Have you ever wondered what it was like to work with patients who live with serious mental illness? If you’ve thought about working with this particular population but weren’t sure what it was like or even knew someone in the field, don’t worry; we’ve got you covered.
Erin Walczykowski, MSN, APRN, PMHNP-BC, works as a psychiatric nurse practitioner at MBI Health Services, LLC in Washington, D.C. In addition to speaking with us about the types of patients she works with, she also talked with Daily Nurse about long-acting injectable medications (LAIs).
What follows is our interview, edited for length and clarity.
Erin Walczykowski, MSN, APRN, PMHNP-BC, is a psychiatric nurse practitioner at MBI Health Services, LLC in Washington, D.C.
How did you get interested in being a Nurse Practitioner working with patients who have serious mental illnesses? What drew you to it? How long have you been doing it?
I have been working with patients for six years. My interest in the brain and behavior connection drew me to this line of work. I am naturally curious and have always been drawn to why people behave the way they do.
Once in nursing school, my interest solidified when I discovered that I enjoyed working with patients with mental illnesses. I find satisfaction in helping others explore their lives, why they see the world the way they do, and how to make choices that help them reach their goals.
I am particularly drawn to those with serious mental illness, as these individuals often have the most challenges managing their lives due to the severity of their symptoms—the more challenging the client, the more alienated and misunderstood. So, I find significant meaning in helping people live the best life possible, even if their way of existing in the world does not fall within the expected norms of society.
Those with serious mental illness are most often disregarded and outcasted. Yet, these same individuals are empowered to live lives of meaning through medication management and building therapeutic relationships.
What types of patients do you serve? What kind of care do you provide for them?
I primarily serve patients diagnosed with serious mental illnesses. I provide medication management to adults with chronic and persistent psychiatric disorders within the Assertive Community Treatment (ACT) setting. ACT provides high-level, wraparound care to what are often the sickest of patients in the community, who otherwise struggle to engage in their mental health treatment on their own without a great amount of staff support.
The most common patient diagnoses I treat are:
Major depressive disorder.
Post-traumatic stress disorder (PTSD).
Varying anxiety disorders.
Co-occurring substance use disorders.
Tell us about long-acting injectable medications (LAIs). What conditions are they used for? How do they work? Why are they more beneficial for some patients than taking a pill?
Long-acting injectable medications (LAIs) are currently used for patients diagnosed with schizophrenia and other serious mental illness. LAIs contain the same active ingredient as the pill form of the medicine. But when injected into the muscle, they allow for the slow release of medication into the blood over a more extended period and avoid the gastrointestinal pathway. This also reduces the peak-trough plasma levels inherent to oral meds, allowing for steady blood levels.
For many of my patients, I believe LAIs can help manage symptoms, as they can struggle with taking their medication in pill form on a consistent basis, as prescribed. Adherence tends to be even more of an issue within psychiatry. LAIs can ensure better adherence, resulting in fewer hospitalizations and fewer relapses while decreasing the risk of overdose on oral medications. If the amount or severity of relapses can be reduced, then the brain can be better-protected long-term from subsequent damage, possibly improving the lifetime prognosis and its resulting impact on the patient’s life.
Consider this: Most oral medications prescribed to treat schizophrenia are taken daily, sometimes twice a day. Unfortunately, such a dosing schedule means non-adherence will not be detected until a major problem develops. In contrast to oral medications, LAIs have different dosing schedules. While some are administered every two weeks, others are given every month, every two months, or longer. Often, this is more suitable to the lifestyles of my patients.
How do LAIs give patients more freedom? How do they support the whole patient? How long have they been used?
While oral antipsychotic medications are taken daily, LAIs include various dosing scheduling options, allowing patients more freedom to go about their day without worrying about taking a daily pill. LAI administration can be monitored, and thus staff can know for certain if a patient is consistent with adherence and prevent lapses in treatment.
This is particularly helpful for patients who decompensate quickly upon an oral medication lapse and those who lack insight into their illness. Some patients will not take oral medications regularly if they don’t believe they have a mental illness, are paranoid, think they are better, and no longer need medications when they are no longer symptomatic or are without stable housing.
Despite LAIs being available for some time now, there needs to be more education regarding LAIs in the healthcare community. However, they have become increasingly popular in the past few years due to their proven patient benefits and outcomes. Unfortunately, LAIs are underutilized as a first-line treatment option and are often seen as a last resort which ideally will change with time and education.
