When Tina Carlson, MSN, APRN, PMHCNS-BC, began searching for nurse practitioners willing to be trained to care for patients with mental health conditions, she knew it wouldnt be easy. Primary care providers in rural New Mexico are scarce and family NPs are in high demand. But she discovered not only was it hard to recruit providers willing to focus on mental health, but how little the candidates knew about mental illness, even though they all had patients with mental health issues.
From training to treating
Many clinics and providers say they dont want to screen for mental illness because they dont know how to treat it, she said. If a screening indicates a mental health problem, they dont know how to treat it and cant offer a referral to a mental health provider because of a shortage of these providers, they could be held negligent.
No chronic illness is simple, said Carlson, a clinical nurse specialist with Project ECHO (Extension for Community Healthcare Options), based at the University of New Mexico Health Sciences Center in Albuquerque. But by learning about a condition, healthcare providers better understand how to manage it with behavioral changes and medications. There are a lot of commonalities in treating chronic mental and non-mental illness, she said. Both usually involve co-morbidities that affect a patients overall health and response to treatment. Both often require a combination of lifestyle changes, medication and support systems to be successful.
Most pediatric NPs are up to date and aware of neurological disorders in children, such as autism and ADHD, and education programs for pediatric NPs generally do a good job of encompassing mental health, said Susan N. Van Cleve, DNP, RN, CPNP-PC, PMHS, associate professor and interim director of the DNP program at Robert Morris University School of Nursing and Health Sciences in Moon Township, Pa. But many FNPs are uncomfortable diagnosing and treating behavioral and mental health disorders in adolescents and children, even though mild-to-moderate conditions can be treated in a primary care practice, she said.
In recognition of a severe shortage of mental health providers in rural areas, Project ECHO received a three-year grant from the GE Foundation to train NPs and community health workers in rural community health centers to screen for, diagnose and treat mental health and addiction problems, including follow-up support from mental health specialists at the university. (For more on Project ECHOs program, see www.Nurse.com/Article/Project-ECHO.)
A similar program in Maryland, offered by the Johns Hopkins University School of Nursing, uses a combination of online classes and training at hospitals and clinics for NPs working in underserved areas. The one-year program includes advanced courses in the neurobiology, diagnosis and treatment (including psychopharmacology and brief psychotherapy) of mental health and addiction disorders, as well as clinical sessions with local psychiatrists, psychiatric NPs and other mental health providers.
The beauty of this program is that we can train nurse practitioners who are already working with patients in rural areas in a more advanced level of psychiatric practice, Karan Kverno, PhD, PMHCNS-BC, PMHNP-BC, an assistant professor at Johns Hopkins, said in a statement announcing the program, which started in January. The training is all online, but we are developing contacts in outlying areas where the NPs are living so that they may continue to work part time and keep up their practices while they are being trained.
Nurses in acute care settings face similar challenges caring for patients who are mentally ill in addition to other conditions that brought them to the hospital, said Cynthia von Grauvogl, MSN, RN-BC, CARN-AP, a full-time instructor at the California State University, Fullerton, School of Nursing. A hospital stay may trigger anxiety or depression, even in patients without previous symptoms of mental health problems, which could affect how they respond to treatment, she said.
Unlike diabetes or high blood pressure, which can be determined with a quick test, assessing for anxiety or depression can take a while, she said. It puts more pressure on busy bedside nurses, who may feel uncomfortable asking questions related to mental health that their patients may feel uncomfortable answering.
Though nurses in three Southern California hospitals reported feeling relatively confident about assessing mental health conditions in their patients, particularly for signs of alcohol withdrawal and drug use, they were less confident in their ability to intervene appropriately and particularly to recommend psychotropic medications when appropriate, according to a study published last year in the Journal for Nurses in Professional Development. (http://www.vanguard.edu/provost/wp-content/uploads/2013/10/Behavioral-Health-Article_Published.pdf)
They dont know about the psychiatric medications, said Jeannine Loucks, RN-BC, MSN, PMH, an ED manager at St. Joseph Hospital in Orange County, Calif., and one of the authors of the study. As a result, some nurses might wait until patients become extremely agitated and need a heavier dose, instead of offering to talk to a physician about prescribing something to relieve anxiety at the first signs of agitation, she said, much as they would offer pain medication at early signs of discomfort.
At St. Joseph, Loucks created an education program on psychiatric and mental health for non-psychiatric nurses at the hospital. The eight-hour course covers symptoms and nursing interventions for depression, anxiety, bipolar disease, PTSD, schizophrenia; the causes of mental illness; common medications, including reactions and side effects; the recovery model, which emphasizes hope and the ability to recover from a mental illness or substance abuse disorder; interviewing and communication techniques; and how to respond when people with mental illness become agitated, using a system called TACT tone, atmosphere, communication and timing.
Loucks starts the classes using scenarios from the hospital, but nurses soon bring up their own examples and talk about their techniques or about how they should have handled a situation involving a patient with mental illness. She has developed a similar course for police officers and other first responders.
Since putting the program into place, St. Joseph has seen a decrease in code grays unruly patients and an improvement in nurse satisfaction scores, Loucks said. Med-surg and ED nurses are better at identifying patients at risk for suicide and calling psychiatric nurses for support when they need it. People arent discriminating as much against patients with mental health or substance abuse disorders, she said. The days when the staff put patients with psychiatric conditions at the end of the hall so no one had to deal with them seem to be over, she said. I think the nurses are better able to communicate with them, and families and patients appreciate the nurses care and understanding of their situations.
In many ways, assessing and treating mental health conditions is no different than treating other health problems, both in acute and primary care, psychiatric nurses said.
Part of the process is keeping an open mind while figuring out what is causing symptoms. Diana Portillo, DNP, RN, an NP with Project ECHO, describes a woman in her 70s who was referred to her for an anxiety disorder. The woman told Portillo she felt anxious because she couldnt sleep. When Portillo asked why not, the woman said she was waking up every couple hours to urinate. Portillo immediately suspected a urinary tract infection, which tests confirmed.
Helping patients manage mental illness requires connecting them with resources and working in teams with other providers, Carlson and Portillo said. Integrated health clinics, where mental health providers work in the same office as primary care providers, make this process more seamless for patients and clinicians, Van Cleve said, but providers who arent in these clinics can develop their own referral and consultation networks with therapists, psychiatrists, psychiatric NPs, neurologists and other mental health professionals. Nurses also should feel comfortable educating patients about preventing mental illness through diet, exercise, sleep and stress reduction, Van Cleve said.
Healthcare reform and the increasing demand for mental healthcare means nurses at all levels of practice should avoid making the artificial distinction between mental and physical health and look at the whole patient, in keeping with their training, mental health nurses said. Were moving to a time when people are going to have to know that mental health is part of any healthcare delivery, Carlson said. The times are going to demand that we bring the brain back into the body.