changes

okay, so it is cliche, but we can all agree that the one constant in life is change, yes?

the changes that have been happening to me because of the changes that were manifested (through lots of prayer and conversation with god) and then acted upon, in regards to my career, are changing me in ways that were not fully thought out. i mean, how can you really think through something entirely that hasn’t happened to you yet? some of the changes are very welcome- i feel myself resonating, vibrating, with a much slower, and relaxed energy. the difference between two minutes being too long to wait for something a patient needs and two hours being a fast turnaround for a request. the difference between having to clock in and clock out and being salaried. the difference between chest compressions and a caring conversation.

sure, there are lots of reasons that my new gig is challenging: politics, learning the tactics needed to move a large bureaucracy toward the changes it says it wants, but that all actions suggest otherwise, the inefficiencies of a clinic workflow that have gone unchecked for years. not to mention adding a new specialty area to my repertoire.

and it would be a lie if i said i didn’t miss the OR.

but this new work that i am being called to do, the new spotlight on the areas of my self, of my soul, of the way i walk through the world, it is intense. i feel directed to lean in and do some hard work on how i interact with my environment. to look at the root cause of my impatience, to explore the deepest, darkest parts of my personality and draw those places into the light.

to surrender to the imperfection, acknowledge it, and love it anyway.

and, i think my very favorite consequence of my new job is that i am really sleeping again, dreaming again. when oscar died my sleep left. don’t get me wrong, i still slept “well” because i’ve always been a strong sleeper, but i didn’t dream and explore as much in my sleep as i did before he died. that has been my very favorite change. and one i think comes from my heart being satisfied that i am on the right path.

like my nurse navigator mentor told me yesterday, “you have the heart of a navigator”. that resonates so deeply with me; i feel that. ultimately, it will be my heart that keeps me pushing forward on this new path. and, truly, i would not have the relationship i have now with my heart if i hadn’t spent the last year of my OR career working in open hearts. beyond grateful for my experience in the CVOR.

so, i choose to keep rolling with the changes. learning from life. open to the challenge. baby steps.

too long

THERE IS SO MUCH!!

It has been way too long since I have written. I feel like I have been through at least two lifetimes in the past few months. My new job is pushing me to grow in ways I didn’t realize I needed to grow. It is interesting, as I have been adjusting to my new unit and the culture there, I have been turning inward. I have been reluctant to share my inner journey with you, which had become such a big part of who I was and what I needed to do to stay healthy before my transition to the CVOR.

After my therapy yesterday with my treasured psychologist it became very clear to me that I need to reach inside and determine what I need to do to stay healthy and then do those things. I need to fiercely guard the time I need to do those things. I am saying that as if it is some incredible realization when really it is a well-known fact, the problem is simply that if I spend too much time away from what I need to do to keep myself healthy my grief comes out sideways.

This is what I have been doing too much lately and not paying attention to myself because of: healing my relationship with Grant. There, I said it. Well, not to mention Covid-19 (learning how to live the new normal with the rest of the planet). Grant always pushes me to be so quiet about what we have going on with each other, and I get it, he enjoys privacy, but I am not a quiet person when it comes to my life. I like for things to be out in the open. Transparent.

I lived a long time in the dark during my youth. I really had two lives then: the life on the outside that looked mostly okay to everyone looking in on us (the mask) and the one at home that was full of anger, alcohol, and marijuana with an abusive husband who had me convinced if I tried to get help for my addiction he would lose his job. Back then I was just trying to keep it together enough to get through school and maintain a job. I have started a writing exercise that my psychologist recommended might help me integrate those traumatic memories. It takes so much emotional energy to do it I can only face it in small bits.

Right now Grant and I have reached a point where we want to live together again but there are some major issues that need to be figured out. The first is that I get virtually zero alone time when we spend a lot of time together. This is because Phoenix prefers my care to Grant’s care when the two of us are together. I have been encouraging Grant to try being more assertive and maybe that will help if I also stop stepping up right away. This kind of change takes time when you are working on this sort of reintegration. Another issue is that we do need couples counseling. And, of course, we seem to be attracted to completely different types of therapists. Of course. Another big issue is our motivation: are we doing this because we are in love with each other or are we doing it for Phoenix?

Another big issue that Grant and I have is our reluctance to share our journey with our friends and family.

