DiversityNursing Blog

Doctoring, Without the Doctor

Posted by Erica Bettencourt

Tue, May 26, 2015 @ 02:59 PM

By 

www.nytimes.com 

26NEBRASKA master675 resized 600There are just a handful of psychiatrists in all of western Nebraska, a vast expanse of farmland and cattle ranches. So when Murlene Osburn, a cattle rancher turned psychiatric nurse, finished her graduate degree, she thought starting a practice in this tiny village of tumbleweeds and farm equipment dealerships would be easy.

It wasn’t. A state law required nurses like her to get a doctor to sign off before they performed the tasks for which they were nationally certified. But the only willing psychiatrist she could find was seven hours away by car and wanted to charge her $500 a month. Discouraged, she set the idea for a practice aside and returned to work on her ranch.

“Do you see a psychiatrist around here? I don’t!” said Ms. Osburn, who has lived in Wood Lake, population 63, for 11 years. “I am willing to practice here. They aren’t. It just gets down to that.”

But in March the rules changed: Nebraska became the 20th state to adopt a law that makes it possible for nurses in a variety of medical fields with most advanced degrees to practice without a doctor’s oversight. Maryland’s governor signed a similar bill into law this month, and eight more states are considering such legislation, according to the American Association of Nurse Practitioners. Now nurses in Nebraska with a master’s degree or better, known as nurse practitioners, no longer have to get a signed agreement from a doctor to be able to do what their state license allows — order and interpret diagnostic tests, prescribe medications and administer treatments.

“I was like, ‘Oh, my gosh, this is such a wonderful victory,’” said Ms. Osburn, who was delivering a calf when she got the news in a text message.

The laws giving nurse practitioners greater autonomy have been particularly important in rural states like Nebraska, which struggle to recruit doctors to remote areas. About a third of Nebraska’s 1.8 million people live in rural areas, and many go largely unserved as the nearest mental health professional is often hours away.

“The situation could be viewed as an emergency, especially in rural counties,” said Jim P. Stimpson, director of the Center for Health Policy at the University of Nebraska, referring to the shortage.

Groups representing doctors, including the American Medical Association, are fighting the laws. They say nurses lack the knowledge and skills to diagnose complex illnesses by themselves. Dr. Robert M. Wah, the president of the A.M.A., said nurses practicing independently would “further compartmentalize and fragment health care,” which he argued should be collaborative, with “the physician at the head of the team.”

Dr. Richard Blatny, the president of the Nebraska Medical Association, which opposed the state legislation, said nurse practitioners have just 4 percent of the total clinical hours that doctors do when they start out. They are more likely than doctors, he said, to refer patients to specialists and to order diagnostic imaging like X-rays, a pattern that could increase costs.

Nurses say their aim is not to go it alone, which is rarely feasible in the modern age of complex medical care, but to have more freedom to perform the tasks that their licenses allow without getting a permission slip from a doctor — a rule that they argue is more about competition than safety. They say advanced-practice nurses deliver primary care that is as good as that of doctors, and cite research that they say proves it.

What is more, nurses say, they are far less costly to employ and train than doctors and can help provide primary care for the millions of Americans who have become newly insured under the Affordable Care Act in an era of shrinking budgets and shortages of primary care doctors. Three to 14 nurse practitioners can be educated for the same cost as one physician, according to a 2011 report by the Institute of Medicine, a prestigious panel of scientists and other experts that is part of the National Academy of Sciences.

In all, nurse practitioners are about a quarter of the primary care work force, according to the institute, which called on states to lift barriers to their full practice.

There is evidence that the legal tide is turning. Not only are more states passing laws, but a February decision by the Supreme Court found that North Carolina’s dental board did not have the authority to stop dental technicians from whitening teeth in nonclinical settings like shopping malls. The ruling tilted the balance toward more independence for professionals with less training.

“The doctors are fighting a losing battle,” said Uwe E. Reinhardt, a health economist at Princeton University. “The nurses are like insurgents. They are occasionally beaten back, but they’ll win in the long run. They have economics and common sense on their side.”

Nurses acknowledge they need help. Elizabeth Nelson, a nurse practitioner in northern Nebraska, said she was on her own last year when an obese woman with a dislocated hip showed up in the emergency room of her small-town hospital. The hospital’s only doctor came from South Dakota once a month to sign paperwork and see patients.

“I was thinking, ‘I’m not ready for this,’ ” said Ms. Nelson, 35, who has been practicing for three years. “It was such a lonely feeling.”

Ms. Osburn, 55, has been on the plains her whole life, first on a sugar beet farm in eastern Montana and more recently in the Sandhills region of Nebraska, a haunting, lonely landscape of yellow grasses dotted with Black Angus cattle. She has been a nurse since 1982, working in nursing homes, hospitals and a state-run psychiatric facility.

As farming has advanced and required fewer workers, the population has shrunk. In the 1960s, the school in Wood Lake had high school graduating classes. Now it has only four students. Ms. Osburn and her family are the only ones still living on a 14-mile road. Three other farmhouses along it are vacant.

The isolation takes a toll on people with mental illness. And the culture on the plains — self-reliance and fiercely guarded privacy — makes it hard to seek help. Ms. Osburn’s aunt had schizophrenia, and her best friend, a victim of domestic abuse, committed suicide in 2009. She herself suffered through a deep depression after her son died in a farm accident in the late 1990s, with no psychiatrist within hundreds of miles to help her through it.

