Nurses Emphasize Recovery, Safety When Managing Patients With Psychiatric Illness

An estimated 1 in 5 adults and 1 in 6 children in the U.S. lives with mental illness. In many cases, the care of these patients falls to behavioral health nurses, who are charged with addressing the complex physical and psychological maladies that often accompany mental disorders and trauma.

As with any other medical specialty, the primary goal of behavioral health — or psychiatric — nursing is to treat illness; however, managing patients with anxiety, depression, bipolar disorder, PTSD, schizophrenia and substance abuse, among other disorders, requires a special level of resolve and compassion, notes Monica Bender-Walker, MSN, MSEd, RN, LPCC, Director of Nursing at Cleveland Clinic’s Lutheran Hospital.

“First and foremost, psychiatric nurses help maintain patients’ personal and environmental safety so they can achieve their recovery or wellness goals,” she says. “However, the appropriate management of these patients – many of whom are quite vulnerable – requires a degree of vigilance and sensitivity that extends beyond ordinary care.”

Behavioral health nursing is based on formal recovery principles, Bender-Walker explains, while noting that caregivers are not only tasked with managing physiologic disease, but also with facilitating meaningful activities, encouraging socialization and providing education.

“Behavioral health nurses become entrenched in patient dynamics; they have an intimate knowledge of each person’s medical and personal history,” she explains. “This close therapeutic alliance enables our caregivers to de-escalate conflicts, provide guidance and ultimately help patients function as optimally as they can in every realm of their lives.”

Customized, expert care

Cleveland Clinic’s behavioral health nursing team supports patients in every life stage from childhood and adolescence through late adulthood. Although patients are referred to the program by a variety of healthcare providers, Bender-Walker notes that emergency departments are the primary referral source.

“Unfortunately, many of our patients present to the hospital because they’re battling an acute crisis,” she says. “The emergency department is often their first stop.”

Once a patient has been admitted to an inpatient behavioral health unit, clinicians approach their care from a trauma-informed perspective, which requires specialized training in healing and recovery. Bender-Walker explains that the approach includes motivational interviewing and partnering with patients and families to ensure they remain an integral part of treatment.

“Our program is based on specific trauma-informed principles designed to avoid re-traumatizing patients once they’re in our care,” she says. “Our nurses are dedicated to creating an environment that is absent of coercion with minimal use of restrictive tactics, including restraints and seclusion. We want to refrain from using any language or management techniques that could distress patients or their families.”

Instead of treating all behavioral health patients in one space, Cleveland Clinic has developed dedicated units that reinforce safety and enable customized care. The psychiatric rooms have several important design features to prevent injury, including walls with rounded corners, immovable furniture to deter barricading or throwing, high ceilings, open floor plans for visibility and doors that swing outward. In addition, the rooms are free of sharp objects, including glass mirrors, which can be used to self-harm.

“We triage psychiatric patients the same way we would any other patient by first identifying what level of care is required,” says Darlene Morocco, MHA, BSN, RN, NE-BC, FACHE, Chief Nursing Officer at Cleveland Clinic’s Lutheran Hospital. “For instance, high-functioning individuals who are struggling with depression or anxiety are managed in one unit, while patients with more severe illness may be placed in a unit where they can be treated by caregivers who are highly trained in providing that degree of therapy. This approach allows us to address the unique needs of every patient.”

In particular, individuals with substance use disorders have distinct physical and psychological needs that must be addressed by experts in addiction and recovery, explains Bender-Walker. Most of these patients are managed at Lutheran Hospital, which is equipped with a state-of-the-art inpatient detox unit. “The nurses in this unit possess yet another level of training that enables them to address substance use disorders and facilitate safe withdrawal,” she says. “Our goal is to provide these patients with the support they need to progress to the next stage of their recovery journey.”

Challenges and rewards

Workplace violence is among the chief concerns faced by behavioral health nurses, says Bender-Walker. “Unfortunately, we’re seeing an escalation in workplace violence across every healthcare domain, but this is especially true in behavioral health, where we manage patients who are predisposed to impulsivity,” she explains.

Despite the ongoing threat, Bender-Walker says her team is well-prepared for unpredictable situations. “Psychiatric nurses specialize in recognizing early warning signs of violence and are well-trained in de-escalating high-risk situations,” she says. “We are doing everything we can to ensure that our caregivers and patients are safe, and constant surveillance is key.”

The behavioral health team performs a visual check-in with each patient at 15-minute intervals to assess their mood and behavior. “Patients’ thoughts and emotions can change – sometimes dramatically – in a short period of time,” Bender-Walker explains. “We’ve found that consistent, frequent interactions are critical for ensuring the wellbeing of our patients and the safety of our caregivers.”

Although Morocco admits that behavioral health nursing has its share of challenges, she emphasizes the job’s ample rewards. “Many of our nurses have dedicated their entire careers to behavioral health, and they truly love what they do,” she says. “Helping patients overcome psychiatric illness and trauma requires enormous commitment and compassion, and our caregivers demonstrate those things every day.”

Because of the chronic nature of many mental illnesses, behavioral health nurses frequently care for individual patients over a span of many years. These personal connections, says Bender-Walker, can be tremendously gratifying. “There is nothing more fulfilling than witnessing a patient who may have once wanted to take their own life leave the hospital with renewed hope for the future,” she says. “Building close relationships with patients and watching them flourish is why our nurses do what they do. It’s a privilege to be part of their lives.”