A PATH FORWARD

Cindy Shively, a psych mental health nursing student, has been the sole full-time clinician at the Rocky Mount, Va. Free Clinic since 2013.

Between 50 to 80 percent of the Free Clinic's nearly 1,000 patients suffers from a diagnosed mental illness.

Wishing to serve those patients better is what drove Shively back to school to seek a psych-mental health master's degree.

In Rocky Mount, more than half of residents live on less than $20,000 a year, and many of the manufacturing jobs that had enabled a middle class existence are long gone.

8How psychiatric mental health NPs offer heart and hope during our nation’s mental health crisis

STORY AND PHOTOS BY CHRISTINE PHELAN KUETER

* Last name withheld to protect patient identity

Ray* was sure he was having a heart attack.

As usual, he’d headed on foot to walk the few miles to his job at the Dollar General, bundling up in a hoodie to stave off late winter chill. Sipping an energy drink between puffs on a cigarette, by the time he arrived at work, he “felt like [he’d] done a big old bag of cocaine,” he told nurse practitioner Cindy Shively (MSN ’12, PM ’19), noting the visible vibration of his coat hood beating to the thump of his fluttering heart. For the middle-aged Memphis, Tenn., native, the racing pulse was terrifying.

Even a day after being whisked by ambulance to the ER, where doctors couldn’t find any evidence of heart trouble, Ray still felt rattled. So he headed to see Shively, the only full-time clinician at the Free Clinic of Franklin County in Rocky Mount, Va., who listened intently to his story while orbiting around him, checking ears, pulse, and nostrils, Ray yes ma’aming, and no ma’aming each of her questions.

Physically, all seemed normal. Circling a stethoscope about her neck, Shively leaned in and gently prodded Ray about his caffeine intake, as well as his eating, digestive, and sleep habits. She knew he’d tried Zoloft for depression, and that he hated how it blunted his emotions; she knew, too, that Ray sometimes struggled to keep his temper in check—“I’m allergic to B.S.,” he’d told Shively. Her diagnosis: An anxiety attack. “Now you see me holding this coffee cup,” confided Shively, “so you know I’m not going to tell you not to have a cup or two in the morning. And back in the day, I was a smoker, too. But I’ve seen people have a full-blown anxiety attack, and know it can feel like a heart attack. Drinking some more water will help; fewer energy drinks will help, too. And let’s see what we can do to adjust your meds.”

Ray caught Shively’s eyes. “I still need to find my Zen,” he said softly, twisting his wool cap in his hands. Smiling, she nodded back.

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1in 5adults

44 million people — experiences a mental illness each year

National Alliance on Mental Illness

In many ways, Shively’s job is a perfect fit for a psychiatricmental health nurse practitioner. Because billing is not based on an appointment’s length, she’s unrushed, and can ask after the particulars of patients’ habits, prod a bit into their social and economic lives, and, if she knows them— and she usually does—ask after their children, grandchildren, pets, and jobs.

Here in Franklin County, population 56,000—the former home to thriving furniture, paper, and textile factories—patient stress is the rule, not the exception. About 10 percent of residents (including more than 12 percent of children under 18) live below the federal poverty line. And the stressors of being poor—in itself “a full time job,” says Donna Minnix Proctor, executive director of the Free Clinic—often exacerbate existing mental health issues, or provoke and establish them. Well over half of patients have mental illnesses for which they’re receiving medication, Shively says, as well as a complex cascade of other chronic health conditions, such as diabetes, hepatitis, alcoholic cirrhosis, fatty liver, and cardiovascular disease.

Those factors—as well as the fact that the area’s community services board tasked with providing psychiatric, mental health, and crisis services often takes weeks or months to make a diagnosis—makes Shively’s job a constant challenge: precisely the reason she returned to UVA in pursuit of answers.

“For me, it became more and more evident that I needed to, had to learn a lot more,” says Shively, a pattern Catherine Kane, a psychiatric mental health nursing professor at UVA since 1992, knows well.

“When folks first go into nursing and medicine, they want to see results, stitch up things, work with all the shiny baubles, save lives,” says Kane. “But psych is long-term, and often kind of messy. And many discover what we know: That more than half of people seen in family practice have a diagnosable mental health problem. Facing that, they say, ‘You know, I’m not quite knowing what I’m doing here, and I have to learn more about it.’

