INTERVIEW

Nine years ago, Nursing Administration Quarterly (NAQ) published issue 31:3, Administrative Aspects of Behavioral Health. At that time, Editor-in-Chief Barbara Brown stated,

Our healthcare system has not paid adequate attention to the mentally ill and we need to do something about it as a mission from nurses who care. The next anorexic or bulimic young woman needs our attention. The alcohol or drug addicted person needs our attention. The acute depressive disorder nurse needs our attention.1

For this addition, current NAQ Editor-in-chief, Kathleen Sanford, interviewed 5 nurses who are doing something about improving the mental health of our patients. We still have challenges and issues in our mental health system, as these professional colleagues remind us.

Our interviewees include Brad Lincks, Vice President of Patient Care Services and Chief Nursing Officer (CNO) for a large provider of mental health services, Our Lady of Peace, in Louisville, Kentucky; Robin Conyers, Vice President of Patient Care Services for the Behavioral Health Service Line and Lasting Hope Recovery Center, Omaha, Nebraska; Shirley McJohnston, Vice President of Patient Care Services and CNO of, Sts. Mary and Elizabeth hospital, an acute care facility in Louisville, Kentucky; Carla Trolia, regional Director for Inpatient Mental Health services at CHI Franciscan Health in Washington State; and Lois E. Hoell, currently a commissioner for the Washington State Board of Nursing and a longtime advocate for mental health.

NAQ:Thank you for your willingness to be interviewed on this subject, Behavioral Health, which is so important to nursing, individuals, communities, and this country as a whole. "Mental health services" is a specialty, and psychiatric nurses are specialists who work with teams of caregivers both within inpatient facilities and throughout the continuum of care. Some of you are mental health nurses. How did each of you get your start in this specialty?

Lincks: I knew mental health was for me when I was an undergraduate nursing student. I had a psychiatry clinical rotation at a community hospital and was fascinated with the way the teams worked with the patients. Mental health was underserved then and it continues to be. I wanted to make a difference. I was also drawn to how fascinating the patients were-and how the team had such a nonjudgmental approach with them.

I was blessed to be from the Louisville, Kentucky, area, where Our Lady of Peace continues to be one of the largest providers of mental health services in the nation. Hired there, I was afforded an opportunity to work with many different populations, which was a unique experience for a new graduate. My love for mental health continued to flourish, and I knew I wanted to make this my body of work.

Hoell: I'm not, by education, a psychiatric nurse. I participated in a countywide committee that was addressing mental health services in the county. At the time, I was a nurse executive at a local community hospital, and I knew there were pressing needs in the community. I wanted nursing's voice at the table where these would be addressed.

Trolia: I have spent all but one year of my nursing career in the behavioral health field. When I was a student nurse, I, like Brad, found it to be fascinating. Our psychiatric rotation was 3 months at the state hospital, and I knew when I finished the rotation that I wanted to work in the field. When I graduated, the state of Washington had just changed the mental health statutes. The new focus was on treating patients in their own community, and inpatient mental health units began appearing in acute care medical hospitals. I had an opportunity to work in, and be a part of, the creation of a new unit in an acute care hospital. I've worked in inpatient settings since then.

Conyers: As a student, I worked as a float pool unit secretary. When I graduated with my bachelors' degree, the mental health director offered me a position as the first new nursing graduate welcomed into psych. (Previous nursing experience had always been a prerequisite.) She said I'd either "make it or break it" for other new nursing graduates, depending on how I did. I'm happy to say, we do hire new nursing graduates! I started as a mental health tech until I took my nursing boards and then after I took boards (the week of my wedding), I started orienting as a child/adolescent nurse for the inpatient unit and I've been with mental health ever since.

NAQ:Any facts or statistics about this subject that you can reference to better inform the nursing management population about mental health in the United States, or the world?

