess ICU nurses' attitudes, preparedness and approaches to including patients with mental illness in their care (Keresi et al. 2019).
In a systematic evaluation of 11 studies, Thomas et al. (2021) discovered that ICU nurses showed inadequate understanding of delirium, a prevalent mental health issue among critically ill patients. This lack of information had a detrimental effect on nurses' professional practice and self‐assurance when providing care for ICU patients with mental illness. The authors stressed the importance of targeted educational initiatives to enhance nurses' readiness, self‐assurance and the standard of mental health care in critical care environments.
Recent research suggests that providing care for patients with mental health conditions in intensive care settings requires more than individual nurses' clinical knowledge and technical competence. A 2025 scoping review reported that ICU nurses' experiences are influenced by interconnected factors, including mental‐health‐related knowledge and skill development, empathy toward patients, concerns about patient and staff safety and access to appropriate clinical support. The review concluded that effective care requires targeted mental health education alongside sufficient resources and support within the ICU setting (Wilson et al. 2025).
Complementary qualitative evidence from general hospital wards shows that nurses caring for patients with medical‐psychiatric comorbidities experience emotional strain, time pressure, competing clinical demands and care environments that may be poorly suited to patients' mental health needs. Nurses described developing competence through clinical experience but emphasized that education alone is insufficient; organizational support, multidisciplinary collaboration and mental‐health‐responsive care environments are also needed to strengthen confidence and person‐centred care (Jong et al. 2025). Recent ICU‐specific evidence similarly indicates that stigma, assumptions about violence and aggression, perceived skill deficits and limited support may shape nurses' engagement with patients who have comorbid mental health disorders and may compromise holistic care (Teece and Baker 2025).
According to qualitative research, stigmatizing attitudes, power disparities among medical staff and dominant biomedical objectives all contribute to the marginalization of patients with diagnosed mental illness in intensive care units. These elements restrict the delivery of comprehensive, patient‐centred mental health treatment and add to the emotions of unpreparedness experienced by ICU nurses (Corfee et al. 2018).
Bandura's Self‐Efficacy Theory gives a way to understand how ready and confident ICU nurses are in treating patients with mental health issues (Bandura 1977). This theory suggests that a person's confidence in their ability to complete a task—called self‐efficacy—affects their drive, effort and outcome. In the situation of ICU nursing, self‐efficacy can explain why certain nurses may feel unprepared to handle patients with mental disorders, even if they have received formal training. Improving nurses' self‐efficacy through education, hands‐on experience and supportive measures might boost their confidence and the quality of care they provide, tackling the difficulties noted in earlier studies (Thomas et al. 2021; Corfee et al. 2018).
Importantly, nurses' perceived preparedness and confidence should not be viewed solely as individual characteristics. In critical care, the ability to provide effective mental health care is also shaped by the complexity of patients' conditions, the intensity and unpredictability of care demands and the complexity of nursing work required to manage multiple competing priorities. Recent evidence has highlighted the interplay between patient complexity and nursing complexity and its implications for clinical outcomes (Cesare, D'Agostino, Damiani, et al. 2025; Cesare, D'Agostino, Nurchis, et al. 2025; Cesare, D'Agostino, Nursing, Public Health G, et al. 2025; Cocchieri et al. 2026, 2025). This perspective suggests that nurses' perceived capabilities should be understood within the context in which care is delivered, particularly in ICUs where patients may simultaneously experience physiological instability, cognitive or psychological symptoms, behavioural challenges and complex treatment requirements.
Given these challenges, it is important to examine ICU nurses' perceptions of their knowledge, skills, attitudes and confidence in caring for patients with mental illness. Therefore, this study aimed to explore Jordanian ICU nurses' self‐reported knowledge, skills and attitudes regarding the care of patients with mental illness and to examine factors associated with their perceived confidence in managing mental health conditions in critical care settings.
2. Methods and Subjects
2.1. Study Design
A descriptive cross‐sectional research design was used with a self‐administered questionnaire to assess Jordanian ICU nurses' self‐reported knowledge, perceived skills and attitudes regarding the care of patients with mental illness.
2.2. Study Setting
The study was conducted in adult intensive care units (ICUs) of 20 hospitals selected using stratified random sampling from a sampling frame of 121 hospitals operating in Jordan. The sampling frame was developed from national and institutional records, including information from the Ministry of Health and the Private Hospitals Association (The Private Hospitals Association, n.d.; Tamimi et al. 2024). The sampling frame comprised 71 private hospitals, 48 government and military hospitals and 2 university hospitals.
Hospitals were stratified by health‐care sector: private, government/military and university. Within each stratum. Twenty hospitals were then selected using a computer‐generated random‐number sequence. The number of hospitals selected from each stratum was allocated proportionately to the number of eligible hospitals in that stratum using a prespecified allocation to ensure representation of all sectors and to provide geographic and organizational diversity. This approach facilitated recruitment of ICU nurses from a range of clinical environments and healthcare sectors.
The selection of 20 hospitals was considered feasible and appropriate for the study because methodological guidance for facility‐based surveys suggests that selecting approximately 15–30 facilities can provide adequate coverage when the sampling frame comprises approximately 100–200 facilities (Turner et al. 2001). The inclusion of hospitals from different sectors was intended to enhance the diversity of the participating settings and the applicability of the findings across different ICU environments.
2.3. Population and Sample
The target population comprised all licensed registered nurses working in adult ICUs in Jordan. Eligible participants were registered nurses who had worked in an ICU for at least 6 months and could read and understand Arabic or English. The 6‐month minimum ICU experience was selected to ensure that participants had sufficient exposure to the ICU environment, routine critical care practices and the mental health needs of critically ill patients while reducing the likelihood that responses would primarily reflect orientation or initial training experiences. Nurses working on a full‐time, part‐time or casual basis were eligible if they met the minimum 6‐month ICU experience criterion. Nurses who were in orientation or training, students, interns or not currently working in an ICU were excluded.
Because no comprehensive national registry of nurses working specifically in adult ICUs in Jordan was available, the target population was estimated at approximately 3000 eligible ICU nurses. This estimate was derived from staffing information obtained from the selected hospitals and national hospital workforce records by summing the reported numbers of adult ICU nurses across hospitals in the sampling frame. The estimate was used solely for sample‐size planning and should be interpreted as approximate.
Using this estimated population size (𝑁 = 3000), a 95% confidence level, 5% margin of error and a conservative expected proportion of 50%, the minimum required sample size was calculated as 341 nurses using OpenEpi version 3 with finite population correction (Dean et al. 2025). The final sample of 502 nurses exceeded this minimum.
To assess the influence of uncertainty in the estimated target population, sample‐size calculations were also considered for plausible population sizes. At a 95% confidence level, 5% margin of error and 50% expected proportion, the required sample is approximately 341 for N = 3000, 357 for N = 5000 and 370 for N = 10,000. Therefore, the achieved sample of 502 exceeded the minimum required sample across these plausible population‐size assumptions.
Participants were recruited from 20 public, private and university hospitals across different regions of Jordan. Data were collected exclusively using an online, self‐administered questionnaire. The survey link was disseminated through professional nursing networks and electronic communication channels, including WhatsApp, email and Messenger, with multiple rounds of reminders to encourage participation.
To facilitate access during shift breaks, printed QR codes linking directly to the same online questionnaire were made available in participating hospitals. Participants scanned the QR code using their personal mobile devices and completed the questionnaire electronically. No paper‐based questionnaires were distributed or collected. This approach facilitated access to ICU nurses across geographically dispersed hospitals and contributed to the final sample of 502 participants. However, because recruitment relied on voluntary participation through social media and professional networks rather than probability‐based sampling, selection bias cannot be excluded.
Nurses who were more interested in mental health, more active on social media or more motivated to participate may have been more likely to respond, whereas nurses with limited digital connectivity or lower engagement with these platforms may have been underrepresented. This potential digital access and self‐selection bias may have affected the representativeness of the sample and the distribution of participants' characteristics and responses. Therefore, although the achieved sample exceeded the calculated minimum and included nurses from 20 hospitals across different healthcare sectors and regions, the findings should be interpreted with caution regarding their generalizability to all ICU nurses in Jordan.
2.4. Study Instrument
The study used an adapted version of the questionnaire developed by Weare et al. (Weare et al. 2019), which was originally developed in Australia to assess ICU nurses' knowledge, skills and attitudes toward caring for patients with mental illness. Permission to use and translate the instrument was obtained from the original authors. Because the original instrument was developed in an Australian context, a linguistic and contextual adaptation process was undertaken before use in Jordan. The original English questionnaire was translated into Arabic by bilingual experts. The Arabic version was then back‐translated into English by a bilingual translator.
The original and back‐translated versions were compared, and discrepancies in wording or meaning were resolved through discussion to preserve conceptual and semantic equivalence. The Arabic and English versions were reviewed by 5 experts with expertise in intensive care nursing, mental health nursing, research methodology and the Jordanian health‐care context. The review considered item clarity, cultural appropriateness, clinical relevance and contextual applicability to ICU practice in Jordan. Minor wording modifications were made to improve clarity and local relevance without changing the intended construct of the original items.
One contextual modification was made to the item assessing legal knowledge. The item was adapted to read, “I have a good working knowledge of the Mental Health Law in Jordan,” because mental health legislation and related professional responsibilities are country specific. This item was included to assess nurses' self‐reported familiarity with Jordanian mental‐health legislation and was not treated as an objective measure of legal knowledge.
The final questionnaire was provided electronically in Arabic and English, and participants selected their preferred language. Before the main data collection, the adapted questionnaire was piloted with 20 ICU nurses who met the study eligibility criteria. The pilot participants assessed the clarity, readability and relevance of the items to their ICU practice. Only minor wording refinements were made, and pilot data were excluded from the final analysis.
The final questionnaire included demographic questions‐ the respondents' age, gender, nursing credentials and years of professional experience‐ and 67 five‐point Likert‐type items grouped in the original broad domains of perceived knowledge and beliefs (12 items), self‐reported skills (15 items) and attitudes (40 items). Although internal consistency was assessed in the present sample, the translated and contextually adapted version was not subjected to a full psychometric validation study. Therefore, its findings should be interpreted as self‐reported perceptions and should be confirmed in future research using comprehensive cross‐cultural validation procedures.
