"I'm just going to try to get through it!" is what assistant professor Nan Chadwick hears often from her undergraduate nursing students at the University of West Georgia in Carrollton when they talk about the school's required 40-hour psych-mental health clinical rotation.

"Students are often frightened by psychiatric nursing, and I understand that," Chadwick said. "I'm passionate about this field, but I didn't like it at all in the beginning."

In 1969, when Chadwick was working toward her associate's degree in nursing, her first clinical rotation was at a Florida mental hospital. At that time, patients still were being treated with insulin shock therapy, hypothermia therapy and strong anti-psychotic drugs, such as Thorazine. Some patients were kept in cages.

"I was terrified. I had wanted to be a nurse all my life, but I didn't think I could handle this at 19," said Chadwick, Ph.D., RN. "Fortunately, my nursing instructor settled me down."

She can empathize with the fears but wants her students to understand how much has changed since the 1960s. She encourages students to look at treating mental illness as an opportunity to ask open-ended questions and to be a part of exciting research.

Psychiatric nurses have more therapy tools and better medications to help patients today. The focus has changed from institutional to outpatient care, with the aim of patients living independently.

"We've learned so much more about the brain from radiology technology and the Human Genome Project," she said. "There's a great need for psych nurses, and it's harder to recruit in this field, but the career opportunities are many and the rewards are great."

She speaks from experience; Chadwick has been a psychiatric nurse for more than half of her 36-year career.

She was teaching and supervising students in a clinical rotation that included a mental health unit in Savannah when she had an encounter with a patient that changed her career focus. That patient told Chadwick that she was the only nurse who sat down and talked with him. That planted the seed for her to become a psychiatric nurse, and she earned her master's degree at Georgia State University.

"I got intrigued with how the mind works — how patients with mental illness expressed themselves — and I found the field challenging," she said. "I got smitten with psych nursing and still love it."

Chadwick's experience in the field is diverse. She has taught psychiatric nursing courses at several universities. She has worked as a clinical nurse specialist in Grady Memorial Hospital's emergency room. She has served in an ambulatory substance abuse clinic for adults and has worked with schizophrenic patients living in group homes. She also was employed at a clinical drug-trial center, where she wrote protocols for studies on depression.

In treating mental health issues, the answers are rarely obvious, Chadwick tells her students.

"You can look at an appendectomy scar and see if it's red, but you can't see inside the brain," she said.

Different challenges

Never knowing what to expect is one of the things that Linda Puterbaugh, assistant nurse manager at RiverWoods Southern Regional Psychiatric Center in Riverdale, likes about mental health nursing. She fell into a psychiatric nursing job after completing a nurse re-entry program in 1988 and discovered that the field suited her.

"The challenges are different," said Puterbaugh, RN. "It's not as medically oriented as the hospital. We're not monitoring patients with IVs or other machinery, and our patients don't stay in bed. In fact, we're encouraging them to come into the community room and interact with others."

Members of the nursing staff wear street clothes to make them more approachable and to create a more casual environment than in hospitals. "We may not dress like nurses, but we are constantly using our assessment skills and watching behavior," she said.

Nursing assessments are used to help diagnose patients, to monitor treatments, and to check for drug interactions and adverse symptoms.

Teaching is a big part of the job. Psychiatric nurses are responsible for training the staff about medications and for teaching patients how to care for themselves.

"Because mental health stays are shorter and shorter, we have to make sure that there's a good discharge plan in place," Puterbaugh said.

The role calls for someone who can be an authority figure and set limits when a patient is out of control.

"But you're always the encourager and the listener," Puterbaugh said. "People often respond when there are support systems in place, and it's always gratifying to see them feeling better."

Personal touch

Working in the field also requires the ability to relate to patients.

"Psych nurses need a whole lot of patience and a sense of humor," said Donna Anderson, RN. "It's not so much about technology as it is your capabilities. While you don't have so many life-and-death situations as you do in ICU, you can make a difference in how a patient lives out the rest of his life."

Anderson has worked in community mental health clinics, in hospital psychiatric wards and with teens, foster children and substance abusers.

"You have to have a pretty good constitution and be self-assured to work in a residential treatment center for abused teens," Anderson said. "You can't be wishy-washy or afraid; the kids pick that up right away.

"It was hard work but rewarding, because I saw kids who had come from dysfunctional homes turn their lives around with a little structure and love. I still hear from some of those patients."

Anderson retired from nursing after a 34-year career, but she still teaches disaster mental health classes to American Red Cross staff and volunteers. She has used her skills to help people cope after hurricanes, earthquakes and fires, and she spent months working with people in Washington, D.C., and New York City after the Sept. 11 tragedy.

"It's now rare (when) we don't have a [American Red Cross] shelter without some cases of physical or mental abuse," she said, "and we never have enough trained psychiatric professionals to work after disasters. Mental health issues tend to come out more in times of stress."

Anderson also works as a paraprofessional with autistic children.

"All autistic children have certain areas that they shine in, whether it's math or puzzles or music. It's a trial-and-error process, but once you find that area, it makes such a difference to these kids and their families," she said.

Caring for individuals

Nursing mental health patients is always about individualized care, said Susan Heilig, RNC, patient services supervisor at the SummitRidge Center for Psychiatry and Addiction at Gwinnett Medical Center in Lawrenceville. People can have the same bipolar disorder or schizophrenia diagnosis yet need totally different medications or therapy, depending on medical history, health, chemical makeup and socio-economic support systems.

It's often a psychiatric nurse who recognizes the individual characteristics that help medical staff formulate the best treatment for patients.

"You're dealing with unknowns," Heilig said. "You can't see a wound that is oozing, but you see behavior that points to the wound. There's no definitive science, so it puts the nurse/patient relationship on a different level.

"Being able to collaborate with the patient in his care, to teach him about his illness, to make a connection is imperative. Trust is at the very root of that."

Heilig had planned to major in psychology in college, but an aunt talked her into attending nursing school.

"It was great advice. I love being able to make a connection with patients and teach them," she said. "There are very few environments left where nurses can do that in a sustained way."

Psychiatric nurses work in a variety of settings, including community health centers; hospital and institution inpatient and outpatient care; schools; nursing homes; home health care settings; and medical research facilities.

The skills of psychiatric nurses have advanced, as knowledge about therapeutic care and medications have progressed, but time and funding remain major challenges for Heilig and her staff. "Every day, we're faced with how to do what we need to do in a shorter amount of time and in a cost-effective manner. When stays were longer, nurses could see a patient respond or not respond to medication and try something else," she said.

Now, nurses must educate patients, send them home and hope the medications that are prescribed will work.

"You learn to appreciate small successes, like someone needing to be admitted less frequently or carving time out for some impromptu therapy that makes a difference," Heilig said.

"I love it when you teach someone about their disorder, and you see the light come on and hear him say, 'Oh, that's why I do that,' " Chadwick said. "You know you're helping them grab a better quality of life."