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Psychiatric nurses also face many of the same challenges
as their medical counterparts-lack of community resources,
shorter hospital stays, more acutely ill patients, battles
with insurance companies for compensation and a shortage
of qualified RNs and other health professionals to care
for an increasingly needy population.
Patients who previously may have stayed up to a year
in a psychiatric hospital now are discharged from an
acute care psychiatric unit within seven days. Even
patients who once would have had two weeks of inpatient
therapy and medications now must leave in a few days.
"We generally have an opportunity to stabilize
them on medications for a few days and then they're
out the door," said Marlene Nadler-Moodie, MSN,
APRN, clinical nurse specialist for behavioral health
at Scripps Mercy.
The lucky ones go home to families or even to their
own apartments and good outpatient care, such as home
health, a community clinic or a private practitioner.
But many have nowhere to go, despite the best efforts
of nurses to place them.
"We're spending a great deal of money on education
because we have nothing else to offer," said Sulema
Luna, MS, CNS, RN, director of adult, emergency room
and pediatrics in psychiatrics at Harris County Hospital
District, Ben Taub Hospital in Houston. Her nurses give
patients resources and phone numbers, and teach them
as best they can how to watch for recurring symptoms.
"There's no long-term support," she said.
Some patients who are discharged to board-and-care
facilities don't take their medications properly or
the dosage becomes unbalanced and they end up on the
streets, psychiatric nurses said. One of the greatest
frustrations for hospital psychiatric nurses is a "revolving
door" of patients who end up back in the hospital
again and again because their families can't care for
them and adequate community facilities are not available
to help them.
By the time mentally ill patients are admitted to a
hospital, they are usually quite ill, said Dale Cohen,
MSN, CS, RN, past president of the California chapter
of the American Psychiatric Nurses Association. No one
questions whether someone with chest pains is admitted
to a hospital or whether they proper tests and medications
are administered, she said.
"But for mental health patients, the only way
to get admitted is to say, 'I want to kill myself' or
'I want to kill somebody else,' " Cohen said.
Insurance companies and other payers often do not cover
mental illnesses the way they do medical ones, he said.
Many policies limit the amount of medication or number
of therapy sessions that will be paid. Policies may
cover 50 percent for treatment of mental illness, compared
with 80 percent or 100 percent for physical illness.
Before physicians or nurse practitioners can prescribe
newer medications that work faster and have fewer side
effects, some payers require they first prove patients
haven't responded to older medications that have side
effects.
These requirements are devastating for people who need
medications or therapy for an indefinite period of time
and can't afford to pay, or don't want to take a medicine
because it makes them groggy, Cohen said. "So many
of our admissions are precipitated by people not taking
their medications," he said.
Few formally trained psychiatric nurses existed in
the United States before the late 1800s, according to
the American Psychiatric Nurses Association. Many opposed
the idea of women caring for the insane. In 1882, Linda
Richards, considered the first psychiatric nurse in
the United States, opened Boston City Hospital Training
School for Nurses to teach nurses to care for psychiatric
patients. By the second decade of the 1900s, nursing
schools had started to offer psychiatric nursing programs
and eventually nursing programs at psychiatric hospitals
closed. Graduate programs in psychiatric nursing began
in the mid-1950s.
Until the 1960s, psychiatric patients were mostly cared
for in state-run institutions, and nurses were trained
to care for them there. At her orientation, Henley said,
no one talked about intervention skills or evidence-based
practice. Nurses did the housekeeping. No one worked
with patients even on basic things like bowel and bladder
control-they were changed when someone had a spare moment.
"As a new nurse, it was very frustrating for me,"
she said. "I was very unhappy with what I saw."
She believes that many psychiatric nurses became strong
advocates for the mentally ill because of what they
experienced in those hospitals.
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