Lincks: We partner with the National Alliance on Mental Illness, and they report some staggering numbers. Approximately 1 in 5 adults in the United States experiences mental illness in a given year.1 Approximately 1 in 5 youth aged 13 to 18 experiences a severe mental disorder at some point during his or her life2; 18.1% of adults in the United States experienced an anxiety disorder such as posttraumatic stress disorder, obsessive-compulsive disorder, and specific phobias.3 Among the 20.2 million adults in the United States who experienced a substance use disorder, more than 50% had a co-occurring mental illness.4 Only 41% of adults in the United States with a mental health condition received mental health services in the past year.4 More than 50% of children aged 8 to 15 received mental health services in the previous year.5 Half of all chronic mental illness begins by age 14: three-quarters by age 24, despite effective treatment, there are long delays-sometimes decades-between the first appearance of symptoms and when people get help.6 More than 90% of children who die by suicide have a mental health condition.7 Each day an estimated 18 to 22 veterans die by suicide.8 Serious mental illness costs America $193.2 billion in lost earnings per year.9

NAQ:Obviously, the data points to the need for mental health care and clinicians who specialize in this area. There is quite a bit in the literature about nurses and nursing leaders getting burnt out in every specialty. What keeps you interested in working with people who have issues and challenges with their mental health? In other words, what brings you back to this work day after day?

McJohnston: I am passionate about patient care and the opportunity that we have to make a difference in people's lives. While I'm a nurse executive in a primarily medical-surgical hospital, many of our patients have mental health issues that impact their primary medical diagnoses. I'm energized by opportunities to ensure that that we care for the whole person.

Hoell: As I became more informed on the community's mental health care issues and challenges, I became more active in helping to develop solutions. I was working in a leadership role in an acute care setting when I first got involved, and I got "hooked" on trying to "pull" a coordinated system together to provide care to a group of people who were seemingly invisible to their neighbors and the health care system. They were folks interacting with a variety of community services, but the services were not interacting with each other.

Lincks: It's really all about seeing the improvement in our patients. Sometimes this is through the eyes of my care teams. Challenging patients and situations really do bring teams together. We are like a big family here at Peace. Each day is different, as individuals' care and unit concerns can change quickly. I enjoy working with our teams to problem solve and develop better processes that ultimately impact patient care. My interest remains strong. That's because I know we are making a difference for our patients. It is very unique to work in a facility where all employees are caring for patients who have a mental health disorder or substance use issue. It really brings the team together for one cause.

Trolia: I believe I have a heart for every patient with a mental illness. This is a population of patients that are often disenfranchised. They face societal stigma. Advocacy and addressing stigma are important aspects of our work. Over my career, there have been encouraging changes in care delivery, as well as development of medications that are more effective in managing symptoms. Most recently, the Recovery and Trauma Informed Care Movements have energized mental health treatment and provide hope and empowerment for our patients.

Conyers: I see my role as being a servant leader to these people who suffer with mental illness. I guess I'm for the underdog. I believe recovery can happen, and after working with and hearing our patients' stories, I know this disease is nothing one would wish on anyone else. I see my calling to serve as their voice, to educate internally and externally about mental health challenges, as well as mental wellness and resiliency. I love to solve problems, and each day there are multiple problems that need attention.

NAQ:It's a fairly common discussion point among nurses and nursing leaders that we do not have adequate availability and quality of mental health services in many, if not all, communities. What challenges are of particular concern to you?

Hoell: This is a loaded question! My observation is the entire country is disparate in how care is provided. I attend our state annual Behavioral Health conferences and have seen the disparity as evidenced by speakers from various states. For the first time, last year, there was actually a speaker who espoused a word I have never heard in all the years I have been involved in mental health: Prevention! As a nurse, I thought why not? Aren't there early warning signs? (This is a question I have asked often.) However, the system is predicated on a person reaching a level of illness first and then getting treatment. Treatment is offered only to those who meet specified criteria for mental illness. There are some programs and strategies being implemented to more closely integrate mental health and primary care, but funding and bureaucratic change comes slowly. In Washington State, the Department of Corrections is the largest provider of mental health care! That speaks volumes about what is wrong with our system.

