Cynthia von Grauvogl, RN-BC, MSN, CARN-AP, has heard of mental health and psychiatric clinical rotations that start with a showing of "One Flew Over the Cuckoo's Nest," a film set in a 1950s-era psychiatric hospital run by a tyrannical nurse. She sees no need for that. "The students already show up terrified," said von Grauvogl, a full-time instructor at the California State University, Fullerton School of Nursing. "They've seen news stories about face-eating attackers or people who shot up theaters and schools. They think all mental patients are like that, and they're wondering if they'll escape with their lives." The vast majority of patients with mental illness, "which is mostly all of us," she said, deal with depression and anxiety that may be chronic or may come and go at different points in their lives, but seldom require treatment outside of a community setting. "Despite this, our focus [in nursing education] seems to always be on the acute, really sick psychiatric patients," von Grauvogl said. "The stigma is a huge problem to overcome. Imagine if you believed all patients were dangerous and could hurt you. You'd need to be constantly on the defensive. It would create problems in caring for them.
Reality check
Many mental illnesses strongly affect other aspects of health, said Ursula A. Kelly, RN, ANP-BC, PMHNP-BC, PhD, assistant professor at the Emory University Nell Hodgson Woodruff School of Nursing in Atlanta. Nursing students need to be prepared to recognize, understand and care for patients who have them. Do nurses at the graduate and undergraduate levels need to be educated about mental health? Absolutely. Are we doing it well? Absolutely not. Not that nurses need to become mental health experts in addition to everything else they do, she said. But there is a growing need for nurses who can identify more frequently seen mental health problems, such as depression, and know when to bring in someone with more expertise. Studies overwhelmingly show all healthcare providers, whether in hospitals, clinics, home care, schools or anywhere else, regularly encounter people with mental health problems who need proper care for their illnesses. For instance:
- About one in four adults suffers from a diagnosable mental disorder in a given year and patients with chronic conditions such as diabetes, asthma and heart conditions have higher rates of mental health problems, according to a 2010 report by the Center for American Progress.
- A number of studies, including a 2011 literature review published in World Psychiatry, estimate people with mental illness die between 13 to 30 years younger than the national average, mainly because they don't receive appropriate care for physical illnesses.
- Mental disorders and substance abuse are related to one in eight ED cases in the U.S., according to the Agency for Healthcare Research and Quality.
- Failure to treat both physical and mental health conditions results in poorer health outcomes and higher healthcare costs, states a report from the American Academy of Family Physicians.
The most important thing a nursing program can do to prepare nurses to care for patients with mental illness, say those who teach psychiatric/mental health nursing, is to teach them that mental health issues are widespread among the population and that someone with mental illness deserves the same care, compassion and respect as any other patient. "A lot of it is just awareness that psych/mental health is everywhere," said Mary Wickman, RN, PhD, director and professor at the nursing program at Vanguard University of Southern California in Costa Mesa. Von Gravogl tries to make her courses as comfortable as possible for her students. She assumes none of them is planning to become a psychiatric nurse (though, by the end of the rotation some decide that's what they want to do) and makes sure what she teaches applies to other areas of nursing - the ICU, med-surg, ED and OR. A recent study indicates nearly one in four people suffer symptoms of PTSD following an ICU stay - valuable information for patients and families to know. Von Gravogl holds her clinical rotations at the VA Long Beach Healthcare System, which exposes her students to a variety of settings in one place. "They have some of the best psychiatric care I've ever seen in my life," she said. Students see patients in the chemical dependency program, the outpatient psychiatric clinic, the women's care clinic and in a home health program, as well as in an acute inpatient unit. They see people with PTSD, bipolar disease and schizophrenia, but also with depression, anxiety and adjustment disorder. They see nurses working as case managers and referring patients. "It really broadens their view of what mental healthcare is," von Gravogl said. "Once they talk to the patients, they find it's like talking to anyone else. It's quite an eye opener." She also uses part of her classroom time as a therapy session where students talk about what's bothering them, share ways to deal with stress, discover things they have in common and experience group therapy in action. Toward the end of the rotation they come to see her as someone who is supportive of them being successful, she said. In 10 years of teaching, it has happened every time.
Equal opportunity learning
Emory has started integrating mental health into non-mental health specialties for graduate nursing students, Kelly said. Students have been coming to us desperate for this kind of content. A new mental health course recently became mandatory for all advanced practice nursing students who are not in a psychiatric nurse practitioner program. The one-semester class includes discussions of mental health issues for APRNs, self-care and wellness and caring for patients with mental health illness. Students learn to assess and screen for anxiety, depression and substance abuse; common medications for mental illness; motivational interviewing and therapeutic communication; how family dynamics influence care; and how mental illnesses are often comorbidities with diabetes, cancer and cardiac disease. Students in all specialties are together for an hour, then break into clinical seminars based on what mental illness they may encounter in their specialty. For instance, pediatric NPs might delve into behavioral disorders in children, while geriatric NPs might discuss Alzheimer's and depression in the elderly. The students learn how to identify resources and make connections so they can refer their patients to mental health professionals, therapists, support groups, stress-reduction classes and other support systems. The course does not have a clinical component; students are expected to use what they learn in their work with patients, Kelly said. "Its main objective is to take an eraser to the solid line that's established between physical health and mental health," she said.
Hollywood softens perceptions
Nurses who teach mental health and psychiatric nursing say they believe perceptions about mental health are changing, driven in part by healthcare reform requiring insurance coverage for mental health conditions and pilot programs in integrated care. Movies such as "Silver Linings Playbook," whose main character has bipolar disorder, and "It's Kind of a Funny Story," about a teen with depression, show people with mental illness in a sympathetic light. "Hollywood and the media are talking more positively about it," said Jeannine Loucks, RN-BC, MSN, PMH, an ED manager at St. Joseph Hospital in Orange County, Calif., who designed a mental health education course for hospital staff and law enforcement officers. "The stigma still exists, but more people, including nurses, recognize depression and anxiety in themselves and in family members, particularly during stressful times. I think it's getting better because people are willing to talk about it."
Give nurses the right tools
Psychiatric nurses and nursing instructors recommend the following to prepare nursing students to address the mental health needs of patients they will see in practice:
- Students should be exposed to a variety of settings, not just an inpatient psychiatric unit, during their clinical training. Community clinics, integrated health sites where psychiatric and non-psychiatric clinicians work in teams, rehabilitation programs are possible sites for psych/mental health clinical rotations.
- Mental health should be integrated into all nursing specialties, including pediatrics, med-surg and emergency nursing. For instance, a pediatrics class can include information on more frequently diagnosed childhood conditions such as autism and ADHD. An emergency nursing class can discuss how to talk to a patient experiencing psychotic hallucinations, while an obstetrics course might cover maternal mental illness.
- Faculty who teach psych and mental health to students, both in classroom and clinical settings, should feel comfortable working with patients with mental illness, and promote a holistic view of patients, connecting mental health to all aspects of nursing.
- Both undergrad and APN programs should include information about how to identify, assess and treat more frequently seen mental illnesses, including screening tests and the drugs commonly prescribed for them, as well as preventive measures, such as diet and exercise.
- Nurses at all levels should become familiar with the role of mental health specialists, both in the hospital and in the community.
- Instead of waiting until the end of the undergrad nursing program, psychiatric and mental health should be introduced earlier in the curriculum if possible, preferably in the first year, so students can apply what they learn about mental health and mental illness to other areas of their training and develop good mental health habits to help themselves during what is usually a stressful time of their lives.
