Empowering clients to achieve a self-determined level of function and a satisfying quality of life is the mission of the mental health faculty nursing practice at the Vine Hill Community Clinic (VHCC) of Vanderbilt University School of Nursing (VUSN). This nurse-managed clinic, currently in its eighth year, was initially supported by grants from the W.K. Kellogg Foundation and die Department of Health and Human Services Division of Nursing. VHCC is now fully reliant on third-party reimbursements, managed-care capitation contracts, and sliding-scale self-pay.
The clinic is located in a lowincome, public housing development in Nashville, Tennessee. Family nurse practitioners (FNPs) provide primary care at the clinic, while mental health nurse practitioners (Psych-NPs) offer a wide spectrum of mental health services that integrate the principles of psychosocial rehabilitation. These mental health services include: consultation; crisis intervention; psychosocial rehabilitation planning; case management; individual, group, and family therapy; medication management; community outreach; and client-consumer participation (Richie et al., 1996).
The primary care clinicians cover 4,000 capitated lives and serve an additional 1,000 clients as primary care providers. Diabetes, hypertension, and depression are the most frequent primary diagnoses, followed by gynecologic services, acute infections, and arthritis. The mental health clinicians provide services to an active caseload of 200 to 250 clients. In the past fiscal year, mental health faculty clinicians, whose collective time equals 32 hours a week (less than one full-time employee), provided 1,100 therapy hours, while graduate psychiatric nursing students delivered 800 therapy hours as free service. The mental health caseload is composed of the following diagnostic categories: 12% schizophrenia; 5% bipolar disorders; 65% affective disorders (major depression, dysthymia); 10% anxiety disorders; and 3% miscellaneous.
Faculty, Student, and ClientConsumer Involvement
This faculty practice site is also used for clinical placement of graduate students in the Psychiatric-Mental Health Nurse Practitioner (Psych-NP) program at VUSN. Students are immersed in the advanced practice role of mental health nursing and learn the importance of building collaborative partnership with clients through observation of and experience with faculty role models. Throughout their experience, students work to develop a foundation that integrates principles of psychosocial rehabilitation into their intervention strategies.
Client Satisfaction Data
Students learn functional assessment of client abilities as well as differential diagnosis using psychiatric nomenclature. Clients are assessed for their readiness to engage in setting rehabilitationoriented goals. They are actively involved by the nurse-therapist to: identify current life stressors; assess necessary skills for living and coping in the community; assess needed community supports and resources; and assess the individual's and his or her family's knowledge base regarding psychiatric disability (Palmer-Erbs & Anthony, 1995; Palmer-Erbs, Connolly, Bianchi, & Hoff, 1996).
A psychosocial rehabilitation plan with short- and long-term goals is developed with the client that focuses on building life skills and knowledge to successfully manage one's disability; developing a social support system; and linking the client to resources within the community to maximize independence in major life roles and daily functioning. The plan is designed to create opportunities for success in reaching small goals that build the client's confidence.
Appointment Compliance Data (N=16)
Striving for client satisfaction
Within both a psychosocial rehabilitation framework and a managed care delivery model, clients are viewed as consumers of mental health services. Actively involving client-consumers in evaluating the quality and type of services available is an essential component of program evaluation. VHCC conducts semi-annual satisfaction surveys to elicit this information with plans underway to initiate consumer focus groups in the next year (Tables 1 and 2).
Client-consumer feedback has already lead to the development of a variety of services and community activities in recent years: stress management classes; women's life skills group; a men's issues group; a "Living with schizophrenia" group; a life transitions group; parenting classes; and new activities at the annual health fair. The value of this client-consumer involvement extends beyond continuous improvement of program services to the increased self-esteem and sense of ownership client-consumers experience when their ideas are sought, heard, and implemented.
A rich client contribution
Mental health client-consumers have richly contributed to the education and training of graduate students at VHCC and VUSN through participation as guest lecturers, demonstration interviews, and willingness to have a new graduate student as a primary therapist each year. Although client-consumers are given the option to request either a faculty clinician or graduate student clinician as primary therapist, there are advantages to having a graduate student clinician. For example, the availability for more frequent visits, lower sliding-scale fees for self-pay clients, and no billing fee for managed care or privately insured clients. Clientconsumers get a fresh perspective on their individual life situations, and perhaps different approaches in reaching their respective treatment goals. Some clients prefer the continuity of having the same faculty clinician over a period of years, but are encouraged to periodically see a graduate student clinician to their benefit.
Relating the struggle
As guest lecturers and during demonstration interviews with faculty, client-consumers share their daily life experiences of coping with a psychiatric disability as well as their symptoms and history. A poignant and recurring theme is their individual and collective struggle with the stigma of living with a mental illness (Wahl, 1995; Wright, 1960; Yankelovich, 1990). In repeated efforts to initiate, develop, or maintain a friendship, clients report the repeated pattern of emotional distancing and withdrawal when new acquaintances, neighbors, and even family members learn that they are on a psychotropic medication or suspect mental illness. Efforts to seek or maintain employment bring a plethora of emotionally traumatizing stories of rebuff and rejection, countered by an occasional "success" story.
