Into the Light
Psych nurses step out of the shadow of Nurse Ratched and institutionalization, bringing specialized care for the mentally ill into community settings

By Cathryn Domrose
April 8, 2003

Mozettia Henley, DNS, MSN, RN, started her psychiatric nursing career in the 1960s at a 9,000-bed state hospital in New York, a typical facility for the chronically mentally ill in those days.

Henley remembers a group of female patients that woke up, got dressed, then walked to the institution's front porch. Each patient sat in the same chair every day. They left the chairs only for meals. They did not get up to go to the bathroom. No one worked with them or organized therapy groups. "They were institutionalized," said Henley, president of the California chapter of the American Psychiatric Nurses Association. "It was their life."

After she left the facility, she heard that one day the women sat down in their chairs and the porch fell in. "I'm glad those days are gone," said Henley, now associate administrator at the mental health rehabilitation facility at San Francisco General Hospital Medical Center, a skilled nursing home for people with chronic mental illness. Her patients receive care from an interdisciplinary team of health professionals that helps them learn to care for themselves and manage their illness.

Her facility is one of a few these days that admit psychiatric patients involuntarily for long-term stays. Most of the mentally ill now are treated as outpatients or for a short time in a hospital psychiatric unit. Restraints are seldom used and only under strict legal guidelines. Patients receive one-on-one assessments, group therapy and vocational rehabilitation.

New medications control symptoms of anxiety or depression with few or no side effects. Mental illness is seen as a brain disorder rather than as a character flaw, and psychiatric nurses work hard to treat their patients with dignity and respect, even if a patient hurls insults at them or becomes violent.

Still misunderstood

But many people, including nurses, still see psychiatric nursing as something straight out of "One Flew Over the Cuckoo's Nest," with white-uniformed Nurse Ratched-types keeping patients drugged and strapping them down for electroshock therapy or a lobotomy.

"They think we have two heads and come from the planet Zork," said Kathleen Smerko, MS, CS, a psychiatric nurse practitioner in private practice in Phoenix. Some of her medical colleagues used to ask her in amazement, "You do psych?" She always responded, "And you think you don't?"

"Mental health is still misunderstood or seen as separate," Smerko said. "It's not really viewed as an integral part of care. Yet every good med/surg nurse will tell you the benefits of sitting at the bedside and talking to someone."

Psychiatric nursing may not involve elaborate IV pumps or complicated medical procedures, but in many ways it represents the essence of nursing, say those who practice it. Psychiatric nurses must understand the mental, physical, sexual and spiritual aspects of their patients. They work with individuals, families and communities. They must offer both medications and a willing ear to someone who desperately needs to talk.

"It's a different kind of care," said Amanda Saxe, RN, a psychiatric nurse in the behavioral health inpatient unit at Scripps Mercy Hospital in San Diego. "It's not physical, it's mental. The symptoms may be different and the medications are different. But you do the same steps as in medical nursing. You're still doing nursing care, those basic things you learn in nursing school."

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.

In the beginning

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.

When the patients left the institutions, so did the nurses. After state hospitals were ordered closed and patients released, community-based mental health centers staffed by nurses with advanced degrees were supposed to take over the care of the mentally ill.

The community mental health centers didn't work, said Jane White, DNSc, MSN, CS, RN, executive director of the American Psychiatric Nurses Association. The government never came through with funding for the centers, she said. "Those [community resources] fell apart." Instead, public funding for mental health plunged and has not come close to catching up. States spend fewer dollars on mental health now than they did in the '50s and '60s, Henley said.

Without community resources, "it's very difficult to rehabilitate patients," White said. Counties, which now bear the burden of mental health spending, don't have money to provide services. "We're there," White said of psychiatric nurses, "but we're there without resources, taking heavy caseloads."

A different direction

Although enrollment in advanced degree psychiatric nursing programs has dropped since the '60s and '70s, psychiatric nurses have a wide variety of jobs to choose from. Some are staff nurses in freestanding psychiatric hospitals or in the psychiatric units of general hospitals. Some work in home health, treating discharged mentally ill patients in their homes. Some work as psychoanalysts in private practice or as clinical nurse specialists in community mental health centers or hospitals.

Increasingly, many with advanced degrees are becoming psychiatric nurse practitioners, seeing patients and prescribing medication in private practice. Some specialize in treating children or adolescents; others may work in assisted living facilities with geriatric patients.

Smerko sees an important place for psychiatric nurse practitioners in long-term care, treating the elderly for mental as well as physical disorders. "You have to go in and take a good long and thorough look at what's going on," she said. For instance, delirium, depression and dementia may look the same in an older person, she said, but delirium, untreated, can result in death. Or an older person who seems depressed may be experiencing a side effect from a medication for a physical problem.

