NURSES CARE for the whole person. Incorporating body, mind, and spirit into clinical management isn't only altruistic, but also necessary. Nurses can offer an integrated approach to their plan of care to enhance healing. Age-old concepts and techniques such as compassion, consciousness, communication, and insight are familiar approaches that create positive and predictable patient outcomes.1 Humanizing care in this way builds patient resilience. Nurses are prepared to meet the multifaceted needs of persons and build connections across health settings through behavioral health.2
The Substance Abuse and Mental Health Services Administration views behavioral health as essential to overall health, and promotes positive choices and actions that affect mental and emotional wellness.3 Behavioral health concerns encompass a range of problems including mental illnesses, substance misuse and abuse, suicide, and serious psychologic distress.
The versatility routinely demanded by nursing prepares nurses well for moving into this field. This article presents a model for integrated care with examples, and makes recommendations for incorporating behavioral health into nursing practice and policy.
The need for behavioral healthcare
In 1978, behavioral health was defined and redefined in a manner that reflected an “integrated biobehavioral perspective.”4-5 This early thinking encouraged movement away from separating physical/medical care and mental/psychiatric disorders to addressing the patient's overall needs.5 This type of thinking about the connections between physical and behavioral health gained significance as primary care providers recognized the association between mental illness and physical disorders and the consequent importance of interdisciplinary care.
Behavioral health challenges affect individuals of all ages in significant numbers. The World Health Organization (WHO) has found that behavioral health disorders are a rising social burden.6 The WHO predicts that by 2020 behavioral health problems will surpass major healthcare problems and disabilities such as heart disease and diabetes in prevalence.6 Further, the CDC estimates that 46% of U.S. adults will experience a mental disorder.7 The CDC expects that by 2020, mental health and substance use disorders will be responsible for most disabilities worldwide.8
Even the very young among us face behavioral health challenges: The number of children with mental health issues has increased over the years.3 Millions of children in the United States, ages 3 to 17, live with primary mental health issues such as depression, anxiety, attention-deficit/hyperactivity disorder, Tourette disorder, substance use disorder, and autism spectrum disorder.9,10
These predictions about the growth in disease burden due to behavioral disorders underline how important expanded efforts in behavioral healthcare are. They also point to a remarkable opportunity to direct future nursing programs and services toward behavioral health.
Nursing's historical role
Nurses have had a long involvement in attending to both the physical and behavioral health of their patients (see Heroes of behavioral health). Klainberg and Dirschel note that in the 19th century, during the Crimean War and the American Civil War, nurses weren't formally educated and in many instances had to use their own resources to acquire supplies to provide for the physical and mental needs of the soldiers under their care.1 During World Wars I and II, the number of trained nurses grew. Nurses experienced many of the hardships of war themselves: They were captured and held as prisoners of war and endured shellfire while caring for patients, without official rank or benefits.
During the mid- to late- 20th century, nurses understood more about the importance of mental health issues in combat and trauma. They incorporated public health approaches to disease prevention and health promotion into their care, including home healthcare, rural care, postpartum and newborn care, and family planning.
In the 21st century, with the rising influence of insurance guidelines, multiple career options, second careers, and the emphasis on healthy lifestyles, the growth of nursing outside of the traditional hospital setting encourages a more comprehensive approach to care. The Institute of Medicine reports on the shift from hospital to community care as well as a change in focus from treating only acute illnesses and injuries to caring for patients holistically despite a complex care system.12 This shift has created opportunities for nurses to make greater contributions to care.
A natural nursing fit
Because nurses can choose from scores of career paths, entry into behavioral health may not be a priority for many nurses just entering the field. A 2008 survey of nurses conducted by the Health Resources and Services Administration (HRSA) confirms the relatively small number of nurses currently involved in behavioral health: Depending on the setting, only 5.1% to 6.5% of RNs indicated psychiatric/mental health as the clinical specialty most required by their principal nursing position.13
While relatively few nurses indicated that they're involved in behavioral health, change in the nursing profession is common. The HRSA survey found nearly 40% of new graduate nurses leave their positions within 3 years.13 These nurses should consider behavioral health because many of the concepts that promote behavioral health are already concepts nurses work with in their current positions. For instance, nurses know that prevention, early disease identification, and intervention influence positive results. These same core components are central to behavioral health, such as with early screening for depression and anxiety.
As the field of behavioral healthcare expands, nurses will find more opportunities to move into this area. Signed into law in March 2010, the Patient Protection and Affordable Care Act (ACA) expands these opportunities, incorporating behavioral health (such as mental health and substance use disorder services) as an essential health service. Many nurses see the ACA as an opportunity to effect long-term, positive change in underserved populations.
Even for nurses whose primary responsibilities aren't psychiatric or mental healthcare, the ACA opens opportunities for nurses employed in many of the prenatal and primary childcare settings where parents-to-be and children are involved, such as healthcare providers' offices, schools, community centers, hospitals, shelters, and treatment centers. A nurse's role in promoting behavioral health may be as basic as participating in continuing education. The nurse may also choose to learn about mental health promotion and the prevention of mental, emotional, and behavioral disorders through early identification of signs and symptoms.
Models of integrated care
With new evidence of positive clinical outcomes, the healthcare community is more receptive to integrating the treatment of physical and mental illness. The integrated care model offers an array of services that include prevention, treatment, research, education, and recovery support. This model is espoused by the U.S. Department of Health and Human Services.
