Why the high turnover in behavioral health?

cleback · Jul 8, 2018

I used to work behavioral health. At the time, the nurses joked that it was an "elephant graveyard, where nurses go to retire." There was probably some truth to that, as a lot of the nurses I've worked with in behavioral health were older. It may be an attractive position for some to avoid the physical labor of medsurg, icu, etc.

Other than that, I think the field is completely underfunded and underappreciated. It really is demoralizing seeing the same people over and over again (inpatient) because of poor outpatient resources. Some patients leave and you wonder how long it will be before they hurt someone in their mental state. But nearly all of them are too sick to work and lack the resources/capacity for better care... and the health care system isn't incentivized to fill in the gap.

So yeah, I got discouraged and burned out and left. Some of the same issues are in medical care, but at least I feel like I accomplish a bit more by getting them hydrated, out of dka, treating a pnemonia. But that's just me too.

Sour Lemon · Jul 8, 2018

I know a lot of nurses who "used" to work in behavioral health. Is this not a good area to work in?

I think it may be a less desirable area that more people are able to "try out" as a result. It might also be more available to new graduates who move on after getting experience, and LVNs who move on after getting a higher degree.

I work in behavioral health about half of the time and I love it. I would worry about it being my only recent experience, though. I also like to keep my foot in the door in med/surg because I feel like that's more marketable.

elkpark · Jul 8, 2018

I'm sure there are lots of people who tried psych, didn't like it, and have moved on, but I've been in psych all of my career and most the nurses I've worked with in psych settings have been career psych nurses. So, there are plenty of people on either "side." I'm sure the same is true in lots of other specialties, too.

One thing I have observed over the years is that nurses in other specialties tend to believe psych nursing is "easy" compared to other kinds of nursing, and I've seen some nurses from other areas take psych jobs because they want an "easier" job -- then, once they are working in psych, they find out it's not easy, it doesn't suit them, and they move on.

brownbook · Jul 8, 2018

I was night supervisor for 5 years and made twice a shift rounds to the locked psych facility that was part of the acute care hospital. It was one of my favorite units for a variety of reasons.

The nurses were 30 to 40 years old and quite happy with their career choice.

I'd love for you to ask the nurses you know why they left? Then let us know.

umbdude, MSN, APRN · Jul 9, 2018

I haven't seen very high turnover in places I worked. But in my last job, quite a few nurses told me that they work in psych because they couldn't find a job in a medical specialty and they needed a pay check. I told them I plan to stay in psych and they looked at me like I had 2 heads.

CharlieFoxtrot · Jul 9, 2018

Caveat: I have not done psych nursing, but have worked in outpatient psych services.

The facility in which I worked was a CMHC in Oklahoma, which is fiscally upside-down when it comes to funding due to the state governing parties. Whatever direction you lean politically, not funding mental health services has consequences: higher costs for corrections, less productivity, higher health care costs as people are seen in the ER, higher costs for disability, etc. Poo rolls down hill, and due to the high amounts of opioid, meth, and heroin usage in Oklahoma, there's a lot of poo.

Less funding meant seeing more clients, having a lower salary (state workers had pay freezes in place), lack of service coordination, and institutional barriers as to what services we could provide. Our facility provided medical management and social service linkage, and that was about it. The problem with this is that you can medicate a person all you want to treat the symptoms of mental health, but in many cases, unless the root cause is addressed, it's the same shirt, different day.

Many of our clients had co-occurring substance usage, but our area of the state lacked real treatment options apart from 12 Steps. Almost all of our clients had co-morbid health conditions, but due to Oklahoma not expanding their Medicaid services for the ACA, unless you made less than $2000/yr, you fell into the ACA gap. I saw so many people without insurance who, if they had been able to see a PCP, most likely would have had more manageable mental health symptoms because their HTN, DM, thyroid, or vitamin B12/D2 deficiencies would have been in check.

You do see a lot of the same people and that's discouraging. However, when you start looking further up the food chain as to the systems in place that are creating that problem, you realize that it's not your department that is broken, but a lot more.... and that's the discouraging part.

pixierose, BSN, RN · Jul 9, 2018

It can be a great area to work in ... if you have realistic expectations.

Take last night (I work per diem, adult Geri and peds ED). My 62-year-old schizophrenic patient (who has been refusing meds for the last 11 days) decided to tear up the unit. Just prior, I received a finger in the face, lots of shouting, lots of posturing. She needed an IM, unfortunately... after multiple attempts at de-escalation.

But she's in the throes of psychosis.

I don't take it personally.

She's also a repeat patient ... in a world of poor outpatient services. A broken system.

Now, enter your nurses who think "psych nursing is easy."

