I Didn’t Sign Up To Be a Psych Nurse!

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by John C. Ziegler, ASNA Executive Director

Although psychiatric nursing is a distinct discipline, all nurses need to have a fundamental knowledge of mental illnesses and their impact on overall health. As the mental health system has continued its evolution from institutional to community-based care, more and more nurses have expanded their skills to include assessment and care of the mentally ill.

In spite of system transformation efforts to integrate mental health into the mainstream healthcare system, there remains a distinct “mental health system” dedicated to that patient population. Nurses who are not mental health specialists can benefit greatly by knowing more about this distinct system. After all, the patient in the exam room, hospital bed or emergency room may have a history of receiving services through the mental health system. You may wonder how your ASNA ED has any knowledge about the mental health system and what can he say that will help me as a nurse…

My Story

Before becoming Executive Director of ASNA, I served as the Public Information Officer for the Alabama Department of Mental Health from 2001 to 2012. As PIO, I worked with the commissioners, executive staff and the directors of 14 mental health hospitals/facilities across the state. Our hospitals were JAHCO certified and at that time, the department had over 3,000 employees serving over 125,000 Alabama citizens with mental illnesses per year. The state has now closed a number of its facilities and contracts services through hospitals and community mental health providers across Alabama.

Although much progress has been made, there remain many challenges in providing coordinated services for people with a mental illness. It is extremely difficult to provide continuum of care coordination for people who crisscross between public and/or private services. The pro slang term is – to provide care for “people who fall through the cracks” or gaps in the service system. Here is a quick “overview” regarding challenges in the mental health system. Hopefully, it will add perspective and motivate you to advocate for the mentally ill and mental health services.


Alabama’s Mental Health System – Challenges:

  1. To be fair, mental illnesses are complicated. Assessments and diagnoses may vary between practitioners. Many patients have comorbidities with other disorders/illnesses and treatments vary in effectiveness between patients.
  2. The subjects of “barriers” and “access to care” always come up when talking about the mental health systems. Ironically, fear and the unwarranted stigma associated with some mental illnesses keep many people from seeking treatment until symptoms are in crisis stage. Even for people who are willing to seek help, the lack of resources is a barrier.
  3. There is a huge shortage of providers. For example… there are less than 20 board certified child and adolescent psychiatrists in Alabama and 90+% practice in large cities. Regarding adult services – one of our largest community mental health centers recently had a four-month waiting list for new patients to see a doctor! For mental health patients to have to wait months for an appointment is a prescription for a crisis.
  4. Money. State hospitals like Bryce Hospital in Tuscaloosa are funded 100% by state dollars. When services are contracted to the community, patients often can qualify for federal assistance…and federal dollars. The federal dollars are passed through the states via bloc grant or healthcare entitlements and do not drain the Alabama general fund. States have saved millions by transferring the financial burden from state hospitals to federally financed community services. Now, the good thing about serving mental health patients through community services is that people can be closer to family and avoid possible stigma of residing in a state institution. This presents however a dilemma, for community providers because of compliance issues. Some patients who do not comply (take their meds)…decompensate, leave home (or a group home), possibly use substances to offset symptoms, decompensate more and come see their local nurse in the emergency room!
  5. Former seclusion room

    Public/Private System. When people seek and can afford access to private mental health care and do so voluntarily…they are indeed fortunate. If an individual has a psychiatric crisis that poses a danger to themselves or others they may be adjudicated for mandatory care, pending stabilization. Most patients who are committed can be stabilized and discharged from the hospital in a matter of weeks. Most simply go home. Other people, are discharged with the recommendation of community-based care through a contract provider. Once a patient is discharged, their compliance with treatment is a matter of personal choice. As stated above in item D, compliance issues may occur and the client may decompensate into a crisis stage again. In severe cases, this creates what some call the “revolving door.”

  6. The Revolving Door. One Probate Judge told me that he just committed the same person for the 17th time! Even after a commitment order, many patients may wait in jails or crisis stabilization units for days waiting for a bed to open in a hospital. Because of the crowded “front door” there is enormous pressure on mental health staff to discharge patients (out the back door). Administrators in state hospitals may feel pressure to “get them stabilized” and out of the “state funded” beds…into the “federal dollar” services system. To complicate matters even more, patients not under a court order can walk at any time. That is their civil right. For patients who choose non-compliance with treatment, going through the revolving door again (recidivism), Seeing a nurse in the emergency room or homelessness may be next.
  7. Treatment Compliance. The Mental Health System has an inherent dilemma. Like a storm, the present system is a product of winds blowing in the right direction colliding with winds blowing in the opposite direction. Nurses have studied ethics. Think of the ethical dilemma in disease control. With personal health issues, people have the right to decide to comply or not with recommended treatment. However, when there is a disease outbreak (like Ebola) the public good takes precedent and public officials can mandate quarantine for contagious individuals. People with mental illness have a brain disease that is NOT contagious. In rare cases (less than 2%) some people may become a danger to others. In these rare cases, the public safety takes precedence and patients may be placed in mandated care until they are stabilized. When they are no longer considered a danger to themselves or others, their personal rights again become primary and treatment compliance reverts to a personal choice. Did you know that these “rights” of persons with a mental illness were non-extent until a few decades ago? Did you know that, in the same way Alabama was the birthplace of civil rights for minorities, it was also the birthplace of civil rights for people with a mental illness!  Nurses need to understand this issue.
  8. Civil Rights for People with Mental Illness. Wyatt v. Stickney was the longest running federal mental health lawsuit in history. I had the privilege of sitting in the federal courtroom in Montgomery, Alabama when the lawsuit was finally settled in 2002. It was initially filed in federal court in 1971, over the issue of patient overcrowding and alleged inhumane conditions at Bryce Hospital in Tuscaloosa, Alabama. At that time, there were over 5,000 patients at Bryce and only three (3) psychiatrists! Once committed, patients had NO civil rights. The only way out…they had to be discharged by a medical team that included one of those psychiatrists. Various rulings, related to the suit over the years, eventuated in the establishment of a patient’s right to due process (a hearing), minimum standards of care and speedy discharge when they were stabilized. Through my role at the Department of Mental Health, I came to know Rickey Wyatt and attended his funeral at a little country church in Tuscaloosa County. Family didn’t have the funds for the funeral…yet the man changed the nation regarding civil rights for people with mental illnesses. NURSES… This is why there are now regulations on use of restraints, forced medication and forced hospitalization.


Nurse Tips and Mental Illness:

  • Mental Illnesses are biological brain diseases…not character flaws.
  • Nurses should NEVER use derogatory language on or off the job like “crazy” “psycho” or other slang terms that stigmatize patients.
  • Patients with a mental illness have civil rights. Advocates had to fight for them. Respect them.
  • Become an advocate. Contact ASNA and ask how you as a nurse can advocate for better access to care, quality services and respect for people with mental illnesses.