As an NP, how do you—and how can other nurses—work as a team with patients and caregivers to figure out what treatment will work best for them? What are the biggest challenges in working as a team? What are the greatest rewards?
When working with patients and caregivers, nurses and providers on their team must encourage and ensure that the patient is directly involved in their treatment plan within their means. Ensure they have a say in their care and feel they are a team partner. Find out the patient’s goals, strengths, and weaknesses elicited from their perspective. Once you determine this, help ensure the goals and necessary steps are realistic based on their circumstances and symptoms and help them to develop alternative options if there are limitations.
It is also important to build a good rapport and work on developing trust. Those with mental illness–particularly serious mental illness–typically have a history of what they identify as bad experiences with psychiatric care, resulting in a general lack of trust in mental health providers, even if the care was appropriate given the circumstance and safety risk. This can be due to the nature of their symptoms, multiple medication trials, and even jail or hospital encounters perceived to be hostile or punitive. Determining the proper combination of medications, which are as individual as the patient, is a bit of trial and error. Because of this, patients often feel they are guinea pigs.
The biggest challenges are ensuring that each team member is on the same page regarding patient status and progress, that communication is consistent to ensure there are no gaps in care, and that monitoring of patient progress is consistent. This allows the team to anticipate, get ahead of, or address any triggers that can preclude a decompensation or exacerbation of symptoms.
The greatest reward of working on a team is that if everyone is committed to ensuring collaboration of care, outcomes for the patient are better. Every team member is valuable and can develop different relationships with the patient that are beneficial in various scenarios. It also helps build camaraderie and prevent burnout, which is very prevalent when working with patients with serious mental illnesses and high emotional needs.
How can LAIs enhance patient outcomes? Please explain.
One LAI treatment that I utilize in my practice is ARISTADA® (aripiprazole lauroxil), a prescription medicine given by injection by a healthcare professional and used to treat schizophrenia in adults. This medication is available in several different doses, including monthly (441 mg, 662 mg, 882 mg), every six weeks (882 mg), and every two months (1064 mg), allowing me to tailor each treatment regimen to my patient’s needs. It is not known if ARISTADA is safe and effective in children under 18 years of age.
In some of my patients with schizophrenia taking ARISTADA, I have seen reduced symptoms such as delusions, social withdrawal, and hallucinations. But, more importantly, I have witnessed improved adherence rates and feel the reduced dosing schedule offers a convenient option for patients.
Based on my experience with ARISTADA and other LAIs, I would strongly advocate for LAIs to be considered as an option both early in a patient’s treatment journey and for the long-term maintenance of their disease. We should help patients be more receptive to LAIs and to see these injections as not a punitive treatment that takes away their control but instead as a way for them to take control of their treatment. Ultimately through the use of LAIs, there is greater symptom stabilization. If they gain control of their symptoms, they gain control of the outcomes and thus control their life goals.
How can using LAIs improve public health? In what specific communities have they been proven to do so?
With LAIs, we can improve the treatment experience for individuals with schizophrenia and other complex mental health conditions. I have witnessed LAIs improve symptoms and prevent relapses which can lead to hospitalizations and other serious outcomes, which is a powerful testament to the impact these medications can have on public health. While there is no cure for schizophrenia, with the right care plan and a supportive care team, patients can have the opportunity to live meaningful and productive lives.
LAIs should be considered across all patient populations. But they can have the most impact within patient populations where their symptoms, living, and socioeconomic status result in low engagement with their healthcare team. This can include: not having housing to store medications, limited access to transportation, physical limitations, embarrassment regarding taking daily medications, memory issues, and those who are frequently hospitalized.
It is also very helpful in young adults early in their illness. Young adults can find it challenging to accept they have a mental illness and what adjustments they may need to make to accommodate this. It also can greatly impact how they perceive themselves relative to their peers. Stabilization early increases the chance of a better prognosis long-term.
Is there anything else that is important for our readers?
I think it is important for readers to know that many people with mental illness are still people. They have many of the same wants, needs, and desires as those without mental illness. However, their symptoms directly impact their ability to attain these goals, feel productive, valued, and have healthy relationships.
So, we must remember they want the same things we all do, but they need additional support to get there. They need empathy, patience, and understanding. Often this means having an open mind and being creative in interacting with and caring for those with mental illness. LAIs give you more flexibility in how treatment can be provided.
