The Call of Caring: Community Mental Health Nursing as Humanitarian Practice

Nursing is fundamentally rooted in the principles of care, equity, and advocacy for high-risk, underserved, and vulnerable populations (ANA, 2025; AACN, 2021). Historically, figures like Florence Nightingale and Lillian Wald demonstrated the integration of clinical practice with social responsibility, creating early models for nursing’s involvement in public and community health (Lewenson, 2010). Nurses have a professional duty that goes beyond bedside care to include a broader commitment to addressing social determinants of health and reducing disparities in access and outcomes (Marmot, 2005).

In the United States, community mental health centers (CMHCs) play a vital role in our healthcare system (Wishon & Brown, 2023). Created in response to deinstitutionalization policies during the mid-20th century, CMHCs are intended to offer comprehensive, community-based psychiatric and psychosocial services to individuals with serious mental illness (SMI), many of whom also face poverty, housing instability, and systemic marginalization (AACP, 2022). Although often underfunded and affected by workforce shortages, these centers remain crucial for providing accessible mental health care.

This article argues that nursing practice within CMHCs serves as a form of localized humanitarian engagement. Relying on nursing’s ethical frameworks (ANA, 2025) and caring theories (Watson, 2012), it suggests that CMHCs give nurses a unique chance to address unmet needs through culturally responsive, trauma-informed, and socially conscious care. By viewing work in CMHCs through the perspective of local humanitarianism, the nursing profession can better acknowledge and support this important area of practice.

Community Mental Health Centers in the United States: An Overview

Community Mental Health Centers (CMHCs) became a key part of behavioral health care in the United States after the Community Mental Health Act of 1963 was passed (Hamm, et al., 2020). This landmark legislation aimed to move psychiatric care away from large, institutional settings and toward more humane, community-based options. The Act created a network of centers designed to offer a range of mental health services, including outpatient therapy, crisis intervention, case management, and psychosocial rehabilitation (AACP, 2022). The goal was to help people with mental illness become part of their communities while maintaining access to proper care close to home.

Despite the promise of this model, CMHCs have faced persistent challenges in achieving full implementation. Many centers operate with limited funding, heavy caseloads, and significant workforce shortages, especially in rural and underserved areas (Wishon & Brown, 2023). These problems are worsened by broader systemic issues such as fragmented care coordination, inadequate reimbursement systems, and the ongoing stigma surrounding mental illness (Davenport, Bridget, Gray, & Spear, 2023). However, CMHCs remain vital safety-net providers for individuals with serious and persistent mental illness (SPMI), many of whom are uninsured or underinsured and face multiple social marginalizations, including homelessness, unemployment, substance use disorder, and involvement with the legal system (AACP, 2022).

For nurses, CMHCs are a vital practice setting where the full range of psychiatric and community health nursing can be achieved (APNA, 2022). Roles in these centers may include psychiatric mental health nurse practitioners, clinical nurse specialists, registered nurses, and case managers—each playing a part in an interprofessional care model that focuses on recovery, empowerment, and holistic well-being (AACP, 2022). The complexity of care within CMHCs demands not only clinical expertise but also cultural humility, trauma-informed approaches, and ongoing dedication to health equity (National Academies of Sciences, Engineering, and Medicine, 2021). Therefore, nurses working in CMHCs serve as a strong example of applied professional ethics in practice.

The Ethical Mandate: Caring as the Core of Nursing Practice

Caring has long been acknowledged as the moral and philosophical foundation of the nursing profession (AACN, 2021). Nursing theorists such as Jean Watson and Madeleine Leininger have defined caring not only as a technical or emotional act but as a deliberate, ethical stance aimed at preserving human dignity, especially amid suffering, vulnerability, and inequality. In Watson’s Theory of Human Caring (Watson, 2012), the nurse–patient relationship is viewed as a transpersonal encounter where both parties are transformed through genuine, compassionate engagement. Similarly, Leininger’s Culture Care Theory (McFarland & Wehbe-Alamah, 2019) emphasizes the importance of culturally appropriate care, promoting practices that respond to the social and cultural contexts of individuals and communities. Caring has long been acknowledged as the moral and philosophical foundation of the nursing profession.