McJohnston: With the nationwide trend to cut mental health budgets in communities, many of these patients come to community hospital emergency department (EDs), such as ours, for care. Medication refills are unfunded in many cases, so we stabilize, treat, and procure medications though our charitable resources. The patients, without care and medications, cycle through again and again. We are fortunate to have a sister hospital that is a freestanding psychiatric acute care hospital with over 200 beds. They are an invaluable resource for our acute and outpatient psych referrals. However, as my colleague Betty Cochrane, the ED Director of Sts Mary and Elizabeth, tells me, "Our emergency department (ED) frequently keeps substance abuse patients while they detox, causing lack of ED space for treating patients with other emergency conditions."

Conyers: I agree with all my colleagues. There is one thing I'd like to add and emphasize: there are not enough lower levels of care to assist with discharge planning and to help keep patients who have chronic diseases out of the hospital and within the community. Thus, when they return to an inpatient setting, they are coming to the highest (most expensive) level to get care. They may not really require that level of care. As a result, the case gets denied for payment, and hospital denial rates remain high. Unfortunately, there is no other place for them to go. This continues to be a system issue. Having enough inpatient beds is not the issue; having enough adequate, affordable, and available resources within the community is essential. Agencies must come together to make change in the best interest of the patients we serve. Payers need to be flexible in order to make adjustments for those patients who do not fit the mold but could benefit from a "creative discharge plan" instead of a standard discharge plan that involves outpatient therapies and medications, which might have failed them over and over again.

Trolia: Mental health has been significantly underfunded for a number of years. This has contributed to the lack of resources and the number of patients being detained in acute care medical hospitals. No psychiatric beds are available. This is a significant problem in the South Sound Region in Washington State, particularly in the larger counties. Chemical dependency and mental health care are treated and funded separately, even though they are often co-occurring in the same patient. Even though parity for mental health care is the law, some insurance companies do not contract with enough providers in a community. This leaves patients without access to care. We need to remember that as we move to population management, recognition and treatment of behavioral health disorders will become increasing important in managing the cost of care.

Lincks: A major challenge is our work with the Managed Care Organizations (MCOs). Kentucky started allowing MCOs to offer services about 3 years ago. This has created new challenges for hospitals and the patients and families we serve because the denial rate has risen dramatically and lengths of stay have been greatly decreased. Many times we encounter denied days because the MCOs will not approve them. When we feel the patient is unsafe to leave the hospital, we always put patient safety first, so we end up keeping them in the hospital. The result is unapproved (unpaid) days, but again patient safety comes first.

Sometimes, a patient is stable and ready for discharge, but we are unable to find a placement willing to receive him or her due to the patient's history. This is frustrating for families and caregivers.

We need more availability in the community for step-down services. Patients may be decertified by their MCO, and we receive no payment for the care provided. There needs to be more accountability from MCOs to assist their members and families with discharge placement needs, including needs for behavioral health services.

NAQ:Have you experienced care issues when patients with mental health issues are admitted to hospitals or units where staff do not specialize in behavioral health?

Conyers: This is the biggest issue: stigma perceived by health care providers who don't want to care for those who suffer from mental illness, who stand in doorways to do a screening and do not treat their conditions as true medical emergencies or situations. These patients may get suboptimal medical care as a result.

Hoell: In Washington State, what has occurred over the many years is a move to community-based services. That idea is all well and good, but we are a very rural state and not all areas provide the same level of services as the urban areas do. This creates a huge disparity in care. In addition, the availability of mental health beds at the state hospitals has been reduced. Acute care hospitals have also either reduced or closed mental health units due to poor funding, lack of psychiatrists, or difficulty finding appropriate discharge options. The Joint Commission sanctioned an acute care hospital in the state for "boarding" mental health patients in the emergency room (ER) without providing mental health care. That prompted some actions to alleviate that practice, but it is a Band Aid, not a solution. The state is attempting to address the issue, but, thus far, there has been no action.

