Healing Troubled Minds

Tune into a television medical drama and most often you will get a glimpse into the emergency department of a hospital. Nighttime TV portrays the fast-paced environment of the ER as an exciting, even sexy, place for nurses to work. But one area of nursing that doesn’t receive nearly as much media attention, yet is just as rewarding a career opportunity, is psychiatric-mental health (PMH) nursing—a specialty that is in urgent need of more minority nurses from all racial and ethnic backgrounds.

“If [people who are interested in pursuing careers in nursing] only see what’s on television and the glamorous parts of the ER or some other very acute care setting, they don’t get to see much about what working with patients who have mental disorders is all about. We have to do a better job in our nursing programs to get [students interested in the specialty],” says Ann K. Beckett, PhD, RN, assistant professor in the Division of Mental Health Nursing at Oregon Health & Science University School of Nursing in Portland.

While PMH education is now incorporated into most nursing school curricula, it’s not a specialty that many nurses choose to pursue. Beckett believes that students need to have positive exposure to mental health nursing early on in their studies, including exposure to faculty members who have a strong interest in mental health.

“A lot of curricula are changing and [schools are teaching] mental health nursing in all of the [programs] so that [students] at least know enough about it to make a decision if that’s where they want to work,” she says. One reason why more nurses in general do not go into PMH nursing is because of fear and misperceptions about mentally ill patients, who are often stereotyped as dangerous and untreatable. But PMH nurses who are passionate about their field believe it provides an exceptional opportunity to make a real difference in improving the quality of people’s lives. Untreated mental illness can have a devastating impact on individuals, families and entire communities.

“Poor mental health is the thief of all health,” says Faye Gary, EdD, RN, FAAN, Medical Mutual of Ohio Kent W. Clapp chair and professor of nursing at Case Western Reserve University’s Frances Payne Bolton School of Nursing in Cleveland, Ohio. “Without good mental health people can’t function in their families, they can’t function on the job as a valuable and productive employee and they cannot contribute to their communities and neighborhoods. So they fail in three of the basic domains where it’s important for people to be productive.”

Well-documented racial and ethnic disparities in mental health outcomes and access to treatment point to a huge need for more minority nurses in the specialty. According to the Centers for Disease Control and Prevention (CDC)’s Office of Minority Health & Health Disparities:

  • African Americans are more likely to experience mental disorders than whites, but are less likely to seek treatment.
  • Asian Americans and Pacific Islanders are only 25% as likely as whites and 50% as likely as African Americans and Hispanics to seek outpatient mental health care, and they are less likely than whites to receive inpatient care. When they do seek care, they are more likely to be misdiagnosed as “problem-free.”
  • American Indians and Alaska Natives suffer from disproportionately high rates of depression and substance abuse and are overrepresented in inpatient mental health care compared to whites.

“There’s a definite stigma attached to mental illness, and yet African Americans are more apt to be diagnosed with schizophrenia than any other ethnic group. Latino women are more apt to be diagnosed with anxiety and depression than any other group,” says Norma Martinez Rogers, PhD, RN, FAAN, clinical professor at the University of Texas Health Science Center at San Antonio School of Nursing and president of the National Association of Hispanic Nurses (NAHN).

Gary decided at 17 that she wanted to work in mental health nursing after being exposed to psychiatric patients as a student nurse. She quickly realized that these patients were some of the most vulnerable people she had ever encountered.

“To be confused about one’s thoughts, one’s identity, one’s reality [is a frightening thing]. All of one’s capacity to think through situations and make good, sound decisions is gone when one has mental health problems,” Gary explains. “When I saw that level of human suffering, I decided that I would specialize in caring for mentally ill individuals and their families. Mental illness is chronic, it doesn’t go away, but it can be managed.”

Ruby D. Murphy, MSN, RN, MHA, CAP, a nurse educator at Jackson Health Systems Mental Health Hospital in Miami, Fla., was always fascinated with the mind and how it controls a person’s behavior. “I ended up in psychiatric nursing because I really like the field,” she says. “I like working with the patients, looking at research and [exploring what we can do to help treat illnesses] like schizophrenia and depression. I find the brain to be the most fascinating part of the body.”

For other PMH nurses, like Jodi Gooden, PhD, RN, BC, clinical nurse specialist at Shadow Mountain Behavioral Health System in Tulsa, Okla., the interest in mental health care developed later in their career. “When I went to nursing school the very first time, I had no clue about mental health nursing and it certainly wasn’t anything I wanted to pursue,” she says.

Gooden had a love for pediatrics and it was while working as a pediatric nurse in the late 1970s that she became exposed to psychiatric nursing. “Because of the shortage of nurses, we had to cross-train into the psych portion of it and I just kind of got hooked. I realized that it wasn’t that much different from [regular pediatric nursing] except that the kids had psychological problems instead of physiological problems.”

Today Gooden, who is part American Indian, focuses on adolescent psychiatric care in her facility’s children’s/adolescent clinic, where she works part time prescribing and monitoring medications. She sees between 150 and 200 teens each month. Most of her young patients have attention deficit hyperactivity disorder (ADHD) and are having trouble in school. Gooden’s job is to ensure that their medication levels are balanced and to educate her patients and their parents about the medications.

“I can’t tell you the number of patients I’ve [seen] who are on these medications but have no clue about what they’re for, because nobody has bothered to tell them. So I do a lot of education in that area,” she says.

