Meet our Get to Know Nurse Patricia Cunningham, president of the American Psychiatric Nurses Association and associate professor at the University of Memphis Loewenberg School of Nursing in Memphis, Tennessee. I ask Pat about her career in nursing and also shared questions from current nursing students, as part of our “Ask A Nurse” portion of the podcast.

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Jamie Davis:         Hi, Pat, and welcome to Nursing Notes Live. It’s great to have you on the show this time.

Patricia Cunningham:               Thank you, Jamie. It’s nice to be asked.

Jamie:                   So tell me a little bit about your background in nursing. We get questions all the time from student nurses and nurses starting their careers about how they should decide on a specialty or something and I find that it’s often a great opportunity for us to find the various paths that nurses take to reach their career goals. And I thought it would be great to hear how you arrived at – why you wanted to become a nurse to begin with and also what path your career in education took.

Patricia:               Okay. Well, in terms of nursing, I’m an old girl, so I had the early influence of the 1970s where the emphasis was on baccalaureate education and that was the path that I took. I had a mother whom many of us have someone influential like that who understood that education should be at the college level versus, at the time, in the ‘70s, the diploma way of going to school which was very also common in my neighborhood but my mother had a vision and I’m really grateful for that. I was able to attain my baccalaureate degree and became interested in mental health nursing because of the complexity of patient behavior. From a very early point on I understood that patient’s capacity to get well varied quite a bit based on their own motivation, their own understanding, and their own, if you will, what we call now “healthcare literacy.” And I became fascinated early on with human behavior. So within two years of completing my baccalaureate nursing education, I went into psychiatric mental health nursing. And, in terms of, where to start, if you wanted to be a psychiatric mental health nurse, I would highly recommend you pick a really good place to start. And I want to give a shout out to Friends Hospital in Philadelphia which I call a “watershed year” for me. I was only there for one year. I’ve been married and relocated. And it was at Friends Hospital in Philadelphia that I learned the fundamentals of therapeutic communication. The fundamentals once again of the interpersonal relationship and how foundational those two things were to be for the rest of my nursing career as I went on and jumped through all the hoops that we do in nursing for graduate school and pursuing advanced practice that that’s what people like to do and all the different possibilities. The thing about nursing is it’s filled with possibilities to go any direction you want to go.

Jamie:                   An advanced practice nursing really is taking off in many ways, especially, in psychological or psychiatric nursing realm. I know in my area we have a VA hospital nearby and the nurse practitioners there really run the show.

Patricia:               Yes. Depending on the state, of course, nursing in the advanced practice role have different arrangements in terms of state law as to how we function. And that’s a different conversation. But I don’t know of any nurse at any level who doesn’t believe in collaboration and we very often will be the first point of contact and maybe the only point of contact like you just mentioned Jamie in a VA system where, through the assessment of the nurse, we can recognize that is what is necessary and what is needed. We might refer or we might handle the pharmacology or we might be doing therapy only and we would handle that aspect. You do that in collaboration with the patient. Thank goodness, there’s a movement of making things person-centered and patient-centered. The patient’s voice: what is it that they want, how do they want to go forward, making sure that they understand all the options that are available with them. I think that’s been one of the biggest contributions I make in my – any one-to-one on with – in whether it would be a patient or whether it would be a student. The point of entry and the point of contact with the clinician or with me now as an educator or in my role as APNA president, that you let people know the full possibility especially in kind of a conversation or in a series of conversations. So people can be fully informed about what’s available for them out there. There are so many ways to approach one’s care, to approach one’s education, to approach one’s career aspirations. There’s an old family therapist-thinker back in the day that was named Salvador Minuchin. What Minuchin always said is our job is to help people create better roadmaps. And very often the maps that people have of how to go forward in their healing or in their education are poor roadmaps and our job is to make better roadmaps with them.