I can only speak for myself here, but I feel like we have been through so much and reached such a very low point together that our friends and family were very happy and relieved to see us separate when we did. I mean we went through the whole deal for a proper separation with lawyers and parenting plans and all of it.

Since I started working in the CVOR I have changed in ways I didn’t predict. I have been through some major ups and downs during my transition to my new unit and I finally have started to feel like I am finding my place. This is great because for a few days there I thought I had made a big mistake! One of the things that has come out of my experience caring for this patient population is a renewed and deepened Christian faith.

This is an issue for Grant because he does not vibe with Christianity. He also tells me that he doesn’t think I will maintain my Christian faith for long. I have tried explaining that this has been a lifelong dance and I have finally reached a point where I am comfortable in it and so I am feeling the strength to own it and ground myself in it like I never have before. This will be a sort of living amends for me to Jesus. And time will tell. I will say that a very beautiful realization and discovery has come from my renewed faith: chaplaincy. Becoming a healthcare chaplain as my long-term career goal makes sense and every time I think about it I feel deep peace.

All of this and the churning of difficult times of the year for my grieving soul: Mother’s Day, Pierce’s birthday, Father’s Day, Vivian’s birthday, Phoenix’s birthday, and on Friday, Nick’s birthday.

Here is the good news: Grant and I settled on him not moving in for at least six more months and I am refocusing on my alone time. I think it is best for us to honor our parenting plan and spend time alone together on dates. Certainly, plan time to spend together with Phoenix and my Lane kids as a family, too, but mostly focus on alone time getting to know each other more intimately. No more spending time together like we are living together. There are too many unhealed hurts and I need to spend time alone doing things like writing updates to my blog.

No more hiding.

 

16

Wow. Pierce just turned 16.

Oscar died about 2 months before his 16th birthday, so this was huge.

Nick wasn’t here. Nick’s death from suicide in September 2018 has completely thrown me out of orbit. Any of the patterns or rhythms of living that I had just started to re-establish since Oscar’s death in September 2015 were all erased when those two police officers rang my doorbell.

I have had so many difficult emotions since May 23rd, which is Pierce’s birthday. I want to be happy and celebrate and feel joy for Pierce that he made it! He did it! Look at what a strong, beautiful, and amazing young man you are!! He had straight A’s this semester and he aced his pre-calculus final. And I couldn’t share that with his brother or his dad.  I know, I know, they are here even though we cannot see them and sure, we have my folks, and they are wonderful support. They encourage and nurture and teach and set excellent examples of how to be successful in life.

But I really missed Nick yesterday during our family dinner. Because I had gotten used to the idea of not having Oscar at these events, but this was the first big event that I really missed Nick. He would have had a sparkle in his eye and that goofy grin on his face- so proud of his living son. See, in my hopes after Nick moved here when he had hit what I wanted to be his rock bottom in 2017, I saw a future where he was in recovery from addiction and we had made amends to each other and we were co-parenting Pierce and Vivian successfully. So he would have been invited to Pierce’s family birthday dinner.

That isn’t my reality, though.

My reality is that half of my family is dead from suicide. First my oldest son, Oscar, on September 11, 2015, and then his dad, my ex-husband, Nick, on September 11, 2018.

Since we set the date for Nick’s memorial, the burial of his ashes, on September 11, 2019, I have been slowly processing what it is going to take for me to get through that week clean. I have been in recovery from addiction since February 20, 2012. I haven’t been back to the Pacific Northwest since I got clean in 2012. I will be faced not only with impossible grief when I am there, but legal marijuana and lots of old friends who I used with. I am aware enough of how addiction works to know that is a recipe for relapse.

The past year I have not been actively going to 12-step meetings or doing what it takes to really work my recovery. I have been staying clean, focusing on group grief therapy for suicide loss survivors and talk therapy with an amazing psychologist. I have been working full time, in school part-time and figuring out how to be a single mom with the complex emotional needs of my two older children and a very physically active toddler who is nearly two.

As I have turned my face back toward being active in recovery all sorts of things have started to happen. I have spoken with the woman who was my sponsor more than I have in over a year. We are not formally in a sponsor-sponsee relationship anymore, but it is nice to just be speaking with each other again. I have re-connected with some wonderful women who I know will be key in my network moving forward. I have gone to two meetings in the past week. I picked up my black key tag for the 7 years that I celebrated on February 20th.