The principal segments of the questionnaire include: (1) Perceived knowledge, preparedness and beliefs domain: This domain comprised 12 Likert‐type items adapted from the instrument developed by Weare et al. (2019). The items assessed nurses' self‐reported perceived knowledge and familiarity with mental illness, psychotropic medications, mental‐health legislation, mental‐state examination, risk assessment and the relationship between mental and physical health. The domain also included items concerning nurses' beliefs about the frequency of mental illness in ICU patients, self‐harm‐related ICU admissions and the association between mental illness and violence or aggression. Accordingly, this domain was interpreted as a measure of perceived knowledge, preparedness and beliefs, rather than as an objective test of factual mental‐health knowledge. Although the original instrument categorized these items under “knowledge,” not all items represent factual knowledge. In particular, agreement with generalized statements regarding violence/aggression or self‐harm admissions was not interpreted as evidence of greater knowledge. Such responses may reflect clinical assumptions, misconceptions or stigmatizing beliefs. These items were therefore reported and interpreted separately from self‐reported perceived knowledge and preparedness. (2) Skills and Competencies Subscale: 15 self‐reported items that assess confidence and perceived capacity to manage behavioural disturbances, facilitate effective communication and enforce safety protocols. (3) Attitudes Subscale: 40 items aimed at evaluating nurses' perceptions, comfort levels and convictions concerning the care of patients diagnosed with mental illness. Ultimately, participants were asked whether they had received training in areas pertinent to mental health care for critically ill patients (e.g., mental status assessment, fundamental counselling skills), and they were given the opportunity to submit open‐ended suggestions regarding their requirements for caring for patients with mental illness in the ICU.
The questionnaire was piloted before data collection among a convenience sample of 20 ICU nurses and was well received. The report of the internal consistency, as the tool was formally evaluated using Cronbach's Alpha, suggested good reliability within each of the three scales (Knowledge: α = 0.76; Skills: α = 0.90; Attitudes: α = 0.82) (Weare et al. 2019). However, in the current study, the Cronbach's Alpha reliability test similarly revealed acceptable reliability of the questionnaire in all subscales (Knowledge: α = 0.81; Skills: α = 0.92; Attitudes: α = 0.87).
2.5. Data Collection Procedure
Ethical approval was obtained from the relevant Research Ethics Committee prior to conducting the study. Permission from hospital administrations was also secured. Eligible participants received a link to the online questionnaire, which included a cover page detailing the study purpose, procedures, benefits and a consent form for participation.
Informed consent was obtained, and participation in the questionnaire was voluntary, with participants given 15–20 min to complete it. The online survey link was distributed through WhatsApp, email and Messenger, enabling voluntary participation without coercion. To increase accessibility during work hours, printed QR codes linking to the online survey were made available during shift breaks. Participants used their personal mobile devices to scan the QR code and complete the questionnaire electronically. No paper‐based questionnaires were used, and no responses were collected in person. Because the online survey link and QR code were disseminated through multiple professional and electronic channels, the total number of eligible ICU nurses who received or viewed the invitation could not be determined. Therefore, a conventional response rate could not be calculated.
Although hospitals were selected using stratified random sampling, participation by individual nurses was voluntary. The online recruitment approach may have favoured participation by nurses with greater access to digital communication platforms, stronger interest in mental health or research or higher academic qualifications. Therefore, the final participant sample may not fully represent the educational profile of all ICU nurses working in Jordan. Data collection occurred over 3 months, from June to August 2025. All electronic responses were stored securely for analysis.
2.6. Data Analysis
Quantitative data were analysed using SPSS Version 30. The analysis included descriptive statistics, including means, frequencies and standard deviations, for attitudes, knowledge, skills and barriers. For item‐level descriptive findings, endorsement was defined as the combined percentage of participants who selected “agree” or “strongly agree.” Reliability testing was performed using Cronbach's alpha for each subscale. Inferential analyses were conducted using nonparametric methods for demographic group comparisons because the mean scores for the knowledge, skills and attitudes domains significantly deviated from normality based on the Kolmogorov–Smirnov and Shapiro–Wilk tests. Specifically, the Kruskal–Wallis test was used to compare scores across demographic groups. Before conducting Pearson correlation analyses, bivariate scatterplots were visually inspected to assess the linearity of the relationships and identify potential influential outliers; no influential outliers were detected. Pearson correlation coefficients were then calculated to examine the relationships among self‐reported knowledge, skills and attitude scores. Multiple regression analysis was also performed to identify factors associated with self‐reported competence and confidence in providing mental healthcare. Statistical significance was set at p ≤ 0.05.
2.7. Ethical Consideration
Ethical approval was granted by the ethics committee at Princess Aisha Bent Al‐Hussein College of Nursing at Al‐Hussein Bin Talal University before data collection (Ethics approval No. LBY/2/1 on January 7, 2025). Informed consent from participants was mandatory before they participated, with approval to complete the survey. All information related to the study objectives, duration, importance, methods and effects was explained to participants on the questionnaire cover page before they agreed to participate in the study. The study guaranteed voluntary participation and the participants' right to withdraw at any time, and participants were assured that no one would be victimized for not participating or for withdrawing after consent. All responses remained anonymous and confidential, and data were stored securely for research purposes only. All ethical considerations in scientific research were strictly followed in accordance with the Helsinki Declaration.
3. Results
A total of 502 Jordanian intensive care unit (ICU) nurses participated in this study (Table 1). Most respondents were female (58.8%), while males comprised 41.2% of the sample. Most participants were aged 26–35 years (61.0%), followed by those aged 36–49 years (29.9%), and a smaller proportion were aged 25 years or younger (9.2%).
TABLE 1.
Sociodemographic and professional characteristics of the participants (N = 502).
| Sociodemographic data | n | % |
|---|---|---|
| Gender | ||
| Female | 295 | 58.8% |
| Male | 207 | 41.2% |
| Age | ||
| 25 years or under | 46 | 9.2% |
| 26–35 years | 306 | 61.0% |
| 36–49 years | 150 | 29.9% |
| Qualification | ||
| Diploma in nursing | 50 | 10.0% |
| Bachelor of nursing | 229 | 45.6% |
| Higher diploma in nursing | 62 | 12.4% |
| Master's in nursing | 150 | 29.9% |
| PhD | 11 | 2.2% |
| Years working as a qualified nurse | ||
| 2 years or less | 67 | 13.3% |
| 3–10 years | 65 | 12.9% |
| 11–20 years | 101 | 20.1% |
| 21–30 years | 244 | 48.6% |
| More than 30 years | 25 | 5.0% |
| Years of experience in the ICU | ||
| 2 years or less | 247 | 49.2% |
| 3–10 years | 152 | 30.3% |
| 11–20 years | 45 | 9.0% |
| 21–30 years | 58 | 11.6% |
| Have you had any experience working as a nurse in a mental health area? | ||
| Yes | 204 | 40.6% |
| No | 298 | 59.4% |
In terms of educational attainment, nearly half of the participant nurses reported holding a bachelor's degree in nursing (45.6%), while 29.9% reported holding a master's degree. A smaller proportion reported having a Higher Diploma (12.4%), a nursing Diploma (10.0%) or a PhD (2.2%).
Regarding overall nursing experience, the largest group (48.6%) had been practicing as qualified nurses for 21 to 30 years. This was followed by those with 11 to 20 years of experience (20.1%), 2 years or less (13.3%), 3 to 10 years (12.9%) and more than 30 years (5.0%).
ICU‐specific experience showed a slightly different pattern, with nearly half of the nurses (49.2%) reporting 2 years or less of ICU experience. Another 30.3% had 3–10 years of ICU experience, while smaller percentages reported 21–30 years (11.6%) and 11–20 years (9.0%).
Finally, when asked about prior experience working in mental health settings, the majority of participants (59.4%) indicated they had no such experience, while 40.6% reported having worked in a mental health area. This suggests that a significant proportion of ICU nurses may lack direct exposure to mental health care environments.
Table 2 presents nurses' self‐reported perceived knowledge, preparedness and beliefs regarding mental health care in the ICU. For items assessing perceived knowledge and preparedness, responses suggested moderate self‐reported familiarity with mental illness, psychotropic medications, mental‐health risk assessment and the relationship between mental and physical health. However, participants reported lower perceived preparedness to care for patients with mental illness.
TABLE 2.
Nurses' self‐reported perceived knowledge, preparedness and beliefs regarding mental health care in the ICU.
| Nurses knowledge | Strongly disagree | Disagree | Neutral | Agree | Strongly agree | Mean | SD |
|---|---|---|---|---|---|---|---|
| 1. I understand the causative factors of mental illness | 2.2% | 15.5% | 22.9% | 51.8% | 7.6% | 3.47 | 0.919 |
| 2. I have a good knowledge of psychotropic medications used in the ICU for mental health issues (e.g., antipsychotics) | 6.4% | 12.7% | 43.8% | 30.1% | 7.0% | 3.19 | 0.964 |
| 3. I have a good working knowledge of the Mental Health Law in Jordan | 7.2% | 23.1% | 43.4% | 18.5% | 7.8% | 2.97 | 1.007 |
| 4. I feel adequately trained to deal with patients with mental illness | 9.8% | 21.3% | 41.0% | 25.5% | 2.4% | 2.89 | 0.972 |
| 5. I have a good knowledge of psychiatric illnesses | 5.6% | 18.1% | 28.7% | 38.2% | 9.4% | 3.28 | 1.043 |
| 6. I am familiar with the components of a basic mental state examination screening for psychiatric illness | 3.2% | 31.7% | 29.0% | 31.7% | 4.4% | 3.02 | 0.968 |
| 7. I am familiar with the key elements of a basic mental health risk assessment | 2.2% | 24.1% | 36.6% | 27.1% | 10.0% | 3.19 | 0.983 |
| 8. Psychiatric illnesses are common among patients admitted to the ICU | 3.4% | 24.1% | 31.9% | 37.6% | 3.0% | 3.13 | 0.926 |
| 9. A majority of patients with mental illness in the ICU are admitted because of self‐harm a | 3.2% | 25.7% | 35.8% | 28.9% | 6.4% | 3.10 | 0.960 |
| 10. I understand the ways that mental health can impact other aspects of health | 8.8% | 13.5% | 28.1% | 37.6% | 12.0% | 3.30 | 1.118 |
| 11. I understand the causative factors of drug or alcohol addiction | 12.9% | 11.6% | 32.2% | 34.1% | 9.2% | 3.15 | 1.149 |
| 12. Patients with mental illness are more prone to violence or aggression than other patients b | 2.0% | 9.4% | 40.0% | 26.5% | 22.1% | 3.57 | 0.998 |
| Overall perceived knowledge‐and‐beliefs score c | 5.6% | 19.2% | 34.5% | 32.3% | 8.4% | 3.1877 | 0.70297 |
This item reflects respondents' beliefs about the clinical presentation and pathways to ICU admission; agreement should not be interpreted as evidence of greater knowledge.