“And that’s when they come to our program.”

In colonial days, people with mental illness who lacked a family caregiver were often confined to jails and almshouses where they mingled with the elderly, the blind, people with epilepsy, abandoned children, unwed mothers, and petty criminals. 1 Those tending them earned the moniker “keepers,” a nod to the restrictive nature of the job.

Though the Pennsylvania Quakers were the first to offer formal hospital space designated for the mentally ill in 1752— albeit in the basement, with shackles and chains for the unruly 2 —Virginia was the first state to set aside funds to open a small hospital for the mentally ill in Williamsburg in 1773, a place today known as Eastern State. New York City, as well as the cities of Philadelphia, and Lexington, Ky., soon followed suit, and by 1890, every state in the United States had at least one mental institution. 3

But demand was fierce. By the mid-1900s, American mental institutions housed more than 500,000 patients, including Long Island’s massive Pilgrim State Hospital where, by 1954, more than 13,000 patients lived. 4

By the early 1900s, “nurse” became the preferred term for individuals caring for the mentally ill, marking the “shift from viewing nurses as domestic servants toward a developing profession.” 5 Though asylum staff had traditionally been hired for brawn, leading thinkers increasingly understood that caregivers could positively impact their patients. The 1885 publication of The Handbook for the Instruction of Attendants on the Insane “represented a move away from the oral tradition [of] passing on nursing skills [to] the beginning of a literature base of mental health nursing.” 6 By 1902, 15,000 copies of the “little red book” had been sold, and by 1920, the first psychiatric nursing textbook—Nursing Mental Diseases, authored by Harriet Bailey—was published. Psychiatric nursing education had officially been born.

Still, it took a while to take hold. Even by the 1950s, when more than half of the nation’s patients were mentally ill, nurses were “primarily taught how to care for the other half.” 7

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“One of the best things we can do as nurses is to listen, to give our patients our undivided

attention.”

Bridgette Vest (DNP ’13)

With the advent of pharmaceuticals, from sedatives in the late 1800s to tranquilizers and anti-psychotics by the 1950s, many mentally ill patients were prepared for their next cultural shift: transitioning out of mental institutions and into the community. The Community Mental Health Center (CMHC) program, initiated by the federal government after President Kennedy signed the Community Mental Health Act in 1963, propelled this progress.

The CMHC also hugely expanded services. Between 1955 and 1977, the total number of patient care episodes for mental health grew from 1.7 million to nearly 7 million, with CMHCs tending a third of those cases, “[shifting] the primary locus of mental health care from hospital-based, inpatient locations to community-based outpatient locations.” 8

As those with mental illness began to trickle into society, on-the-ground psychiatric support staff had expanded roles. Now, managing the care of mentally ill patients—helping with medication, and nurturing socialization, emotional and work life—meant caring for family members, too. As a provider through the 1970s and 80s, Kane recalls being the navigator for parents struggling to understand why their progeny didn’t just snap out of it, why they couldn’t will themselves to change, and what a path forward might look like. Many times, Kane recalled, it wasn’t the path they’d imagined, but one, nevertheless, that offered hope.

Today, thanks to a growing ability to diagnose mental

illnesses, an array of psychotropic medications, insurance companies’ expanded coverage, and a variety of government and community programs aimed at helping the mentally ill integrate into and contribute to society, psychiatric nursing is a field that’s powerfully positioned to improve the nation’s mental health.

But it’s a colossal undertaking. One in five Americans—about 44 million people—has a diagnosed mental illness: addiction, anxiety, and depression each exact a sizable toll. And while the specialty of psychiatric mental health nursing accounts for only a small portion—about 4 percent—of the more than 234,000 nurse practitioners in the United States 10 , there’s a growing appreciation for the expansive role this special group of clinicians play as gatekeepers of physical and mental health. And thanks to technology, their help is reaching farther than ever.