Lincks: This is another very challenging situation for all hospitals. Of course, many times the needs of the patient are not fully understood. Nationally, many community hospitals have closed their inpatient mental health units due to various issues, including payment issues, liability concerns, or a lack of understanding about how to care for the population.

Many medical-surgical facilities utilize sitters to stay with patients, but they also need special training to be able to ensure the safety of a patient who has a mental illness. Many times medical issues make it difficult to address mental health needs. You can't really separate the two. In our system, we have psychiatrists who see patients in the acute hospital so that individual mental health needs can be addressed. When the patient is medi-cally stable, the behavioral health team works to determine what we need to do to help address his or her long- and short-term mental health needs.

McJohnston: The majority of the mental health patients we see are either patients who have attempted suicide or substance abuse patients. They are often admitted to inpatient care until medically cleared to transfer to the psychiatric hospital. The majority of staff RNs have had minimal mental health training other than what they received in basic nursing school. We have provided training for our staff on suicide prevention and assessment, as well as de-escalation training. In addition, we are fortunate to have a full-time psychiatric assessment professional position based in our ED. This person also serves as a resource for inpatient staff nurses. We also rely heavily on our social work staff members for assistance with our mental health patients.

NAQ:What other solutions do you think might be helpful for us to do a better job for individuals who have mental health challenges when they present for care in the outpatient arena, ERs, or non-mental health units in acute care hospitals?

Trolia: Many organizations, including CHI Franciscan Health, are moving to an integrated model of care that includes providing behavioral health care in the primary care setting. Patients are more likely to follow up with care if it is easily accessible. It is less stigmatizing and normalizes care for behavioral health disorders. We need to include screening for depression, anxiety, and suicide in all of our settings. Our primary care providers need access to consultation from a psychiatric provider and education about treatment of mental disorders.

We need to encourage community support for screening, assessment, and brief interventions for psychiatric crises to minimize the need to take patients to EDs. This could be a Psychiatric Response Center or a Psychiatric Emergency Service inside or outside of EDs. If the volumes warrant it, organizations should consider hiring staff with experience in mental health screening, assessment, brief intervention, and disposition. It may be helpful to hire a psychiatric nurse who is familiar with psychiatric medications.

Utilizing a Psychiatric Assessment Team comprising psychiatric nurses, behavioral health specialists, and a psychiatric provider may be helpful in providing support for the staff caring for the patient in a medical setting. The team will ensure patients receive the psychiatric care they need regardless of where the medical care occurs. Psychiatric clinical nurse specialists can provide education, recommendations for care, and staff support when they are managing patients with psychiatric needs.

McJohnston: Unfortunately, in our area, unless the facility is a psych facility, there usually aren't any of these mental health workers readily available. In our ED, we are fortunate to have a full-time psych assessor on-site, but this is only for 40 hours a week. The remainder of the time, we rely on a mobile assessment team. Most EDs in the community don't even have this resource in house. Social workers and nursing staff handle the care, and underlying mental health needs are not addressed unless a psych consult is specifically ordered. The patient gets the mental health needs addressed when and if he or she is transferred to the acute psychiatric facility or to an outpatient program.

Hoell: My experience is more like what Carla describes. Some places are adding a mental health professional to family practice clinics so that basic psychiatric assessments get done. We are seeing some success in this strategy. The issue with this model will continue to be payment for the service and the availability of qualified personnel. Our county funds a community-based clinic for the economically disadvantaged where each client is assessed for mental health and substance abuse issues. In addition, the county health department has embarked on a process termed "Collective Impact." This is a plan to gather together various services in the community, identify issues common to all, and develop strategies to provide for the common good. I would suggest a similar process for EDs: hire an intake person to do a basic mental health and substance abuse assessment.