Activities of Clients With Schizophrenia After 1 Year VHCC-MH Services
"fry" and "try again"
In addition to sensitizing students to the stigma of mental illness, client-consumers share what they have experienced as being helpful and effective in facilitating their recovery. Opportunities to "try" and persons who "believe in me" are the universal comments. Opportunities to try new skills, learn new ideas, discover and use community resources, learn from mistakes, and try again are most often cited.
Encouragement from staff, clinicians, other clients, and family members that tìiey can succeed at this next step is what most often motivates a client-consumer to "try" something new or "try again" (Kirkpatrick, Lundeen, Byrne, Woodside, Pawlick, & Bernardo, 1996). Client-consumers challenge graduate students and faculty to integrate these concepts into their clinical practice. It is a lesson not easily forgotten.
Information about community resources is maintained and shared among clinicians and client-consumers, because programs change over time in response to usage and to private and public funding sources. Frequently used resources by VHCC client-consumers include: sheltered workshops, work training and placement programs, community sites for remedial math and reading skills, self-help groups, church activities, and community centers (Table 3). The collaborative partnership developed between client-consumer and nurse clinician draws on these resources to foster recovery through personal growth, increased knowledge, improved coping skills, and strengthened personal support systems. Client-consumer involvement in community activities is effective in normalizing daily life experiences and in breaking down the barrier of stigma. The following vignettes illustrate how the nurse-client partnership encourages the recovery process.
A Nurse-Client Partnership
"John," a 39-year-old single man, was initially seen at VHCC for hypertension by an FNP. The FNP referred him to the Psych-NP for stress reduction, anger management, and improvement of coping skills. During the third session, John trusted the nurse-therapist enough to disclose that he was hearing voices. He had not mentioned the voices earlier because he feared being labeled mentally ill.
John related that he first heard these voices at age 20 when he was in college. The physician he saw at that time told him that he had schizophrenia and gave him medication that "made him feel like a zombie." He stopped treatment and quit school. During the next 19 years, he lived alone, withdrew from his family of origin, was unable to hold any retail sales job for longer than 1 year. He was afraid of being stigmatized by being labeled as mentally ill, and struggled with low selfesteem. John was currently facing eviction from his apartment because the landlord had received numerous complaints about his loud music that he played "to drown out the voices."
Morning departure for the work training center.
Upon hearing his history and assessing his daily functional abilities and knowledge base, the nurse-therapist and the client devised a treatment plan aimed at decreasing hallucinations and helping him be a productive member of the community. Four main goals were identified by the client and nurse-therapist:
* Education about the biological basis of schizophrenia;
* Consultation with the psychiatrist for initial psychotropic medication management;
* Exploration of coping styles and stress-reduction strategies; and
* Investigation and linkage of community resources.
After 6 months of bimonthly visits with the nurse-therapist, John reported that the voices no longer bother him. He is attending the men's support group, visiting with his family on weekends, working part-time at a grocery store, and attending school part-time. His continuing therapy with the nurse focuses on the anger and regret he is experiencing for the lost 19 years of his life. Being a volunteer at the local mental health center and helping others like himself has made his journey less lonely.
Kitchen clean-up after an evening meal.
The Family as Partners in Recovery
The value of family involvement is evident in the following case.
Peggy and Jerry, both 47 years old, married 8 years ago after meeting at an inpatient unit at a state psychiatric facility where both had been hospitalized for symptoms of schizophrenia. Because this is Peggy's third marriage and Jerry's second marriage, the couple began their relationship with a sense of clinging to each other for emotional support. Each had struggled with symptoms of schizophrenia for more than 20 years.
Their involvement with the VHCC Mental Health Clinic began when Jerry was seen by an FNP for the "flu." During the physical assessment, the FNP discovered that Jerry had lost 20 pounds in the preceding 8 weeks, had no appetite, had stopped taking his psychotropic medication some time ago, was neglecting daily hygiene, and spent most of the day curled in bed.
His wife, Peggy, accompanied him on this visit to express her concern and advocate on his behalf. She feared that he would be hospitalized and she felt unable to function alone. The FNP consulted the Psych-NP who provided a brief triage visit with the couple and arranged for a mental health intake appointment the following day. Jerry was hallucinating intermittently, but not experiencing suicidal or homicidal ideation. He agreed to restart the oral Navane that afternoon until a medication re-evaluation could be arranged. His weight loss was determined to be from malnourishment and irritable bowel syndrome, which the FNP addressed with dietary interventions.