HOW IT’S BEEN TAUGHT

As early as 1921, third-year nursing students were

required to take Mental and Nervous Diseases, a

16-credit course. By 1938, the second-year course Psychiatric Nursing had doubled in scope to 30 hours, aiming to develop students’ “basic understanding of the etiology, symptomology, course, and treatment of the more common types of psychiatric disorders.” 9

Today, mental health topics are naturally interwoven into the content of many general nursing courses, like Foundations of Nursing CARE, while others are semester-long dives into the subject: Psychiatric Mental Health Nursing, Biological Basis of Mental Health Nursing, Mental Health Theories and Therapies, and Psychiatric Diagnostics and Differential Diagnoses, to name a few. Today, graduate students seeking the psychiatric mental health certification must accumulate at least 500 hours of clinical experience through rotations available at a variety of mental health sites throughout Virginia. Undergraduates complete nearly 100 hours of mental health nursing training at local community clinics, hospitals, and social services sites. While UVA’s psychiatric mental health clinical nurse specialist master’s program was established in 1972, it was largely supplanted by the psychiatric mental health nurse practitioner program established in 2001, following a push in the late 1990s from the National Organization of Nurse Practitioner Faculty. Today, UVA’s psych mental health programs are offered via a variety of routes, including a traditional master’s degree; a certification en route to a Doctor of Nursing Practice degree; or as a post-master’s certificate for individuals with other certifications, like family nurse practitioners.

And while the psychiatric mental health nurse practitioner program has traditionally been among the School’s smallest, interest is building. Once again this year, applications are up sharply—89 percent over 2017 numbers—for entry in fall, 2018. “People are increasingly aware of the need for psych nurses,” says assistant professor Edie Barbero, one of four fulltime psychiatric mental health faculty members, “and feeding that is the opioid crisis, a growth in the number of insured, a growing awareness of mental health as the gateway to overall health, and the fact that many family nurse practitioners want to come back and better serve their practices.” +

TELEPSYCHIATRY

“makes me even more attentive to cues, clarifying what patients are saying, and being even more observant.”

Sean Sembrowich (PM ’12)

COE SWEET

If professional experience sharpened Sean Sembrowich’s (PM ’12) knowledge of addiction—he’s a member of UVA’s Center for Leading Edge Addiction Research, where he monitors patients enrolled in trials assessing the efficacy of drugs to fight alcoholism, opioid addictions, and cocaine and methamphetamine use—technology has expanded it. In addition to working as a provider at UVA’s Elson Student Health Center, where he works with UVA students struggling with substance abuse and other mental health issues, Sembrowich also sees patients via telemedicine in locations that can be hundreds of miles away, where there are few mental health providers.

Always keen-eyed and a good listener, Sembrowich, a former ER nurse and family nurse practitioner, finds himself very much at home in the work. And if he was initially skeptical of telemedicine as an approach, these days Sembrowich is sold. The usually 45-minute appointments—which involve a Skype-like secured video link and face-to-face contact across the miles with patients being treated for mental illnesses, sometimes with addiction lurking in the background—actually fine-tune his therapeutic skills, he says, making him “even more attentive to cues, clarifying what patients are saying, and being even more observant.”

Other psychiatric mental health nurse practitioners define their practice by population, tending to those who are homeless, or individuals working in law enforcement, for example. Bridgette Vest’s (DNP ’13) population of choice? Veterans.

Vest, who’d “always cared for people, even as a child,” first worked with veterans during a summer internship while on break from college. Across her nursing career, however, she felt particularly drawn to those suffering from substance abuse. Today, with more than 30 years’ experience at the Salem Veterans Administration Medical Center caring for veterans from Vietnam to Iraq and Afghanistan, she continues to find the work powerful and relevant. It’s also been a journey of discovery. In her early work as a nurse practitioner, Vest noted that many patients who suffered from substance use disorders frequently had mental health diagnoses. Noting the complexity of their cases, she determined that there was much more to learn about mental health, and returned to UVA to pursue a DNP, earning a post-master’s certificate as a psychiatric mental health nurse along the way.

“I really felt like I needed more,” she recalled, “much, much more, so I could help them.”

Rigorous training in the facets of mental health nursing “just made sense” to her work, says Vest, noting that UVA mentors Kane, Barbero, and Rebecca Harmon always taught her “the importance of being present and being a life-long learner.”

Today, Vest is part of the V.A.’s team working with more than 78,000 eligible veterans living in 26 counties and 13 cities in southwestern Virginia, and serves on the Veterans Health Administration’s Tobacco Advisory Group. With a private practice and several faculty positions, Vest is also exploring

10.1years

reduction in life expectancy attributable to mental disorders

JAMA Psychiatry (2015), 72(4), 334-341.

new and novel ways to ease pain, manage stress, and treat addiction to drugs, alcohol, and tobacco through medication and acupuncture, among other therapies.