Lincks: I agree, there is a lot of opportunity in the ER as many of our mental health patients come to us via that setting. More systems are now utilizing telemedicine and mobile assessment clinicians, as we do in Kentucky. Our goal is to work to move patients who meet criteria to our psychiatric hospital as soon as they are medically stable. The telemedicine option allows a clinician to complete an evaluation quickly and confer with the ER. The mobile assessment teams consist of master's prepared therapists who can be deployed to various ER locations to facilitate timely access and development of follow-up plans with the patient and the ER team.

In addition, our acute care hospitals contract with local psychiatrists who are able to assist the primary providers with medications and determination of safety of patients with mental health needs. The psychiatrist must determine medical stability before sending the patient to our specialty hospital.

In the outpatient mental health areas, the majority of the patients are voluntary and willingly attend the programs. However, even the most dedicated clients are likely to not have an adequate form of support at home, should a personal crisis arise. Wherever we work with them, we must improve our ability to adequately screen patients for safety. We need a more intense level of offerings within the community. We also need to develop strategies to engage our clients' friends and family. It's a challenge to find an avenue to reengage the patient with his or her family. Many times, patients do not wish to share information with their families-sometime because of harmful stereotypes.

Conyers: In the outpatient arena, primary care physician (PCP) integration with mental health providers is a must. We are just starting to see a shift, with PCPs embracing the plan to work directly with psychologists/therapists within the outpatient medical settings. In our EDs, it would be ideal to have access to mental health therapists who can assist with a psych consult. This would help the ED physician make an informed decision regarding level-of-care determination. As my colleagues have stated, though, this is a non-revenue-generating position, so it is rarely approved. While the EDs play an important role, this should not be the primary care site for people in psychiatric crisis. Sitting in an ED for hours at a time is not healing, nor therapeutic.

Expanded use of telehealth/telemedicine to assist in this process would certainly be a benefit, as there are not enough psychiatrists or psychiatric nurse practitioners to meet demands.

NAQ:Do you think the needs of patients are being adequately addressed when they are admitted into mental health units or programs?

Lincks: At our mental health facility, we work to assist patients to meet their needs or treatment goals. We do have issues with patients who don't appear motivated for care, yet present to our hospitals on a frequent basis. Obviously, they need care but not the intensive care that is provided in the hospitals. We are currently working with our community mental health provider to ensure we offer the patient the continuum of services they need.

Substance use continues to rise in our community. To better meet the needs of our patients, we recently added a substance use unit for adolescents.

McJohnston: Programs in formal mental health facilities have resources available but may not keep up with the demand for this service. Payers often require patients to be discharged to outpatient services, and the patients may not follow through with the treatment plan. Substance abuse patients often do not want to change their behaviors and will not comply with treatment until they are ready to do so.

NAQ:For those of you who are working in mental health right now, what makes you especially proud of your program? Is here something unique about what your organization is going for people with psychiatric diagnoses?

Trolia: I believe we have created a safe environ-ment on our inpatient psychiatric unit. This is conducive to healing, reduces risk for patients and staff, and promotes patient and staff engage-ment. We have implemented a Psychiatric Assess-ment Team to support patients and staff on acute care medical units. One of our biggest challenges for this team is that we have exceeded the demand on their time and are challenged to meet the need with our current level of staffing. We have adopted an Integration Model for our out-patient primary care clinics (The Collaborative Model developed at the University of Washington) and are beginning to move forward with imple-mentation of a pilot project. Last June we sent a team to participate in the Zero Suicide Academy in Baltimore and have initiated that work in our organization as well. We have created a joint venture with the other health care system in our community to build a 120-bed psychiatric hospi-tal. We are also considering other areas in mental health where collaboration will provide better access and outcomes for the patients we serve.