Smerko does a lot of consultation with family nurse practitioners who respect her knowledge of mental illness and the medications to treat it. "The relationship between the family adult nurse practitioners and the psychiatric nurse practitioner just keeps getting better all the time," she said.

As hospital stays for psychiatric patients have decreased, home health is playing a more important role in psychiatric care, said Dierdre Fisher, MSN, APRN, CNS, director of psychiatric services for Concord Home Care Inc. in San Antonio. Home health nurses have time to do more than just control symptoms, she said. "We get to see the families. We get to see the patients in their natural environment." Home health nurses can educate patients and families and help them stay out of the hospital, she said.

Besides deinstitutionalization, one of the greatest changes in psychiatric nursing has been the discovery of the role of neurotransmitters and the realization that most mental illnesses have a biological basis, psychiatric nurses say. As brain research has improved, so have the medicines that control mental illness.

"We have seen a great change from the old anti-psychotic drugs," Luna said. Those drugs had side effects such as weight gain and sluggishness that made patients not want to take them. The newer medications have fewer side effects or have ways to control the side effects and patients seem more willing to take them, nurses said.

The realization that mentally ill patients suffer from brain disorders has influenced not only the treatment of their symptoms, but the way they are treated by hospital staff, Saxe said. As with any medical patient, the nurse's greatest responsibility is to make the psychiatric patient feel safe and comfortable, she said, by talking, giving prescribed medications, adjusting the environment as much as possible and trying to control mental as well as physical pain.

"I personally believe that the No.1 thing that psychiatric nurses do is to use themselves as a therapeutic tool," Nadler-Moodie said. Psychiatric nurses don't have diagnostic tools such as X-rays or lab reports or even a reliable report from the patient to help figure out what is causing pain. They must rely on their ability to listen, talk and assess.

Many psychiatric patients who live on the streets or abuse substances are incapable of caring for themselves and have substantial physical as well as psychiatric problems. Luna recalled a patient who came into the emergency room claiming her vagina was falling out. The medical team thought she was hallucinating, but it turned out that she had a serious medical condition, and she was psychotic.

"Her delusion had been part of her reality," Luna said. "When you're a psychiatric nurse, you never put aside your physical assessment skills."

Mind games

Sometimes-but rarely, psychiatric nurses said-patients become violent. Cohen has been burned by a cigarette, strangled, bitten and had her blouse ripped. But that's after nearly 30 years of psychiatric nursing, she said, and she has learned to follow procedures to deal with violent behavior. "When you think of it, the number of times I have been attacked are so few given all the time I've worked."

One of the most difficult parts of psychiatric nursing is reminding yourself that the patient who is spitting or swearing or striking out at you is ill and has no idea what he or she is doing, Saxe said. "You can't let yourself fall into being angry or hostile back toward the patient. That may be the greatest burnout factor for psychiatric nurses-controlling yourself."

The other difficult part of the job is explaining to families, community members and the public that mental illness is nothing to be ashamed of. Even her own family would not understand if she were admitted to a hospital with a mental illness, Saxe said. 'd be hush-hush about it because it is such a social stigma."

Part of her job is making sure that patients know they are acting strangely because some part of their brain is out of balance. "They come in and they feel bad because they're different," she said. "I can show them that they have the ability to correct the imbalance through medication, through therapy, so let's do that."

Watching people who had been brought into the emergency room screaming in terror leave the hospital calm and confident with their symptoms under control is her greatest reward, Saxe said. "I can make a difference. I can get them back to their baseline so they can walk out that door and go on with their lives."

An important and exciting part of treating the chronically mentally ill, Henley said, is involving the patients in their own treatment and helping them to set goals, including what they want to do for a living, where they want to live, and what they need to take care of themselves.

"It's really hard work," she said, partly because the patients' goals don't always match what caregivers think they should be. One of the patients in Henley's facility was a concert pianist whose illness kept her from performing or giving lessons. While in the facility, she regained enough confidence to give lessons to others there. "But she is not interested in continuing to do that when she leaves," Henley said. "She is not using the wonderful gift she has because of her illness."

But as the woman learns to work with her illness and control its symptoms, she may change her mind about teaching piano again, Henley added. "That's the best thing. What we're seeing now is not hopeless. We're offering so much more than we were able to offer back in the 1960s."

Despite the frustrations from lack of resources and compensation, care for the mentally ill has come a long way since the days the women in the New York state hospital fell through the porch, she said. "A big part of the allure of psychiatric nursing is hope."

Contact Cathryn Domrose at kaguilar@well.com