The first meeting involved obtaining a thorough psychiatric history on both Jerry and Peggy and scheduling medication consultation with the psychiatrist. The nurse-therapist considered both clients potential candidates for a trial of atypical antipsychotic medications to address the evident negative symptoms of social withdrawal, amotivation, and impaired social and communication skills.
The second visit involved completion of a functional assessment that included physical, emotional, intellectual, social, and spiritual dimensions. The third visit was a collaborative process among the couple, the student-therapist, and the supervising faculty clinician to formulate a psychosocial rehabilitation plan with short- and long-term goals. The initial plan established the following goals:
* Stabilization of weight, physical and nutritional health;
* Education about symptom management and new atypical antipsychotic medications;
* Acquisition of more effective communication skills as a couple;
* Identification of common interests and activities to enhance their marriage relationship; and
* Exploration of community resources to build work skills that might lead to sheltered or competitive employment.
Within 2 months of the initial visit, Jerry had regained 10 pounds, was eating 3 to 4 small meals a day of soft easily digestible foods, no longer hallucinating, sleeping 8 to 10 hours a night, and spending his day helping Peggy and listening to favorite television and radio shows. He started an atypical antipsychotic medication that markedly reduced the muscle stiffness and fuzzy thinking he reported on previous psychotropic medications. His interest and energy level steadily improved.
As Jerry's health improved, Peggy was able to focus on her own health care needs. She had a complete physical and gynecologic exam for the first time in several years. She took an active interest in learning to select and prepare wellbalanced meals. She enjoyed practicing the relaxation techniques learned in their counseling sessions, and encouraged Jerry to practice as well. With the help of their student-therapist, they both improved their communication skills, and discovered feelings for each other that had long been hidden.
With encouragement from their student-therapist, they began attending educational meetings at a consumer-sponsored clubhouse that decreased their feeling of isolation.
An interest they both shared was to find employment and be able to purchase some of the amenities they had never been able to afford. The dream of a vacation still seemed a distant impossibility. Accompanying Jerry and Peggy to the vocational rehabilitation center facilitated their entry into a job training and work placement center. Now, after several months at the center, the possibility of competitive employment is a step closer.
They actively share their enjoyment of daily job training with other mental health clients at VHCC. They offer to accompany other clients on an initial visit to the work center and introduce them to staff and other trainees. In less than a year, this couple has made significant progress in their recovery process and continues to realize many of the goals they hoped to achieve.
These selected cases illustrate how nurse therapists integrate the principles of psychiatric rehabilitation to build partnerships with clients and their families that facilitate the recovery process.
The future still holds many challenges. Among these are the need to:
* Develop educational opportunities that are supported by local, state, and federal funding sources; and identify ways for clients to easily access these resources;
* Build partnerships for work training and placement among community employers;
* Identify ways for clients to easily access educational, employment, and recreational resources within the community;
* Influence state and federal legislators to establish insurance parity for psychiatric disabilities; and
* Erase the stigma of mental illness within the media, health care providers, employers, and the community at large.
Nearly everyone will be touched at some point and in some way by mental illness - through their own struggles or the struggles of someone they care about. Let us resolve as nurses to build environments that eliminate prejudice and stigma and that nurture hope and recovery for persons with psychiatric disabilities. Only in these settings will the mentally disabled client reach his full potential.
- Kirkpatrick, H., Landeen, J., Byrne, C, Woodside, H., Pawlick. J.. & Bernardo, A. (1995). Hope and schizophrenia: Clinicians identify hope-instilling strategies. Journal of Psychosocial Nursing and Mental Health Services, 33(6), 15-19.
- Palmer-Erbs, V.K., & Anthony, W.A. (1995). Incorporating psychiatric rehabilitation principles into mental health nursing: An opportunity to develop a full partnership among nurses, consumers, and families. Journal of Psychosocial Nursing and Mental Health Services, 33(3), 36-44.
- Palmer-Erbs, V.K., Connolly, P.M., Bianchi, R., & Hoff, L. A. (1996). Nursing perspectives on disability and rehabilitation. In K.N. Anchor (Ed.), Disability analysis handbook (pp. 173-201). Dubuque, IA: Kendall/Hunt Publishing Co.
- Richie, M.F., Adams, S.M., Blackburn, P.E., Cone, CP, Dwyer, K.A., Laben, J.K., & Seidel, S.S. (19%). Psychiatric nursing faculty practice: Care within the community context. Nursing and Health Care: Perspectives on Community, 77,317-321.
- Wahl, O.E (1995). Media madness: Public images of mental illness. New Brunswick, NJ: Rutgers University Press.
- Wright, B. (1960). The psychosocial aspects of disability. New York: Harper and Row.
- Yankelovich, D. (1990). Public attitudes toward people with chronic mental illness. Princeton, NJ: Robert Wood Johnson Foundation.
Client Satisfaction Data
Appointment Compliance Data (N=16)
Activities of Clients With Schizophrenia After 1 Year VHCC-MH Services