“One of the best things we can do as nurses is to listen, to give our patients our undivided attention,” says Vest, who keeps her grandfather’s American flag in her office as a poignant reminder of her patients’ sacrifices. “Helping veterans is incredibly rewarding. With every veteran, there is a story.”

13

U.S. veterans commit suicide each day

Centers for Disease Control (2017). Morbidity and Mortality Weekly Report. Altanta, GA: US Department of Health and Human Services.

“My goal as a provider isn’t to tell you what to do—you’ve been told what to do your whole life. It’s to engage in a relationship to impact you where you are.”

Rosalind DeLisser (MSN ’02)

For Teresa “Sid” McColley (BSN ’96, MSN ’97), her first clinical interactions as a nurse included outreach and medication services for homeless individuals with serious mental illness who needed housing and therapy. After years of pounding the pavement throughout Charlottesville-based Region 10’s catchment area, terrain that included Charlottesville and Albemarle County, McColley was on the interdisciplinary team that established the novel Program for Assertive Community Treatment, or PACT, which targeted difficult-to-reach people with mental illness who otherwise did not engage with or respond to traditional mental health service programs. As part of PACT, McColley met with clients where they were most comfortable—at the drop-in center, a coffee shop, a park, or the public library—to provide medication, supportive counseling, cognitive-behavioral tools, and training in independent living skills.

For people with mental illness, “there’s very little advocacy, and so much stigma,” says McColley, today the section manager for Sonoma County, Calif., Behavioral Health, where she oversees everything from mental health community clinics to a robust crisis intervention team training program for law enforcement. “But I find the people I’ve encountered over the years who have mental health challenges are just brilliant, and so interesting, and they just keep plugging away at this thing that our whole culture really misunderstands. There’s a real social justice aspect to it.”

That same passion for social justice drives Rosalind DeLisser (MSN ’02) in the classroom, just an hour to the south of McColley. Though DeLisser’s nursing career has taken her around the world and involved a great deal of intense onthe-ground advocacy for the homeless, those suffering from substance abuse and HIV, and military veterans traumatized by injuries and combat, today, she’s sharing her experiences to inspire the next generation. And oh, the stories DeLisser can tell. It was the early 2000s when, with help from San Francisco General Hospital and the city’s Mission Mental Health Clinic, DeLisser painstakingly established a novel program integrating primary and psychiatric care under the same roof. Knowing that people with severe mental illness are often too disorganized, chaotic, and paranoid to get routine primary care, DeLisser determined to build a “clinic within a clinic” so that mental health visits might be combined with routine care, like Pap smears, or heart and blood sugar monitoring. There, she worked with individuals suffering with severe mental illness, substance use disorders, victims of domestic violence, Latino immigrants, and African-American men with severe mental illness recently released from jail.

Following that experience, DeLisser was stationed in a German hospital where she cared for American soldiers traumatized by combat, and, after returning to the United States, worked with HIV-positive women in a trauma-informed primary care clinic at the University of California San Francisco (UCSF), where she now leads the clinic’s substance abuse treatment services and provides psychiatric assessments, consultation, and treatment for severe mental illness.

While each segment of DeLisser’s career has been powerful and disparate, certain themes have emerged.

COE SWEET

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84

number of hours of clinical experience each UVA Nursing undergraduate has as part of their Psychiatric Mental Health Nursing course

MENTAL HEALTH BY THE NUMBERS

#1

Depression’s rank, worldwide, as the leading cause of disability 1

2-3X

LGBTQ+ youth are two to three times more likely to attempt suicide than straight youth 2

4%

Percentage of America’s 234,000 advanced practice nurses who are certified in psychiatric-mental health nursing 3

2/3

Proportion of primary care providers who report difficulty in accessing psychiatric services 4

2M

Number of jail bookings that involve a person with a mental illness 5

1 in 5 80%

Percentage

Number of U.S. children that show signs or symptoms of a mental health disorder each year. 6

of children who need mental health services but won’t get them. 7

87%

#11

Increase in Psychiatric-Mental Health program applications in 2018, over 2017

National rank of UVA Nursing’s psychiatric mental health graduate program (US News & World Report, 2019)