“The need here is so great,” she said, sitting in her kitchen with windows that look out over the plains. She sometimes uses binoculars to see whether her husband is coming home. “Just finding someone who can listen. That’s what we are missing.”

That conviction drove her to apply to a psychiatric nursing program at the University of Nebraska, which she completed in December 2012. She received her national certification in 2013, giving her the right to act as a therapist, and to diagnose and prescribe medication for patients with mental illness. The new state law still requires some supervision at first, but it can be provided by another psychiatric nurse — help Ms. Osburn said she would gladly accept.

Ms. Nelson, the nurse who treated the obese patient, now works in a different hospital. These days when she is alone on a shift, she has backup. A television monitor beams an emergency medicine doctor and staff into her workstation from an office in Sioux Falls, S.D. They recently helped her insert a breathing tube in a patient.

The doctor shortage remains. The hospital, Brown County Hospital in Ainsworth, Neb., has been searching for a doctor since the spring of 2012. “We have no malls and no Walmart,” Ms. Nelson said. “Recruitment is nearly impossible.”

Ms. Osburn is looking for office space. The law will take effect in September, and she wants to be ready. She has already picked a name: Sandhill Behavioral Services. Three nursing homes have requested her services, and there have been inquiries from a prison.

“I’m planning on getting in this little car and driving everywhere,” she said, smiling, behind the wheel of her 2004 Ford Taurus. “I’m going to drive the wheels off this thing.”

Topics: mental health, AANP, health, healthcare, nurse, medical, patients, medicine, patient, treatment, psychiatrist, psychiatric nurse, health laws

Grown-Ups Get Out Their Crayons

Posted by Erica Bettencourt

Mon, Mar 30, 2015 @ 12:27 PM

By 

Source: www.nytimes.com

coloring master675 resized 600It may surprise fans of Johanna Basford’s intricately hand-drawn coloring books that the artist is, by her own admission, “pretty bad” at coloring.

“I can’t stay in the lines,” she said sheepishly.

Not that it matters. Ms. Basford’s coloring book “Secret Garden,” a 96-page collection of elaborate black-and-white ink drawings of flowers, leaves, trees and birds, has become a global best-seller.

Since its release in spring 2013, “Secret Garden” has sold more than 1.4 million copies in 22 languages. It shot to the top of Amazon’s best-seller list this month, overtaking books by authors like Harper Lee, Anthony Doerr and Paula Hawkins. Her follow-up, “Enchanted Forest,” which came out in February, is briskly selling through its first print run of nearly 226,000 copies.

What makes Ms. Basford’s breakout success all the more surprising is her target audience: adults who like coloring books.

There are, it seems, a lot of them. Though it is tempting to describe the market for her books as niche, Ms. Basford, a 31-year-old illustrator in Aberdeenshire, Scotland, has quickly outgrown that label.

Like Play-Doh, jungle gyms and nursery rhymes, coloring books have always seemed best suited for the preschool set. So Ms. Basford and her publisher were surprised to learn that there was a robust — and lucrative — market for coloring books aimed at grown-ups. When they first tested the waters with “Secret Garden” a year ago, they released a cautiously optimistic first printing of 16,000 books.

“I thought my mom was going to have to buy a lot of copies,” Ms. Basford said. “When the sales started to take off, it was a real shock.”

Surging demand caught Ms. Basford and her publisher off guard. Fan mail poured in from busy professionals and parents who confided to Ms. Basford that they found coloring in her books relaxing. More accolades flowed on social media, as people posted images from their coloring books.

Hard-core fans often buy several copies of her books at a time, to experiment with different color combinations. Others have turned it into a social activity. Rebekah Jean Duthie, who lives in Queensland, Australia, and works for the Australian Red Cross, says she regularly gathers with friends for “coloring circles” at cafes and in one another’s homes.

“Each page can transport you back to a gentler time of life,” she said of Ms. Basford’s books in an email.

Ms. Basford has become something of a literary celebrity in South Korea, where “Secret Garden” has sold more than 430,000 copies, she says. The craze was kicked off in part, it seems, by a Korean pop star, Kim Ki-bum, who posted a delicately colored-in floral pattern from Ms. Basford’s book on Instagram, where he has 1.8 million followers.

Part of the apparent appeal is the tactile, interactive nature of the books, which offer respite to the screen-weary. “People are really excited to do something analog and creative, at a time when we’re all so overwhelmed by screens and the Internet,” she said. “And coloring is not as scary as a blank sheet of paper or canvas. It’s a great way to de-stress.”

Ms. Basford started out in fashion, working on silk-screen designs. Then she opened a studio on her parents’ trout and salmon farm in Scotland, and began designing hand-drawn wallpaper for luxury hotels and boutiques. When the financial crisis hit, her business evaporated. She closed the studio and found work as a commercial illustrator for companies like Starbucks, Nike and Sony.

Her publishing break came in 2011, when an editor at Laurence King Publishing discovered her work online. The editor thought her graceful illustrations could work well as a children’s coloring book.

“I came back and said I would like to do a coloring book for grown-ups, and it got a bit quiet for a moment,” Ms. Basford said. “Coloring books for adults weren’t as much of a thing then.”

To convince them that it was a viable market, she drew five sample pages of detailed, mosaic-like illustrations. The publishers were sold.

“When Johanna first approached us with the idea, we knew that people would love her illustrations as much as we did, but could never have predicted just how big the adult coloring trend would be,” said Jo Lightfoot, editorial director of Laurence King Publishing.