All of this because I sent a Facebook message to an inspiring man a week ago today after he posted a picture of himself on Facebook graduating from college. We met around the time that Oscar died, he was new to recovery and had just moved back to KC. I have been making an effort to be active on Facebook as part of building my networking skills to help me grow my business. I have been sending messages on Facebook to people I haven’t spoken with in ages to reconnect.

He has been an amazing addition to my life this past week. Usually, people shy away from my pain and my grief and end up relying on platitudes that just make me feel worse. As a response, I shrink away from interaction with them. Maybe because he has had trauma in his life and he carries his own heavy grief he seems to always know what to say.

When I was having a hard time shopping for Pierce’s card (since Oscar died I have not put so much effort into these types of seemingly mundane tasks that make up the little- read that big- celebrations that we take for granted in life) I texted him and he said of course you are feeling pain, you are growing and you know as well as I do Oscar is right there picking that card out with you. No one says things like that to me! It was amazing. There are so many other little ways he has been an amazing support for me over the past week and I am grateful.

This is the other side of 16. Life keeps on going whether we want it to or not. As much as I would love for time to just pause, just for a few minutes, it is not going to. I have almost become a graceful expert at choking back the tears. There were a few times last night that Pierce and I met each other’s gaze knowingly and our hearts acknowledged each other and how incredibly difficult it felt to move forward. Those are the moments I live for now.

As I discover my new pattern of recovery and I begin actively applying the principles of the program to my life it won’t be easy- the program is simple, not easy. I have fear about how the intimate awareness of my character will intertwine with my grief. The steps are in the order they are in for a reason and if I let myself go at the pace my heart dictates and I don’t use, no matter what, everything will be okay. More than okay.

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Health care policy and reform- this is what I am doing this AM

As I have said before, this blog is not just about the pain and grief of being a bereaved mother and suicide loss survivor, but it is also about sharing my thoughts on the research that I do as I go through finishing my BSN. I have been a practicing registered nurse since 2006 with an Associate’s Degree in Nursing, but after Oscar died I felt that the only way my voice would truly carry and give strength to my opinions regarding health care reform is if I had a Bachelor’s in Nursing. So, in Oscar’s memory, I started back to school the fall a year after he died and I am on track to finish after fall semester this year. It has been a long, hard road, especially now that I am newly grieving for the loss of Oscar’s dad, my ex-husband, Nick, also to suicide. Here is what all of my research and thought processes keep boiling down to: we need universal health care and a universal electronic medical record. Period, end of story. I wrote the following paper for my Public Health Nursing class this morning and I wanted to share.

 

The recent article I found is, “Rebounding with Medicare: Reform and Counterreform in American Health Policy,” by Paul Starr of Princeton University.  From my research on the topic of universal health care in the United States, it became clear that Mr. Starr has a strong voice on the matter with a history of several articles and books pertaining to the subject of health care reform in America.  Mr. Starr proposes that we have an opportunity to expand Medicare through a program he refers to as “Midlife Medicare” in response to the Trump administration’s recent setbacks on our progress to provide every one of our citizens with basic health care.

My personal experience as a suicide loss survivor and my professional experience as a registered nurse inform my passion for health care reform.  One thing has become clear to me as I grapple with the disabling pain of suicide loss- our health care system is the root cause of our ills.  And how extremely infuriating!  Here we are in one of the world’s richest countries and we cannot afford to provide universal health insurance for our citizens?  Mr. Starr analyzes the history of health care reform in the United States and notes that all important reform has been made on the rebound from the failure of more progressive proposals.  He acknowledges that the Affordable Care Act (ACA) has had very limited success in fulfilling its goal of ensuring all American citizens have health insurance.  The ACA has been a downright failure in some respects.  It has forced the price of premiums up while not guaranteeing basic coverages to patients.  In other words, just because someone is insured doesn’t mean they can afford to get care, which does nothing to solve the problem of health care for all.

The devastation of not having health insurance or not having adequate health insurance is heart breaking.  There are so many stories to illustrate the social injustice that not having universal health care causes.  It seems that each of us has been directly affected or is only one person away from being directly affected.  The implications on nursing of universal health care are tremendous.  I believe that the positive effects of universal health care are all encompassing.  If we had universal health care, as a nurse and mother, I would have been able to get the care my oldest son needed without traumatizing him with mental health hospitalization.  I would have been able to guide my ex-husband to the care he needed so he could have received the care he required for the treatment of Crohn’s disease without worrying how he was going to pay for it.  I believe, deep in my heart and soul, that if I had been able to make those two interventions my family would still be complete.