This item reflects a generalized belief about mental illness. Agreement may reflect a stereotype or stigmatizing perception and should not be interpreted as evidence of greater knowledge.
This composite score is presented for descriptive comparability with the original instrument. It includes self‐reported perceived knowledge, preparedness and belief‐based items; therefore, it should not be interpreted as a measure of objective factual knowledge. Higher scores on Items 9 and 12 do not necessarily indicate more accurate knowledge.
Among perceived knowledge and preparedness items, the lowest endorsement was for feeling adequately trained to deal with patients with mental illness (27.9%; mean = 2.89, SD = 0.97) and having a good working knowledge of the Mental Health Law in Jordan (26.3%; mean = 2.97, SD = 1.01). Only 27.9% of participants agreed or strongly agreed with the statement, I feel adequately trained to deal with patients with mental illness, indicating lower self‐reported perceived training adequacy for caring for patients with mental illness. The participants reported limited perceived knowledge of the Jordanian Mental Health Law (mean = 2.97, SD = 1.01) and limited familiarity with components of a basic mental‐state examination (mean = 3.02, SD = 0.97). These findings represent perceived competence and familiarity rather than objectively assessed knowledge.
The highest mean score was observed for the statement, “Patients with mental illness are more prone to violence or aggression than other patients” (mean = 3.57, SD = 1.00); 48.6% of nurses agreed or strongly agreed with this statement. This result is presented as a generalized belief rather than an indicator of knowledge. Because the statement may reflect a stereotype associating mental illness with dangerousness, agreement should be interpreted cautiously as a potential stigmatizing perception or misconception.
The second highest scored statement was their understanding of the causative factors of mental illness (59.4%; mean = 3.47, SD = 0.92), followed by understanding how mental health can affect other aspects of health (49.6% agreed or strongly agreed; mean = 3.30, SD = 1.12). Similarly, 35.3% of participants agreed or strongly agreed that most patients with mental illness admitted to the ICU were admitted because of self‐harm (mean = 3.10, SD = 0.96). This item reflects a belief about ICU admission patterns and is not interpreted as an indicator of higher knowledge.
In summary, while ICU nurses in this sample demonstrated a general awareness of mental health issues, the data indicate a lack of comprehensive training, particularly in legal knowledge, clinical assessment tools and practical management strategies. These findings underscore the need for targeted mental health education and professional development within ICU nursing practice.
Table 3 provides insights into nurses' self‐reported skills and competencies in mental healthcare. The findings reveal a moderate skill level, with a mean skills score of 3.20 (SD = 0.51), indicating a general uncertainty and variability in confidence when managing psychiatric aspects of care in ICU settings.
TABLE 3.
Self‐reported skills and competencies related to mental illness care among Jordanian ICU nurses.
| Nurses' skills | Strongly disagree | Disagree | Neutral | Agree | Strongly agree | Mean | SD |
|---|---|---|---|---|---|---|---|
| 1. I have the ability to complete a basic mental state examination screening for psychiatric illness | 11.0% | 15.3% | 37.4% | 28.5% | 7.8% | 3.07 | 1.089 |
| 2. I have the ability to complete a basic mental health risk assessment | 9.0% | 17.5% | 33.3% | 37.6% | 2.6% | 3.07 | 1.005 |
| 3. I feel uncomfortable caring for a patient with mental illness who has a history of violence | 3.0% | 17.1% | 30.1% | 36.5% | 13.3% | 3.40 | 1.015 |
| 4. I am confident in engaging with patients who present suicidal and self‐harming behaviours | 10.6% | 9.6% | 42.3% | 33.9% | 3.6% | 3.10 | 0.996 |
| 5. I feel hopeless when trying to help patients who are mentally ill | 8.6% | 26.9% | 32.4% | 25.1% | 7.0% | 2.95 | 1.068 |
| 6. I am concerned I might say the wrong thing when talking to patients with a mental illness | 7.2% | 22.3% | 25.7% | 40.6% | 4.2% | 3.12 | 1.035 |
| 7. I find it confronting to talk to patients expressing delusional or paranoid ideas | 1.0% | 9.4% | 37.5% | 39.6% | 12.5% | 3.53 | 0.865 |
| 8. I find it confronting to talk to patients who are hallucinating | 5.2% | 15.1% | 34.4% | 35.1% | 10.2% | 3.30 | 1.014 |
| 9. I find it confronting to talk to patients about suicide or self‐harm | 3.8% | 10.0% | 38.8% | 30.7% | 16.7% | 3.47 | 1.006 |
| 10. I am able to differentiate delirium from other psychiatric illnesses | 12.7% | 15.7% | 35.3% | 26.3% | 10.0% | 3.05 | 1.153 |
| 11. I am confident/comfortable in discussing patients' mental illness with them | 10.8% | 12.7% | 38.4% | 32.5% | 5.6% | 3.09 | 1.048 |
| 12. I feel confident in communicating medical information to patients with mental illnesses | 9.6% | 14.3% | 28.7% | 42.4% | 5.0% | 3.19 | 1.056 |
| 13. I am able to identify signs of mental illness in patients I am caring for | 6.6% | 10.2% | 34.6% | 43.0% | 5.6% | 3.31 | 0.961 |
| 14. I believe that the training I have received in the ICU to date has given me adequate skills to care for patients with mental illness | 10.6% | 20.7% | 20.1% | 41.2% | 7.4% | 3.14 | 1.149 |
| 15. I find it difficult to understand the perspective of a patient who has self‐harmed | 6.8% | 18.1% | 37.4% | 29.1% | 8.6% | 3.15 | 1.033 |
| Mean skills score | 7.7% | 15.7% | 33.8% | 34.8% | 8.0% | 3.1964 | 0.51498 |
The highest positive endorsement was for the ability to identify signs of mental illness in patients under their care (48.6% agreed or strongly agreed; mean = 3.31, SD = 0.96), followed by confidence in communicating medical information to patients with mental illness (47.4%; mean = 3.19, SD = 1.06). The lowest positive endorsement was for the ability to differentiate delirium from other psychiatric illnesses (36.3%; mean = 3.05, SD = 1.153), followed by the ability to complete a basic mental‐state examination (36.3%; mean = 3.07, SD = 1.09) and to complete a basic mental‐health risk assessment (40.2%; mean = 3.07, SD = 1.01).
Several items highlight areas of discomfort and limited confidence. For example, only 36.3% of nurses agreed or strongly agreed that they could complete a basic mental health risk assessment, and just 36.3% felt capable of conducting a basic mental state examination, with both items averaging a mean score of 3.07. Similarly, the ability to differentiate delirium from other psychiatric conditions scored low (mean = 3.05), emphasizing a critical gap in clinical diagnostic skills.
Emotional and interpersonal challenges were also apparent. A considerable proportion of nurses reported discomfort when dealing with complex psychiatric symptoms: 52.1% found it confronting to speak with patients expressing delusional or paranoid ideas (mean = 3.53), and 47.4% reported similar discomfort when talking to patients about suicidal ideation or self‐harm (mean = 3.47). These emotional barriers could hinder effective communication and the provision of care.
Regarding communication, moderate confidence was observed. While 47.4% of nurses reported confidence in communicating medical information to mentally ill patients (mean = 3.19), fewer were confident engaging with patients who exhibit suicidal behaviours (mean = 3.10). Furthermore, only 48.6% felt that the training they had received in the ICU setting had adequately equipped them with the necessary skills, with this item yielding a mean of 3.14.
Despite these challenges, some encouraging signs emerged. Nearly half of the nurses (48.6%) indicated they could identify signs of mental illness in patients (mean = 3.31), which may reflect basic awareness or observational experience developed through practice rather than formal training.
In summary, the data suggest that Jordanian ICU nurses generally possess moderate self‐reported skills in managing mental health issues, yet they also experience considerable discomfort and uncertainty, especially in situations involving psychotic symptoms, suicidal ideation and complex communication. These findings strongly underscore the need for targeted mental health training and skill‐building programs in critical care settings to enhance nurses' competence and confidence in this vital area.
Table 4 presents a comprehensive analysis of nurses' attitudes toward mental illness in the ICU setting. The findings reflect a mix of empathy, stigma, uncertainty and practical concern, with an overall mean attitude score of 3.28 (SD = 0.44), indicating generally neutral to slightly positive attitudes.
TABLE 4.
Attitudes of Jordanian ICU nurses toward care of patients with mental illness.