Conyers: We are a freestanding psychiatric hospital, created through a unique private-public partnership with community philanthropists who have a passion to care for the mentally ill population. In April, we will celebrate our eighth year of offering services to our community. We are a 64-bed adult hospital and the primary clinical site for interprofessional training of medical students and residents. We work with 2 universities and multiple schools of nursing. In May 2015, we launched the first Dedicated Education Unit (DEU) for psychiatric rotation with nursing students where our nurses become the clinical site instructors to the students. This gives students a more realistic observation of what psychiatric nursing entails. Our hope in offering this nontraditional rotation among nursing students is to recruit those interested in being psych nurses, as well as retaining our staff, by providing them with mentoring opportunities. These staff instructors are amazing and take great pride in the work they do. Comments from the students based on the entire experience have been overwhelmingly positive. We are the only organization in this region to offer this to nursing students during their psych clinical rotation.

We were the first site to implement the Schwartz Center Rounds in a psychiatric setting in the local Midwest. We place strong emphasis on employee resiliency and patient recovery. The Schwartz Center Rounds program currently takes place in more than 375 health care organizations throughout the United States and Canada and more than 120 throughout the United Kingdom. It offers health care providers a regularly scheduled time during their fast-paced work lives to openly and honestly discuss the social and emotional issues they face in caring for patients and families. In contrast to traditional medical rounds, the focus is on the human dimension of medicine. Caregivers have an opportunity to share their experiences, thoughts, and feelings on thought-provoking topics drawn from actual patient cases. The premise is that caregivers are better able to make personal connections with patients and colleagues when they actually have greater insight into their own responses and feelings.10

Lincks: We are very blessed to have 10 distinct inpatient units to care for children through the adult population.

We have 4 adult units. Two are dedicated to patients with substance use, and we offer detox services as well. The other units are dedicated to patients who suffer from a variety of mental illnesses. To better serve the community, we have tripled our number of adult beds since 2011. We now have 95 inpatient adult beds. Growing the service line has allowed us to meet the needs of our local ERs in a more timely way because we have more beds available. We know the ER setting is very difficult for providers and patients alike, so our goal is to see every patient within 1 hour of receiving the call for an evaluation.

We have 3 units dedicated to children and adolescents with developmental delays. We are one of the few providers in the region to care for children on the autism spectrum. We employ masters prepared behavioral analysts who work with our teams to develop very detailed plans to assist patients to achieve goals.

We utilize hippotherapy at Our Lady of Peace. Hippotherapy is a physical, occupational, and speech-language therapy treatment strategy that utilizes the movement of horses as part of an integrated intervention program. We have a large campus with more than 40 acres, so our patients can receive this valuable therapy on-site. The therapy has helped our patients with developmen-tal difficulties to improve their gait. It is also self-esteem building and helps patients become more comfortable with sensory experiences.

We have a very robust SafetyFirst program at Peace. We are very lucky to have over 100 employees who have volunteered to be Safety Coaches. As a coach, each completes monthly rounding with employees and assists in being a role model and trainer to our teams.

We have a mobile assessment team that can be deployed throughout our EDs to serve patients who are in crisis. Several years ago, we determined we needed to better engage with EDs to understand their challenges. This helped us develop our goal to see patients in a timely manner. We were able to branch out on this approach and now offer telemedicine as an option. We also work with EDs to complete direct admissions, when appropriate. We have begun to better integrate our services into primary care practices. We recently added a licensed clinical social worker to a primary care practice. The referrals have led us to explore other opportunities for better integration.

NAQ:What do you think gets in the way of nurses giving the best possible mental health care?

Hoell: This answer to that depends on the locus of care. There are so many care settings. It is a challenge for nurses to be well versed in all aspects of care. It also depends on the goals of the organization where the nurse works. Specialization can dictate the utilization of resources.

McJohnston: Multiple priorities, staffing shortages, and documentation requirements, which necessitate time away from the bedside, all get in the way. Specific treatment modalities are not available in the acute care inpatient setting, so mental health needs are often overlooked while the acute medical condition is being treated.