Jamie:                   I really like that roadmap image. It says so much about – at least, in my understanding of mental health nursing and mental health care – and nurses seem uniquely positioned for some of these roles. Primarily, because of my estimation, their focus is always so focused on the whole patient. Even in non-psychiatric nursing arenas, we focus somewhat on psychosocial issues and try to help the patient heal as a whole.

Patricia Cunningham:       Yes. The holistic – we used to use that word in a more cavalier way, I don’t mean that in a disrespectful way – but there is a holistic nursing perspective and there’s a holistic nursing organization. But all nurses, as you said, their approach is a whole-person approach. I agree with you wholeheartedly. We also view the patient in the context of their life. Since we were all pop nurses, the thing that we learned was, if a patient has some kind of illness whether it would be depression, anxiety, hypertension, diabetes, whatever the illness was they were struggling with, it’s the nursing helping the patient look at how that is influencing your capacity to do your life as you want to do it and where do we need to help you with that. That is so much of what nursing is about.

Jamie:                   I just read an article recently about ICU patients being in increased risk for depression and other psychiatric issues following their discharge and it really pointed out to me that psychiatric nursing, while it’s a specialty, at least, having some basis in understanding psychiatric nursing and mental health issues is important for all nurses no matter what your specialty may be. Are there resources out there that are provided to nurses as a larger group to help them with these things?

Patricia:               Yes. First off, I want to celebrate what you just said. We all are taught the fundamentals. The notion of psych nursing being located in some of the dark scary places that – it’s been part of its historical tapestry. That’s just the way it is. Just like tuberculosis clinics were part of an infectious disease tapestry at one point in time. So sometimes though those ghosts of the past and some difficult experiences along those lines, for nurses, cast a shadow that makes people say, “Oh, I don’t like psych.” Well, the reality is that all nurses do mental health and therapeutic communication and interpersonal connecting with patients and families all the time. So you brought up an important point about the issues of mental health disorders and how they affect patient care outcomes in all patients. Depression is called the “unwelcome companion.” It is a name I’ve really come to appreciate and I think anyone who hears this conversation is going to appreciate. The outcomes of care are always for the patient, are always going to be less. If indeed they’re struggling with depression, anxiety or other disorders, including substance abuse and all the other mental health disorders, so that when mental health is not robust or there are some symptoms that are not addressed, all the outcomes are less. It’s called the “unwelcome companion.” In terms of your question, Jamie, about resources, there’s a lot of resources out there about approaches to mental health care. You can just Google that just about and you will hit tons of stuff. So how do you begin to screen? Of course, the National Institute of Mental Health and then SAMHSA, “Substance Abuse and Mental Health Services Administration.” Their website has many things. For nurses, also, the American Psychiatric Nurses Association, we have a number of Continuing Ed for all nurses available at the baccalaureate and also at the graduate level. Of course, annual conferences and being part of our professional association and stretching ourselves a little bit to learn some of the things we may need. I know there are many excellent, and I know some myself, critical care nurses. Yet, at the same time, they know what you just said that the outcomes of care are going to be so affected if we don’t do something about this depression that the patient is struggling with, very often the families inform us too, the prior to even coming in for care, that they’ve been worried about the mood or just the overall general mental health of the patient that they love, the person that they love. And now that person is a patient and what is it that we can do to help them? Because they only take care of the quote “physical thing” is to be back in the day where we thought they were separated. We know they’re not separated, that the mind and the body are intimately connected. Again going back to the education side, there’s a lot on the APNA website, for example, as one excellent first source to look for information to learn about how am I going to take care of these things, how am I going to do the best we can for our patients and then working in collaboration with our colleagues.

Jamie:                   Yes. I think collaboration – also part of the key is reaching out to other nurses and other specialties and picking their brains, so to speak, just to say, “I’ve had this issue with the patient and how would you have handled it in your specialty?” and using that as a resource as well. So you mentioned professional associations and it’s a favorite topic of mine because I think that many nurses don’t take advantage of their professional associations and I know you’re biased as president of the APNA. But it really is something that I think that it’s this hidden gem for some nurses. They just don’t even realize the power of being a member of their association and attending their association’s conferences where you not just get the education but the networking and the relationships that are developed. They are so powerful. Would you like to speak to that?