| Nurses attitudes | Strongly disagree | Disagree | Neutral | Agree | Strongly agree | Mean | SD |
|---|---|---|---|---|---|---|---|
| 1. Understanding patients' psychological state has no bearing on their ICU treatment | 12.5% | 19.9% | 36.3% | 29.1% | 2.2% | 2.88 | 1.034 |
| 2. Understanding patients' psychological state has no bearing on their outcomes | 10.6% | 23.3% | 38.2% | 25.7% | 2.2% | 2.86 | 0.991 |
| 3. Patients with mental illness are partly responsible for what they are experiencing | 3.0% | 16.9% | 38.0% | 36.1% | 6.0% | 3.25 | 0.909 |
| 4. If I had a choice, I would rather not directly care for people with a mental illness | 5.0% | 12.9% | 37.0% | 33.1% | 12.0% | 3.34 | 1.012 |
| 5. Mental illness is an illness like any other illness | 9.6% | 5.6% | 28.3% | 44.0% | 12.5% | 3.44 | 1.089 |
| 6. Once a person has a mental illness, they are mentally ill forever | 8.2% | 32.3% | 23.6% | 26.3% | 9.6% | 2.97 | 1.139 |
| 7. Patients who are mentally ill are irresponsible | 9.4% | 12.9% | 35.5% | 27.7% | 14.5% | 3.25 | 1.141 |
| 8. I would feel ashamed if a member of my family had a mental illness | 7.2% | 24.3% | 33.0% | 25.7% | 9.8% | 3.07 | 1.084 |
| 9. Patients with a mental illness occupy more staff time, so staff are unavailable to patients who are “in greater need of help.” | 8.0% | 7.2% | 25.4% | 50.4% | 9.0% | 3.45 | 1.025 |
| 10. Empathy demonstrated by nurses may positively influence the experience of a patient with mental illness | 3.2% | 12.0% | 28.4% | 44.6% | 11.8% | 3.50 | 0.958 |
| 11. Whenever I care for patients with a mental illness, I feel uncomfortable | 8.2% | 16.3% | 25.7% | 35.1% | 14.7% | 3.32 | 1.154 |
| 12. Sometimes I feel nervous when I have to care for a patient with a mental illness | 7.2% | 11.4% | 35.9% | 36.3% | 9.2% | 3.29 | 1.024 |
| 13. I am happy to care for patients with mental illness, and I feel the same empathy as I do when caring for other patients | 9.0% | 17.7% | 42.2% | 25.3% | 5.8% | 3.01 | 1.011 |
| 14. It is frustrating to treat patients with mental illness | 5.8% | 12.4% | 38.7% | 33.5% | 9.6% | 3.29 | 0.996 |
| 15. I enjoy caring for patients with mental illness | 12.0% | 20.1% | 43.6% | 24.3% | 0.0% | 2.80 | 0.941 |
| 16. Patients with mental illnesses have sensibilities that are not detectable by others around them | 5.4% | 12.9% | 27.3% | 49.2% | 5.2% | 3.36 | 0.958 |
| 17. I often feel empathy and understanding toward patients with mental illness | 4.4% | 9.8% | 36.2% | 40.4% | 9.2% | 3.40 | 0.940 |
| 18. I believe that patients with mental illness will be unable to have a normal life following their discharge | 5.2% | 16.9% | 34.2% | 34.9% | 8.8% | 3.25 | 1.007 |
| 19. Patients with mental illness think only of themselves | 4.6% | 29.3% | 35.8% | 23.5% | 6.8% | 2.99 | 0.992 |
| 20. It is more important to set strict boundaries when caring for patients with a mental illness | 5.8% | 13.9% | 32.5% | 41.0% | 6.8% | 3.29 | 0.984 |
| 21. Patients with mental illness are not responsible for their actions, but are victims of their environment, and they need understanding | 2.2% | 8.4% | 30.8% | 52.4% | 6.2% | 3.52 | 0.821 |
| 22. Patients receive adequate psychological support in the unit where I work | 14.3% | 6.0% | 30.1% | 40.2% | 9.4% | 3.24 | 1.164 |
| 23. Patients with mental illness are treated with empathy in the unit where I work | 8.6% | 11.2% | 32.0% | 38.4% | 9.8% | 3.30 | 1.069 |
| 24. Patients with mental illness receive good therapeutic care in the unit where I work | 10.6% | 10.2% | 28.4% | 37.5% | 13.3% | 3.33 | 1.152 |
| 25. When I care for patients with a mental illness, I feel depressed | 1.0% | 19.3% | 34.6% | 33.7% | 11.4% | 3.35 | 0.950 |
| 26. Virtually anyone can become mentally ill | 7.4% | 10.2% | 24.1% | 45.8% | 12.5% | 3.46 | 1.071 |
| 27. Patients admitted to the ICU following self‐harm make me feel frustrated and irritated | 4.4% | 12.2% | 28.7% | 39.6% | 15.1% | 3.49 | 1.030 |
| 28. Caring for patients who have self‐harmed is a waste of my time | 10.2% | 29.3% | 22.1% | 22.1% | 16.3% | 3.05 | 1.255 |
| 29. People with drug and alcohol addictions are partly to blame for what they are experiencing | 1.0% | 11.0% | 33.1% | 38.2% | 16.7% | 3.59 | 0.926 |
| 30. Addiction is an illness like any other | 7.6% | 21.7% | 24.5% | 40.6% | 5.6% | 3.15 | 1.063 |
| 31. Patients who deliberately harm themselves do not deserve to come to the ICU | 14.5% | 17.7% | 35.4% | 19.3% | 13.1% | 2.99 | 1.217 |
| 32. Patients with psychiatric illnesses have unique needs | 4.0% | 12.4% | 22.3% | 47.8% | 13.5% | 3.55 | 1.003 |
| 33. The ICU is not a good environment in which to try to manage mental illnesses | 3.2% | 13.7% | 41.6% | 29.1% | 12.4% | 3.34 | 0.969 |
| 34. I have enough time to build rapport with patients with mental illness when providing care in the ICU environment | 8.6% | 18.5% | 31.2% | 34.3% | 7.4% | 3.13 | 1.072 |
| 35. My workload makes it difficult for me to care for patients with mental illness | 1.0% | 2.6% | 42.8% | 36.1% | 17.5% | 3.67 | 0.828 |
| 36. Having the support of a mental health nurse with me will enable me to better engage with my patients who have a mental illness | 1.0% | 3.6% | 36.5% | 46.4% | 12.5% | 3.66 | 0.780 |
| 37. Having a patient with mental illness in the ICU makes it an unpredictable environment | 1.0% | 10.8% | 39.3% | 36.9% | 12.0% | 3.48 | 0.875 |
| 38. I am more likely to consider the use of physical restraints if I see that a patient has a mental illness | 2.0% | 8.8% | 33.4% | 45.8% | 10.0% | 3.53 | 0.863 |
| 39. Managing patients who have mental illness should not be part of my job | 3.0% | 34.5% | 29.0% | 22.1% | 11.4% | 3.04 | 1.068 |
| 40. Having a patient with mental illness in the ICU has a negative impact on other patients | 3.0% | 15.5% | 26.8% | 40.4% | 14.3% | 3.48 | 1.014 |
| Means attitude score | 6.3% | 15.1% | 32.7% | 35.8% | 10.1% | 3.2837 | 0.44287 |
Many nurses acknowledged the complexity and validity of mental health conditions. For example, a substantial proportion agreed that mental illness is an illness like any other (mean = 3.44) and that virtually anyone can develop a mental illness (mean = 3.46), suggesting an underlying awareness and normalization of mental illness. Similarly, there was strong endorsement of empathetic care: 56.4% agreed that nurses' empathy may positively influence patients' experiences (mean = 3.50), and 66.0% believed patients with psychiatric illnesses have unique needs (mean = 3.55).
However, attitudes reflecting stigma and emotional discomfort were also prevalent. A notable portion of nurses expressed a preference to avoid direct care of patients with mental illness (mean = 3.34), and 49.8% admitted feeling uncomfortable when caring for such patients (mean = 3.32). Frustration was evident in responses to patients with self‐harming behaviour, with items like “patients admitted after self‐harm make me feel frustrated and irritated” receiving a high mean score of 3.49.
There were also misconceptions and deterministic beliefs. For instance, over a third of nurses believed that patients with mental illness are partly responsible for their condition (mean = 3.25), and many viewed people with drug or alcohol addiction as partly to blame (mean = 3.59), revealing a persistent attribution of mental illness to personal failings. Furthermore, 45.8% of respondents agreed they were more likely to use physical restraints for mentally ill patients (mean = 3.53), suggesting safety concerns may influence clinical decisions.
Environmental and systemic challenges were also highlighted. Many nurses perceived the ICU as not ideal for managing mental illness (mean = 3.34), and workload pressures were cited as a barrier to effective care (mean = 3.67). Importantly, nurses strongly endorsed the benefit of having a mental health nurse present in the ICU (mean = 3.66), signalling a desire for interdisciplinary collaboration and support.
In summary, Jordanian ICU nurses demonstrated a mix of empathetic and stigmatizing attitudes toward mental illness. While many recognized the legitimacy of mental health issues and expressed willingness to provide care, discomfort, blame‐oriented beliefs and systemic limitations were also evident. These findings suggest the need for targeted attitude‐shaping interventions, organizational support and integrated mental health training to foster more supportive and nonjudgemental care environments in ICUs.
Table 5 presents data on participants' training experiences in mental health care within critical care settings. The results highlight a significant gap in formal training: only 32% (n = 160) of nurses reported having never received formal training in mental health care for critically ill patients, while the majority, 68% (n = 342), had not.
TABLE 5.
Training of nurses in mental health care in the critical care settings.
| Question | Choice | n | % |
|---|---|---|---|
| Have you ever received formal training in the mental health care of critically ill patients? | Yes | 160 | 32% |
| No | 342 | 68% | |
| If yes, what specific topic related to mental health care for patients did you receive training on? (select any that apply) | Mental status assessment | 52 | 22% |
| Suicide risk assessment | 23 | 10% | |
| Psychiatric crisis intervention strategies | 9 | 4% | |
| General counselling skills | 23 | 10% | |
| Psychological interviewing skills | 9 | 4% | |
| Critical incident debriefing | 14 | 6% | |
| Mental health pharmacology | 7 | 3% | |
| Alcohol use/abuse | 15 | 6% | |
| Physical/sexual abuse | 9 | 4% | |
| Illicit drug use/abuse | 11 | 5% | |
| Grief and loss | 13 | 6% | |
| Individual therapy | 9 | 4% | |
| Family therapy | 20 | 9% | |
| Aggression management | 18 | 8% | |
| Do you feel you could be better prepared to deal with situations concerning patients with mental illnesses in the ICU? | Yes | 396 | 79% |
| No | 106 | 21% |
Among those who received training, the content areas covered were limited and fragmented. The most reported topic was mental status assessment (22%), followed by suicide risk assessment and general counselling skills (each 10%). Other important domains, such as psychiatric crisis intervention, psychological interviewing, mental health pharmacology and individual or family therapy, were reported by less than 10% of respondents. Training in complex or sensitive topics like physical/sexual abuse (4%) and grief and loss (6%) was also minimal.
Importantly, a large majority of nurses (79%, n = 396) reported feeling better prepared to manage situations involving patients with mental illness in the ICU, reinforcing the study's overall theme. This finding aligns with the noted deficiencies in knowledge, skills and attitudes across the previous tables and emphasizes the need for systematic, comprehensive mental health education and ongoing professional development for ICU nurses in Jordan.
These results underscore the critical importance of integrating structured mental health training programs into critical care nursing curricula and workplace education to ensure that ICU nurses are adequately equipped to provide safe, effective and empathetic care to patients experiencing mental health issues.
