You don’t have to be a movie buff to know that nurses, psychiatric nurses in particular, have suffered a bum rap. Late night comedians made such fun of Nurse Ratched in One Flew over the Cuckoo’s Nest that even if you never saw the movie, you probably still have some image of Louise Fletcher’s character. She is a lean, mean machine, controlling, and ultimately as irrational as her patients. Earlier, in the ’50s classic The Snake Pit, vengeful nurses administered electric shock therapy to helpless inmates. All this might be riveting drama, but it hardly moved the profession forward.
In fairness, psychiatrists did not fare much better; but it is the role of nurse we’re dealing with. Fortunately for patients everywhere, reality is much more interesting and benevolent.
For one thing, mental health nurses are no longer confined to “asylums.” You find them in outpatient settings, in private practice and on inpatient staffs. Most psychiatric nurses form an integral part of a multidisciplinary approach that may involve many treatment modalities, including medication, therapy and case management. Large mental hospitals still exist; and there will always be forensic hospitals for the criminally ill. Yet, for the most part, care of even the most seriously impaired occurs largely in an outpatient setting. The field is a specialty with many subspecialties, including substance abuse/addiction, child or adolescent, forensic, community mental health, crisis intervention and education.
The Roundabout Way
How do you prepare for this type of nursing? According to Ben Evans, RN, APN-C, very few nurses actually think of going into the field during their student years. In fact, many students are positively evasive about any exposure to mental health clients because they don’t see the value to their career plans. Sometimes they are afraid. They don’t yet understand that the need for psych-emotional nursing interventions emerges in all patient settings. The skills have wide application and consist of far more than “communication.”
Not until near the end of the rotation does it dawn on the student that this person he played pool with in the day room might not be so threatening. Maybe the student’s intervention even helped the patient open up a bit or calm down. Then, sometimes, psychiatric nursing becomes a possibility.
Mr. Evans himself brought a varied nursing background to his post as clinical director of mental health services at St. Michael’s Medical Center in Newark, N.J. He started out with an associate degree; now two master’s degrees later he considers himself a hybrid: an adult nurse practitioner/clinical nurse specialist with a background in oncology, counseling and teaching. He has worked extensively with AIDS patients, including those with substance abuse problems and those needing case management.
On the day we spoke, he was busy with staffing and budget issues and pointed out that, at any given time, his job could also include medication management and patient intervention. His duties involve supervision of all aspects of mental health services offered by the medical center, including a 20-bed inpatient unit with voluntary and involuntary admissions, a 20-bed inpatient detox facility and an outpatient substance abuse program.
He is the perfect person to ask: What is the difference in working with patients who are afflicted with emotional rather than physical illness? “They are both challenges in different ways,” he said. “If you work with the severely, persistently mentally ill, there is a lot of recidivism, which can be kind of draining of staff. However, I think [it is] refreshing for staff when they see somebody who has been ill for a long period of time stabilize and increase their length of time back in the community without frequent hospitalization.”
The Perks of Psychiatric
Mary Whytock, RN, works at Loma Linda University Behavioral Medicine Center. Like Mr. Evans, she is an articulate advocate for the field of psychiatric nursing. Her first exposure came as a student in the ADN program at Victor Valley College, where she had a teacher inspire her and help her to see patients not with fear, but compassion. Although Ms. Whytock worked in critical care nursing as a new graduate, she quickly came to see that caring for patients in an intensive care setting was not for her. The work hours were too task oriented, leaving not enough time for her to nurse the whole patient.
By contrast, she sees her current role as one that allows her to attend to the patients’ needs in a more comprehensive way — their spiritual, emotional and psychological as well as physical needs. And psychiatric patients do often have physical illness, too.
The work on her 18-bed adult unit is varied. She views the ward as an “emergency room for the mentally ill,” requiring that all staff get up to speed quickly with each client. Patients may be voluntary or not, acutely psychotic or suffering from severe anxiety or depression. Their stays are often short, five to seven days, and intensive work is required to achieve enough resolution for discharge. “A therapeutic calm is the constant goal,” Ms. Whytock says, but the atmosphere changes as the mix of patients does.
The challenge of dealing with forensic patients, those whose illness has possibly led to criminal acts, is especially difficult because their underlying pathology may be intractable personality disorders. Still, Ms. Whytock appreciates that there is the time and the structure to work with individual patients, especially in the evening. “Compliance is an issue, so time for medication instruction is very important for all our patients.”
