Join our Psych Nursing panel discussion with two distinguished guests. First off we have 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. Here’s that discussion.
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Jamie Davis: Rebecca and Michael, I want to welcome you to Nursing Notes Live and thank you for taking some time out of your busy schedules to join me on the show this week.
Michael Rice: Well, thank you for having me.
Rebecca Lehto: Yes, thank you.
Jamie: I always ask our nurse panelists to share a little bit about their backgrounds and help new nurses and nursing students understand how we arrive, where we arrive in our careers. Rebecca, would you like to go first and just tell us a little bit about why you wanted to become a nurse and how that whole career progressed through your education to where you are now?
Rebecca: Sure. After I graduated from nursing school, I was mainly interested in finding work in a hospital environment just to – I guess, so I can gain some essential nursing experience. When I first submitted my applications, my first offer came from a manager of an inpatient oncology unit so this was a medical unit which took care of patients with hematological kinds of cancers and so that was where I found myself working. So, over time, as I continued to do that sort of work, I became somewhat inspired by this work and, as a result, I just continued down that trajectory where I went back to school and became trained as a clinical nurse specialist. While I was working as a Masters student, I worked as a research assistant for a nursing professor who was interested in neuropsychiatric problems that cancer patients would have as a result of the treatment regimens they were on. So I tested patients for her on that study and then ended up going back to school and getting my PhD and became a researcher and even did a post doc after that just to continue my education to better understand the psychological issues that challenged patients when they’re facing chronic diseases such as cancer. I can honestly say that, as an oncology nurse, from when I was a clinician, even as an educator and now as a researcher, I really never stopped learning and I’ve never been bored. I’ve always kind of had a sense that my work has value and meaning so I actually felt pretty privileged to have this type of a career.
Jamie: Excellent. Well, thank you for sharing that. It seems like you’ve done quite a lot in your career.
Rebecca: Oh, I would say and it’s been over 20 years. It’s a significant chunk of time.
Jamie: Michael, how about you? Why did you decide to become a nurse and how did that progress to your advanced practice nursing today?
Michael: Well, it’s a circuitous tale. I grew up a cowboy in Sand Hills, Nebraska. One day, I decided I didn’t want to farm a ranch and one of the options I looked at initially was a program that I went to had a dual-track nursing and anesthesia which was I was in until I did my clinical rotation in psych. Met a young gentleman who had schizophrenia and while he had total word salad, he could play “Flight of the Bumblebee” in classical style to perfection. I was absolutely fascinated. It just grabbed me. I then went to the University of Nebraska Medical Center and there was a nurse tech and then after I graduated, got a job there. About three months later, some folks recruited me under Hildegard Peplau’s old NIH training, nurse traineeships for mental health. I became initially a clinical specialist and then did some work at UCSF. I went back and got my PhD to answer questions, kind of things, and have kind of gone on from there. I continued to expand my credentials as a nurse practitioner and it kind of in conjunction. My major research area really had to do with an interaction with a colleague of mine, Dr. Cathy Records, now at the University of Missouri, who is an OB/GYN nurse, who accused me of holding out on her one day because my dissertation area was on Partner Violence. She raised a question about women having longer labors if they’ve been in an abusive relationship. At the time, there was absolutely nothing in the literature. And so we began to research on that and, simultaneously, I wrote her some training grants using distance education and kind of the rest has been just a series of repeating studies and education grants at different locations. So I agree with Rebecca. It’s never boring. It’s always been somewhat demanding in terms of filling the need that other people have and I think now what we’re seeing is kind of a move away from being an isolated specialty into this integrated behavioral healthcare. And I think that’s really very important and one of the waves for our future.
Jamie: I have to agree and we have all seen mental health being on the radar, in the news and being discussed as an integral part of total healthcare package. That’s something that we as nurses have been focusing on the whole patient for a long time. So it seems to me that many nurses should have a strong approach or, at least, some background in understanding psychology and psychiatric issues that patients deal with. I know both of you have done some research in that regard. I talked to Pat Cunningham, who is the current president of the American Psychiatric Nurses Association, and she said something interesting to me. She calls “mental health issues” the “unwelcome companion” in healthcare because it so negatively affects all aspects of a person’s health. Rebecca, would you like to comment on that because, obviously, you are seeing that effect in oncology nursing?
Rebecca: Yes. Well, it is reasonably obvious I think that humans are – we’re kind of holistic beings. Our mental health is connected to our physical health. We’re also social beings, spiritual beings. And so when one area starts to get out-of-whack, so to speak, it can pull down the other areas. When we think about the linkages between mental and physical health, we think about being sick with the flu even. That can impact how well you feel mentally and make you a little bit more tired, more depressed, it can even impact your ability to inhibit irritation. You know they’re just very simple examples but I think it stretches a lot farther when it comes to people who have more life-limiting types of conditions like maybe congestive heart failure or a cancer diagnosis or something like fibromyalgia.