A model of integrated care has been adopted by the Veterans Healthcare Administration (VA), which has transformed care by promoting interdisciplinary collaboration in order to meet the needs of diverse veterans from World War II and more recent conflicts.14 Further, the Department of Defense and the VA have created state-of-the-art traumatic brain injury (TBI) centers that provide an interdisciplinary approach to medical treatment, behavioral health services, and education.15
Community-based behavioral health resources and interventions are a large part of managing these patients with TBI. Also, efforts to combat complications associated with TBI such as posttraumatic stress disorder are a significant training component for the multidisciplinary staff of these TBI centers.14 Patients obtain strategically developed coordinated care from an interdisciplinary team of professionals, from diagnosis to recovery. Nurses are instrumental in caring for these patients. In addition to linking patients to available interventions, nurses monitor patient progress and help patients develop healthy coping skills and improved self-esteem.
Other efforts are underway to incorporate critical concepts of behavioral health into clinical practice, training, and education. For instance, the conceptual framework of the Patient-Centered Medical Home (PCMH) utilizes a multidisciplinary team approach to provide clinical services and meet patient-care objectives. PCMHs offer a conduit for clinicians in primary care centers to work with behavioral health providers to offer targeted, patient-centered care.16
Experience and research suggest that barriers created by the stigma of mental illness and other behavioral health disorders are lessened by approaches to care offered in convenient (and community-based) settings such as home-based care, community centers, healthcare provider offices, and hospitals.17 Clients may not always be able to determine the best “door” to care; therefore, it's important that healthcare professionals take an integrated approach to understanding the patient's needs for care and accessing appropriate services. The current science about mental health and substance abuse substantiates the need for efficient and effective strategies of care in the community.18
Building a framework
While progress is evident, a significant lack of understanding about how behavioral health can be integrated into the healthcare system remains. Now more than ever, nurses must take their seat at the table where decisions are made. Nurses can advocate for behavioral health as a significant part of the larger vision within an organization and ensure its inclusion in any effort to provide holistic healthcare.
Because prevention and early identification are key areas of engagement in behavioral health, schools provide an excellent setting in which to influence the mental, emotional, and behavioral health of children and youth through evidence-based prevention programs and the early identification of behavioral health problems. Nurses can seek opportunities to participate in school career days to talk about the field of behavioral health nursing. School nurses and parents who are nurses can help facilitate such events and are welcome models for students interested in pursuing such a meaningful career. Behavioral health nurses can use this forum to share the importance of behavioral health to child and youth development as well as encourage prospective nurses to consider this career path.
Social media is an influential tool for nurses and other care providers to disseminate information and build interest in behavioral health. The WHO recommends the use of multiple communication channels to share strategies that improve the experience and care of persons who have mental health challenges.19 It also promotes the value of linking clinical approaches with personal effort to aid in prevention, treatment, and rehabilitation.
Nurses are engaged across the nation in broadening the discussion of integrating medical and behavioral care into policy and practice, education, and legislation; and these discussions need to occur in many arenas. For instance, The Joint Commission, which accredits and certifies healthcare programs and organizations, has long been a proponent of providing effective mental health and substance abuse care.20 The Joint Commission engages a broad group of stakeholders to ensure that a metric of performance is developed and maintained in the mental health and substance abuse fields.20 For nurses to contribute to such discussions, it helps to begin with basic information about behavioral health and its application to a specific area of practice. Take advantage of the many nursing workgroups and committees available that aim to integrate behavioral health into the larger discussion and agenda.
Full speed ahead
The fact that behavioral healthcare is now a required benefit under the ACA gives nurses an opportunity to develop new skill sets in behavioral health, creates new ways to integrate care, and potentially offers new career opportunities.21 A public health approach to behavioral health policy, practices, and programs offers nurses new fields for practice and service.
Heroes of behavioral health
During the 19th century, Florence Nightingale became well known for championing the cause for clean medical facilities and a comforting approach to care and healing during the Crimean War.1 Historians believe that Nightingale herself suffered depression, but she nonetheless contributed significantly to the field of nursing and mental health through research and published writings.2
Another leader in behavioral health nursing was Dorothea Dix, who advocated for the poor and persons with mental illness during the Civil War. In 1852, she also worked with Congress to establish what is now St. Elizabeth's Hospital in Washington, D.C., to care for persons with mental illness; she ultimately facilitated the establishment or expansion of 30 mental health hospitals.3,4
In 1948, Hidegard Peplau of the Army Nurse Corps created and later published the landmark nurse-patient model that encourages nurses to partner with their patients to create positive behavioral outcomes.5 Virginia Henderson, an Army nurse, wrote in 1955 about nursing's role in fostering activities that propel the patient to self-care and build resilience.6
- British Heritage. Florence Nightingale: facts summary information. 2014. http://britishheritage.com/florence-nightingale.
- Carson J, Wakely E. Mental illness: a curse and a blessing. History Today. 2013;63(2):10-16.
- Parry MS. Dorothea Dix (1802-1887). Am J Public Health. 2006;96(4):624-625.
- DesRochers A. Dorothea Dix: Mental Health Reformer and Civil War Nurse. Smithsonian Institutional Archives. 2012. http://siarchives.si.edu/blog/dorothea-dix-mental-health-reformer-and-civil-war-nurse.
- University of Pennsylvania. Hildegard E. Peplau papers, 1949-1987, MC 59. 2004. www.nursing.upenn.edu/history/Documents/Peplau_FINAL.pdf.
- Klainberg M. An historical overview of nursing. In: Klainberg M, Dirschel KM, eds. Today's Nursing Leader: Managing, Succeeding, Excelling. Sudbury, MA: Jones & Bartlett Learning; 2010.
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