In this study, tests of normality were conducted to assess the distribution of the main continuous variables: knowledge, skills and attitude scores among Jordanian ICU nurses. The Kolmogorov–Smirnov and Shapiro–Wilk tests both yielded statistically significant results, indicating that the mean scores for the knowledge, skills and attitudes constructs were not normally distributed. Accordingly, the nonparametric Kruskal–Wallis test was used to compare mean ranks across three or more groups.
Multiple linear regression analysis was conducted to identify demographic and professional factors associated with the perceived knowledge‐and‐beliefs domain score. The overall model was not statistically significant, and none of the included demographic or professional variables were significantly associated with this score. Because the domain includes self‐reported knowledge, preparedness and belief‐based items, this analysis should not be interpreted as identifying predictors of objectively assessed mental‐health knowledge.
Specifically, gender (p = 0.724), age (p = 0.474), qualification (p = 0.850), years working as a nurse (p = 0.436), years of ICU experience (p = 0.145) and prior mental health nursing experience (p = 0.129) all failed to reach statistical significance. The standardized beta coefficients were also small across all predictors, further suggesting weak or negligible influence on the knowledge outcome. These results indicate that the demographic and professional background characteristics included in the model do not significantly predict ICU nurses' knowledge of mental health care, highlighting the potential influence of other unmeasured factors, such as specific training, workplace culture or exposure to psychiatric cases in the ICU.
Multiple linear regression analysis was performed to examine the predictors of ICU nurses' skills in mental health care (Table 6). The results revealed that two variables were significantly associated with nurses' self‐reported skills in mental health care: (1) Qualification was a significant positive predictor (B = 0.062, p = 0.011), suggesting that nurses with higher educational attainment reported higher mental health care skills. (2) Years working as a qualified nurse also had a significant positive effect (B = 0.103, p = 0.005), indicating that increased overall nursing experience is linked to stronger perceived mental health care competencies. In contrast, other variables such as gender, age, years of ICU experience and previous mental health nursing experience did not show statistically significant associations with skill scores (all p > 0.05).
TABLE 6.
Multiple linear regression analysis for ICU nurses' knowledge, skills and attitudes about mental health care.
| Perceived knowledge‐and‐beliefs domain model | Unstandardized coefficients | Standardized coefficients | t | Sig. | ||
|---|---|---|---|---|---|---|
| B | SE | β | ||||
| 1 | (Constant) | 3.117 | 0.109 | 28.536 | 0.000 | |
| Gender | 0.025 | 0.071 | 0.018 | 0.353 | 0.724 | |
| Age | 0.079 | 0.111 | 0.067 | 0.717 | 0.474 | |
| Qualification | −0.007 | 0.035 | −0.010 | −0.189 | 0.850 | |
| Years working as a qualified nurse | 0.040 | 0.052 | 0.066 | 0.780 | 0.436 | |
| Years of experience in the ICU | −0.058 | 0.040 | −0.083 | −1.459 | 0.145 | |
| Have you had any experience working as a nurse in a mental health area? | −0.108 | 0.071 | −0.076 | −1.521 | 0.129 | |
| Skills model | Unstandardized coefficients | Standardized coefficients | t | Sig. | ||
|---|---|---|---|---|---|---|
| B | SE | β | ||||
| 1 | (Constant) | 2.890 | 0.077 | 37.405 | 0.000 | |
| Gender | −0.141 | 0.050 | −0.135 | −0.807 | 0.543 | |
| Age | −0.056 | 0.078 | −0.064 | −0.713 | 0.476 | |
| Qualification | 0.062 | 0.025 | 0.129 | 2.537 | 0.011* | |
| Years working as a qualified nurse | 0.103 | 0.036 | 0.229 | 2.817 | 0.005** | |
| Years of experience in the ICU | 0.022 | 0.028 | 0.043 | 0.788 | 0.431 | |
| Have you had any experience working as a nurse in a mental health area? | 0.142 | 0.050 | 0.136 | 0.819 | 0.557 | |
| Attitudes model | Unstandardized coefficients | Standardized coefficients | t | Sig. | ||
|---|---|---|---|---|---|---|
| B | SE | β | ||||
| 1 | (Constant) | 2.949 | 0.064 | 46.362 | 0.000 | |
| Gender | −0.071 | 0.041 | −0.079 | −1.712 | 0.088 | |
| Age | −0.124 | 0.065 | −0.165 | −1.914 | 0.056 | |
| Qualification | 0.072 | 0.020 | 0.174 | 3.567 | 0.000** | |
| Years working as a qualified nurse | 0.140 | 0.030 | 0.362 | 4.658 | 0.000** | |
| Years of experience in the ICU | 0.093 | 0.023 | 0.211 | 4.035 | 0.000** | |
| Have you had any experience working as a nurse in a mental health area? | 0.014 | 0.041 | 0.015 | 0.334 | 0.739 | |
Note: Dependent variable: mean perceived knowledge‐and‐beliefs score, mean skills score and mean attitude score.
Significant at 0.05.
Significant at 0.01.
To identify predictors of ICU nurses' attitudes toward mental health care based on demographic data, multiple linear regression analysis was used (Table 6). The regression revealed that three variables were statistically significant predictors of nurses' attitudes: (1) Qualification had a positive and significant effect on attitude scores (B = 0.072, p < 0.001), indicating that higher educational attainment was associated with more positive attitudes toward mental health care. (2) Years working as a qualified nurse were also a strong positive predictor (B = 0.140, p < 0.001), suggesting that general nursing experience contributes meaningfully to more favourable attitudes. (3) Years of ICU experience similarly showed a significant positive relationship with attitude scores (B = 0.093, p < 0.001), implying that more prolonged exposure to critical care settings fosters improved attitudes toward patients with mental illness. Other variables, including gender, age and prior experience in mental health nursing, did not significantly predict attitudes in this model.
A Kruskal–Wallis test was conducted to examine differences in mental healthcare skill scores among ICU nurses according to educational qualification and years of nursing experience (Table 7). There was a statistically significant difference in skill‐score mean ranks across qualification groups, H (4) = 22.634, p < 0.001. Nurses with a Higher Diploma in Nursing had the highest mean rank for skills (MR = 305.90), whereas nurses with a PhD had the lowest mean rank (MR = 94.00). The mean ranks for nurses with a Diploma, Bachelor's degree and Master's degree were 236.96, 246.91 and 252.42, respectively.
TABLE 7.
Difference in the mean‐rank skill scores of nurses based on their qualification and years of nursing experience.
| Variable | N | Mean rank of skills score | Kruskal–Wallis H | Asymp. Sig. | |
|---|---|---|---|---|---|
| Qualification | Diploma in nursing | 50 | 236.96 | 22.634 | 0.000** |
| Bachelor of nursing | 229 | 246.91 | |||
| Higher diploma in Nursing | 62 | 305.90 | |||
| Master's in nursing | 150 | 252.42 | |||
| PhD | 11 | 94.00 | |||
| Total | 502 | ||||
| Years of nursing experience | 2 years or less | 67 | 205.71 | 19.681 | 0.001** |
| 3–10 years | 65 | 257.01 | |||
| 11–20 years | 101 | 225.79 | |||
| 21–30 years | 244 | 265.17 | |||
| More than 30 years | 25 | 330.36 | |||
| Total | 502 | ||||
Significant at the 0.01 level.
Skill‐score mean ranks also differed significantly according to years of nursing experience, H (4) = 19.681, p = 0.001. Nurses with more than 30 years of experience had the highest mean rank (MR = 330.36), followed by those with 21–30 years of experience (MR = 265.17) and those with 3–10 years of experience (MR = 257.01). Nurses with 2 years or less of experience had the lowest mean rank (MR = 205.71).
In summary, the findings indicate that ICU nurses' perceived mental healthcare skills differed according to both educational qualification and years of nursing experience. Nurses holding a Higher Diploma in Nursing had the highest mean rank of skill scores among the qualification groups, which may reflect the practical orientation or specific mental health content of higher diploma programs. In addition, skill‐score ranks generally increased with greater professional nursing experience, with nurses who had more than 30 years of experience demonstrating the highest mean rank. These findings highlight the potential importance of practice‐oriented educational preparation and accumulated clinical experience in strengthening nurses' perceived capacity to provide mental healthcare in ICU settings.
A Kruskal–Wallis test was conducted to examine differences in ICU nurses' attitudes toward mental healthcare according to educational qualification, years of nursing experience and years of ICU nursing experience (Table 8). Attitude‐score mean ranks differed significantly across educational qualification groups, H (4) =9.566, p = 0.048. Nurses with a Higher Diploma in Nursing had the highest mean rank (MR = 271.57), followed closely by those with a Master's degree in Nursing (MR = 268.57), whereas nurses with a Diploma in Nursing had the lowest mean rank (MR = 154.00).
TABLE 8.
Difference in the mean attitude scores of nurses based on their qualification, years of nursing experience and years of ICU nursing experience.
| Variable | N | Mean Rank‐attitudes score | Kruskal–Wallis H | Asymp. sig. | |
|---|---|---|---|---|---|
| Qualification | Diploma in nursing | 50 | 154.00 | 9.566 | 0.048* |
| Bachelor of nursing | 229 | 240.88 | |||
| Higher diploma in Nursing | 62 | 271.57 | |||
| Master's in nursing | 150 | 268.57 | |||
| PhD | 11 | 245.48 | |||
| Total | 502 | ||||
| Years of nursing experience | 2 years or less | 67 | 168.46 | 34.681 | 0.000** |
| 3–10 years | 65 | 223.05 | |||
| 11–20 years | 101 | 255.81 | |||
| 21–30 years | 244 | 274.01 | |||
| More than 30 years | 25 | 310.92 | |||
| Total | 502 | ||||
| Years of ICU experience | 2 years or less | 247 | 216.48 | 40.489 | 0.000** |
| 3–10 years | 152 | 262.07 | |||
| 11–20 years | 45 | 295.16 | |||
| 21–30 years | 58 | 339.07 | |||
| Total | 502 | ||||
Significant at the 0.05 level.
Significant at the 0.01 level.
There was also a statistically significant difference in attitude‐score mean ranks according to years of nursing experience, H (4) = 34.681, p < 0.001. Attitude mean ranks increased across experience categories, ranging from MR = 168.46 among nurses with 2 years or less of nursing experience to MR = 310.92 among those with more than 30 years of experience.
