Mental Health Nurse
By Lisa Legge
Phyllis Goranson, RN, was a nursing student when she set out to be a mental health nurse. She had just finished a psychiatric clinical rotation at a state hospital, in the 1950s, the time of lobotomies and punitive-style care. Stereotypical loose-hanging light bulbs, patients screaming from windows and nurses straight off the set of One Flew Over the Cuckoo’s Nest were part of her experience.
“They would line the residents up for shock treatments along the wall in a basement room, one cot after another, with no drape in between and no relaxant, no premedication, and just go from one patient to the next. One person would lie there and be able to see the other one convulsing. They were held down if they resisted.
“If the weather was fierce, we had to go from one building to the next through dirt tunnels,” she continued. “On the tunnel walls were cut-out holes where they had formerly put people in solitary confinement. Some of the iron-barred doors were still there. ...
“The day I left, I just cried, thinking of all those dear souls there,” she said. “I thought, ‘I’m coming back and clean up this place.’ ”
Gone are the days of punitive care — and clinical rotations at state hospitals for that matter — thanks in part to the compassion and determination of nurses such as Goranson, who indeed “cleaned up” her area of mental health care. At Minneapolis’ Andrew Residence, a 212-bed long-term care facility for people with mental illnesses, residents live in a homey atmosphere with a close-knit staff. She personally orients new hires — a practice that has paid off in instances such as a housekeeping staffer who reported a patient’s diabetic reaction.
“I always put myself in people’s shoes and ask, ‘How would I feel about this?’ ” said Goranson, who is semi-retired from her job as Andrew’s nursing director.
Today, nurses in hospitals and treatment centers are caring for sicker people — those with complex and multiple diagnoses — and are doing so with fewer resources. And, as more and more patients with chronic mental health problems move out to the community, nurses everywhere are caring for this population. Several inpatient mental health nurses — those working with the most ill — took time to share the skills that any nurse, regardless of practice area, can use in mental health care.
“Nurses see mental health patients all the time,” said Marcia Justic, RN, MSN, CS, a psychiatric liaison at Methodist Hospital’s medical-surgical departments and psychiatric editor for the journal Critical Care Nurse. “When you think of all the people who have family or personal histories of any psychiatric disorder... very few people have not been touched by this.”
SUBHEAD: Addressing the clichés
Justic, a career-long mental health nurse, maintains that at least two clichés exist in her specialty area. One is that psychiatric nurses use their own sense of self — rather than machines or physical techniques — to help someone achieve health. The other is that “communication is important.”
“I think that’s true, but what does it mean?” Justic says. “I think the skill set isn’t well identified.”
First, the “use of self.”
Maintaining a therapeutic presence, keeping clear boundaries between themselves and the client and not taking things personally — avoiding the “transference/countertransference” trap — are all things learned in nursing theory courses. Nevertheless, it’s something nurses must reflect upon often, veterans of the field say.
“A big part is maturity, of having faced your own issues,” Justic said. “If you don’t know what your own issues are, when you’re dealing with patients you may respond on the basis of your own unresolved issues, rather than on what they’re presenting to you. You have to know yourself enough to have a sense of when that’s happening.
“As nurses, it’s important if we have unresolved issues that we don’t try to work with those patients who engender a lot of emotional effect within us, because then we’re not responding to the patient and their needs, but to ours,” Justic continued. “That comes with time. There aren’t many great 21-year-old psych nurses.
“Authenticity” — not trying to be more than we are — is important particularly in mental health care. (It also helps us avoid feeling like our patients’ savior, which destroys professional boundaries.)
Unconditional caring and respect is essential, but in an authentic way,” Justic said. “I don’t want to behave as though I’m somebody’s best friend and know them well, when I don’t. I can’t expect this patient to unconditionally trust me. And, in acute care, I want to be clear about what I can and cannot help them with, rather than telling them I can fix every [long-term issue] and will be with them through thick and thin.”