Patricia:               Oh, you’ve hit a hot topic. You bet. I have the opportunity right now to be teaching a professional seminar course at the university, the Loewenberg School of Nursing, here in Memphis, Tennessee, at the University of Memphis. And I have this wonderful group of young minds. One of the assignments they have is they get to talk to registered nurses out there practicing. And so they get to compare the kind of messages they’re learning in professional seminar and the kinds of things that faculty say and they compare that with the real world people. Many of them were surprised and a little bit disappointed to discover how many nurses don’t belong to their professional associations at all. So we had a good conversation about that. One of the things I think happens to all this nursing is we don’t understand that you can just put a big toe into an organization. We’re all in people. We work hard. We have many roles in our lives and sometimes just belonging and going on the website is what you can do for a couple of years while your children are young or you have other professional or family commitments when you are in graduate school. You don’t have to run for office. Only some people run for office and you only do that for part of your time in the organization. But to think that you have to not only join an organization but that you have to be involved. I think maybe that message has been put forth by maybe nursing education. One must be involved. You know, involved is paying your dues. That’s involved – going on the website, having a general working knowledge of the website of your professional organization, the American Nurses Association and, for me, of course, the American Psychiatric Nurses Association. But we don’t have to be all in. We can do what we can do. But I’ll you the thing that I said to my students. There’s constant movement on the Internet and legislation. Nursing, I think we might know that we have a few enemies, do you think? There might be a few enemies we have. Even though we’re the most trusted profession, there’s just been times when what would be at our best interest might not be represented if we’re not at the table. I want to make sure that my professional association has my back. That’s why I pay dues and I pay dues whole career. But I wasn’t always involved. I was in graduate school. I had babies. I was involved with different parts of life and I will always pay my dues though because I have to know that something came along that there was someone there. And that’s what a professional association does.

Jamie:                   That’s a great way to put that. You’re the first person I’ve asked that question that’s mentioned the way that the associations represent us even if at the governmental level and I think that that is important to remember as well.

Patricia:               Right. And not all of them are involved in lobbying. Like APNA, it’s not a lobbying group but, boy, they sure take our voice and take positions to help inform the body of policy people out there. I once heard Hildegard Peplau. She’s the grandmom of Psych Nursing. I had to say that on this call, Jamie, how to get that in? That Hildegard Peplau said that politics is the allocation of scarce resources. I’m sure she quoted that from someone else and I remember that. It’s not an unlimited budget out there. Yes. I thank you for echoing my comment.

Jamie:                   No, it was worth the echoing I guess I can say. [Laughter] So one of the questions we get a lot of times is, what is the greatest piece of nursing advice you ever received?

Patricia:               Don’t take any shortcuts. I, at one point, was going to pursue a degree. I forget what I was thinking at the time. We read something and we start having a conversation with someone and I thought, “Well, maybe I’ll be a psychologist.” Someone said, “Well, are you a psychologist or are you nurse?” Then I said, “Well, I’m a nurse.” And they said, “Why are you pursuing a degree in psychology?” I said, “Well, the psychology program is 15 minutes from my house and the other program, at Indiana University, was an hour-and-a-half” and she looked at me and she said, “Don’t get a degree of convenience.” I’ve never forgotten that. So that’s the one advice. The other really good piece of advice came from someone named Ann Mariner. She was a thought leader. I’m not too sure where she is these days but she was a thought leader and I was in a seminar. I was just out of grad school. So I knew everything, of course. I was 28 and knew everything. She was saying about how one approaches change and thoughtful ways of moving an agenda through an organization in a leadership capacity. And someone challenged her about if you hit so many obstacles what should you do? She paused and she said, “Well, then maybe you need to back off and give up for a little bit.” Oh, my goodness. That’s all I heard was “give up.” And I went down to the front of the class at the break and said, “You’re telling them to quit. Nurses aren’t quitters.” And she smiled and she said to me, “You know, nurses like you scare me. When you’re banging your head against the wall losing blood, you don’t know when it’s enough.” Ever since that time I’ve learned and it was a very good lesson to learn that to be thoughtful about what you’re capable of and what the organization is capable of. The key word is “thoughtful.” I think a lot of us in our passion, in our advocacy for patients can get hooked but going about things in a systematic way and knowing when to back off that you don’t get so frustrated and get burnout. Burnout is a phenomenon, I think, you would agree, Jamie, you’ve been in nursing a while, you’re visit us from time to time. It’s not a one-time phenomenon. You’ll get some edges of that and how to stay refueled and take care of yourself and be in this for the long run. I’ve been working continuously as a nurse since I left nursing school when I was 22 years old. I love it.