Ms. Basford spent the next nine months working on the book at night and freelancing as an illustrator during the day. Occasionally she had doubts. “I was worried that coloring for adults was silly and it was just me that wanted to do it,” she said.

It turns out she was far from alone. Other entries to this small but growing category include Patricia J. Wynne’s lavish, nature-themed Creative Haven coloring books — discreetly described as being “designed for experienced colorists” — and the more explicitly titled “Coloring Books for Grownups,” released by Chiquita Publishing. A subspecies of these books promote the meditative aspects of coloring and doodling, including “Color Me Calm” (subtitle: “A Zen Coloring Book”) and books that promise “Easy Meditation Through Coloring.”

Major publishers are seizing on the trend. This year, Little, Brown will release four illustrated coloring books for adults, all subtitled “Color Your Way to Calm.” The books, “Splendid Cities” by the British artists Rosie Goodwin and Alice Chadwick and three titles by the French illustrator Zoé de Las Cases, feature detailed cityscapes with famous landmarks, cafes and street life. Promotional materials for the books emphasize the health benefits of “mindful coloring,” noting that the activity “has been shown to be a stress reliever for adults.”

Ms. Basford is now working on her third book, after soliciting suggestions for themes from fans. A vocal faction has requested an ocean-themed coloring book. “I’ve been drawing starfish and seahorses this afternoon,” she said.

In the meantime, “Secret Garden” has sold out in many markets, to the consternation of fans. Laurence King is reprinting 75,000 copies for the United States.

This month, Ms. Basford tried to calm her followers with a post on her Facebook page, promising that newly printed books would be shipping in a few weeks: “Don’t panic! New stock of Secret Garden and Enchanted Forest is on its way!”

Some were not placated. “WEEKS?” one frantic follower replied. “I can’t possibly wait WEEKS!”

Topics: mental health, adults, health, healthcare, stress, coloring books

New York City To Teens: TXT ME With Mental Health Worries

Posted by Erica Bettencourt

Mon, Mar 30, 2015 @ 09:56 AM

MAANVI SINGH

Source: www.npr.org

texting teens df0ddcde040bae0d5cd6afbb0d46cdfa8f1d9d13 s800 c85 resized 600

The majority of teenagers with mental health issues don't get help. But maybe if help were just a text message away — they wouldn't be so hesitant to reach out.

That's the thinking behind NYC Teen Text, a pilot program at 10 New York public high schools that allows teens to get help with mental health issues by text.

Chiara de Blasio, the 20-year-old daughter of Mayor Bill de Blasio who has been vocal about her own struggles with depression and substance abuse, helped launched the program. "I know from personal experience that reaching out when you're in pain can be the turning point – the first step on the road to recovery," she said at a press conference on Tuesday.

The initiative is managed by the city's health department in collaboration with the Mental Health Association of New York City, which already runs a citywide crisis phone service.

"Teens can be more candid on text than even in a phone conversation or in person," says John Draper, director of the National Suicide Prevention Lifeline, which helped design the Teen Text program. "This generation of teens make and break up relationships by text. So you can get pretty strong levels of intimate conversation with text."

The program is inspired by similar initiatives, including the Teen Line service in Los Angeles and the Crisis Text Line — which is available 24/7 for teens all over the country.

The advantage of having a local service is that counselors can look up and recommend local counselors to teens who need extra help. "We have more than 2,000 providers in our databases," Draper says.

And when teens who text the helpline appear to be in imminent danger of harming themselves or others, counselors can work with the local police department to track them down make sure they're safe.

But the text-based approach poses a few challenges, as well, Draper says. "One of the tricky things is making sure we're communicating our empathy. You can't hear someone say 'Mhm, mhm' over text."

Counselors who operate the text line receive extra training, Draper says. "Over text, counselors go out of their way to make it clear that they're actively listening. We may say something like 'It sounds like this loss has been terribly devastating for you, I'm so sorry to hear that.' "

And teens who reach out to such services may need extra validation, Draper says. "The whole world could be black today and it may feel like that's the way it will be forever. They don't have life experience telling them that this is going to end and get better," he says. "The counselor's job is to really be there in the moment so they learn that they can get through this."

Privacy is another concern. "We use encrypted messages and store all the information in secure databases," Draper says. "Still, on their end, we have no control over what they do with their information. The advantage of keeping the texts on their phone is that they can read and reread these messages that were useful or important to them. But we do warn them — if they're concerned about someone seeing, they should forward their texts to a more secure setting."

"I was very excited about this program," says Nadine Kaslow, the president of the American Psychological Association and vice-chair of Emory University's psychiatry department. "I think it has a great deal of potential."

In-person counseling is the best, most effective way to help teens with mental health trouble, says Kaslow, who isn't involved with the Teen Text program. "But there will be some subgroup of teens where this text service is the only way to connect with them."

There is a lack of research on the long-term efficacy of text and mobile app based services, she notes. "The issue is that everything is anonymous and there's no way to follow-up with them to see if they ended up seeing a counselor later, or if they're doing better."

The NYC Department of Health and Mental Hygiene will be tracking the number of students who use the new service, and they're planning on gathering feedback from students at the 10 pilot high schools, according to Gary Belkin, the executive deputy commissioner for mental hygiene.

If the program is successful, the health department hopes to expand it and promote it in high schools citywide.

Topics: mental health, technology, health, medical, patients, teens, text message, mobile phone

Is Therapy Worth It? Seven Personal Stories About The Price Of Mental Health

Posted by Erica Bettencourt

Wed, Feb 18, 2015 @ 11:52 AM

Jana Kasperkevic

bb1a1a7f a4a5 4bf0 a925 b3236aa1e101 620x372 resized 600

Far from offering patients pennies for their thoughts, mental health therapists often end up billing them hundreds of dollars per month.