Similarly, attitudes differed significantly by years of ICU nursing experience, H (3) = 40.489, p < 0.001. Nurses with 21–30 years of ICU experience had the highest attitude‐score mean rank (MR = 339.07), while those with 2 years or less of ICU experience had the lowest mean rank (MR = 216.48). Overall, the findings indicate that attitudes toward mental healthcare differed significantly by educational qualification, general nursing experience and ICU‐specific experience, with higher attitude‐score ranks generally observed among nurses with more extensive nursing and ICU experience.
In summary, more positive attitudes toward mental healthcare were generally observed among ICU nurses with higher educational qualifications and greater general and ICU‐specific nursing experience. These findings highlight the importance of targeted mental health education, orientation, mentorship and ongoing professional development for newly qualified and less experienced ICU nurses.
Table 9 illustrates the correlations among ICU nurses' perceived knowledge‐and‐beliefs, self‐reported skills and attitudes toward mental health care. The Pearson correlation coefficients reveal significant positive relationships between all three variables, indicating that higher scores in one area are strongly associated with higher scores in the others.
TABLE 9.
Correlations among nurses' perceived knowledge‐and‐beliefs, self‐reported skills and attitudes toward mental health care.
| Correlations | Means knowledge score | Mean skills score | Means attitude score | |
|---|---|---|---|---|
| Means perceived knowledge‐and‐beliefs score | Pearson correlation | 1 | 0.790** | 0.606** |
| Sig. (2‐tailed) | 0.000 | 0.000 | ||
| N | 502 | 502 | 502 | |
| Mean reported skills score | Pearson correlation | 0.790** | 1 | 0.745** |
| Sig. (2‐tailed) | 0.000 | 0.000 | ||
| N | 502 | 502 | 502 | |
| Means reported attitude score | Pearson correlation | 0.606** | 0.745** | 1 |
| Sig. (2‐tailed) | 0.000 | 0.000 | ||
| N | 502 | 502 | 502 | |
Correlation is significant at the 0.01 level (2‐tailed).
Specifically, nurses' perceived knowledge‐and‐beliefs scores showed a strong positive correlation with their self‐reported skills scores (r = 0.790, p < 0.001) and a moderate positive correlation with their self‐reported attitude scores (r = 0.606, p < 0.001). Similarly, skills scores were strongly correlated with attitude scores (r = 0.745, p < 0.001).
The positive correlations indicate that nurses reporting higher perceived knowledge‐and‐beliefs scores also reported higher self‐rated skills and more favourable attitude scores. Because all domains were measured by self‐report in a cross‐sectional survey, these associations should be interpreted as relationships among perceived constructs rather than evidence that factual knowledge causes improved skills or attitudes. The strong interrelationship among knowledge, skills and attitudes underscores the importance of integrated training programs that simultaneously enhance these domains to improve mental health care in critical care settings.
4. Discussion
This study examined Jordanian ICU nurses' self‐reported perceived knowledge, skills, attitudes and preparedness to care for patients with mental illness. Findings concerning the questionnaire's knowledge domain require cautious interpretation because the domain included heterogeneous items assessing perceived knowledge, preparedness and beliefs. Thus, the overall score should not be understood as a direct measure of objectively verified mental‐health knowledge.
More than half of the participants reported understanding the causative factors of mental illness, indicating a relatively solid foundational understanding in this domain. The highest‐rated statement in this domain was the belief that patients with mental illness are more prone to violence or aggression than other patients. This finding should not be interpreted as higher knowledge. Rather, it may reflect a generalized stereotype associating mental illness with dangerousness and may contribute to fear, avoidance or restrictive clinical practices. The finding is consistent with the attitude‐domain results, in which many participants reported discomfort caring for patients with mental illness and indicated that they were more likely to consider physical restraints when they knew that a patient had a mental illness. These results indicate a need for education that addresses not only clinical knowledge and assessment skills but also stigma, risk perceptions, de‐escalation, trauma‐informed care and person‐centred communication.
Educational interventions should explicitly address the misconception that mental illness alone predicts violence or aggression. Training could include evidence‐based information on risk factors for aggression, emphasizing the contribution of acute clinical conditions, delirium, substance intoxication or withdrawal, previous violence, environmental stressors and unmet needs rather than diagnosis alone. Case‐based discussion, simulation of de‐escalation and therapeutic communication and contact‐based learning involving people with lived experience of mental illness may help nurses challenge stereotypes, improve confidence and promote person‐centred, non‐stigmatizing care (Sreeram et al. 2022).
The lowest‐rated perceived training item indicated that less than one‐third of participants felt adequately trained to care for patients with mental illness. This finding reflects nurses' perceived adequacy of training rather than objectively measured training exposure or clinical competence; nevertheless, it identifies a clear self‐reported need for additional mental‐health‐specific education and supported clinical learning within ICU practice.
Previous research has reported that limited mental‐health‐specific knowledge and training may hinder nurses' ability to provide appropriate care for patients with mental health conditions (Holmberg et al. 2020; Østervang et al. 2022). In the present study, however, the findings should be interpreted as indicating moderate self‐reported perceived knowledge alongside specific areas of lower perceived familiarity and confidence.
Consistent with our findings, a previous qualitative study in Australia revealed that ICU nurses linked ‘dangerousness’ with mentally ill patients. They believed these patients were more vulnerable to violent and aggressive behaviours. Such patients were viewed as problematic and, unlike ICU patients without a co‐morbid mental health disorder, were considered responsible for any aggressive actions (Patterson et al. 2023). Furthermore, an integrative review revealed discriminatory attitudes rooted in the incorrect belief that patients with a mental disorder are more likely to be violent (Teece and Baker 2025). The findings align with those of a prior qualitative review, suggesting that nurses frequently perceive a deficiency in knowledge when providing care to patients with mental health conditions (Johanna et al. 2022).
Findings from this study should be compared cautiously with research conducted in Australia, the United States and the United Kingdom. Differences in cultural perceptions of mental illness, stigma, health‐care system structures, availability of mental health specialists, ICU staffing and workload and mental‐health education opportunities may influence nurses' experiences across countries. In Jordan, previous research has documented mental‐health‐related stigma and moderate mental health literacy among health‐care professionals, suggesting that nurses' perceived knowledge, attitudes and confidence are influenced by both clinical education and local sociocultural factors. Accordingly, the findings should be understood within the Jordanian health‐care context and should not be assumed directly generalizable to Western health‐care settings (Dalky et al. 2020, 2023).
The findings indicate that ICU nurses reported a moderate level of perceived knowledge and beliefs regarding mental health care. Although participants reported general awareness of several mental health issues, lower perceived familiarity was observed in specific areas, including the Mental Health Law in Jordan, components of a basic mental‐state examination, psychotropic medication use and perceived adequacy of training. These item‐level findings suggest targeted areas for further education and support rather than a universal deficit in mental‐health‐related knowledge.
These findings align with previous research in Australia, showing that critical care staff rarely receive targeted training for managing mental health conditions. They have a limited understanding of the unique needs of individuals with mental illness and feel unprepared to provide care when mental health issues are involved. As a result, additional training and education are essential for caring for patients with mental illness in the intensive care setting (Weare et al. 2019).
Supporting these findings, previous studies indicate that nurses require additional knowledge to perform essential assessments (Andersson et al. 2020). Although collaborating with psychiatric nurses has proven effective, emergency medical service nurses also require further training in mental health issues and in appropriate approaches to evaluating these patients (Todorova et al. 2021).
The results of the existing study suggest that Jordanian ICU nurses generally report moderate self‐reported skills in managing mental health issues. Yet, they also experience considerable discomfort and uncertainty, especially in situations involving psychotic symptoms. More broadly, educational research suggests that anxiety can influence nursing students' attitudes toward unfamiliar or complex areas of practice, reinforcing the value of structured preparation and supported learning (Ayed et al. 2025). These findings indicate that limited hands‐on training opportunities and the demanding ICU environment contribute to uncertainty and discomfort in caring for patients with mental health problems. Furthermore, variations in nurses' educational backgrounds and clinical experience may hinder the consistent application of evidence‐based interventions; therefore, building competence involves learning through experience and underscores the need for education and multidisciplinary collaboration.
These findings can be explained in terms of Bandura's Self‐Efficacy Theory, which emphasizes the importance of perceived capability in determining people's effort, persistence and performance. The relatively modest skills self‐report, combined with the high level of anxiety and uncertainty reported by nurses, may be a reflection of limited confidence in their perceived capacity to deal effectively with complex mental health situations. From the self‐efficacy perspective, the opportunities for successful clinical experiences, practical training, feedback and supportive supervision can increase nurses' confidence and perceived competence. In this regard, the association between clinical experience and self‐reported skills may reflect that accumulated clinical exposure provides opportunities to develop greater confidence in managing patients with mental health needs. Taken together, the findings suggest that higher self‐reported knowledge and perceived skills are associated with greater confidence in managing mental health situations. From a self‐efficacy perspective, these associations may indicate that educational and practical experiences could contribute to nurses' perceived capability; however, the cross‐sectional design and reliance on self‐reported measures do not allow conclusions about causality or objectively demonstrated preparedness.
These findings align with existing evidence showing that critical care staff have restricted knowledge about the specific requirements of people with mental illness and often lack confidence in delivering care when mental illness complicates a case (Patterson et al. 2023). Additionally, nurses frequently face challenges and barriers, including unpredictable behaviour, resource shortages, inadequate knowledge and skills, perceived danger and a lack of positive reinforcement from patient interactions, all of which may hinder effective care delivery (Poggenpoel et al. 2011). These issues reveal the intricate connection between personal abilities and systemic constraints in acute care settings.
A qualitative interview study showed that caring for patients with mental illness necessitates more than just individual coping strategies. Organizational, educational and interprofessional support are valuable for enhancing care quality and nurse well‐being. Approaches such as simulation‐based training, structured reflection and interprofessional collaboration can boost their competence and confidence. Additionally, organizational changes may promote safer, more person‐centred care (Jong et al. 2025).
Regarding communication, moderate confidence was observed in the current study. Less than half of nurses reported confidence in communicating medical information to mentally ill patients, and fewer were confident engaging with patients who exhibit suicidal behaviours. Furthermore, they felt that the training they had received in the ICU setting had not adequately equipped them with the necessary skills for such complex interactions. These findings highlight a critical gap between clinical demands and the communicative competencies fostered through current training models.
Aligned with this perspective, studies from California and Italy emphasize the importance of ongoing education in enhancing nurses' skills for effective suicide assessment and prevention (James et al. 2025; Litta et al. 2024). Similarly, research in Turkey shows that nurses have low suicide literacy and self‐report a need for additional mental health training and skill development (Karakaya et al. 2023), as well as a need for further mental health education and skills development (Corfee et al. 2020).