$193 billion

Earnings lost due to serious mental illness in America each year 8

1. National Institutes of Mental Health, www.nimh.nih.gov 2. National Alliance for Mental Illness, www.nami.org 3. 2017 AANP National Nurse Practitioner Sample Survey 4. Cunningham, P. (2009). Beyond Parity: Primary Care Physicians’ Perspectives on Access to Mental Health, Health Affairs. 5. National Council for Behavioral Health, www.thenationalcouncil.org 6. National Alliance on Mental Illness, www.nami.org/getattachment/Learn-More/Mental-Health-by-the-Numbers/childrenmhfacts.pdf 7. Kataoka, S.H., Zhang, L., & Wells, K.B. (2002). American Journal of Psychiatry, 159(9), 1548-55 8. American Journal of Psychiatry and the U.S. Surgeon General’s Report, 1999

“One of the things that makes nurse practitioners unique is having a framework of nursing education based in humanism, holism, and patient-centered care,” says DeLisser from her UCSF office where she directs the psychiatric nurse practitioner program, which has more than doubled in size since her 2013 appointment. “My goal as a provider isn’t to tell you what to do—you’ve been told what to do your whole life. It’s to establish an alliance not based on power, or hierarchy, but to flatten that dynamic and really think about being a facilitator of an individual’s health and wellness.

“That’s just what we do,” adds DeLisser. “We engage in a relationship to impact you where you are.”

Caroline McKinnon’s (MSN ’02) patient—a 60-something

woman with chronic schizophrenia—wasn’t talking. But that wasn’t for McKinnon’s lack of trying.

Her task—part of her psychiatric rotation as an undergraduate back in the 1980s—seemed simple enough: Have a 15-minute conversation with the same patient each week, and record and analyze the interaction. But McKinnon’s patient had almost nothing to say. And that, laughs McKinnon— today a psychiatric nursing professor at Augusta University in Augusta, Ga.—made the then-19-year-old nascent nurse a nervous wreck.

“The less she would say to me, the more anxious I became,” recalls McKinnon, who worked for years as a nurse psychotherapist at the Gilder Regional Institute for Children & Adolescents, in Rockville, Md., before transitioning to academia in 2014. “And the more anxious I got, the more mistakes I made, trying to get her to talk to me. If I had just stopped and paid attention—focused on the feelings, rather than the task I had to complete—we might’ve been in a different place.

“It never occurred to me then to say to her what I’d say now: ‘It’s OK for us to sit here quietly.’ I was too focused on what was going on for me to be able to communicate.”

It’s a story McKinnon now shares with her students—some of them budding mental health nurses themselves. She also shares how she responds to the question she’s been asked her entire professional life when she shares that she works with individuals living with mental illness: “Why would you ever want to do that?”

“Having the opportunity to take care of people with mental health conditions is a privilege, and something to be desired,” asserts McKinnon. “For me, it’s where I should be. That’s what I tell my students all the time: No matter what they want to do in nursing, pay attention to that internal passion, that drive.

“This is work you get to do,” she adds, “not something you end up doing. There’s a real difference.” +

WATCH ‘A DAY IN THE LIFE OF CINDY SHIVELY’: MAGAZINE.NURSING.VIRGINIA.EDU

“This is work you get to do, not something you end up doing. There’s a real difference.”

Caroline McKinnon (MSN ’02)

1. Heseltine, J., & Heath, J. (2015). History of mental health nursing: The Royal College of Nursing. Retrieved from http://mht.rcnlearning.org.uk/Information/

2. Ozarin, L. (2006). Diseases of the Mind: Highlights of American psychiatry through 1900. U.S. National Library of Medicine. Retrieved from https://www.nlm .nih.gov/hmd/diseases/index.html 3. Ibid. 4. Ibid. 5. Heseltine, J., & Heath, J. (2015). History of mental health nursing: The Royal

College of Nursing. Retrieved from http://mht.rcnlearning.org.uk/Information/ 6. Ibid. 7. Kalisch, P., & Kalisch, B. (2004). American Nursing: A History. Philadelphia:

Lippincott Williams & Wilkins. 8. Community Mental Health Journal, 19(2), 1983. 9. Circular of Nursing, UVA School of Nursing, 1938. 10. 2017 AANP National Nurse Practitioner Sample Survey

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