This focus on caring is reflected in professional codes of ethics. The American Nurses Association (ANA) Code of Ethics highlights advocacy for vulnerable groups, dedication to social justice, and collaboration to reduce health disparities as fundamental responsibilities for all nurses (ANA, 2025). Provision 8.2 specifically urges nurses to participate in “Collaboration to uphold human rights, mitigate health disparities, and achieve health equity” (p. 34), placing nursing practice firmly within the scope of human rights and public advocacy. These ethical guidelines closely align with the realities of community mental health nursing, where practitioners often support individuals whose lives are impacted by systemic poverty, trauma, discrimination, and exclusion (AACP, 2022).

In this context, caring becomes an act of resistance against social invisibility and structural neglect (Fromm, 1981). It involves more than clinical skills; it requires a commitment to relational presence, cultural humility, and advocacy (National Academies of Sciences, Engineering, and Medicine, 2021). Nurses working in CMHCs fulfill this ethical obligation by addressing not only psychiatric symptoms but also the social determinants of mental health, such as housing insecurity, food instability, and access to supportive services (Alegría et al., 2018; Kirkbride et al., 2024). Thus, community mental health nursing demonstrates what it means to embed the moral duty of caring into daily professional practice (Falk-Rafael, 2005).

Community Mental Health Work as Local Humanitarian Practice

Humanitarian work is often linked to international disaster relief, conflict zones, or global health missions (Fletcher, Reddin, & Tait, 2022). However, such a limited view can miss the widespread and ongoing forms of human suffering that occur within high-income countries, including the United States. Structural violence—shown through poverty, racial disparities, homelessness, and lack of access to care—creates ongoing vulnerabilities that are just as urgent as those faced abroad (Kirkbride et. al., 2024). In this context, community mental health nursing can be seen as a form of localized humanitarian work (Lashley, 2025).

Nurses working in community mental health often serve individuals and families who are marginalized not only by psychiatric and substance use diagnoses but also by socioeconomic and systemic barriers (AACP, 2022). Patients in these settings frequently present with complex co-occurring conditions, including substance use disorders, histories of trauma, chronic medical conditions (i.e., “physical” illnesses), and social disconnection or isolation. Providing effective nursing care requires an integrated approach that includes not just clinical treatment but also advocacy, harm reduction, psychoeducation, and coordination with social services (National Academies of Sciences, Engineering, and Medicine, 2021). In this way, nurses act as both caregivers and navigators, addressing needs that go far beyond the clinic walls (Budde, et. al, 2021).

The humanitarian aspects of this work are clear in the ethical and relational commitments it requires. Culturally responsive care, trauma-informed practice, and a steady presence amid ongoing adversity are key traits of nurses who choose to work in community mental health (AACP, 2022). Instead of responding to sudden disasters, these nurses address the slow crises of overlooked neighborhoods, fractured systems, and ongoing inequality (Davenport, et. al, 2023). Their work fights against making invisible those who lie outside the scope of mainstream health care, closely aligning with humanitarian nursing principles of dignity, justice, and compassion.

Moreover, by maintaining sustained therapeutic relationships with clients over time—often without institutional prestige or recognition—nurses working in community mental health engage in what might be called "quiet humanitarianism” (Hamm, et al., 2020). Their work challenges the idea that meaningful humanitarian action must be distant, dramatic, or global in scope (Fletcher et al., 2022). Instead, it affirms that essential, transformative care can happen within one’s own neighborhood, clinic, or caseload.

Challenges and Rewards of Working in Community Mental Health Centers

CMHCs aim to provide services to individuals regardless of their insurance status or ability to pay. These centers are usually funded through a mix of state and local government support, with some also receiving federal funds or grants. Organizational structures vary; some CMHCs operate independently, while others are integrated into larger healthcare systems or nonprofit networks (AACP, 2022). Staffing generally includes an interprofessional team of licensed professionals such as social workers, counselors, psychologists, nurses, and psychiatrists. However, ongoing budget constraints and high service demand often make recruitment and retention difficult. ...the complexity of the client population—often characterized by chronic psychiatric conditions, trauma histories, poverty, and housing instability—places significant emotional and psychological demands on clinicians.

The CMHC setting presents a unique set of professional and systemic challenges for nurses. Among the most urgent are limited resources, high client acuity, and organizational instability (AACP, 2022). Many CMHCs operate under financial strain, resulting in staffing shortages, overwhelming caseloads, and insufficient access to evidence-based interventions or supportive infrastructure. These constraints can hinder the delivery of consistent, high-quality care and lead to moral distress among nurses and other clinicians, especially when client needs exceed the capacity of available services (Salari et al., 2022).