Evidence from Taiwan indicates that ICU nurse training mainly focuses on advanced clinical and technical skills. This emphasis unintentionally supports the biomedical model of care, often at the expense of a more humanistic approach, which may hinder nurses' ability to address patients' psychological needs (Lee and Chang 2022). Additionally, an Australian study shows that communication barriers, stigma and the power imbalance in the nurse–patient relationship within the ICU can lead to patients with MHD being viewed as dangerous or morally problematic (Corfee et al. 2020). To facilitate competent, compassionate and person‐centred mental health care, it is crucial to integrate strategies such as structured communication training, suicide literacy education and stigma‐reduction techniques into ICU nursing education.
The findings reflect a mix of empathy, stigma, uncertainty and practical concern, with an overall mean attitude score indicating generally neutral to slightly positive attitudes. A substantial proportion agreed that mental illness is an illness like any other and that virtually anyone can become mentally ill, suggesting an underlying awareness and normalization of mental illness.
Our results concur with previous research indicating that ED nurses often find caring for patients with mental health issues more challenging than treating typical physical conditions. They report that insufficient knowledge and training in mental health significantly limit their capacity to deliver proper care (Østervang et al. 2022). Feelings of uncertainty and discomfort regarding mental health matters can lead to varying views among nurses about their role in caring for these patients (Derblom et al. 2022).
Our findings are consistent with a prior narrative review that strongly supports empathetic care, with more than half of nurses believing that nurse empathy can improve patients' experiences. It also emphasizes that patients with psychiatric conditions have particular needs. These positive views align with recovery‐focused approaches that aim to improve mental health by fostering hope, options, choice and self‐determination (Subandi et al. 2023).
The results of the current study indicate that a notable portion of nurses expressed a preference to avoid direct care of patients with mental illness and have uncomfortable feelings when caring for patients with mental illness. This may be attributed to limited mental health training, insufficient clinical exposure to psychiatric settings and a lack of confidence in managing complex behavioural symptoms.
Consistent with these findings, qualitative studies in London found that nurses often have lower professional satisfaction when caring for patients with a SDMI (Foye et al. 2020). This is due to several factors: nurses feeling unable to complete their tasks because the patient was too challenging to care for; feeling a lack of competence and wanting to distance themselves from the patients; experiencing compassion fatigue; and perceiving their care as ineffective due to the recurring hospitalizations of SDMI patients (Alwar and Addis 2022).
Additional qualitative evidence from Australia indicated that having MH patients in the ICU was perceived to disrupt other patients and nursing routines (Patterson et al. 2023). Another US study found that nurses feel clinically unprepared and lack essential knowledge to deliver proper care (Kolb et al. 2023).
The results of the existing study indicate that misconceptions and deterministic beliefs persist. For instance, over a third of nurses believed that patients with mental illness are partly responsible for their condition, and many viewed people with drug or alcohol addiction as partly to blame, revealing a persistent attribution of mental illness to personal failings. Furthermore, less than half of respondents agreed they were more likely to use physical restraints for mentally ill patients, suggesting that safety concerns may influence clinical decisions. These findings reflect the persistence of stigma within healthcare settings. These beliefs may be shaped by sociocultural norms, media portrayals and traditional views that emphasize individual blame rather than recognizing mental illness as a multifactorial condition influenced by biological, psychological and social determinants.
Our results are supported by prior research conducted in Saudi Arabia and Jordan, which identified high levels of stigmatizing attitudes among tertiary hospital physicians and healthcare providers, respectively, toward individuals with mental disorders (Dalky et al. 2020; Saad et al. 2019). An additional study in Qatar specifies that nurses within the emergency department exhibit the highest levels of stigma. Subsequently, the negative attitude displayed by healthcare professionals operating in the emergency department poses a significant concern, as this is the initial point of assessment for individuals requiring acute psychiatric care (Ghuloum et al. 2022).
Our findings align with a prior study in Taiwan that suggests nurses, including those in ED settings, sometimes harbour negative attitudes, such as fear and blame, toward patients with psychiatric conditions (Chou and Tseng 2020). Likewise, a systematic review found that stigma against mental health disorders has been examined among nurses working in emergency departments (ED). Participants reported concerns about the suitability of the ED environment for these patients, feeling insufficient in their skills and the influence of negative perceptions they hold about mental illness (Sacre et al. 2022).
The results highlight a significant gap in formal training, with two‐thirds of nurses reporting that they had never received formal training in mental health care for critically ill patients. Among those who received training, the content areas covered were limited and fragmented. The most reported topic was mental status assessment, followed by suicide risk assessment and general counselling skills. Notably, a large majority of nurses expressed that they felt they could be better prepared to manage situations involving patients with mental illnesses in the ICU, reinforcing the overall theme of the study. This finding aligns with the reported deficiencies in knowledge, skills and attitudes across the previous tables, emphasizing the need for systematic, comprehensive mental health education and ongoing professional development for ICU nurses in Jordan. The observed lack of formal mental health training among ICU nurses may reflect the prioritization of physiological and technical competencies over psychosocial care within critical care education and practice, underscoring the crucial importance of integrating structured mental health training programs into critical care nursing curricula and workplace education to ensure that ICU nurses are adequately equipped to provide safe, effective and empathetic care to patients experiencing mental health issues.
Our findings are consistent with a previous study conducted in the United States, which identified that the deficiency of knowledge, formal education or training related to mental health constitutes a significant barrier encountered by nurses when providing care to patients with a serious mental illness (Avery et al. 2020). Likewise, prior investigations have reported that hospitals often fail to deliver adequate in‐service training in psychiatric nursing competencies (Foye et al. 2020; Alwar and Addis 2022). Therefore, by strengthening ICU nurses' clinical skills and competencies, we aim to cultivate a culture of empathy and dispel safety misconceptions through further training and skill development. Providing strong clinical support is essential for achieving the best possible physical and psychological outcomes for our patients (Wilson et al. 2025).
The results of the current study reveal significant positive correlations among knowledge, skills and attitudes toward mental health care, indicating that higher scores in one area are strongly associated with higher scores in the others. These findings suggest that ICU nurses with greater knowledge of mental health care also tend to demonstrate better skills and hold more positive attitudes toward caring for patients with mental illness. The strong interrelationships among these variables underscore the importance of integrated training programs that simultaneously enhance these domains to improve mental health care in critical care settings. In addition, the results show that nurses' qualifications and years of experience are significant positive predictors of nurses' attitudes and self‐reported skills in mental health care, suggesting that nurses with higher educational attainment and more years of experience report higher mental health care skills, which are linked to stronger perceived mental health care competencies.
Higher educational qualification was associated with higher self‐reported skills and more favourable attitudes in this sample. However, this finding should be interpreted cautiously because nurses with postgraduate qualifications may have been overrepresented among survey respondents. In addition, the cross‐sectional and self‐reported design does not establish that postgraduate education caused higher skills or more positive attitudes.
This finding is consistent with Bandura's Self‐Efficacy Theory, particularly the role of mastery experiences in developing perceived capability. Greater clinical experience may provide nurses with repeated opportunities to encounter, manage and learn from challenging situations, which may strengthen their confidence in their ability to provide mental health care. Therefore, clinical exposure may represent an important pathway through which nurses develop both practical competence and perceived self‐efficacy.
From the perspective of Self‐Efficacy Theory, these relationships may also indicate that greater knowledge and perceived skills can support nurses' confidence in their ability to provide mental health care. Nurses who feel more capable of performing mental health‐related tasks may be more likely to approach these patients with greater confidence and more positive attitudes. However, because self‐efficacy was not directly measured in this study, this interpretation should be considered a theoretical explanation rather than a direct test of the theory.
These findings are corroborated by an earlier systematic review, which indicated that negative attitudes and perceptions, along with identified deficiencies in knowledge and skills, contribute to medical‐surgical nurses' self‐reported inability to deliver effective holistic care to patients with an SDMI (Tyerman et al. 2021). Furthermore, multiple studies have disclosed an association between inadequate education and increased negative attitudes (Alwar and Addis 2022; Avery et al. 2020).
Clinical experience alone may not necessarily translate into preparedness for managing mental health conditions in the ICU. Unlike physiological emergencies, mental health presentations may occur less frequently within routine critical care practice and may therefore provide nurses with fewer opportunities for repeated, supported mastery experiences. Evidence from Palestinian ICU nurses during the COVID‐19 pandemic found that higher stress was associated with lower resilience and that inadequate preparation was a major source of stress, highlighting the importance of organizational support and staff well‐being in high‐intensity ICU practice (Aqtam et al. 2023).
Moreover, ICU organizational culture traditionally emphasizes rapid physiological stabilization, technical competence and management of life‐threatening conditions, potentially giving psychosocial and mental health needs lower priority. Within such an environment, nurses may have substantial general ICU experience while still feeling insufficiently prepared to manage behavioural, psychological and communication challenges associated with mental illness. Thus, preparedness may reflect not only individual knowledge and experience but also the extent to which the ICU provides opportunities for mental health training, psychological support, interdisciplinary collaboration and a culture that values holistic care. A supportive clinical learning environment may also be important for building readiness beyond technical experience alone. Among Egyptian nurse interns, professional identity, wellness and future hope were positively interrelated, and having a nursing role model was associated with stronger professional identity, which supports the value of role modelling and structured clinical support in developing nurses' confidence and professional readiness (Hussien et al. 2021). This interpretation may help explain why experienced nurses in the present study could continue to report uncertainty and limited confidence despite their years of clinical practice.
Recent commentary similarly argues that moral distress in critical care should be understood as a systems‐level problem, with workload, staffing, resources, hierarchical structures and organizational support shaping nurses' capacity to provide the care they consider appropriate (Aqtam 2026). Consistent with this systems‐level interpretation, a recent ICU study found that moderate knowledge and favourable attitudes did not consistently translate into recommended pressure‐ulcer‐prevention practices in the context of workload‐related barriers and very high burnout, underscoring the need to address nurse well‐being and organizational support alongside education (Shahin, Elgazzar, et al. 2026). A Saudi study found that burnout was common among critical‐care nurses, with moderate burnout most frequently reported, and that greater professional experience was associated with lower burnout (Shahin 2025). Another Saudi study of critical‐care nurses similarly found that job satisfaction and organizational conditions were associated with caring behaviours (Alenezi et al. 2024). Although not focused on mental‐health care, these findings reinforce the importance of organizational support and mentorship for nurses in high‐intensity ICU environments.