Conyers: The nursing shortage has a significant impact. Nurses may fear working with violent/aggressive patients and fear of injury. Education budgets get cut first in times of limited resources. The result is nursing continuing education units and on-site workshops are available, but attendance is low. Nursing burnout and compassion fatigue are a challenge.

Trolia: It is difficult for nurses to care for patients with mental illness in an acute care medical setting. Patients with psychiatric illness or those with comorbid conditions often take more time, have medications staff are unfamiliar with, have legal requirements they do not understand, and behavioral challenges they do not feel safe or competent to manage. In our inpatient psychiatric setting, I see our nurses struggle with unwieldy documentation requirements, increasing complexity of patients with comorbid conditions, and a significant increase in psychosocial needs. The nurses don't believe they have enough time to spend with patients.

Lincks: While we have a low percentage of turnover at Our Lady of Peace, it is difficult to fill open RN and mental health worker positions. We still struggle with a lot of preconceived notions about mental health nursing. Unfortunately, many nursing school programs don't allow the needed time to give students a well-rounded experience.

NAQ:What education do nurses need, either in school or postschool, to make them better prepared to assess and intervene appropriately when there are mental health issues?

Conyers: As I mentioned earlier, we implemented a DEU model with a few of the nursing schools this past year. In this model, the staff become the clinical instructors for 1 to 2 students. Students have stated they feel much more prepared to enter the workforce after this experience than they would in a traditional model, as they have observed and learned delegation, time management, critical thinking, problem solving, teamwork, etc.

I'd also say it would be beneficial to find a way for the nursing rotations within the nursing schools to provide more face-to-face clinical hours. It is such a short rotation these days. Imple-mentation of resiliency practices should be part of the nursing school curriculum, and self-care is the key for ongoing success in this specialty.

Hoell: I have a background as a nurse educator in a variety of nursing programs. In each program, we teach the basics of mental health assessment and various modalities of treatment. The content is based on providing a foundation for knowledge of mental illness and basic care. Preparation for specializing in mental health care is usually at the postschool level. Given the increasing numbers of people experiencing mental health issues, it would behoove us to integrate concepts throughout the curriculum.

McJohnston: Time for more hands-on clinical rotations, and experience, although finding facilities that can accommodate this is challenging since many psych facilities have closed and outpatient settings are full to the maximum and understaffed in many places. I would think there would be much demand for mental health-trained advanced practice nurses, although some acute care budget-conscious hospitals may view this as an unaffordable luxury.

Trolia: I believe nurses need more focus on mental health nursing in their training, including more clinical hours devoted to working in a mental health setting. All nurses working in an acute care hospital could benefit from de-escalation training, an overview of psychiatric medications, basic communication skills, and general knowledge about suicide, major mental disorders, and substance misuse.

Lincks: I agree. A more well-rounded rotation in mental health at the baccalaureate level is needed. It concerns me that mental health is a big topic for the nation, yet our education system does not appear to be making changes to address the concerns.

NAQ:Are there books, online resources, or other resources that you would recommend to nurses who are not mental health specialists to increase their mental health skills when they encounter patients with mental health issues?

Lincks: The American Psychiatric Association would be a great place to start.

Trolia: The American Psychiatric Nurses Association is a good resource for nurses interested in increasing their mental health skills. In addition to specific skills education, they offer "Transitions in Care," a certified program for new nurses or those transitioning into the field. We have incorporated this training into orientation for nurses new to psychiatric nursing.

Conyers: Another resource is Substance Abuse and Mental Health Services Administration (SAMSHA).

NAQ:In regard to the specialty of mental health nursing: How do you see the role of nursing fitting into the overall team (in the therapeutic milieu)? Are there any political or interprofessional issues that get in the way of nurses practicing to the top of their license and ability to be therapeutic?

Trolia: I view each member of the multidisciplinary team as being key to the success of treatment. Each member brings unique training and perspective to the team, one is not more important than the other.