The cost is a growing burden as depression among US adolescents and adults rises. The US is suffering a mental health crisis, with a San Diego State University study in October finding that one in 10 Americans is depressed – and more report symptoms of depression.

More Americans are seeking help, and that help can come at a financial sacrifice of thousands of dollars a year. Aside from the cost of often-weekly visits to psychologists – which may or may not be defrayed by insurance – there can be additional costs for psychiatrists and any medicine they prescribe.

The cost of therapy is especially acute for young Americans, many of whom are underemployed and burdened with college debt. This year, a record number of college freshmen reported being depressed. And while many campuses provide free mental health care, affordable help is often harder to find after students leave school.

The Guardian interviewed seven young professionals about their experiences to find out how young Americans manage to pay for therapy – and if they think it’s worth it. To protect their identities, we have kept their surnames anonymous.

Click on the titles below to read their stories: 

‘I just can’t afford to go’

– AK, 27

‘Why do I need to pay someone to listen to me?’

– Matt, 23

Therapy was ‘the best chance I had of feeling OK’

– JE, 29

I needed someone to help me find courage to leave [my job]

– Eve, 33

‘At its best, it’s paying for a friend’

- John, 27

‘Therapy is not a magic wand’

-Jenn, 26 

‘I’d rather be sad’

– Alex, 27

Source: www.theguardian.com

Topics: mental health, therapy, health, healthcare, depression, patients, medicine, patient, treatment, therapists, cost, psychiatrists

This Is What’s Keeping Teens From Getting Enough Sleep

Posted by Erica Bettencourt

Mon, Feb 16, 2015 @ 11:21 AM

By 

Up to a third of teens in the U.S. don’t get enough sleep each night, and the loss of shut-eye negatively impacts their gradesmental well-being and physical health. Biologically, adolescents need fewer hours of slumber than kids — but there’s a bigger reason for teens’ sleep loss, according to a new study in the journal Pediatrics.

Katherine Keyes, an assistant professor of epidemiology at Columbia University, looked at survey data from more than 270,000 eighth-, 10th- and 12th-grade students at 130 public and private schools across the country, gathered between 1991 and 2010. Each student was asked two questions about his or her sleep habits: how often they slept for at least seven hours a night, and how often they slept less than they should.

She found that over the 20-year study period, adolescents got less and less sleep. Part of that had to do with the fact that biologically, teens sleep less the older they get, but Keyes and her team also teased apart a period effect — meaning there were forces affecting all the students, at every age, that contributed to their sleeping fewer hours. This led to a marked drop in the average number of adolescents reporting at least seven hours of sleep nightly between 1991–1995 and 1996–2000.

That surprised Keyes, who expected to find sharper declines in sleep in more recent years with the proliferation of cell phones, tablets and social media. “I thought we would see decreases in sleep in more recent years, because so much has been written about teens being at risk with technologies that adversely affect the sleep health of this population,” she says. “But that’s not what we found.”

Instead, the rises in the mid-1990s corresponded with another widespread trend affecting most teens — the growth of childhood obesity. Obesity has been tied to health disturbances including sleep changes like sleep apnea, and “the decreases in sleep particularly in the 1990s across all ages corresponds to a time period when we also saw increases in pediatric obesity across all ages,” says Keyes. Since then, the sleep patterns haven’t worsened, but they haven’t improved either, which is concerning given the impact that long-term sleep disturbances can have on overall health.

Keyes also uncovered another worrying trend. Students in lower-income families and those belonging to racial and ethnic minorities were more likely to report getting fewer than seven hours of sleep regularly than white teens in higher-income households. But they also said they were getting enough sleep, revealing a failure of public-health messages to adequately inform all adolescent groups about how much sleep they need: about nine hours a night.

“When we first started looking at that data, I kept saying it had to be wrong,” says Keyes. “We were seeing completely opposite patterns. So our results show that health literacy around sleep are not only critical but that those messages are not adapted universally, especially not among higher-risk groups.”

Source: http://time.com

Topics: mental health, studies, pediatrics, health, research, sleep, teens, insomnia, childhood obesity, grades

Super Food Super Guide for Super Seniors!

Posted by Erica Bettencourt

Wed, Sep 24, 2014 @ 11:11 AM

By Felicity Dryer

senior foods (2)

Infographic Courtesy of PresidioHomeCare.com

Topics: mental health, physical health, foods, nutrients, health, seniors, infographic

What 30 Minutes a Day can do for Your Mind and Body

Posted by Erica Bettencourt

Wed, Sep 24, 2014 @ 11:04 AM

By Felicity Dryer

guestblogFD 300x200 resized 600

We live in a high-stress world. Between having to attend to work, kids, homes and run back and forth between meetings and all of the other demands of everyday life, to say that things can get stressful is an understatement. 

If your constant on-the-go lifestyle has left you feeling run down, beat down and just plain old exhausted, then you need to stop and smell the proverbial roses for a little bit.

Taking time to enjoy something that is peaceful and that is just for you can do wonders for your health, your mental clarity and for your happiness. You don’t have to invest much time in such activities, either; reserving just 30 minutes a day to something that you enjoy and that promotes a bit of peacefulness and tranquility can do wonders.

Here’s a look at some activities that you can do for just 30 minutes a day and that will provide you with some simply amazing benefits.