Additionally, the complexity of the client population—often characterized by chronic psychiatric conditions, trauma histories, poverty, and housing instability—places significant emotional and psychological demands on clinicians. Nurses working in these settings are especially vulnerable to compassion fatigue, secondary traumatic stress, and burnout, particularly when supervision, peer support, and institutional recognition are lacking (AACP, 2022). Burnout is reported by over 50% of behavioral health providers, highlighting its widespread nature and the urgent need for systemic intervention (SAMSHA, 2022). Further complicating these challenges are organizational factors such as inconsistent leadership, bureaucratic hurdles, and frequently changing policy mandates, all of which can impede care delivery and make staff recruitment and retention more difficult (Hamm et al., 2020).

Despite these challenges, many nurses experience a deep sense of purpose and professional fulfillment in community mental health work (Soltis-Jarrett, 2023). The chance to build long-term, trusting relationships with clients, to observe incremental yet meaningful recovery, and to advocate for individuals who have been historically marginalized affirms the core values of nursing practice. For some, this environment offers a level of clinical autonomy and creativity that is often lacking in more traditional or acute-care settings. The interprofessional nature of CMHCs also promotes collaborative, person-centered care that aligns with holistic nursing approaches (AACP, 2022).

Nurses in these roles often become key agents of systems-level change—through outreach, program development, health education, and policy advocacy. Their embedded presence in underserved communities uniquely positions them to identify gaps in care, propose culturally responsive interventions, and engage in community resilience efforts (Wishon & Brown, 2023). While the work is demanding, it offers a compelling model of nursing practice that integrates clinical skill, ethical commitment, and social responsibility (ANA, 2025).

Implications for Nursing Education and Policy

Recognizing community mental health nursing as a form of localized humanitarian practice has significant implications for both nursing education and health policy. To sustain and grow this essential workforce, academic institutions and policymakers must actively promote interest, readiness, and structural support for nurses (and other clinicians) working in community mental health centers (Soltis-Jarrett, 2023). Recognizing community mental health nursing as a form of localized humanitarian practice has significant implications for both nursing education and health policy.

In nursing education, there should be a stronger focus on community-based mental health as a fundamental practice area instead of a secondary or optional choice. Undergraduate and graduate programs ought to include comprehensive clinical experiences in CMHCs, along with classroom lessons on trauma-informed care, social determinants of mental health, cultural humility, and interprofessional teamwork (AACN, 2021; Soltis-Jarrett, 2023). These placements should be viewed not as fallback or low-resource environments, but as environments rich in intellectual and ethical value that uphold the profession’s highest principles. Faculty role models with experience in community settings can significantly influence students' perceptions and future career paths (AACP, 2022).

At the policy level, strategic investment in the community mental health nursing workforce is crucial. This involves increasing funding for training programs, loan forgiveness initiatives, and competitive salaries to attract and retain qualified nurses in underserved areas (HRSA, 2024). Regulatory reforms that expand the practice authority of advanced practice nurses—such as psychiatric mental health nurse practitioners—can further improve service delivery, especially in regions facing severe provider shortages (APNA, 2022). Additionally, public health policies must recognize and support the preventive and recovery-focused work performed by nurses in these settings, ensuring their inclusion in decision-making processes and mental health infrastructure planning (AACP, 2022). Ultimately, a more deliberate integration of community mental health into the broader nursing and health policy agenda will help legitimize and sustain this vital area of practice. Doing so benefits the communities served and reinforces nursing’s enduring identity as a profession dedicated to justice, care, and human dignity.

Example of Integration and Impact

One example of intentionally supporting the community mental health workforce through education is a postgraduate fellowship program. Recently graduated and newly licensed PMHNPs often face significant challenges during their transition into practice, including low self-confidence and difficulty managing the complex needs of underserved populations with mental health concerns. The Integrated Community Psychiatry (ICP) Nurse Practitioner Fellowship Program was created to address these issues by improving the competencies, confidence, and integration of newly graduated behavioral health NPs during their first year of practice. Hosted in an outpatient community mental health setting, the program is based on experiential learning and emphasizes direct care for high-risk and underserved populations. The ICP Program complies with standards set by the American Nurses Credentialing Center (ANCC) Advanced Practice Provider Fellowship Accreditation (APPFA). This accreditation helps ensure a structured, evidence-based approach to postgraduate education and professional development in nursing.