While medications, particularly LAIs, are a key component to mental health outcomes and treatment, remember the relationship with the patient comes first.
Interested in becoming a psychiatric nurse practitioner? Then check out Daily Nurses Career Center to get jobs, scholarships, and nursing news delivered weekly to your inbox.
“I loved it – to sit and talk with my patients and try to understand the context of their lives and how to support them,” recalls the Chicago native. “It was such an enjoyable experience that I knew specialize in psychiatry from that moment on.”
Pivoting to Psychiatry
Bounds, who planned to go into medical-surgical nursing, took a position in an inpatient child and adolescent psychiatry unit right after graduation.
Being in such a challenging environment came naturally to her – so much so that she used to joke she’d return after she retired. Bounds worked there while earning a master’s degree to become a family psychiatric-mental health nurse practitioner and a Ph.D. in nursing science at Rush University.
As a nurse practitioner, Bounds served in high schools and the county juvenile detention center on Chicago’s West Side. There, she helped at-risk female youths caught in a cycle of running away and getting locked up.
“I had two questions: Who are you running away from – what’s happening in the household that keeps you running? And who are you running to?” she recalls.
“Years ago, I attended a forensic nursing conference. They were talking about sex trafficking and sexual exploitation and all the red flags. I couldn’t help but think, ‘These are the girls I’m already taking care of,’” Bounds says.
“But nobody’s calling it sex trafficking or sexual exploitation. They’re just criminalizing these girls’ behaviors. They had these histories of being traumatized, and then on the other end, I was seeing them in juvenile detention, and I thought, ‘Something needs to change.’”
Supporting the Family Unit
Her research and day-to-day treatment took a fresh focus. Child welfare services often remove youngsters from abusive homes. But teens are more likely to remain in tenuous situations until they flee on their own.
Supporting young people, Bounds realized, meant supporting their entire families, especially those with minimal resources.
“These amazing kids were still going to school despite living in neighborhoods with shootings, violence, and substance use,” she says.
“I was just looking for ways to be of assistance and help them solidify some support networks so that they could not just survive but thrive amid many things beyond our control.”
Psychiatric DNP program
At UCI, where she joined the faculty this summer, Bounds will help establish a psychiatric-mental health nurse practitioner specialization in the Doctor of Nursing Practice program.
But the campus is not the only community that will benefit from her expertise and compassion. She plans to partner with primary care providers across Orange County to create an intervention that supports at-risk youths and their caregivers.
She wants to offer support beyond identifying trauma and suggesting emotional regulation techniques like exercise, yoga, and mindfulness.
“I feel like there’s this healthcare gap in how to make that happen. I think nurses and other health workers can become health coaches in the community,” Bounds says.
“Supporting teens chronically exposed to adversity could also mean connecting them to positive environments.”
This includes school-, faith- or sports-based youth programming, mental health care, housing, and support groups.
Technology’s Role in Helping Vulnerable
Her courses in the Sue & Bill Gross School of Nursing are delivered through Zoom, a tool she thinks could also serve a purpose in treating vulnerable patients. Still, Bounds misses the human connection and hopes her students can feel her warmth and sincerity through the screen.
“Being a psychiatric nurse practitioner, I know that those relationships you build are so important,” she says. “Even when they’re not my patients, students, and colleagues, I want that connection to be there.”
When asked about her proudest accomplishment, Bounds cites her mentoring ability.
“I come from a community that could be considered under-resourced, so I’m proud to be a role model for those I work with. A single mom raised me. I’m a first-gen college student. And now I have a Ph.D. and am working at the University of California,” she says.
“To me, I’m an example of that young person who might have limited resources and support right now. Examples like mine that demonstrate possibilities for young people are so important.”
Nursing is a unique profession, with major psychological stressors and equally great emotional benefits. Who would have better self-care tips for you than a psychiatric nurse practitioner and DNP candidate? Jonathan Llamas DNP (c), BSN, RN-BC, PHN, is all that, plus a freelance writer for MinorityNurse.com.
Llamas is pursuing his degree at Loma Linda University while also working full-time as a psychiatric-mental health nurse at Kaiser Permanente in Los Angeles, CA. (Obviously, he knows a thing or two about workplace stress!) He is a Filipino-American, a first-generation college graduate, and an emerging nurse leader who aims to help educate the next generation of nurses.