Yoga: It seems like yoga is all the rage in the fitness world as of late (well, not really as of late; it’s been a trend for quite a while) – and there’s a reason why; yoga provides some pretty amazing benefits.

Just 30 minutes of yoga a day will help to increase your strength and flexibility, as well as tone your body. In addition to physical benefits, yoga can also increase your brain function. A recent study conducted by the University of Illinois found that people who participated in just 20 minutes of yoga a day experienced an increase in the speed and accuracy of their brain functions. Yoga also helps to reduce stress levels and boosts mental clarity; talk about some pretty amazing benefits for just 30 minutes of your time each day.

Meditation: Another activity that can provide fantastic benefits in just 30 minutes a day is meditation. When you think of people meditating, what comes to mind? People who are more peaceful, more astute and have more clarity? If so, there’s a good reason why – Because meditation helps to promote all of these things.

In fact, just 30 minutes of meditating a day can boost your creative thinking abilities, heighten your energy levels, decrease your stress levels and even ease the feelings of depression.

A Long Walk: If someone tells you to ‘go take a walk’, take them up on it! There are so many wonderful benefits associated with walking, and the best part is, it is so easy to do. Walking for just 30 minutes a day improves your cardiovascular health, decreases stress and anxiety, helps to keep off excess weight, tones muscles, boosts energy levels and it can even help to decrease your risk of dementia. Walking also just makes you happy. So kick off those painfulwork shoes and dust off your sneakers, and get moving. There is nothing more therapeutic than soaking up the warm sunshine and observing the beauty of nature while walking on a nice day.

Reading: Everyone knows that reading is important, but do you know why? Reading for just 30 minutes each day can increase your vocabulary, boost your creative thinking and critical thinking skills, stimulate your mind, improve your memory and focus and decrease stress levels. So, when you’re feeling like you just need to escape for a little while, curl up with a book or a magazine and submerse yourself in reading.

No matter how crazy your lifestyle is, you can spare just 30 minutes a day to enjoy the benefits that one of these activities can provide. You’ll be amazed by how much happier you will feel – you owe it to yourself!

Source: http://www.interplayhealth.com

Topics: mental health, body, mind, meditation, relax, pressure, yoga, fitness, physical health, health, benefits, lifestyle, stress

Easing the mind

Posted by Alycia Sullivan

Wed, Oct 02, 2013 @ 11:16 AM

easingthemind resized 600

By Debra Anscombe Wood, RN

Psychiatric emergencies can be as serious as a medical condition, but in traditional EDs, mental health patients may wait for treatment. Specialized psychiatric EDs serve that population quickly and efficiently. “They come in with everything from the need for prescription refills to being actively suicidal,” said Brian Miluszusky, RN, BSN, director of nursing in the emergency medicine department at NewYork-Presbyterian Hospital/Weill Cornell Medical Center in New York. “A suicidal person is as much at risk of dying as someone having an MI (myocardial infarction).” 

As demand for emergency care has increased, so has the number of mental health patients seeking services. A study from the Carolina Center for Health Informatics at the University of North Carolina at Chapel Hill reported in 2013 that nearly 10% of ED visits in North Carolina from 2008-2010 were for mental health diagnoses, and the rate of mental health related visits increased seven times more than overall ED visits. Mental health related ED visits increased by 17.7%, from 347,806 to 409,276 from 2008-2010. Stress, anxiety and depressive disorders were most common. 

A January 2012 American Hospital Association Trendwatch report said, “In 2009, more than 2 million discharges from community hospitals were for a primary diagnosis of mental illness or substance abuse disorder. ... Among children, mental health conditions were the fourth most common reason for admission to the hospital in 2009.”

The report said there were more than 5 million visits to EDs in 2009 by patients who had a primary diagnosis of mental illness or a substance abuse disorder. “Access to [psychiatric] care is not easily found [in the community], but if you are having a mental health crisis, you can walk into our emergency department 24/7 and be seen by a psychiatrist within a couple of hours,” said Jennifer Ziccardi-Colson, RN, MSN, BSW, MHA, vice president for nursing services at Carolinas Medical Center-Randolph, a behavioral health center with a psych ED and 66 inpatient beds in Charlotte, N.C. 

Psych EDs serve patients with acute episodes of behavioral health diagnoses, including feeling suicidal, anxious or depressed or abusing substances. “When patients come to us, they are assessed and seen promptly,” Ziccardi-Colson said. “People can feel comfortable coming to our environment to receive care.” 

Not all patients with mental illnesses receive care in a psych ED. Even at those hospitals with a dedicated psych emergency unit or a stand-alone psychiatric emergency services facility, patients with acute medical conditions, such as an MI or a broken hip, are treated in the regular ED. The ED provider must determine if a medical problem is contributing to mental status changes or if the problem is solely psychiatric in origin. 

Some psych EDs, such as San Francisco General Hospital and Carolinas Medical Center care for children as well as adults. Children and teens receive emergency psych services at Carolinas Medical Center-Randolph. Younger children, ages 3 to 6, come in with situational stress related to family dynamics, such as divorce or custody battles; depression or anxiety, often related to bullying at school or at home; suicidal ideation; conduct disorders; and behavioral issues related to autism or developmental delays. “In the emergency room, it’s crisis stabilization,” said Tez Bertiaux, RN, MSN, nurse manager for the ED at Carolinas Medical. “A lot of these children are followed in the community by a mental healthcare provider.”