Another source of variety is the Rapid Response Team, which can send a nurse to another of the several units in this 86-bed facility on a moment’s notice. It might be a child or adolescent, or another adult on the chemical dependence unit who is escalating. Additional staff mobilizes quickly, usually for about an hour, until a patient can achieve more equilibrium.
Whatever the circumstances, Ms. Whytock keeps in mind that we all function somewhere along the spectrum of mental health. Her patients are, for the moment, at the edges, but they are always people. They need her to be knowledgeable, alert and cautious, but always compassionate.
Helping From Afar
Alertness needs to be RN Patrice Foley’s middle name. She sees patients, or rather hears them, in a completely different way. All of her work is over the telephone at the Access Center of the Los Angeles County Department of Mental Health. She is team leader in a multidisciplinary office that fields calls 24/7 from all over the country.
When Ms. Foley answers the phone, she “may end up speaking to a family member in New York trying to get help for someone in crisis in L.A.,” or she may be responding to a school’s call for assistance with a disturbed child. Most calls are one-time pleas for help, and due to the high volume she does not even recognize if someone is a repeat. She may deal directly with six to eight acutely ill patients in one day, and each phone call can take considerable time to resolve if, say, she has to locate a hospital bed.
In between, she handles calls from other professionals, like case managers or family members seeking referrals or resources. Sometimes she calls the police to intervene. In other cases, she might send a member of a Psychiatric Mobile Response Team (PMRT) or a Systemwide Mental Assessment Response Team (SMART) for patients who have weapons.
Clients most often needing assistance fall in the categories of chronically mentally ill, like schizophrenics, people with major depressions and bipolar individuals. Drug abuse often complicates the picture, and Ms. Foley admits that these patients provide the most challenge because they are unpredictable.
However, since her first day on the job 11 years ago, when the first call she answered in her new role involved a suicidal man, she still finds “the same satisfaction: someone deeply troubled is now safe,” thanks to her skilled intervention. Her ability to handle the call from that man, who the police later located in a phone booth with a rope, gave her confidence that she could handle whatever came her way.
Beyond the Basics
What does it take to do this kind of nursing? Certainly, compassion is needed, the ability to see the mentally ill as people, and patience to deal with what is often chronic illness. A thorough understanding of how inseparable mental and physical health really are is vital. Both Mr. Evans and Ms. Whytock agree that basic nursing education woefully neglects pysch nursing, and both gained much of their experience on the job. Ms. Foley, too, was a very experienced nurse before she took on crisis intervention.
Still, psychiatric nursing often involves study beyond basic preparation. Either the clinical nurse specialist or the nurse practitioner route work, since in this particular field the actual nursing functions are so alike. Credentialing is available from the American Nurses Association or the American Psychiatric Nurses Association. Several graduate programs in the state educate advance practice nurses for mental health nursing, including both public and private institutions (see sidebar).
Professional issues seem similar to other areas of nursing. As a board member at large for the American Psychiatric Nurses Association, Mr. Evans would like to see the profession look more closely at evidence-based practice, so they know what nursing actions produce good outcomes. Both he and Ms. Whytock mention the profession’s concern with standards for the use of restraints and isolation and the dearth of practitioners prepared for child and adolescent care.
Now is an exciting time for psychiatric nursing. Advances in technology help in the study of not only brain structure but also the chemical processes that influence behavior, and sophisticated drugs can give many patients normal lives. With the support of nurses who can provide crisis intervention, therapy and education, there is much to offer beyond drugs, namely hope. Maybe someday there’ll even be a positive role model on the screen.
Statistics From the National Institutes for Health
– 26.2 million people age 18 and above suffer from a diagnosable mental disorder in any given year
– Mental illness is the leading cause of disability in the U.S. and Canada for ages 15-44
– More than 90 percent of suicides have a diagnosable mental disorder/and or substance abuse problem
– 2.4 million Americans have schizophrenia; 2.2 million have obsessive-compulsive disorder
Sites for Graduate Studies
Cal State Los Angeles
Clinical nurse specialist and nurse practitioner in psychiatric/mental health nursing
Neuropsychiatric nurse practitioner with subspecialty in pediatrics or adult
Point Loma Nazarene University
Master’s and post-master’s clinical nurse specialist
Cal State Sacramento
Family nurse practitioner in family mental health nursing
Cal State Long Beach
Nurse practitioner master’s and certificate program in psychiatric/mental health nursing
University of California at San Francisco
Clinical nurse specialist or nurse practitioner in psychiatric/mental health adult, child and adolescent
Elizabeth Hanink RN, BSN, PHN, is a freelance writer with extensive hospital and community-based nursing experience.