With authentic care, nurses can set limits with patients and help them learn to have an internal sense of boundaries. “What frequently happens with nurses is rather than being open with a patient and the destructive behavior they see, [nurses] get angry and punitive with patients,” Justic said. She used an example of a patient who constantly presses the call light. “Rather than working with the patient to interpret what is going on — they’re afraid or they can’t have a sense of delayed gratification, for example — the nurses get mad and don’t answer the light. We have to consider how we work with patients so we’re not responding in a punitive way but helping them look at their behaviors.”
These techniques also help nurses deal with patients’ anger and aggressive outbursts without being fearful. It keeps the care authentic.
“No matter how psychotic they are, they can tell whether you care or if you’re just there for a paycheck,” said Roger Lonnstrom, RN, C, a staff nurse who teaches therapeutic interventions to the nursing staff at Fergus Falls Regional Treatment Center. He described a memorable patient, a man “head and shoulders bigger than I was” who several times was angry enough to strike Lonnstrom but never did because, Lonnstrom figures, the patient could feel his nurse respected him. “One of the things I’ll always remember was when he left, we shook hands and he said, ‘God bless you, Roger.’ ”
A final cliché — but still true in part — is a belief closely related to our culture’s ignorance and fear of mental health care. Marva Thurston, RN, MS, an associate nursing professor at College of St. Catherine, St. Paul, imbues her lectures in mental health nursing with the difficult realities of living with chronic health issues and the “incredible grieving” that comes with mental illness. “I incorporate my high regard and respect for those patients,” Thurston said. “I talk about how I love my schizophrenic clients.”
SUBHEAD: Reframing, Labeling
Listening is particularly important in this nursing area, as is nurses conveying their understanding to patients. Tess Walker, RN, a staff nurse at Andrew, told of a physician who called for an interpretation of a long-term patient’s claims of having “Pontius Pilate bones.” When the physician asked what to do next, the nurse said, “I would x-ray.” She was right: “Sure enough, it was fractured,” Walker said.
“Reframing” a patient’s view of a situation is an important technique.
“It is helping patients who are really in a sense of angst to somehow normalize it, make [the situation] not as catastrophic as it [initially] seems to them,” Justic said. “You almost challenge them to interpret what they’re telling you — maintaining empathy and understanding their pain, but helping them look at the way they perceive things. You help them begin to look at [the situation] differently to get themselves out of the hole they’re in.”
Helping clients reframe their thoughts, set goals for themselves and interpret their behavior can work if they recognize their problems. But nurses also work to facilitate clients’ talking about their feelings, understanding them in the context of their lives and labeling their problems.
Justic offered this example: “If a patient is feeling really down in the dumps, but doesn’t recognize it, is instead just complaining about how bad their back pain is, I help them figure out how their back pain may be related to stressors, their mood or something else. I help them label some of their feelings and experiences so they can confront them, rather than just having this mysterious, overwhelming feeling of being depressed.” Patient teaching — the core of any nursing field — is continuous in mental health care.
SUBHEAD: Drugs
Among the most confounding issues of mental health care is knowing the vast, ever-evolving array of psychotropic drugs available, as well as their potential and often potent side effects and how the drugs interact with other drugs or chemicals.
As an example, Justic pointed to new antidepressants. “New interactions come out every day,” she said Justic. Referring to the news about the drug sertraline, brand named Zoloft, she said: “This week we know it’s grapefruit.”
Goranson credits the nursing staff at Andrew Residence for saving the life of a resident who had been taking the “remarkable” drug Clozaril for his psychosis and schizophrenia. Because it can affect a person’s white blood cell (WBC) count, staff must track it each week. One day, the staff noted the man was fine at 7 a.m. but had a small cough two hours later and, knowing he was on Clozaril, sent him to the lab for a WBC count. The lab sent him back, saying he was fine. “By 1 p.m. he had full-blown upper respiratory infection,” Goranson said. “He was sent to ICU and almost died.”
