Nurses are on the front lines of psychological care more often than many people realize.
When you think of treating depression, social workers or psychologists are often the first healthcare professionals that come to mind. Not nurses.
Yet as the directors of nursing at two residential treatment centers attest, nurses are often on the front lines of psychological care.
Whether they are managing medication or being empathetic listeners, nursing staff’s unique perspective on mental health treatments benefits patients.
“This is the most holistic nursing I can do,” said Marge Crotty, MS, RN, director of nursing, Timberline Knolls, Lemont, Ill. She previously worked in adolescent psychiatry and then as the manager of clinical operations at a medical center.
Crotty retired in 2007, but did not adjust well to that lifestyle, so she took a part-time at Timberline. “Something here absolutely drew me in,” she said. That part-time position grew her current full-time role.
Nurses like Crotty, whether staff or management, have a varied role in treating patients with depression.
“Nursing staff has eyes and ears on patients all day long,” said Susan Menzie, MS, RN, director of nursing, Sierra Tucson, Tucson, Ariz.
Dating back to her days as a med-surg nurse, Menzie has had a career-long interest in the pyscho-social issues patients face. She took a job at a chemical dependency program and that interest blossomed. Eventually, she ended up at Sierra Tucson.
That high level of assessment leads nurses to participate in informal talk therapy with patients. They observe triggers, like a conversation with another patient, and try to diffuse the situation with verbal de-escalation skills.
“We help patients access coping skills and deal with their emotions as they come to the surface,” said Menzie.
As Crotty explained, “The No. 1 thing nurses need to be aware of is identifying harm.” Along with her fellow nurses at Timberline Knolls, she is very careful about assessing patients for possible suicide risks.
At Timberline Knolls, clinicians primarily treat clinical depression, which is more disabling, with symptoms lasting longer; situational depression that can accompany PTSD, atypical depression that can accompany an eating disorder or chronic fatigue; and bi-polar depression, a very complex mood disorder.
“One of the overwhelming things I see at Timberline is past trauma,” noted Crotty. The facility treats mostly young women. The average patient age is 26. Crotty also has experience working with geriatric mental health patients. Their depression is more likely to be a result of chronic illness. They are also more likely to be medically compromised, which affects treatment.
Age & Gender Challenges
Younger and older patients have different challenges. “What a young person faces at 18 is different than someone who is 40. Nursing staff needs to be mindful of where the patient is in their life,” Menzie noted.
A 65-year-old anxious about aging needs a different approach than a twenty-something anxious about body image. “There are so many variables,” she said.
There are special considerations when treating female patients. They are more likely to have hormonal issues, and at least in Menzie’s experience, are more likely to have suffered past traumas. Sierra Tucson has both co-ed and all-female residential lodges. The staff is deliberate about the living situation for each patient, making sure it is the best fit for their recovery.
Patients with a co-occurring disorder also require special precautions. As Crotty put it, “That’s probably our specialty.”
When a patient is first admitted, often only one co-occurring issue, like substance abuse, is evident. Through their daily assessments, nurses are on the lookout for incidences of other disorders, and can recommend a treatment reassessment.
There is also a chemical component to treating depression in women who have a co-occurring disorder. At Sierra Tucson, there are programs to treat addiction; mood disorders, like depression and anxiety; trauma; eating disorders; and pain, as chronic pain and chronic depression often co-exist.
Menzie advises clinicians to really look carefully at the medications patients take and not just those for mental health. What are the side effects and what are the contraindications? Certain anxiety medications are short acting. A nurse can observe changes in a patient’s behavior at particular times of the day and advise the physician to change the timing or dosage.
Patient education is important with medication management. Nurses can coach patients how to manage the side effects and teach them it sometimes takes a few weeks for the full effects of the drugs to take hold.
Of course, there is much more to being a director of nursing at a residential mental health treatment facility.”My role is more like a director of patient care services,” explained Menzie.
Nurses provide 24-7 patient care, and she supervises approximately 115 members of the clinical team, which includes nurses, and clinical technicians, and she assists other professionals in managing patient issues. Menzie provides clinical supervision and continually teaches her team how to manage and communicate with difficult patients.
“There are no two days that are the same at Timberline, which is what I love about it,” Crotty said. Besides supervising the daily operations of the lodges and training the nursing staff, “I really like to be involved with the residents.” She makes rounds and attends resident meetings.
“They built their own registry of nurses who have been trained at Timberline to fill in when the regular staff in unavailable, allowing for a continuum of care. She has hired nurses with a wide range of past experiences-med-surg, OB-GYN, home health, and psych, among others. As she explained, “We learn from each other.”
Collaboration with other disciplines, both scheduled and a spontaneous, is an important part of treatment at the facilities.
At Timberline Knolls, if a nurse notices a change in a patient’s behavior, they call impromptu staff meetings. They’ll pull in the physician, primary therapist, dietician and other clinicians to form an action plan.
Similar situations arise at Sierra Tucson. Menzie said, “I see my role as making sure the teams work correctly.” She’s actively involved with the medical director and the director of clinical services. When dealing with difficult patients, she moderates case conferences where healthcare professionals from various disciplines share their input.
Crotty argues passionately for the inclusion of nursing in the treatment plan for women with depression. “These nurses are clinicians who are with them every hour of the day. They provide in-the-moment intervention,” said Crotty. “I could not imagine Timberline Knolls without them.”
Menzie echoes those sentiments about the power of nursing in the mental health setting. “Behavioral health is a fascinating and dynamic form of nursing. It keeps you on your toes mentally, physically, emotionally and spiritually.”