There is a lot of burn out and I'm one of them (I work mostly neuro ICU now). It can be demoralizing at times to watch someone at their lowest, sometimes repeatedly, sometimes while acting out on you.

allnurses Guide · Jul 9, 2018

I saw a fair number of psych patients due to exacerbated comorbid conditions when I worked ICU Stepdown. I burned out on them pretty fast, mostly due to the large number of them with substance abuse issues and all the manipulative behavior that goes with that. It just wasn't my cup of tea.

kbrn2002, ADN, RN · Jul 9, 2018

I don't work in behavioral health, but I have nothing but respect for those that do. Talk about a specialty that requires a steady personality! Not everybody is cut out to maintain their own composure when all heck is breaking loose around them and a psych episode definitely can result in a chaotic and not necessarily safe environment. Even on a good day dealing with deceptive, manipulative patients is most likely the rule rather than the exception, again not something everybody is equipped to do without losing their own sanity at least a little bit.

Add in the horrible funding for mental health services and by the time a patient is seen they are most likely already in crisis or very close to it. It has got to be frustrating as all get out knowing there are interventions that could have prevented an escalation for a patient if only the funding existed to get them the help they need before it reaches a crisis point.

Related to the ridiculous lack of behavioral health funding is the extremely low pay for the difficulty of the job. A casual employee I work with occasionally works in behavioral health for a TBI group home company, the very poor pay combined with a total lack of appropriate training for employees contributes to massive turnover and chronic short staffing. The front line staff have no idea what they are getting into and have not received the training needed to deal with the special needs of the population they are serving. I can't really say as I blame them for leaving when they realize they can make as much if not more money working in retail without the regular and very real risk of being physically assaulted.

Neats, BSN · Jul 9, 2018

OK here is my 2 cents worth about mental health and burn out.

1. Mental health is treated separately than the rest of the body and it should NOT be.

2. Mental health has traditionally been a taboo subject, much like cancer was called the big C back in the days (even before me). People do not wan to speak about mental health, and growing old. Just subjects that are not pleasant.

3. Mental Health issues are to me hard to handle because it is so taxing on the caregiver. Think of it like a 3 year old asking are we there yet every minute. After a while you just want to yell shut up now (I do not do this). There are some serious mental health issues and the therapy is a slow process that most people do not see results in a short period of time like say if you had active gout and were in the hospital for 3 days, started to get better and was released to home. Mental health you may see these people 3-5 times with no progress at all. How frustrating but at least they re getting help each time.

4. I think you have way more malingering mental health issues than medical issues. I evidence this from the prison system and outpatient community centers. I have shared I have half sisters who are meth heads and quite smart. They know what to say and when to say it to get help, to get off the street or to get out of therapy because the craving for drugs they have are too strong for just the mental therapy they are going through. I get discouraged thinking what users...and quite frankly have no hope they will get any better.

5. To work in the mental health arena you have to have great assessment skills and be able top correlate those skills to what comes back evidence based i.e. labs, direct observation skills about anatomy and physiology. You also have to have great boundaries and knowledge of Erickson's stages. Once you understand these stages you can then begin to approach your patient with what you think the stage that patient is in this reduces the burn out.

6. I am addressing the monies a little as that seems to be a recurrent theme here is to make more monies available to mental health. I think before that is completed we need to treat mental health the same as we do medical health, last I checked my head is part of my body.

verene, MSN · Jul 9, 2018

I think some nurses go into the field thinking it will be easy. It's not. I think there are also those who go into this field with idealized expectations of the work.

Mental health is a broken system at all levels, patient needs are high, the system is underfunded, understaffed, and underappreciated, if not outright stigmatized. There is limited funding, and limited resources, and it is a small community - much smaller than you realize, you will work with the same agencies, same hospitals, same court monitors, same police and jails, same people and same patients over and over again even if you change jobs/roles. Some days you'll be trying to brain storm discharge plans and realize your patient has been through every agency and facility in the system that reasonably makes any sense and there aren't options left.

You will have repeat customers; some frequently. You will find yourself having to fight with other areas of the health system to get your patients medical care, addiction services, and out-patient mental health care. You'll fight the stigma in trying to work with EMTs/police and EDs to treat your patients humanely and take yours and their medical/physical concerns seriously. You'll fight insurance agencies for medications and therapies. There are so many gaps in the system for your patients to fall through and there isn't a safety net. You'll discharge patients back to homelessness, poverty, dysfunctional families, and other untenable living situations that you know will trigger the symptoms that were stabilized in your care all over again - and best case scenario you'll see that patient again.

You'll have patients who are aggressive and violent, patients who are gaming the system, patients who push all your buttons, and patients who touch you deeply with their stories.You'll have patients you never see again and you'll wonder if they are still alive. It can be incredibly intense emotional, mental and physical work with little external reward. You have be able to celebrate the tiniest of victories and find your own meaning. It also takes an awareness of limits, of being able to let go, of recognizing what you can and cannot do for a patient, and of recognizing mental and emotional limits and making space for yourself.

All that said - I honestly can't picture myself working in a different field of nursing. These are my people and this is where I belong.