SUBHEAD: Compliance
One continuous theme in mental health care is patients who quit their medication regime because they’re feeling well, only to fall back to ill health. Citing a 50 percent recurrence rate for depression, Justic says that is often because patients don’t take them long enough. (She is quick to add that medication compliance is an issue across many types of illnesses.)
One major predicter of non-compliance with medicine is side effects, which vary widely among individuals, Justic said. “When they have no libido, for example, what is the first thing they’re going to do when they start feeling better? They’re going to stop those medications.”
Hearing the patient’s concern, helping him or her set priorities and finding alternative medications and ways to treat the side effects are key here.
“We [nurses] get the mindset that, ‘If you’re miserable enough, you’ll put up with this,’ ” Justic said. “Frequently, we don’t do a good enough job of following the patients to figure out what side effects they are having — and how unacceptable those side effects are to them — and changing the medications.”
Compliance is especially difficult for those with bi-polar disorder or chemical dependencies. “We’re asking patients not to feel good,” she said. “Patients many times have to have a lot of difficult episodes under their belt to finally figure out it’s not worth it.”
“Have patience” is Justic’s advice for any nurse working in mental health.
“It’s like we expect psychiatric patients not to be psychiatric patients,” she says. “We expect them to be well-rounded, adjusted, nice people. We have unrealistic expectations and then get mad and punitive with patients when they don’t follow our expectations. We end up not liking the patients for the very reason that they are our patients. It’s much wiser to enter into it with the sense that this will really have to be valuable to the patient for them to continue and that if they have a recurrence, that we hang in there with them.”
Thurston tells her students that psych nursing is “not for concrete thinkers,” that those who tolerate diagnostic gray areas will enjoy it most.
“This kind of nursing takes a lot of patience, understanding, a sense of humor about the human condition and not putting our own ego into whether the patient is compliant. You can be a really good psychiatric nurse and many of your patients will still not be better.”
Says Niki Gjere, RN, CNS, who has worked in every area of mental health over her 19-year career: “We define progress differently. We think in weeks instead of days or hours.”
“We might be excited if someone makes a commitment and stays with it to walk around the block three times a week,” said Cathy Iverson, RN, a health educator at Andrew Residence. “We all cheer for them.”
Finally, maintaining “normalcy” in your own life is paramount, these nurses say. Gjere calls it “staying alive ourselves — not being hardened or callused to people’s pain.
“We hear so much, all the time. It’s not normal to hear about how many patients have tried to kill themselves. ... The things I talk about are very different from what other nurses talk about. ... In mental health, when we have a death, it’s usually not by natural causes. We hear so many tragic stories. We hear about suicide, homicide, abuse. Every day. Sometimes it’s a challenge to keep a foothold in what is normal.”
SUBHEAD: Hard-fought victories
Why do they do it? Why do they make the trip each day, often through locked doors, to get to a job with little immediate gratification? It’s the small, hard-fought victories — seeing a patient take small steps — that is the draw. Many say they bear in mind the tremendous courage their patients possess.
Gjere, who works at Fairview-Riverside Behavioral Services, Minneapolis, remembers a patient she cared for, a 20-year-old man who had been suicidal and hospitalized often. She hadn’t seen him in some time — a potentially negative sign. One day, he called her name in a store and told her he was doing much better, thanks to one small thing she had said to him.
“He said ‘You wouldn’t even remember that you said it, but that’s what made the difference. ... I’d heard it before, but it just made sense then,’ ” Gjere said. “I think part of psych nursing is not even knowing the impact we have.
Gjere, like other mental health nurses, sees her patients — and her work with them — as sacred.
“That people trust us so much to share their innermost thoughts, fears, worries, crises, illnesses, is a huge privilege,” she said. “The day that I can’t continue thinking highly of patients and hope, I won’t be in it anymore.”