I have thought a lot about how to help our citizens who die unjustly, and I am not just talking about suicide, I believe that many deaths in our society happen that could be prevented with adequate access to primary health care for prevention.  My thought processes always boil down to two issues: universal health care and a universal electronic medical record.  At the core of these ideas is patient safety.  Patient safety is the heart and soul of nursing.  I appreciate Mr. Starr’s work and am grateful I found him.  His suggestion of “Midlife Medicare” as a rebound reform to our health care system is right on target.  A positive step in exactly the right direction.

 

 

Starr, P. (2018). Rebounding with Medicare: Reform and Counterreform in American Health Policy. Journal of Health Politics, Policy and Law,43(4), 707-730. doi:10.1215/03616878-6527996

 

 

 

 

Where Primary Care Nursing and Mental Health Nursing Meet; a labor of my deepest love

Here is the research paper that is the culmination of a course filled with so much deep, confusing emotion. I dedicate this to all of us that have lost loved ones to suicide. May we see the changes in our lifetime that it will take to save the lives of millions more who suffer from the worst antagonist: suicidality.

Abstract 

An area of concern in nursing practice is where primary care and mental illness meet.  Suicide is a disease process requiring an urgent and exponential increase in attention from all members of the community, and where primary care nurses can make a lifesaving impact through education and frequent follow up phone calls.  In 2016, 45,000 Americans died of suicide.  “Research indicates that during 2012-2014, an estimated annual average of 30 million mental health-related physician office visits were made by adults aged 18 and over” (Cherry).  Educating patients on best practices for a healthy lifestyle including mindfulness, diet and exercise has long been a primary treatment for chronic disease processes.  In patients with mental health related office visits, is education on healthy lifestyle including mindfulness, diet and exercise in combination with regular follow-up phone calls every other week from primary care nurses effective in decreasing symptoms of mental illness as indicated by lower patient health questionnaire 9 (PHQ-9) score, fewer office visits and emergency room visits over a 12-week period?  Research was reviewed from four articles found utilizing EBSCO-CINAHL Plus with Full-Text.  Four types of research studies including quantitative, qualitative, mixed method and meta-analysis were reviewed and analyzed. The quantitative and mixed method samples were obtained randomly.  The qualitative method sample was obtained purposively.  The meta-analysis was a review of six randomized controlled trials.  The quantitative and mixed methods articles utilized longitudinal data collection.  The qualitative study utilized cross-sectional data collection.  Sample sizes ranged from 5 patients to 696 patients.     

Introduction 

Nearly one in five adult Americans experience the effects of mental illness ranging from depression to suicidality.  Suicide is a disease process requiring an urgent and exponential increase in attention from all members of the community, and where primary care registered nurses can make a lifesaving impact through education and frequent follow up phone calls.  In 2016, 45,000 Americans died of suicide.  “Suicide is a leading cause of death in the US….Health care systems can provide high quality, ongoing care focused on patient safety and suicide prevention” (OADC).  Lack of mental healthcare resources places primary care clinic registered nurses in a position to fill the gap.  “Research indicates that during 2012– 2014, an estimated annual average of 30 million mental health-related physician office visits were made by adults aged 18 and over” (Cherry).  Treating mental illness as a chronic disease process is where the key to change lies.  Educating patients on best practices for a healthy lifestyle including mindfulness, diet and exercise has long been a primary treatment for chronic disease processes.  “In 2014, there were an estimated 885 million office-based physician visits in the United States” (Ashman).  This illustrates the tremendous opportunity for impact primary care registered nurses can make through patient education. 

Most current nursing research revolves around the role of the psychiatric mental health nurse practitioner instead of the role of the office-based ambulatory care registered nurse.  The gap between primary care nursing and mental health nursing would be further closed if there was one electronic medical record (EMR) to unite all EMRs.  This would also assist the registered nurse as case manager, which is the role supported as most effective in integrating primary healthcare and mental healthcare in current research.  Mental health patients are being lost in the United States healthcare system because registered nurses are not involved in patient care at the primary care level to the degree that they could be and should be. 