Michael: I would agree. I think that one of the things – and this is kind of from an evolutionary perspective – because I was initially educated in the purely psychotherapeutic psychodynamic models. Interestingly enough, one of the things that got me in trouble very early in my career was questioning that model – the belief system, the schizophrenias, the failure of an individual to bond in a relationship. When looking at someone with terminal schizophrenia, it just was incredulous to me. But I think that that some of the research in the decade of the brain has largely opened people’s eyes. As nurses, we’ve always known that it’s a holistic perspective. The issue is even in as simple as diabetes, if we need glucose to generate neurochemicals, when a person with diabetes has got to have some of that and should be consistently social assessed for anxiety and depression. And I’ve had some patients who are very brittle diabetics, and as soon as we get their anxiety under control, the brittleness goes away. So there’s a unique inter-relationship here. Much of it is neurochemical and neurophysiologic. And you see a lot of our psych nurse researchers, such as Rebecca, moving into areas that have a large impact across the whole population.
Jamie: It seems that, Michael, you’re uniquely positioned because of the fact that you are representing the mental health advanced practice nurse and, as a nurse practitioner, I see more and more nurse practitioners dealing with patients in the mental health field. I know in the local VA hospital that’s nearby us here, almost all the patients are managed almost exclusively by nurse practitioners in their mental health areas. I think that they serve those patient populations very well.
Michael: Well, yes, I mean the training has changed and, unfortunately, the older people like me in the profession that hadn’t have managed to move and change some of those things – people like Sandra Talley from Yale and Judith Haber from NYU and Kathleen Weaver – all of these folks across the country have over time in many of our meetings talk about what we need for education and what we need to best serve our patients and how to integrate those aspects. So we’re really now in an area where really psych mental health is a primary care kind of field, and I’ve argued that with the different branches of federal government, that you just cannot accept the psychological dimensions without assessing the physiologic components as well. And so that’s part of what we prepare our students to do these days.
Jamie: Rebecca, what do you think about the average nurse, whether she’s working on a Med-Surg floor or maybe working in an emergency department? Obviously you’ve seen this effect of mental health to a person’s total well-being in a disease state but what does an average nurse need to know to be able to be effective at assessing and being open to assessing a patient for these things?
Rebecca: Well, that’s sort of an interesting question. I think it is part of a nurse’s training just kind of like what just mentioned. We do teach nurses to look at the patient as a whole human being. And so part of the training that nurses receive prepares them to be able to look at psych mental health issues as part of the assessment criteria that becomes just part of – like if a patient arrives on the scene in the emergency room, that would be part of the questions that they would ask. In addition, of course, to the presenting problem if it’s a non-psych mental health type condition.
Michael: I think Rebecca’s right. There are the big things that are rather obvious like substance abuse and major biological mental illnesses. But there are also the more subtle pieces such as the depressed mood and anxiety associated with cancer, the coping with the uncertainty of the treatment and diagnosis. These are the more subtle aspects that I think nurses are uniquely positioned to identify and really direct to the rest of the team where to go with it. And oftentimes just addressing some of the treatment protocols and stuff or uncertainty is a major element. I think that’s true anywhere. While we do tend, I think, probably unfairly focus on people with bipolar disorder, schizophrenia or acutely suicidal, but the subtle aspects even in things like cardiac events are critically important. We know that if you treat depression, the mild levels of depression in people who have cardiac events, that you increase their lifespan by 5 to 10 years.
Jamie: Yes. I just remember seeing a recent study that looked at ICU patients dealing with PTSD following periods of being intubated and sedated in an ICU. That they were going home and having mental health issues following these events.
Michael: Is that from Michelle Balas at Ohio?
Jamie: I believe so.
Michael: Yes, she was one of my mentees. Bright woman.
Jamie: Yes. There are many ways that people have to deal with this. It doesn’t just have to approach somebody, like you said, with a major method mental health disorder. Everybody in periods of their life has periods where they have other issues that are impacting their mental health. There certainly are many ways that nurses can approach looking at that. What does the future look like, Michael, from your standpoint for mental health nursing?
Michael: I think we can talk about the future at three different levels. Let me just start at the top and work my way down. One of the big questions with the national conferences and meetings is this whole issue of enhancing mental health skills in the basic education kind of things. We’re not talking about ability to treat schizophrenia but we’re talking about identifying some of the things like Rebecca did in mental illness trajectories that we don’t know about and become critical and important. And just basic communication: identifying family dysfunctions and how that’s going to impact the trajectory of people’s lives. The next level is the graduate nurse practitioner/TNP level. That we’re going to see increased utilization of nurse practitioners. It’s just that the need is enormous. I cannot tell you how many calls waiting. If I had a dozen nurse practitioners graduating in a couple of months, I can get them all jobs. That’s not a question. That’s not a question at all. And I think that the final level then, is the PhD researcher group. One of the big discussions is where have all the psych nurse researchers gone? I think it’s because they’ve shifted. They become looking at really critical issues that have a broader population base like Rebecca’s doing. They’re examining issues that really look across the continuum of diseases and lifespan and not just focusing on the acutely psychiatric illnesses anymore.