McJohnston: Even with a variety of expertise available, there are staffing constraints in the acute care setting. Nurses often must do tasks that are better suited to nonlicensed personnel, thus taking time away from more patient-oriented interactions. Documentation requirements necessitate even more time away from the bedside. Our facility does not have the capacity to complete documentation at the bedside at the present time.

Conyers: In addition, there is a lot of case management that takes place in a hospital setting. Discharge planning starts day of admission, and our patients have complex mental and physical needs that need to be addressed. The level of documentation required is enormous. Nurses and physicians spend hours doing just documentation. No electronic medical record (EMR) that exists meets the needs of mental health documentation. EMRs are mostly medically/surgically based.

Lincks: Furthermore, medical students are not choosing psychiatry as a specialty. We must begin to better integrate advanced practice clinicians with our fellow MDs. Our physicians are now understand the trends related to psychiatry. I believe systems are going to need to explore "grow your own" programs with psychiatric nurse practitioners.

NAQ:Is there anything else that you think is important to say on the subject of mental health? Any other words of wisdom for your nursing colleagues?

Trolia: I would suggest that nurses consider psychiatric nursing as a career choice. We are in need of new nurses entering the workforce to choose this specialty. There are opportunities in a variety of settings. There is increasing recognition in the medical community of the importance of mental health treatment and more funding is becoming available. There is a significant shortage of psychiatrists, which is creating a significant need for psychiatric DNPs (Doctorate of Nursing Practice).

A suggestion for practice is to contract with enough providers on your panels to ensure access to care in a reasonable amount of time. We can thank our state and national government leaders for the shift in recognizing the importance of behavioral health concerns. There has been incre-asing recognition of mental health challenges, and funding is becoming more available. Our administrators and executives of health care systems should consider behavioral health as a service line and provide resources to support it.

Conyers: My hope for all who have never experienced a mental health crisis or know anyone who has struggled with mental illness is to find a level of compassion and empathy when caring for those who suffer. This disease has no socioeconomic boundaries. It affects people who are independently wealthy, who are blue collar workers, who are homeless, who are mothers, fathers, daughters, sons, and those who are on disability. It affects our veterans in way that we can only imagine. We need to remember that this is not a disease where those who suffer wake up one morning and say,

OK, Lord, of all the diseases/medical conditions out there, hand me a mental illness. I want to be judged, I want to be misunderstood, I want people to be afraid of me, and I want my family to disown me. I don't want to have trusting relationships. I want people to tell me this is all my fault because I chose to take that first drink. Don't hand me a physical disease where there are millions of dollars raised for research, national walks, and even designated colors to wear to draw attention to the need for research and cures. I want to carry the burden of having to prove my condition is not made up, to fight for equal healthcare benefits and to find hope on a daily basis where hopelessness tends to be overwhelming. I want to struggle to stay alive on a daily basis.

There is very real suffering among these individuals, and as nurses we need to be leaders in developing a system of care that supports and seeks healing for them.

Lincks: Many states still don't appear to value mental health when you look at expenditures per state. Throughout the United States, we have closed or cut back funding, although we watch the news daily and hear of violence that could possibly have been avoided with early intervention. Our patient population is in crisis, and it's very difficult for them to lobby for better benefits, etc. I believe we are at a real crossroads. In addition, many states don't do enough to regulate payers. Our administrators and executives (including nurse executives) of the health care system have to continue to try to be a voice for this vulnerable population. As caregivers, we have worked to reach out to our local and state governments to alert them of the concerns. We have to make sure we keep working to be a voice for those who cannot tell their stories. Nearly everyone has been a story to tell-and unfortunately-a lot of sad stories that could have been avoided with early intervention.

NAQ:Panelists, your dedication to this field is inspiring. Thanks for sharing with our readers, for caring deeply about mental health, and for choosing to lead.

-Kathleen Sanford, DBA, RN, FACHE, FAAN

Editor-in-Chief

Nursing Administration Quarterly

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