Jamie:                   Yes. It is something to keep in mind is we need to focus on how to take care of our own mental health along the way so that we don’t get burned out and we don’t run ourselves to the ground and run out of our personal resources for care.

Patricia:               Yes. And there’s a lot about that in terms of compassion fatigue and secondary traumatization in mental health care and for mental health care nurses. We walk beside our clients and stay with them through the long haul of their illnesses just like other nurses in other areas of nursing do. And sometimes that can be weary. God bless its weary for the clients and it can be weary for us too. It’s a long journey to have a chronic illness that has remissions and exacerbations. It’s a long journey. You have to make sure you do things to feel yourself along the way so that you can be the coach and the travel companion you’re supposed to be to work effectively with the people we want to serve. And that’s all areas in nursing whether you’re an emergency room nurse or critical care nurse, OB/GYN, nursery.

Jamie:                   What about mentoring? Because I think that that some of the things that can help with this burnout and with this compassion fatigue is to have a good role model or to be a good role model for others. What would you say about the role of mentoring as either a nurse seeking a mentor or a nurse who’s been in practice for a while, who’s looking for the role to be a mentor?

Patricia:               Well, one of the things I know that I was told early on in my career was to look at others around you and go after something they have that you find attractive. I think we also know what the opposite of that is. Sometimes we find ourselves immersed with colleagues or some other colleagues and fellow nurses who maybe have lost their spark and are not as invested at maybe at that point in time – and that could be all of us at some time – to be a good mentor or really a positive force for the younger nurse or the nurse who is new to a specialty. I think all of us have to find the person or the work situation that’s going to help us grow, so that we just don’t get disenchanted. I think that’s a real key thing. So to find someone who you think is – or an organization. Sometimes it doesn’t have to be one person but to find the organization where something just makes you really go home with some enthusiasm again or after the contact or the cup of coffee or the phone call or reading a blog that you just get so excited about the work that you’re in. So surround yourself with that kind of positive energy that’s for sure. I know at the American Psychiatric Nurses Association, we have a Mentor-Match Program because we know that every year we get a large number of people who are new to our organization, who are excited about psych nursing. They might be only one or two in a small organization, just like in other nursing specialties, there are no other nurses around. There might be other disciplines around, other colleagues, but there is not a lot of other nurses around. And that’s the thing you always want to make sure that you hold on to is your nursing identity. In fact, it can get hard sometimes when you’re in the specialty areas that you can get a little blurry on your edges. What makes nursing nursing? What makes nursing unique? You have to hold on to that. Obviously, society thinks we have something or we would have been wiped out a long time ago, but we have to be able to answer it too. But Mentor-Match is something through APNA and just going online. We have something called “Member Bridge” where people post all kinds of things from all over the country and always someone comes and answers it. “Hey, I have more information on this” or “Have you looked at this?” or “Here’s a good reference on that subject.” “If you want to talk more here’s my – reach out to me personally,” so there’s always a way to get what you need and to sustain your own enthusiasm. Because I don’t think those kinds of things are easily – we don’t really get taught how to do that. So it’s one of those things you have to learn along the way.