Jamie: Rebecca, would you like to comment on that piece about the researchers? Certainly, I think, we all understand there is a need for more continuing nursing research in our specialty as nurses and then, of course, specializing in looking further into the effects of mental health issues on total body wellness.
Rebecca: Yes. I think those were really excellent points raised and the only thing that I would add in terms of the psychiatric research piece is that the whole move towards integration. As what like Michael mentioned with the psych mental health people who have a very strong, kind of focus in overt mental illnesses like bipolar disease or schizophrenia or that sort of thing, but then pulling the people who have more expertise in acute and chronic and maybe geriatric conditions, pulling those two groups together so that they can – because I do think that the specialization of the psychiatric mental health discipline is making offers so much to people like myself and the type of work that I’m doing. In fact, a lot of my training has been exactly what people who do have that type of a background because I don’t think you get enough of that when you’re focusing just on the more healthy kind of people that end up with some sort of an issue like we all end up doing at different points in our lives.
Michael: I would agree and I think that’s where the psych nurse researchers have gone. They’re in collaborative relationships. Even Karen Stein, the famous Eating Disorders psych nurse researcher, she is now crossing over and collaborating with a lot of comorbid medical conditions and I think that truly is one of the futures. One of the interesting things that we need to look at as a professional with that is training for integrative behavioral healthcare. Essentially we train on what I call the “50-minute model.” It takes 50 minutes to do an assessment. It takes 50 minutes to do a therapy session, et cetera, et cetera. Unfortunately, that 50-minute model doesn’t work well in a 12-minute primary care setting. So what we need to do is really kind of retool that and that’s going to take a collaborative effort between the people interested in these various diseases and those of us who are specialists.
Rebecca: I was just going to make the comment to Michael that I did my post doc with Karen Stein. She was my mentor.
Michael: Is that right? Karen is a dear friend of mine. Same era. Yes, a dear friend of mine. We’re both on the JAPNA Editorial Board and, as you know, Karen’s the editor. I write the evidence-based practice column for that. But, see, those are some of the changes that have happened is that you find these unique collaborative relationships with people and it’s a demanding but rewarding kind of thing because we use currently what the best evidence is for these kind of things and implement them in all of the settings regardless whether it’s primary care or specialty.
Jamie: Finally, just a real quick question about the professional associations. Of course, the American Psychiatric Nurses Association is one organization but there are oncology nursing organization, there other organizations. Rebecca, starting with you, what would you say to the nurses out there about the importance of being a member of your professional association and the value of attending conferences and networking through those organizations?
Rebecca: Well, that’s a good question. I would say it’s – like just for myself and my experience especially when I was like a new graduate nurse and first in the profession and not as well integrated and what it really means to be a professional nurse, it was the conferences that really helped me gain the knowledge necessary for seeing the value of these groups. I think the networking is absolutely essential, meeting people that are doing different things that you can potentially collaborate with. Also, to add to what it is that you’re doing so that you can basically expand your own work. One of the groups that I’ve recently, in the last five years, have joined is the American Psychosocial Oncology group. Basically, this is an organization that combines oncology with psychiatric mental health. That particular conference draws psychiatrists and psychologists and nurses and social workers, just kind of across-the-board, and all of who are very interested in the mental health issues that cancer patient face. And so I would just say it’s absolutely essential to explore like depending on what your particular area is. To find an organization that sort of speaks to your personal needs and then become involved.
Jamie: Michael, your thoughts?
Michael: Well, I think, as you know, I’ve been long and deeply involved with the American Psychiatric Nurses Association. But there are others and especially they’re good – The International Society of Psychiatric Nurses and International Society of Substance Abuse and Addiction Nurses – but I also tend to agree with Rebecca is that if you’re going to be truly professional it takes more than just a caring heart and a bright head. It takes involvement in the professional organizations to really advance and improve care and address these conditions that we’re looking at. That includes jumping across different specialties and organizations. Some of the organizations like Rebecca’s mentioned are critical for nurses to be professional. That’s what it means to be professional is to truly be identified both within and outside of the specialties as a professional person and address some of these issues. I encourage everybody to get involved and join in these organizations because they do an enormous amount, not just in terms of general education of the public, but also in terms of helping to craft some of our legislation that affects healthcare. I spent, and I’m sure Rebecca has too, the last few years, as everyone has trying to adapt and adjust to the Affordable Care Act and what implications does that mean for different kinds of patients and those kind of things and how do we implement behavioral healthcare and mental health care and diagnosis and assessment in all areas of people’s lives? You can’t do that just by yourself. So I think the true definition of the “profession” is to join the organizations and, like I said, it takes more than a great heart and bright mind.
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 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. You’ll find this and other episodes of Nursing Notes Live in the podcast area on iTunes.
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