The hospital’s social worker will arrange outpatient care for children who do not have a current therapist. Many are admitted to inpatient care. The psych emergency services program treats about 700 children and adolescents monthly, and the hospital admits about an equal number to its inpatient units, said Bertiaux.

Pediatric ED visits tend to increase during the school year, with school staff workers referring students for care. Some of the children are in foster care or are homeless or living in shelters. Some parents and guardians will stay during the stabilization and others do not. “It’s a very complex dynamic, because you are not just treating the patient — the family is involved,” Bertiaux said. 

Bertiaux said many of the mental health issues that bring children into the ED are related to their environment. “And that can be challenging,” she said.

Patients seeking care at a psych ED may be treated and discharged, but others require admission to a psychiatric bed for stabilization. Physicians at NewYork-Presbyterian and San Francisco General admit about 30% of their psych ED patients to the hospital. But treatment begins in the psych ED. “It’s amazing how much we can help people,” said Andrea Crowley, RN-BC, interim nurse manager in psychiatric emergency services at San Francisco General. “Some just need someone to talk to and bring them down from the crisis they are in. It makes you feel you are making a difference, and it’s a visible, tangible thing.” 

Psych care a growing need

Carolinas Medical has seen a steady increase in psych ED volume during the past several years. It treats about 18,500 patients annually with a variety of psych disorders and continuously operates at 100% occupancy. Construction is under way to double the psychiatric hospital’s inpatient beds to 132. 
Johns Hopkins Hospital in Baltimore’s psych ED census has experienced a 30% jump this year. “People are sicker, and there are fewer resources in the community,” said Kate Pontone, RN, MSN, nurse clinician 3 and nursing service line leader for Psychiatric Emergency Services at Johns Hopkins. “Outpatient programs that had space available are no longer options. People are running out of medications or cannot afford transportation. Many of the same reasons emergency departments are crowded.” 

A March 2012 Congressional briefing by the National Association of State Mental Health Program Directors reported, “the economic downturn has forced state budgets to cut approximately $4.35 billion in public mental health spending over the 2009-2012 period,” a trend it expects will continue. While at the same time, there was a 10% increase in consumers receiving state-supported mental health services. 

In July 2012, the Treatment Advocacy Center released the paper “No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals,” which found nationwide, closures of such hospitals “reduced the number of beds available in the combined 50 states to 28% of the number considered necessary for minimally adequate inpatient psychiatric services.” And “in the absence of needed treatment and care, individuals in acute or chronic disabling psychiatric crisis increasingly gravitate to hospital emergency departments, jails and prisons.”

Volume at San Francisco General’s psych ED has jumped from 500 per month to 600 per month. “It could be due to closures in programs,” Crowley said. “We are starting to see a fallout from lack of services in the community.” 

Volume also has increased at NewYork-Presbyterian where, typically, a dozen or more psych patients are waiting in the regular ED for a bed in the psych ED, Miluszusky said. Difficulty transferring patients to an inpatient bed clogs up the EDs. A lack of insurance complicates transfers, and patients may end up boarding in a regular or psych ED. 

Patients may walk in, arrive by ambulance or with a petition for involuntary commitment, because they are deemed dangerous to themselves or others. First responders may take a mental health patient to a psych ED rather than to a community hospital without such specialized services. “This is a growing population, and emergency rooms will have to evolve,” Miluszusky said. “The population is getting so big; we are going to have to think of new ways to handle it.” 

Benefits of a separate psych ED

Psychiatric emergency services programs typically are staffed with behavioral health professionals, allowing mental health interventions to begin quickly, and often the onsite team can stabilize the patient, avoiding a hospitalization, according to the article “Treatment of Psychiatric Patients in Emergency Settings” in the journal Primary Psychiatry. “You don’t have agitated psych patients in the emergency room with all of the sick people,” Crowley said. “It’s a specialized environment where you can begin treatment better.”

Nurses and other members of the psych ED team have a solid understanding about different mental health conditions and their treatment. They can begin therapeutically talking with patients immediately. “Our patients appreciate being cared for by someone who is familiar with their medications and their symptoms and can intervene when they begin to decompensate,” Pontone said. “You get specialized care and the rooms are safe,” said Miluszusky, who adds that improves outcomes. 

Psych EDs often are locked units and feature specially outfitted rooms, with no sharp corners, no cords, nonexposed plumbing and a calm atmosphere. The safety features prevent patients from harming themselves or creating tools to harm others. “Our main priority is patient safety,” Ziccardi-Colson said. “There’s no potential for suicide or other negative outcomes.”

Ziccardi-Colson reported Carolinas Medical’s psych ED operates cost effectively, in part because of its ability to begin treatment and stabilize. “We’re able to process people more quickly than a medical ED,” Ziccardi-Colson said. 

Miluszusky said having a psych ED can be cost effective, because it reduces overtime pay necessitated by providing one-on-one oversight of a psych patient in the medical ED. 

Nurse staffing varies by institution, often with psychiatric nurses providing care, such as at San Francisco General’s psych ED. “It’s an exciting job, where you see a wide variety of people,” Crowley said. “You have a profound effect on people’s lives.”

Emergency nurses, who have received specialized training in the care of mental health patients and de-escalating situations, staff the psych ED at NewYork-Presbyterian. Nurses from a Johns Hopkins inpatient psych unit covers the emergency room, and Pontone describes significant interest from the inpatient staff. The hospital also cross-trains the ED nurses, so they can step in during an emergency. Pontone says nurses who love psychiatric nursing are interested in the management of the acutely ill patient, who needs as much care and support as they can get in a safe environment. “We like to be there when patients are in crisis and need help,” she said. “And we are good in a crisis.”

