The Nurses Role in the Care of Patients with Mental Disorders

Beth Hawkes MSN, RN-BC - 03/12/19

Stacy was frustrated trying to communicate with her patient, Barbara, in 620-1. Stacy works in acute care on a surgical unit and has never worked in behavioral health, but regularly has patients with coexisting mental health diagnoses.

Be Literal

Barbara was post-op day 1 bariatric surgery. She is 41 and was diagnosed with schizophrenia at age 24. She repeatedly put on her call light to ask “When can I have ice chips?” Stacy didn’t know exactly when the doctor was going to round, and repeatedly responded “As soon as your doctor comes and OKs it.”

Once again Barbara put on her call light. “When is my doctor coming?” Stacy replied “Pretty soon”.

In less than five minutes Barbara again put on her call light. “When will my doctor be here?” Stacy took a deep breath and tried a different tack. Looking at the wall clock, she replied firmly “At 0930. If your doctor’s not here by 0930, I will call him.”

Barbara was finally satisfied with the answer and did not put on her call light again. Stacy learned that it’s helpful to be literal with patients with mental illness, such as Barbara, who have schizophrenia. What Barbara needed even more than a time estimate was a concrete answer.

Be Kind

Sheila is a nurse who works in a behavioral health unit and tells this story about a long time resident, Eleanor. “We have an elderly patient named Eleanor who mostly sits quietly all day long in a rocking chair in the day room. Eleanor has advanced Alzheimer’s and sometimes forgets that her husband, George, died several year ago. At times she blots upright, looks around frantically and asks “Where’s George? Where’s George? Where’s my husband?”

Sheila says that at these times she calmly tells Eleanor that everything is fine, that George stepped out to go to the store, and will be back soon. Eleanor peacefully goes back to rocking in her rocking chair.

This goes against conventional training in nursing school, where nurses are taught to not go along with delusions and instead to re-orient patients. Sheila disagrees and explains what she’s learned. “We regularly hire new nurses to the unit and when Eleanor jumps up to ask for George, a new nurse will predictably rush over and say kindly but factually, “Eleanor, George passed away. It’s been 7 years, and he’s gone.” At first Eleanor looks stricken and soon her face crumbles in grief. She moans and cries with a freshly broken heart. She relives her pain as if it’s the first time. It can take hours before the nurses are able to calm Eleanor down.

Have Empathy

Many nurses dread caring for patients with mental illnesses, and even complain that it’s not what they signed up for. It can make experienced nurses feel inadequate and frustrated. But patients with severe mental illnesses have a multitude of medical problems and regularly end up in acute care. The side effects of psychotropic meds combined with lack of access to healthcare contribute to major health issues. Many life below the poverty line and must search for providers who take Medicaid or Medical. The life expectancy of a person with severe mental illness is shorter than the norm.

Be mindful that the person is not their illness. It’s common to say “She’s bipolar” but more respectful to say “She has bipolar disorder”. Likewise, a person is not a stroke, or a heart attack, or an overdose. Bipolar disorder, schizophrenia and other mental illnesses are medical conditions like many other illnesses except they affect the brain.

Mental illness cannot be fixed although it can be treated and managed. Just like diabetes is managed but not cured, so too is mental illness.

Lose the Logic

Brandy’s patient was complaining about spiders crawling on the wall and under his bed. Instead of pointing out that there were no spiders, Brandy replied “That must be so scary”. Rather than logically arguing him out of his delusions (which never works), Brandy mirrored back his feelings. Using logic simply does not work in patients with delusions or hallucinations as delusions are not embedded in logic, but irrationality. Trying to rationalize with a person who is not rational is frustrating for the nurse and usually unhelpful.

Listen and Redirect

Patients with mental illness can perseverate on a thought and re-focusing can help to get them unstuck. When giving instructions, give them one at a time. Processing can be enhanced by short, simple directions.

People with mental illness are someone’s daughter and someone’s son. None of them asked to be afflicted with a serious and chronic neurobiological illness that changed their lives forever. Showing empathy, respect and kindness is the least we can do when they’re under our care.