Our findings are further supported by a recent Egyptian study, which showed a substantial correlation between higher stigmatization attitudes and fewer years of professional experience. This association may be attributed to a lack of clinical skills in managing such patients and poor judgement resulting from low self‐confidence among novice nurses (Hamed et al. 2025). Furthermore, a recent narrative review highlights the significance and influence of educational background and prior personal mental health experiences on nurses' attitudes and perceptions (Pasere et al. 2025).
Similarly, an integrative review study found that stigma toward patients with mental health conditions may lead ICU nurses to lessen their contribution, undermining the delivery of holistic care. Education and ongoing support are crucial for mitigating misunderstandings and biases and for enhancing nurses' confidence in caring for patients with comorbid mental health conditions (Teece and Baker 2025).
4.1. Limitations
This study's goal is to look at how Jordanian ICU nurses feel, what they know, and how well they think they can care for patients with mental illness. However, some problems need to be pointed out. A cross‐sectional design prevents the determination of causal relationships among the study variables. This limitation makes it clear that you need to be careful when looking at the results. So, long‐term follow‐up may be necessary to clarify these connections. Also, using self‐report surveys increases the likelihood of bias and subjective interpretation. Future research must incorporate objective measures alongside self‐reports, including observational assessments and supervisor ratings, to boost the validity of the findings and mitigate potential bias. To tackle these issues, we recommend that future research adopt a longitudinal design to observe changes over time. This approach will enhance our understanding of how the study variables and patient outcomes are interconnected.
The proportion of nurses with a master's degree in this sample (29.9%) was relatively high and may not reflect the educational profile of ICU nurses across Jordan. Although hospitals were selected using stratified random sampling, nurse participation was voluntary and online; therefore, selection and non‐response bias cannot be excluded. Nurses with postgraduate qualifications or greater engagement with digital and professional networks may have been more likely to participate. Accordingly, associations between educational qualification, self‐reported skills and attitudes should be interpreted within this study sample and not generalized to all Jordanian ICU nurses.
A conventional response rate could not be calculated because the denominator—the total number of eligible ICU nurses who received or viewed the online survey invitation—was unavailable. This limits the assessment of non‐response bias and may affect the representativeness of the sample.
A further measurement limitation is that the original “knowledge” domain included heterogeneous items assessing self‐reported perceived knowledge, perceived preparedness and generalized beliefs about patients with mental illness. Consequently, the composite score cannot be regarded as a pure measure of objective factual knowledge. In particular, agreement with the item linking mental illness to violence or aggression may reflect a stereotype or stigmatizing perception rather than accurate clinical knowledge.
Although the questionnaire was adapted from a previously published Australian instrument, translated and back‐translated, reviewed by experts, and piloted before use, it was not subjected to a full psychometric validation in the Jordanian context. Although the instrument demonstrated acceptable internal consistency in the present sample, internal consistency alone does not establish that all items measure the same construct or that the instrument has cultural and conceptual equivalence across settings. Cultural, legal organizational and linguistic differences may influence how individual items are understood and interpreted. In particular, the locally adapted item concerning the Mental Health Law in Jordan reflects self‐reported familiarity with country‐specific legislation and may not be directly comparable with the original instrument. Future research should undertake comprehensive cross‐cultural validation of the Arabic version, including assessment of content validity, construct validity, factor structure, measurement invariance and test–retest reliability, and should use or develop measures that clearly distinguish objective knowledge, perceived confidence or self‐efficacy, clinical competence, attitudes and stigma.
Self‐efficacy was not directly measured on a validated self‐efficacy scale but was used as a conceptual framework for the interpretation of the findings in terms of Bandura's Self‐Efficacy Theory. Thus, the present findings should not be interpreted as a direct empirical test of Self‐Efficacy Theory. The relationships between clinical experience and self‐reported skills, confidence and preparedness are consistent with a self‐efficacy interpretation, although causal relationships cannot be determined. Future research should directly assess nurses' self‐efficacy with validated instruments and investigate whether changes in self‐efficacy after educational or clinical interventions are associated with improvements in mental health care competencies.
5. Conclusion
The study found that Jordanian ICU nurses reported moderate self‐reported perceived knowledge and preparedness, self‐reported skills and attitudes regarding the care of patients with mental illness. Participants also reported limitations in confidence and perceived preparedness in several complex mental health situations, particularly those involving psychotic symptoms, suicidal behaviour, clinical assessment and legal aspects of care. Positive associations were observed among the self‐reported knowledge, skills and attitudes domains, while educational level and clinical experience were associated with higher self‐reported competence. These findings indicate a need to strengthen mental health preparedness within ICU nursing education and clinical practice.
For nursing educators, mental health content should be integrated more explicitly into undergraduate and continuing ICU nursing education, with emphasis on mental health assessment, recognition and management of suicidal behaviour and psychotic symptoms, therapeutic communication, psychotropic medications and legal and ethical aspects of care. Regional evidence from Palestinian nursing students indicates that, although attitudes toward evidence‐based practice may be positive, knowledge and skills for applying evidence in clinical practice may require further strengthening; this supports the need for educational approaches that integrate theoretical content with supervised, practice‐based learning (Ejheisheh et al. 2025). A recent Saudi quasi‐experimental study found that a brief, evidence‐based educational program significantly improved nurses' knowledge and attitudes toward pain management, supporting the use of structured continuing education to strengthen competence in complex clinical‐care domains (Shahin, Alamoudi, et al. 2026). Educational approaches that combine interactive learning methods with interprofessional collaboration may be more effective than passive, digital‐only instruction for strengthening preparedness; however, this principle should be evaluated specifically for mental‐health‐related care in ICU settings (Mersal et al. 2026). Simulation‐based training, case‐based learning and structured clinical scenarios could provide opportunities for nurses to practice these skills in realistic ICU situations. A quasi‐experimental study also found that structured in‐service training improved nurses' knowledge, practice and self‐confidence in a specialized care domain, supporting the use of skills‐based workplace education to strengthen clinical confidence and readiness (Elgazzar et al. 2024). Evidence from paediatric nursing also suggests that structured education can improve nurses' knowledge, practice and self‐confidence in using clinical assessment tools, supporting similar skills‐based approaches for mental‐state and mental‐health‐risk assessment in ICU nurses (Loutfy et al. 2023). Digital or blended learning may supplement face‐to‐face education, but its effectiveness depends on learners' digital readiness and self‐efficacy; these factors should be assessed when developing technology‐supported mental‐health education for ICU nurses (El‐Gazar et al. 2024). Evidence from Saudi critical‐care settings highlights the importance of collaboration between hospitals and universities in identifying nurses' educational needs and delivering continuing professional education; similar partnerships could support sustained, needs‐based mental‐health education for ICU nurses in Jordan (Shahin 2019).
Digital‐health strategies may also complement education and clinical support by facilitating access to mental health resources, clinical decision support, remote consultation and interdisciplinary communication; however, their value depends on digital infrastructure, interoperability, workforce capability, leadership, governance and context‐sensitive implementation (Shahin 2026). Complementary evidence from Saudi health‐sciences students indicates that factual awareness of health risks may coexist with gaps in risk perceptions, beliefs and confidence to change health behaviours, supporting educational approaches that integrate knowledge with attitudes, communication and practical behaviour‐change skills (Rababa et al. 2026).
For policymakers and hospital nursing leaders in Jordan, standardized mental health competency requirements for ICU nurses should be considered, together with regular in‐service training, access to mental health specialists or consultation services, and clear protocols for the assessment, referral and management of patients presenting with mental health needs in critical care settings. These measures could support a more integrated approach to physical and mental health care within ICUs. This recommendation aligns with Eastern Mediterranean Region nursing research priorities, which emphasize workforce development, education, leadership, clinical practice, research capacity and collaboration among nurses, educators, health‐care organizations and policymakers (Nashwan et al. 2024). However, because the study relied on self‐reported measures, the findings should be interpreted as reflecting nurses' perceptions rather than objectively demonstrated clinical competence or preparedness. Future studies should incorporate objective and observational measures, simulation‐based competency assessments, and longitudinal or intervention designs to determine whether targeted education and organizational support improve nurses' actual mental health care competence and preparedness.
5.1. Recommendation
To enhance nurses' confidence, improve clinical decision‐making and facilitate effective communication with patients suffering from mental illness, it is essential to provide robust mentoring and in‐service mental health training. This may encompass comprehensive learning packages that include practical training elements such as simulation exercises, case‐based discussions and supervised clinical exposure. Educational initiatives must explicitly address the stigma and misconceptions surrounding mental health conditions and substance use disorders, promoting empathetic, recovery‐focused and individualized approaches among ICU nursing professionals.
New nurses or those with limited education should be encouraged to participate in ongoing professional development activities, such as workshops, certifications and collaborative learning with mental health specialists across disciplines. Structured preparation and supervised practical training, particularly for undergraduate and pre‐registration nurses, are important for developing the knowledge, skills and confidence required to address the complex needs of patients with mental illness. Future research can make an important contribution to understanding the interplay between ICU nurses' attitudes, knowledge and self‐reported skills when caring for patients with mental illness and nursing practices and patient care outcomes. Additionally, targeted educational programs are needed to investigate strategies to enhance mental health competencies and perspectives among intensive care unit nurses across various healthcare environments.
Author Contributions
Ahmad B. Al‐Rawashdeh: conceptualization, supervision, writing – original draft, visualization. Mahmoud Abdel Hameed Shahin: formal analysis, writing – review and editing, project administration. Samia Eaid Elgazzar: methodology, investigation, data curation, validation, writing – review and editing. Ateya Megahed Ibrahim: methodology, investigation, data curation, validation, writing – review and editing. Rasha Mohammed Hussien: methodology, resources, writing – review and editing, formal analysis, data curation.
Funding
The authors have nothing to report.
Consent
Consent was obtained from all participants before they participated, with approval to complete the survey. All information related to the study objectives, duration, importance, methods and effects was explained to participants on the questionnaire cover page before they agreed to participate in the study. Participation in the survey was voluntary, and participants were assured that no one would be victimized for not participating or for withdrawing after consent.
Conflicts of Interest
The authors declare no conflicts of interest.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.