Ziccardi-Colson said every day presents challenges, but the reward of helping patients to wellness is inspiring and keeps nurses motivated. “Those who like it, love it,” Crowley said. “And for those who are not into it, we are happy to do it for them.” 

Source: Nurse.com

Topics: mental health, ED, nursing, patient, care

Unresolved grief can be hidden health risk, experts say

Posted by Alycia Sullivan

Wed, May 29, 2013 @ 03:22 PM

Moore

By Janice Lloyd

Whether you lose a loved one to disease, war, or a natural disaster like the tornado that tore apart Moore, Okla., last week, grief is the unwanted visitor that comes knocking at your door.

How we wrestle with grief — and ultimately push ahead to a new life — varies among individuals. But many of us who need help to bounce back are not getting it, health experts warn, jeopardizing our mental and physical health.

Toni Miles, director of the Institute of Gerontology at the University of Georgia, is embarking on a research project to find out how loss impacts health and what to do about it.

"Loss creates injury,'' Miles says. "It is a new risk factor for poor health in the public sphere."

Miles suspects grief is behind much of the nation's obesity, depression, diabetes, smoking and hospitalization.

"When you study caregiving, you know (grief) kills people,'' Miles says. "Obesity is also a big problem among caregivers. "

Finding support can be the key to a person's recovery and acceptance of the loss, says the American Cancer Society. Support can come from friends, physicians, spiritual leaders or mental health professionals. Everyone reacts differently to grief and for different periods of time. There's not one easy solution or answer, Miles says.

Getting the right amount of support is rare, according to a 2004 study on family perspectives on dying in the Journal of the American Medical Association. Lead researcher Joan Teno asked participants "during the last month (of their loved one's life), how much support in dealing with your feelings about a patient's death did the doctors, nurses or other professional staff taking care of him or her provide you: less support than was needed, about the right amount or more attention than you needed?''

Overall, 20% of the family members stated they did not have the right amount of support, and most said they got less support than they needed.

Teno, a professor of health services policy and practice in the Public Health Program at Brown University and a palliative care physician at Home & Hospice Care of Rhode Island, says her research shows families who use hospice at the end of life cope better than those who don't.

Donald Rosenstein, a professor of psychiatry at the University of North Carolina, is charting new territory into the bereavement process of fathers who lose their wives to cancer. He started a first-of-its-kind support group called Single Fathers Due to Cancer Program, part of the UNC Comprehensive Cancer Support Program.

"Everyone has a different reaction to grief,'' Rosenstein says. "We (health care professionals) don't have a lot of good information about how to get people to move on. But these fathers have been been teaching us."

Rosenstein says in addition to learning what the fathers need – how to discipline children by themselves, how long to wear their wedding bands, when is it OK to date, how long to call their in-laws in-laws — they're also learning how to help their children.

"For instance, moms always want to keep fighting and stay alive as long as possible for their families, but we're learning it's important for them to say goodbye," to provide a sense of closure for their families, he says. "We are also learning how much that helps the children and how to have that conversation with children."

Miles agrees that children are especially vulnerable: "Time doesn't heal all wounds,'' she says. "People in public health need to be discussing this topic more. There can be healthy outcomes from loss. It's up to us to help to find ways to make that happen more often and to push for policy that guarantees it."

ADVICE FOR DEALING WITH GRIEF

Grief is a typical reaction to death, divorce, job loss, a move away from family and friends, or loss of anything that is important to you, according to the U.S. Department of Health and Human Services:

It can last from several months to several years, and can be accompanied by feelings of guilt, sadness or numbness. It might cause trembling, breathing difficulties and sleeplessness. It is also normal to feel joy and to express humor.

People who don't process their grief can become angry, guilt-ridden and fail to care of their health. Here are the four steps along the way to healing from grief:

• Accept the loss.

• Work through and feel the emotional and physical pain.

• Adjust to living in the world without the person or lost item.

• Move on with life.

For more advice, an online guide to grief and bereavement is available from the U.S. Department of Health and Human Services.

Source: USA Today

Topics: mental health, support, grief, grief management, health field

For school nurses, it’s far beyond Band-Aids

Posted by Alycia Sullivan

Fri, May 17, 2013 @ 01:19 PM

describe the imageThe peak times for student visits to Ronda Kissling’s office are at the start of the school day and around lunch and recess time, but Kissling doesn’t get much downtime.

Kissling is the nurse serving three elementary schools: Croninger, St. Joseph Central and Shambaugh. She began her day Friday at Croninger to see

schoolnurse

 the students who got off the busdescribe the image not feeling well. By late morning, she was headed to Shambaugh to give insulin to thehandful of diabetic students there. Shortly after noon she returned to Croninger to give students insulin and just in time to catch any students injured during recess.

Between student visits and charting throughout the day, Kissling checked on an uninsured student who had broken his arm; urged a doctor’s visit for a student with a particularly suspicious-looking rash; and worked on a letter to send home to parents about immunization changes for next school year.

She said most people don’t realize what school nursing is all about.

“They think we sit around all day and just give out ice packs and Band-Aids,” she said. “There’s so much more to it nowadays.”

Increase in ailments

Much has changed in school nursing in the past 10 to 15 years, said Chris Amidon, a registered nurse serving Crawfordsville Community School Corp. and president of the Indiana Association of School Nurses.

One area in particular is the increase in students’ mental health problems.

“A lot of us were not prepared to deal with that,” she said, because of nurses’ inexperience in psychiatry.