In this Q&A interview, Llamas suggests ways for nurses to practice self-care, while at any point in their career journey.
Jonathan Llamas DNP (c), BSN, RN-BC, PHN
How did you become interested in psychiatry?
I ended up choosing psychiatry because at an early age, I have always been fascinated by the miraculous wonder of the human mind and the inherent beauty and evolution of life that emanates from the adept functioning of the brain.
I developed a profound passion to better understand and treat the psychological, emotional, and spiritual ailments that are often associated with mental illness in contemporary society.
What have you learned—related to stress, self-care, avoiding overwhelm, depression, or burnout—from your psychiatric nurse training that you wish all nurses knew?
The most important concept that I have learned so far during my experience working as a psychiatric-mental health nurse is the importance of self-care. The concept of self-care was never really endorsed until recently, because of the overwhelming influx of individuals suffering from mental illness in recent years.
The interesting part about mental illness that many people tend to forget is that it is non-discriminatory—meaning that it can affect anyone regardless of their race, gender, creed, or socioeconomic background.
I often make it a point to encourage my fellow nurses and colleagues to not be afraid to care for their mental health and address any issues that may produce additional stress and anxiety in the future.
What personal benefits (emotional, psychological, spiritual, etc.) have accrued to you from pursuing this specialty?
Working in psychiatry is a unique experience because it teaches you a lot about the interplay between the emotional, physical, and psychological components of holistic treatment. As a result of this realization, I try to make a concerted daily effort to continue to develop not only creative approaches to my nursing care, but also empathetic techniques that ensure patient safety and satisfaction is achieved across the patient gamut.
You also have previous experience in ICU/trauma and ER settings—what did you learn from those roles, related to stress, overwhelm, and so on?
Although it can be physically and emotionally draining, working in the ER and ICU/Trauma settings—[they] taught me the significance of perseverance, collaboration, and patience.
I have come to learn that the best way to combat stress and burnout is to surround yourself with people and hobbies that energize and remind you as to why you chose to be a nurse in the first place.
Do you have favorite techniques for de-escalating difficult situations, with patients or coworkers?
In the past decade or so, violent incidents have increased dramatically and are now four times more likely to occur in health care than in any other private industry.
Because of this unfortunate reality, one of my favorite de-escalation techniques that I continually perform on a consistent basis is the LOWLINEModel. (Described by Mike Lowry, Graham Lingard, and Martin Neal in a 2016 Nursing Times article.)
LOWLINE is a mnemonic that stands for (L)isten, (O)ffer, (W)ait, (L)ook, (I)ncline, (N)od, (E)xpress.
How has being a minority (gender or racial, ethnic, etc.) nurse played out in your career?
Surprisingly, being a minority male nurse in a predominantly female driven profession has been a positive experience for me thus far. Although I can only speak on my own personal experience, I consider myself blessed and fortunate to be able to care for my patients without fear of being judged or discriminated for my racial, ethnic, gender, or socioeconomic profile.
Since I do work in psychiatry however, I do experience the occasional irreverent name calling from highly psychotic patients, but I do my best to not let it affect me and compromise the type of nursing care I provide.
Listen to Jonathan Llamas on mental health nursing in an “AlumniSpotlight” video clip.
Our organization is moving toward less restrictive policies, which will give us full practice authority and more independence. There are also outstanding benefits, including generous paid time off, flexible scheduling and other perks that help us keep a healthy work-life balance. Above all, we get to give back to Veterans by providing treatment that improves their lives.
How does VA’s integrated model of care impact your typical day?
What are some challenges that come with your position?
Taking the mystery and stigma out of mental health conditions. There’s a growing opportunity to educate others on the topic, so that’s something I’m always doing. My hope is to increase understanding of and empathy for people dealing with these issues. It’s a crucial part of being a Psychiatric Nurse Practitioner at VA.
Lakeview has been a private psychiatric firm for the past two years, providing traveling services to the mentally disabled. The new practice will also serve as a clinical site for students in the WIU School of Nursing. Students will have the opportunity to work with psychiatric testing, counseling, and psychological interviews and medications.
Martin tells WIU.edu, “We will still see the mentally disabled, but we are expanding the practice to include a psychiatrist, a psychologist, a nurse practitioner and a licensed family and marriage therapist. This will allow us to expand to do therapy, addiction treatment, DUI assessments and group therapy.”