Approximately one in five adults in the US experiences mental illness, according to the National Institute of Mental Health. In addition to challenges related to healthcare access, socioeconomic considerations, and other health disparities, patients with mental health disorders may experience a stigma attached to their condition that can negatively influence outcomes. In environments where the patient may feel stigmatized or disrespected by healthcare providers, there may be less-than-optimal mental health outcomes because of failure to access needed services or the lack of follow-through with medical advice. That's why our nursing practice must include proficiency in cultural competence, defined as the “continuous process of cultural awareness.”
Culture may be expressed as a way of life, customs and traditions, habits, mores, and values. A patient's culture can have a great impact on his or her ability to engage in positive interactions in the healthcare setting. Caring for a patient with a mental health disorder requires a comprehensive and empathetic view. We must be sensitive to the issues influencing the patient's symptoms and treatment and be aware of individual differences when developing a culturally appropriate care plan. Viewing each patient as unique can facilitate the nurse-patient relationship and allows us to provide services that reflect the beliefs and values of our patients.
Many factors influence the care of patients with mental health disorders, including family and environmental factors, employment, sexual orientation, and spirituality. Let's take a closer look.
Family and environmental factors
The concept of family goes beyond a traditional husband-wife-children pattern. Family may include grandparents, uncles, aunts, other relatives, and even close friends who aren't traditionally considered to be part of the family unit. Family dynamics may also include components of religion, culture, and other societal standards that influence behavior, as well as self-identified race, tribe, or nationality.
Physical and psychosocial environmental factors should also be considered. We can't take for granted the general circumstances of a patient's life. Social contacts; housing; environmental surroundings, such as geographic location, temperature, air pollution, water contamination, and crime in the community; circumstances of poverty; and mode of transportation are just a few factors that impact an individual's quality of life.
Homelessness may affect our adult and pediatric patients and can have a devastating impact on their emotional, mental, and physical health. Reasons for homelessness may include mental illness, substance use disorders, poverty, unemployment, inadequate access to care, domestic violence, and lifestyle choice. According to the Substance Abuse and Mental Health Services Administration, approximately 50% of individuals who are homeless have a co-occurring substance use disorder and serious mental illness, such as untreated bipolar disorder, schizophrenia, or major depressive disorder. Individuals with schizophrenia account for approximately one-third of the homeless population in the US. While mental illness remains untreated, serious symptoms may occur, such as paranoia, hallucinations, delusions, mania, anxiety, and depression. Individuals with a co-occurring disorder, such as addiction, are at greater risk for violence, medication nonadherence, and resistance to treatment.
Mental illness can debilitate a patient's ability to maintain employment. Frequent provider visits, medication changes, and fluctuating moods may cause loss of employment or consideration of part-time or migrant agricultural/seasonal work without benefits. In turn, the estimated 3 million migrant and seasonal workers in the US are at increased risk for poor mental health due to dangerous work locations; issues with acculturation, isolation, and discrimination; and impaired access to healthcare.
The National Alliance on Mental Illness's Road to Recovery report provides a summary of evidence-based job assistance programs, such as individual placement and support to place patients in jobs that match their talents and interests, assertive community treatment to facilitate community integration and job placement for patients with severe mental illness, and community-based centers that offer supported employment and education programs. In addition, employers may be required to provide reasonable accommodations under the Americans with Disabilities Act.
Understanding sexual orientation may aid in the care of patients with mental health disorders. Viewing each patient as a unique individual, including sexual orientation, helps us provide a holistic approach to care. Terms to understand include:
- sexual identity or orientation—the way in which a person identifies to whom they're sexually or affectionately attracted, such as asexual (not attracted to either sex), bisexual (attracted to both sexes), homosexual (attracted to the same sex), heterosexual (attracted to the opposite sex), or pansexual (no limitations on sexual choice regarding biologic sex, gender, or gender identity); sexual orientation doesn't always relate to gender identity.
- gender identity—the way in which a person identifies along a continuum of constructs of masculinity and femininity; gender dysphoria marks an incongruence between a person's experienced and expressed gender and the gender they were assigned at birth. (Transgender is a term used to describe an individual whose gender assigned at birth doesn't match their gender identity or expression; it doesn't imply a specific sexual orientation.)
- sexual behavior or activity—the way in which a person experiences and expresses their sexuality, including attracting partners and sexual and social interactions.
