Writing about behavioral health issues becomes somewhat painful for me on a very personal level as I begin to prepare for having my son Michael, schizophrenic, for over 25 years and recently also diagnosed as suffering from bipolar disorder, spend the Christmas holidays with me. I received an e-mail that is reflective of the common attitude and humiliating derision people with mental disabilities feel every day, so I had to begin writing.
* Schizophrenia-Do You Hear What I Hear?
* Multiple Personality Disorder-We Three Kings of Disoriented Are
* Dementia-I Think I'll Be Home for Christmas
* Narcissistic-Hark the Herald Angels Sing About Me
* Manic-Deck the Halls and Walls and House and Lawn and Streets and Stores and Offices and Town and Cars and Buses and Trucks and
* Paranoid-Santa Claus Is Coming to Town to Get Me
* Borderline Personality Disorder-Thoughts of Roasting on an Open Fire
* Personality Disorder-You Better Watch Out, I'm Going to Cry, I'm Gonna Pout, Maybe I'll tell You Why
* Attention Deficit Disorder-Silent Night, Holy, Oh Look at the Frog-Can I Have a Chocolate, Why Is France So Far Away?
* Obsessive Compulsive Disorder-Jingle Bells, Jingle Bells Times Twenty or More.
I cried when I received this from a very close and dear friend. Yes, most of the behavioral disorders were made fun of, but there are many more that we have to take care of and assure confident, ethical and privacy in caring for and offering asylum from ridicule and lack of human understanding.
How is this funny? Why do we demean people with behavioral health needs? Why has the overall healthcare system left care for people with mental disabilities so far off the radar screen for so many years? Obviously, I have a very personal reason for wanting Nursing Administration Quarterly (NAQ) to address the administrative aspects of behavioral health. But, since the board determines future topics, I felt only when the topic was recommended could it be featured as an issue. Well, Ann Kobs brought the subject to our attention and offered to be the issue editor for this much needed topic.
Ann Kobs, MS, RN, earned her master's degree in nursing administration from Northern Illinois University, DeKalb. As President of Ann Kobs & Associates, she provides compliance evaluations and implementation for hospitals and long-term care, home care, ambulatory, and behavioral health organizations. Ann's experience includes nearly 10 years at the Joint Commission where she opened the Sentinel Event Unit and was the Associate Director of the Department of Standards Interpretation. Until recently, Ann was Senior Vice President for Accreditation and Compliance at TUV America Healthcare Specialists, a national accreditation company headquartered in Cincinnati, as well as the National Integrated Accreditation for Healthcare Organizations. She has also held the position of Senior Director of Project Development for the Association for Perioperative Registered Nurses, Denver, Colo, focusing on patient safety programming.
Ann has published extensively and has spoken nationally and internationally on standards, patient safety, and infection control and now has completed a RAB QMS ISO 9001:2000 Lead Auditor Program. Having been a nurse executive operational nurse leader has postured Ann to lead NAQ in this most challenging topic of Administrative Aspects of Behavioral Health.
For me, memories evoke many breaks in standards of care for the mentally ill. The earliest psychotic event for Michael occurred when he was a teenager and we had moved to Seattle from Wisconsin. I was speaking out of state, and he had been given marijuana laced with PCP (angel dust) at the high school he attended. He wanted to fit in. He had been an A, B student, a good athlete, and class leader back in Milwaukee. Moving far away in his junior year was disruptive and behavioral incidents led me and his father to believe it was teenage rebellion because we moved from where he grew up in the same house and neighborhood all his life.
In Seattle, he was achieving As in his morning classes and then Fs in the afternoon. What was happening at noon lunchtime? He was a handsome, tall, excellent football player and wanted to fit in. I knew he had tried marijuana before we moved, but we doubted he intentionally took some laced with PCP. That is not to say he might have become schizophrenic without the PCP, but it triggered the chemical disruption in his brain. So, in an acute state of anxiety and agitation induced by marijuana and PCP, he went to the bank to retrieve his money so he could leave town to go wherever he felt the need. As his behavior was so disruptive at the bank, his father was called, and then encouraged 911 to be called. So Michael, age 17, was overcome by 7 men and taken to Harborview Emergency Department where he was strapped on a guerney and left unattended. Thrashing around, he tipped over the cart and broke his arm and then was transferred to a psychiatric hospital before I was able to arrive home from Texas where I had been speaking. Thus began Michael's journey of more than 13 hospitalizations and 3 court commitments to psychiatric care. I could recount so many nightmares, but I will save that for another writing, if Michael agrees. The point is, we have neglected the administrative aspects of behavioral health far too long as we have neglected giving attention to the thousands of mentally disabled wandering our streets as homeless.
Through the years, Michael has been homeless in Seattle, Denver, and the deserts of southern Arizona. Not a pretty picture for a nurse mother to see. Fortunately, for the past 8 years, he has been able to live in his own apartment and remains in a mental health care system provided in Southern Arizona. His counselor and I work together to provide consistent communication and accept Mike as he is. I also have wonderful neighbors who accept Mike as he is even though many people give little thought or support to his lifelong disability. When a physical disability occurs through accident or birth, that is usually accepted and supported. A man with so much promise entered the US army at the age of 19 as an attempt to escape verbal abuse around him and ended up with the definitive diagnosis of acute schizophrenia. Michael eventually received an honorable medical discharge. While he is not on Veteran's benefits, there are so many veterans who have suffered mental disability while serving our country. We read much about those who are experiencing mental breakdowns from the Iraq war. Veterans' mental health care must be a top priority.
Our healthcare system has not paid adequate attention to the mentally ill and we need to do something about it as a mission from nurses who care. The next anorexic or bulemic young woman needs our attention. The alcohol or drug addicted person needs our attention. The acute depressive disorder nurse needs our attention.
In 1985, NAQ published 2 issues dedicated to helping the troubled nurse: Vol. 9, Nos. 2 & 3: Managing the Troubled Nurse and The Troubled Nurse: Management Strategies. These issues are filled with positive and supportive ways to assist the impaired nurse. Nurses, like other medical professionals, are more vulnerable to addictive problems with behavioral manifestations, oftentimes covered up or hidden by working permanent nights. They are less noticed and have less obvious behavioral signs than the staff members who work evenings or days. I recollect my night supervisory position in a large teaching hospital in the midwest, in addition to more than 20 years as a chief nursing officer.
Yes we need to pay attention to our own and look carefully and astutely at whatever support systems we have for our staff. What about the nurse executive burnout and loss of senior, overworked members of our profession? Nursing is seen as the most ethical occupation for the sixth straight year in a USA Today/Gallup Poll. Still the growing demand for professionals to provide behavioral health services is unmet in most settings. Therefore, there are inconsistencies in care provision, and leadership for behavioral health is lacking. With this issue of NAQ, I ask you as nurse leaders to take up the challenge of provision of excellence in all aspects of healthcare, particularly, behavioral health.
Barbara J. Brown, EdD, RN, CNAA, FAAN, FNAP
Editor-in-Chief Nursing Administration Quarterly