In many medical settings, recovery follows a defined path, where healing is visible and progress is linear.
When treating patients with mental illnesses, however, that’s often not the case. And that, in turn, requires a different mindset and a more holistic approach.
Core attributes for success in psychiatric nursing
At the Stewart and Lynda Resnick Neuropsychiatric Hospital at UCLA, which treats both children and adults, nurses have “a real passion for looking at the whole person,” said Patrick Loney, RN, chief nursing officer.
Communication and interpersonal skills are critical, but so is simply being present.
“I think one of our key skills is being able to sit with someone in a very uncomfortable situation and just be there with them to deliver compassion,” said Bob Bencangey, DNP, nurse educator at UCLA Health.
Many nurses who come to Resnick Neuropsychiatric Hospital choose psychiatric nursing over other medical specialties because they want to help fight the stigma of mental illness, and many have personal stories of family members or others whose lives have been affected by mental health issues.
For Loney, who has family and close friends who have struggled with mental illness, the decision to specialize in psychiatric nursing was also shaped by his experience in nursing school.
“I had a professor who taught mental health, and she was amazing,” Loney recalled. Additionally, the professor’s daughter had developed schizophrenia while enrolled in medical school, a turn of events that stayed with Loney and underscored the indiscriminate impact of mental illness. “It was so powerful to me,” he said. “Here’s this really high-functioning person – it really can strike anyone.”
While many choose psychiatric nursing because of the inherent complexity of mental illnesses, the fact that healing doesn’t necessarily follow a traditional path can be challenging for those more accustomed to working in other medical settings. It requires what Loney calls “the therapeutic use of self,” where the goal is to accompany the patient on their mental health journey rather than “fix” them.
“You have to embrace the intrinsic reward of knowing that you're helping people,” Bencangey added. “You may spend weeks working with someone only to see them decompensate. But by developing a relationship, you may be the first person your patient ever opens up to, and this may help save their lives.”
Communication and trauma-informed care
As part of orientation and training, all nurses, care partners and therapists at Resnick Neuropsychiatric Hospital are required to be certified in de-escalation techniques, using an industry-standard day-long class that focuses on successfully managing crisis situations by defusing or de-escalating them whenever possible. They also complete a refresher course every year.
Bencangey, who teaches the courses, also provides an abbreviated version to all physicians who come to work at Resnick Neuropsychiatric Hospital as part of their residencies.
“We teach a baseline framework for how to respond, but it’s just a framework,” Loney explained. “Humans are really complicated, unpredictable things.”
When someone’s agitated, being able to assess what’s needed and help restore a sense of calm requires a personalized approach.
“It’s listening a lot more than talking,” Loney said. “It’s being very patient and having a calm voice even when you’re not feeling calm, and trying to listen for meaning and understand how to meet the patient’s needs.”
This can require some decoding, he noted: “Underneath, there’s usually a message that’s real and worth listening to, but it gets lost in the agitation or the confusion or the physical behaviors.”
Related and also essential: a commitment to providing trauma-informed care, which recognizes that patient behaviors are manifestations of their illness and past experiences.
“We look at patient behaviors as the tip of the iceberg,” Bencangey said. “Everything below the surface of the water is the history this person has and all the stuff they’ve gone through. What we’re seeing in the moment isn’t about us; it’s about something traumatic that’s happened to the patient. Not taking those behaviors personally is a key skill in de-escalating situations.”
Nursing staff are also trained to recognize that different approaches work best in different psychiatric situations. When working with a patient who’s manic, for example, it’s important to remember that “they’re not intentionally doing anything, that this is the disease itself,” Loney said. Many patients initially have trouble sleeping, and they may be irritable or even giddy or grandiose, he explained. They may need to be reminded to eat, drink water and take their medications, he said, but it’s important to do so in a way that’s thoughtful and patient.
Similarly, with a patient who’s delusional, “you’re not going to be able to talk them out of it,” Loney said, adding that trying to do so might just frustrate them. Instead, “it’s important to remain calm and empathetic, avoid arguing and redirect them back to the task at hand.”
There can also be unique communications needs with certain patient populations: For example, working with a child who has a psychiatric illness means taking into account the specific illness as well as the child’s developmental level, he added.
A relationship-based approach
In some situations, a patient may respond differently to one staff member than another. “When somebody’s going into a crisis, we find out who has the best rapport with them, who has the best chance of helping them,” Bencangey explained.
That’s made possible because staff members at Resnick Neuropsychiatric Hospital are all in regular contact with all of the patients, given that various staff members lead therapeutic groups and interact with patients in social spaces on the ward, a practice known as “milieu therapy.”
Working as a team also includes being alert to medication-related changes or other issues and communicating back to the medical treatment staff. “That’s a lot of what psychiatric nursing is: observing and assessing, and making sense of what you’re seeing,” Loney said. “All of the disciplines – social work, occupational therapy, physicians, nursing – we’re very tightly knit, and everything’s very interdisciplinary.”
Empowering nurses and improving patient outcomes
Resnick Neuropsychiatric Hospital is currently pursuing redesignation as a Magnet-recognized facility – a sign of nursing excellence that only a few freestanding psychiatric hospitals have.
Receiving the designation is a lengthy process and is based largely on nurse-led initiatives. The hospital first received the designation in 2019; being redesignated as a Magnet facility includes a site visit to evaluate additional initiatives that have taken place since then to continue to improve patient outcomes.
Loney cited one recent initiative, "Welcome to Resnick Neuropsychiatric Hospital" videos for patients, implemented in 2021 to supplement existing print and online welcome materials. “We wanted to provide an alternative for individuals with preferred visual and auditory learning formats,” he explained. The series of four videos was customized for patients in each of the Resnick programs and can be accessed through the hospital’s website, the UCLA Health app, or via a QR code.
The videos were a collaborative project, Loney noted, and also included input from members of the Patient and Family Advisory Council of past patients and their family members.
Members of the council play a vital role at Resnick Neuropsychiatric Hospital, Bencangey added: In addition to meeting monthly to provide feedback and suggestions, they share their stories as part of new-hire orientation, which can be quite powerful. “Their personal stories provide the context of why we do what we do,” he said.
Hearing these perspectives also underscores the nuances of working with patients with psychiatric illnesses, and the reality that all too often, being discharged doesn’t mean being “cured.”
“A good chunk of our patients will struggle with these issues long after they leave us,” Loney said. “We believe people can get their highest level of functioning, and our job is to support them getting there.”