PMHNP Fellows are integrated into interprofessional teams that include psychiatrists, PMHNPs, therapists, and case managers, working closely with primary care services. The clinical setting also offers medications for opioid use disorder (MOUD) and promotes evidence-based treatment for substance use disorders. This team-based approach encourages holistic care and supports fellows’ growth in providing culturally competent, community-centered, and integrative care. The community members served by the program face significant social determinants of health (SDOH), such as housing instability, food insecurity, and limited healthcare access, which lead to higher rates of chronic illness and early death. The post-graduate fellowship includes transformative learning activities like visits to homeless shelters, drug courts, and food banks, helping fellows understand the social and structural causes of health disparities and reinforcing their dedication to health equity in community mental health care.

There is limited research on nursing knowledge and skills related to -SDOH. From 2020 to 2023, the Fellowship Program gathered data on SDOH competencies among ICP Fellows (a total of 13 Fellows; see Table 1). Specifically, we looked at how SDOH concepts were incorporated throughout our program and assessed how learners applied this knowledge in practice.

We used the core competencies for health centers created by faculty from the National Association of Community Health Centers’ SDOH Academy (2019). These four core competencies included: 1) Improve access to quality health services by increasing capacity for patients to obtain SDOH services; 2) Develop a healthcare workforce capable of addressing current and future SDOH-related needs; 3) Improve population health and reduce health disparities through community partnerships and system delivery changes; and 4) Increase awareness of emerging issues related to SDOH.

To evaluate fellows’ development, we developed program-specific sub-competency statements aligned with these core competencies and assessed them using a 5-point Likert scale. Fellows completed a self-assessment competency tool at program entry, after each SDOH-focused learning experience, and again at the end of the program (see Appendix A). By the end of the 12-month fellowship, all participants scored a 4 or higher across all measured competencies (see Table 1). These findings highlight the importance of integrating SDOH content into nursing education and professional development, demonstrating that structured assessment can effectively foster the competencies necessary for practicing in community mental health settings.

Conclusion

Nurses working in community mental health hold a uniquely influential role at the crossroads of clinical care and ethical practice. Within the often-overlooked areas of community mental health centers, nurses engage daily with individuals whose lives are affected by structural inequalities, stigma, and unmet needs. Their work, though locally based, carries the moral responsibility and practical impact of humanitarian care. By viewing this practice through a humanitarian lens, we not only acknowledge the deep importance of nursing in these settings but also enhance its value within the broader profession and society.

The challenges faced by nurses in community mental health are significant, but so are the opportunities for meaningful engagement, advocacy, and transformation. As the mental health crisis in the United States worsens—especially among vulnerable and underserved populations—the need for a skilled, ethically grounded, and well-supported nursing workforce in community settings becomes increasingly urgent. By embracing community mental health work as an expression of the nursing profession’s core values, educators, policymakers, and health care leaders can help ensure that this kind of care receives the attention, investment, and respect it deserves. In doing so, the profession reaffirms its long-standing commitment to caring not just for individuals, but for the communities and systems that influence their well-being.

Table 1. Competency Tool – Social Determinants of Health Focus

Note: Adopted from National Association of Community Health Centers. (2019, September). Detailed core competencies responding to the social determinants: For health centers, primary care associations, and health center controlled networks.

Rating Scale: 1 – Strongly Disagree 2 – Disagree 3 – Neutral 4 – Agree 5 – Strongly Agree

Appendix A

Author

James K. Tudhope, DNP, APRN, PMHNP-BC, NPD-BC
Email: jtudhope@kent.edu
ORCID ID: 0000-0002-2910-6410

James K. Tudhope, DNP, APRN, PMHNP-BC, NPD-BC has been a registered nurse since 2001, a licensed professional counselor since 2008, and a Psychiatric Mental Health Nurse Practitioner since 2013. He is an Assistant Professor at the College of Nursing, Kent State University, where he coordinates the Psychiatric Mental Health NP Concentration. Additionally, he is the Medication Clinic Coordinator and Program Director for the Integrated Community Psychiatry Nurse Practitioner Fellowship Program at Portage Path Behavioral Health in Akron, Ohio. Dr. Tudhope’s practice-based research focuses on professional development for nurses and the design and development of advanced practice registered nurse (APRN) post-graduate education programs.