Watching her patients’ grades jump from D’s and C’s to A’s and B’s because of their improvements under her care is the most rewarding part of her work, Gooden adds.

Social and Cultural Complexities

Minority health disparities are often a tangled web of inequities that can be traced back to a variety of socioeconomic and cultural issues. When it comes to treating mental illness in communities of color, health care professionals are not only dealing with troubled minds but with complex social problems, such as racism, poverty, crime, violence and historical trauma, all of which can take a toll on mental health. According to the 2001 Surgeon General’s report Mental Health: Culture, Race and Ethnicity:

  • African Americans, Hispanics and American Indians/Alaska Natives have higher incarceration rates than whites.
  • In a 1993 study, over one-fourth of African American youth who had been exposed to violence had symptoms severe enough to meet the diagnostic criteria for post-traumatic stress disorder (PTSD).
  • Many Central American immigrants in the U.S. are not recognized as political refugees, despite the fact that the war-related trauma that preceded their immigration may place them at high risk for PTSD.
  • Many American Indian/Alaska Native people live in stressful environments with potentially negative mental health consequences.

Add in factors like cultural differences and language barriers and it’s clear why more minority mental health nurses are needed. In many cases, minority nurses who share the same cultural background as their patients can bring to the table a first-hand understanding of the patient’s life and societal experiences, which enables them to build trust and rapport. Patients of color who are suffering from depression or other types of psychological distress may feel more comfortable when they are treated by a nurse who looks like them and/or speaks their language. The linguistic piece is especially important in mental health nursing because so much of the treatment is based on verbal communication.

“There is a huge need for bilingual [psychiatric] nurses,” says Gary. “In addition to that, there’s a need for nurses [from all backgrounds] to be culturally competent and patient-centered in the conceptualization, planning and implementation of the care that they provide for individuals and families. I think it’s about more than being bilingual. One can be bilingual and still not understand the culture. Nurses need to know the language, but they also need to know the cultural nuances.”

Culturally competent nurses can also help break through barriers of cultural stigma about mental illness that can prevent patients of color from receiving the care they need. For example, Beckett notes that African Americans tend to keep their mental health problems a secret. They do not talk about it openly or try to seek care, because of the shame and embarrassment they feel. Instead, they are more likely to turn to their church community for help, which may do more harm than good if the pastor or minister doesn’t have a good grasp of mental health principles.

“And even if they do seek care,” she says, “if they have a therapist or [other mental health professional] whom they don’t feel they can relate to based on their cultural background, it limits how much they can build a trusting relationship with that health care provider. It’s a different relationship, because [patients are] very vulnerable in those situations. It’s important for them to have someone they feel they can relate to and [who will] understand what [they’re] experiencing at that time.”

“Minorities [already] have limited access to mental health care,” adds Rogers. “Being treated by someone who lacks cultural sensitivity or who doesn’t understand your culture leads to disparities in the quality of care as well.”

Opportunities Abound

Nurses interested in psychiatric-mental health nursing can find career opportunities in a wide variety of practice settings, including hospitals, community mental health centers, home care programs, veterans’ health facilities, government mental health agencies, prisons, juvenile detention facilities, college/university health services, public schools, the military, insurance companies, public policy organizations, private practice and more.

Advanced practice PMH nurses (APRN-PMHs) can choose to sub-specialize in areas such as pediatric, adolescent, adult, and geriatric mental health, as well as substance abuse, eating disorders and forensic mental health. Specialty certification is available through the American Nurses Credentialing Center (ANCC).

Ann K. Beckett, PhD, RNAnn K. Beckett, PhD, RN

The role that nurses play in mental health care often overlaps with those of psychologists, social workers and psychiatrists. While PMH nurses are trained to perform more standard bedside functions, such as administering medications, much of what they do is heavily focused on one-on-one interactions with their patients. This is often very different from what most RNs are used to, especially if they have a background in traditional bedside care.

Beckett spends a lot of time educating her students about what it’s like to be a PMH nurse. When she explains that in mental health nursing there are no bandages to change or equipment to monitor, many students make comments like, “Well, what do I do [when I’m with a patient]? I don’t have anything to do with my hands.” She advises them that the PMH nurse’s primary function is talking and listening to patients and helping them gain insight into the issues and problems they are facing.

Nursing graduates can enter the specialty with an associate or baccalaureate degree, but advanced education is often encouraged. “Of course, as a PhD-prepared nurse I’m going to encourage people to have as much education as possible,” says Gooden. “However, in reality there’s such a shortage of mental health nurses that [graduates] with a two- or four-year degree could adequately work in this field.”

Because of that shortage, the current job market for PMH nurses at all levels is excellent. According to the American Psychiatric Nurses Association (APNA), basic-level PMH nurses usually start at an annual salary of $35,000–$40,000, while advanced practice nurses, such as psychiatric nurse practitioners and clinical nurse specialists, can earn $60,000 or more. At the highest level, nurse executives in PMH settings can earn $100,000 or more. Psychiatric nursing faculty are also in demand and can earn annual salaries of $65,000 or more.

One emerging opportunity is a growing demand for nurses who can treat co-occurring conditions, such as mental illness coupled with substance abuse. Murphy notes that in Florida many mental health facilities are moving away from separate treatments for co-occurring illnesses.

While psychiatric-mental health nursing may not be the right career choice for every nurse, advocates like Beckett can’t recommend it highly enough. “The role we play isn’t always a very exciting and glamorous one,” she says. “But the influence you can have on patients’ lives is tremendous.”