She estimates about 32 percent of school nurses’ time is devoted to providing mental health services, whether they realize it or not. Often mental health problems can show up as physical ailments like head or stomach aches, she said.

According to a 2011-12 survey by the Centers for Disease Control and Prevention, about 165,000 Hoosier children have emotional, developmental or behavioral problems that require treatment or counseling, and 41 percent of those children do not receive mental health services.

Children born prematurely or with other challenges now live and attend school.

“There’re so many children with time-consuming needs,” Amidon said, such as tube feedings or students who need help using the restroom. Thirty years ago, she said, these children probably wouldn’t have even attended school.

Rates of overweight and obese children as well as the number of children with food allergies are also increasing.

Mary Hess, head nurse for Fort Wayne Community Schools, said more than 13,000 students in the district report having allergies. That includes food allergies, such as to peanuts, and being allergic to bee stings and latex.

About 760 of those students report severe or anaphylactic symptoms if exposed to a certain allergen, she said.

“There’s been a huge increase in allergies from when I started 15, 16 years ago,” Hess said.

Hess reports allergies and diabetes among the top four reported chronic illness of students in FWCS, now the largest district in the state with about 30,600 students. Asthma and seizure disorders also top the list.

“We see an increase every school year with students reporting some chronic health condition,” Hess said.

According to the National Association of School Nurses, the incidence of obesity in the past 30 years has doubled for 2- to 5-year-olds; tripled among 6- to 11-year-olds; and more than tripled for 12- to 19-year-olds. In Indiana, 32 percent of children ages 10 to 17 are overweight or obese, according to the CDC survey.

A disease such as diabetes requires extra effort to manage as treatments have advanced. Diabetic children used to get insulin in the morning, and their blood sugar levels were simply monitored during the day.

“There was not the constant fine-tuning we see in today’s plans,” she said.

Many children require insulin when they eat, which could be twice a day if the child eats breakfast at school.

FWCS to hire nurses

Students’ insulin needs are what led the Crawfordsville schools to make it a priority to provide funding for a full-time nurse in each of its school buildings, instead of its old policy of staffing based on just a few students in certain buildings.

“We used to do that, but it got to the point where there’s at least one child in each building with diabetes or even food allergies,” she said.

Unlike Crawfordsville, not every school in Fort Wayne Community Schools is staffed with a full-time nurse. This year, about 24 nurses split their time among the district’s 51 school buildings. Some nurses, like Kissling, are responsible for three schools, Hess said.

“My nurses have been stretched very thin,” she said.

Northrop High School is one of the district’s busiest schools with more than 2,000 students. The school’s full-time nurse fields 650 to 850 student visits a month.

“Their traffic flow is extremely busy, but I wouldn’t say that’s particularly new,” Hess said. “I’ve felt for some time we’ve needed more nurses.”

FWCS plans to hire additional nurses for next year, bringing the total number of nurses to 30 with no nurses serving more than two buildings.

Ten years ago, Southwest Allen County Schools employed clinical aides, or someone who has medical training but isn’t licensed, in some of its schools instead of a registered nurse.

Amidon said many districts have moved away from using clinical aides, although some districts like Huntington Community School Corp. still use them or other unlicensed staff instead of registered nurses. And in FWCS if a nurse isn’t available, secretaries and other staff receive special training like CPR and medication dispensing.

Southwest Allen changed its policy when it became clear that student health was becoming more challenging and “too medically intense,” said Phyllis Davis, director of human resources in the district.

“In many schools we have children with severe disabilities and who are very unique, medically,” she said.

Southwest Allen employs 11 nurses, with at least one nurse working full time at each school. Others float among schools to give the full-time nurse assistance.

“I can assure you, they’re very busy,” Davis said.

Manic Mondays

A student sat on the cot in Kissling’s small clinic Friday waiting patiently for her to finish her phone call with a parent. He had come in because his eyes were red and itchy. After some questions, Kissling determined it wasn’t pink eye, a highly contagious infection, but that the student’s symptoms were caused by his allergies.

“It’s that time of year,” she said.

She offered him a cold cloth for his eyes and sent him on his way. He was the second student within an hour to complain about allergy-related symptoms.

Amidon said research shows that if students see a school nurse, they are more likely to have their problems addressed and to stay at school. Someone unlicensed who is providing care is more likely to send a student home.

School nurses are an important component in helping students achieve academically, Davis said.

“Our nursing staff is an important part of our school district’s success for our students,” she said.

They’re also an important part of children’s health care. Amidon said for many students who don’t have health insurance, school nurses are primary health care providers. She said Mondays are often busy times with students who’ve been sick all weekend, and their parents send them to the nurse to determine how serious the sickness is.

According to the CDC survey, nearly 12 percent of Hoosier children lacked consistent health care coverage last year.

For all they do, school nurses receive their own special day a year. Wednesday is National School Nurse Day, set aside to celebrate the more than 74,000 school nurses across the country.

“It is a very, very rewarding kind of nursing,” Amidon said.

Source: The Journal Gazette 

Topics: school nurse, full-time, mental health, diabetic, allergies, health coverage

Click me

Article or Blog Submissions

If you are interested in submitting content for our Blog, please ensure it fits the criteria below:
  • Relevant information for Nurses
  • Does NOT promote a product
  • Informative about Diversity, Inclusion & Cultural Competence

Agreement to publish on our DiversityNursing.com Blog is at our sole discretion.

Thank you

Subscribe to Email our eNewsletter

Posts by Topic

see all