Religion is an organized, community-based system of beliefs, whereas spirituality resides within the individual's beliefs. Both help people understand the meaning of life and the way in which a relationship with a higher power may influence that meaning. Spirituality may give some patients structure while coping with symptoms of their mental illness and aid in reflective practices, which allow for inner growth. Religiosity has been shown to reduce suicide rates; decrease alcoholism and drug use; create a sense of belonging; encourage compassion, forgiveness, and gratitude; and give individuals a connection to something bigger than themselves. Whether the patient connects with a specific religion or spiritual practices, spiritual health is important to address.
Nurses practice with empathy and respect for the essential dignity, worth, and unique characteristics of every patient while delivering care to patients, families, groups, communities, and populations. We also advocate for and protect the rights, health, and safety of every patient, making decisions and taking actions consistent with the duty to provide optimal patient care. In collaboration with other healthcare professionals and communities, nurses promote health diplomacy to reduce disparities and advance the profession through scholarship and research, building on the ethical standards of care needed for practice and health policy.
When caring for patients with mental health diagnoses, there are a variety of tools needed to address the many facets of quality healthcare for this patient population. Consider all of the support services that the patient may need, such as collaboration with other healthcare providers to ensure continuity of care, and address socioeconomic burden to reduce barriers to care. Consider available resources to help with adequate housing and stable employment.
Use nonconfrontational, nonjudgmental language and assess concerns from the patient's perspective. Consider personal space, appropriate body language, and how to build rapport to support a trusting nurse-patient relationship. During the patient interview, it's important to include such questions as:
- Do you have a safe home environment?
- Do you have access to clean water?
- Are you able to afford your medications and do you have a safe place to store them?
- Do you have transportation for your follow-up appointment?
Caring for this patient population can be challenging, so don't forget to recognize your own need for self-care to mitigate the risk of compassion fatigue. Self-care may include a healthy diet, exercise, mindfulness, yoga, spiritual care, and other activities that you find beneficial.
A positive impact
Caring for patients with mental health disorders requires nurses to be equipped with a surplus of options to meet individual patient needs. Nurses can make a positive impact on patients' quality of life by advocating for, educating, and empowering them in their overall care. Often, nurses are the initial providers putting together the missing pieces of a patient's care. By being informed about how to deliver culturally competent mental health care, nurses can continue to be champions for this patient population.
- Be mindful of your own perception of mental illness before approaching the patient.
- Approach the patient with mindful care.
- Ensure a solid support system is in place for the patient before discharge.
- Include family, environment, employment, sexual orientation, and spiritual considerations in the patient's care plan.
American Nurse Today. Self-care tips for nurses from nurses. 2017. http://www.americannursetoday.com/self-care-tips-nurses-nurses
American Nurses Association. Code of Ethics for Nurses with Interpretive Statements
. 2nd ed. Silver Spring, MD: American Nurses Association; 2015.
American Nurses Association. Psychiatric-Mental Health Nursing: Scope and Standards of Practice
. 2nd ed. Silver Spring, MD: American Nurses Association; 2015.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders
. 5th ed. Washington, DC: American Psychiatric Association; 2013.
American Psychiatric Nurses Association. Self-care tip sheet for nurses. 2017. http://www.apna.org/files/public/APNASelfCareTipSheet.pdf
Baillargeon J, Penn JV, Knight K, Harzke AJ, Baillargeon G, Becker EA. Risk of reincarceration among prisoners with co-occurring severe mental illness and substance use disorders. Adm Policy Ment Health
Greenstein L. The mental health benefits of religion and spirituality. National Alliance on Mental Illness. 2016. http://www.nami.org/Blogs/NAMI-Blog/December-2016/The-Mental-Health-Benefits-of-Religion-Spiritual
Healey P, Stager ML, Woodmass K, et al Cultural adaptations to augment health and mental health services: a systematic review. BMC Health Serv Res
Kushel MB, Hahn JA, Evans JL, Bangsberg DR, Moss AR. Revolving doors: imprisonment among the homeless and marginally housed population. Am J Public Health
National Center for Farmworker Health. Agricultural worker fact sheets. 2018. http://www.ncfh.org/fact-sheets-research.html
Sadock B, Sadock V, Ruiz P. Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry
. 11th ed. Philadelphia, PA: Wolters Kluwer; 2015.
Sherwood GD, Horton-Deutsch S. Reflective Practice: Transforming Education and Improving Outcomes
. 2nd ed. Indianapolis, IN: Sigma Theta Tau International; 2017.
Smith LS. A nurse educator's guide to cultural competence. Nursing made Incredibly Easy!
Stuart GW. Principles and Practice of Psychiatric Nursing
. 10th ed. St. Louis, MO: Mosby; 2012.
US Department of Health and Human Services. Mental health reports and publications. 2019. http://www.hhs.gov/surgeongeneral/reports-and-publications/mental-health/index.html