Jamie:                   Well, we can probably keep talking here for quite a while, Pat, but I’ll give you my final question and then we can close out. New students, you’re an educator, so I’m sure that this is something you’ve considered over the years. What advice would you give to a student that’s getting ready to leave school and enter their first years of practice as a new nurse?

Patricia:               Well, one the things I know is still available for nurses who are fresh out is an opportunity to be an intern programs or residency programs where they get to go into health community. That could be outpatient. It could be inpatient and move around. And if there is one, they might suggest one. For example, you want to become a psychiatric nurse. I got to get a plug in here for mine. So if you want to be a psychiatric nurse but the world out there tells you, “Well, if you go into psych nursing, you’re going to lose all your skills.” Well, I don’t think so, by the way. There’s a lot that you need to always carry with you in a broad skillset. But suppose you’re a little worried about that as a new nurse. Ask for a collaborative arrangement. Like that you would be able to go into some kind of health system, and that’s the good news. The health systems are big and they may not even have thought about – you don’t want to be assigned to a unit on nights by yourself yet or with maybe one or two other people. You would like to be able to go to a unit or also go to the emergency room or also go to outpatient care or also go to mental health care. And there are such large systems of healthcare now that many nurses can get that and maybe even help design it and find a nurse who you have met while you’re in school who can help you design that. Go to a faculty member. Say, “Hey, look. I got this idea.” There are programs all around the country where nurses get to do this. They’ve been around for 30-some years now – internship programs residency programs – they have different names. But they’re all to allow the nurse time to explore different areas of nursing before the nurse has to commit. Now in smaller areas of the country and rural areas of the country that might not be available but there should be time and to get opportunities to cross over into other areas. Sometimes we have to be the assertive ones and ask for it. The other piece of that is sometimes systems show some limitations in their capacity to respond to what a nurse might need. And sometimes you’ll have to do an inventory of that. The nurse will, like, “Is this the best system for me? If my request can move round a little bit to make sure I stay broader, get a broad exposure, so I can make good choices.” If the system can accommodate that, well, that might be telling you something about the system. So I think there’s ways for nurses to ask for what they want and then also see the system’s response and in terms of what the system’s capacity going to be? Are they going to be consider me a FTE, a full-time equivalent? Plug that hole and they’re done with me? Or is there opportunity for me to grow as a nurse especially if you’re a brand-new nurse? Make sure that system supports your growth. You deserve it. You spend a whole lot of time to get where you are. Go for it. I just get real enthusiastic about all this but don’t settle. Don’t settle.

Jamie:                   I think that’s a great place to wrap it up, Pat. Like I said, when we started, this was not going to be difficult for us to have something to talk about. I never run out of topics when I have these calls. One of the joys I have of being a nurse journalist is the ability to get to talk to people like you every month. It’s quite fun.

Patricia:               Well, Jamie, it’s been great to talk with you. I’m sitting here staring out the window just watching the breeze go through the trees as I’m talking to you and it’s been a wonderful journey down memory lane, even this conversation for me. This is something to point out, Jamie. My conversation with you now has taken my enthusiasm and love for nursing a notch up. I think that’s the kind of thing we’re referring to, is the sustainability of your passion in your caring just through a conversation like this. And we were two strangers, we can pretend we’re having a cup of coffee even though we’re miles away from one another. That’s how easy mentoring can be. That’s the thing, is mentoring, by the way, doesn’t have to be hierarchical. Mentoring can be cross-mentoring. It doesn’t have to be hierarchical. We help each other.

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Make sure you check out the entire April, 2014 issue of Nursing Notes, where we look at the psychiatric nursing specialty. You can read the entire issue online at www.discovernursing.com and don’t miss the other Nursing Notes Live episode this month where I sit down with our panel of psych nurses including Rebecca H. Lehto, assistant professor in the College of Nursing at Michigan State University in East Lansing, Michigan, and also Michael Rice, an advanced practice RN and professor and endowed chair of psychiatric mental health nursing at the University of Colorado College of Nursing in Aurora, Colorado. You’ll find this and other episodes of Nursing Notes Live in the podcast area on iTunes.

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