The role of registered nurse in bridging the gap between what is considered classic disease management processes such as diabetes mellitus and hypertension, and mental health processes such as depression and anxiety, when it has been studied, shows repeatedly that patients respond with comfort and ease to the registered nurses at their primary care physician’s practices which increases their success in treating the symptoms of their disease processes.  Registered nurses are an extremely important key to a patient’s care.  No other healthcare team member treats patients as an entire human being the way registered nurses are trained to do.  Registered nurses address not only a patient’s physical symptoms, but also a patient’s mental, emotional, spiritual and environmental symptoms, as well.  Because of this, registered nurses are poised at an excellent vantage point to understand a patient’s complete care needs, which makes them especially qualified to intervene on multiple levels to ensure a patient is receiving needed therapies to maximize quality and quantity of life.   

Methods 

Research was reviewed from four articles found utilizing the Cumulative Index of Nursing and Allied Health Literature (CINAHL) through EBSCOhost.  Limitations set for the searches included utilizing EBSCO-CINAHL Plus with Full-Text as well as setting search parameters for the past five years only and searching keywords which included nursing education, nursing, depression, mental health, suicide, machine learning, mindfulness and primary care. All articles were published in the English language. All articles were reviewed and analyzed utilizing Avila University’s Nursing Department Literature Review Protocol for each of four types of research studies including quantitative, qualitative, mixed method and meta-analysis. The quantitative and mixed method samples were obtained randomly. The qualitative method sample was obtained purposively. The meta-analysis was a review of six randomized controlled trials. The quantitative and mixed methods articles utilized longitudinal data collection. The qualitative study utilized cross-sectional data collection. The sample sizes ranged from 5 patients to 696 patients.  

Results 

The first article reviewed was a quantitative study, “Collaborative nurse-led self-management support for primary care patients with anxiety depressive or somatic symptoms: Cluster-randomised controlled trial (findings of the SMADS study)” authored by Thomas Zimmerman, Egina Puschmann, Hendrik van den Bussche, Birgitt Wiese, Annette Ernst, Sarah Porzelt, Anne Daubmann and Martin Scherer.  This study was published in 2016 and took place in Hamburg, Germany in twenty general practitioners’ practices with a total of 220 patient participants.  The patients that participated in the study were chosen by, “a biometrician (AD), not involved in field work” (Zimmerman, Puschmann, van den Bussche, Wiese, Ernst, Porzelt, Daubmann, Scherer).  The sample was obtained utilizing certain eligibility criteria including “a) age: 18-65 years old, b) literacy (German), c) fully able to give consent, d) sufficient auditory and visual capabilities, e) currently not in psychotherapeutic treatment, f) Patient Health Questionnaire (PHQ) scoring 5 points or higher” (Zimmerman, et al.).  Patients were divided 1:1 to either participate in nurse-led care or routine care.  Nurse-led care involved case management and counselling techniques to encourage patients to lead their care plan through self-management.  By the end of the study patients who were in the nurse-led intervention group reported increased self-efficacy as measured by several different scales, including the General self-efficacy scale (GSE scale), PHQ, EQ-5D quality of life and the Freiburg questionnaire of coping with illness (FQCI).  Data collection was longitudinal.  The main barrier to implementing this type of intervention across the board in Germany is lack of economic resources and lack of education of healthcare professionals related to what a registered nurse is capable of in the primary care setting. 

The second article reviewed was a qualitative study, “Feasibility of training practice nurses to deliver a psychosocial intervention within a collaborative care framework for people with depression and long-term conditions” authored by Lisa A. D. Webster, David Ekers and Carolyn A. Chew-Graham.  This study was published in 2016 and took place in the North of England with ten clinicians—five general practitioners (GPs), three practice nurses (PNs), one health assistant and one mental health specialist and five patients (four of which completed the interview).  “Recruitment of clinicians…was by personal invitation from the research team to those participating practices who took part in the service development project.  The invitation was made after two months of working within the collaborative care framework in order to explore the implementation of the intervention within the practice” (Webster, Ekers, Chew-Graham).  The recruitment of patients to participate was also by invitation, which was sent about two months after the patients had received the intervention with an offer for a “love to shop voucher” (Webster, et al) for those willing to give their time for an interview.  Demographics of the patient sample were predominately female diabetics with some form of arthritis or back pain in addition to being depressed.  Demographics of the clinician sample were also predominately female.  Practice sizes ranged from 4,402—25,386.  Data collection was cross-sectional and was completed utilizing semi-structured interviews which were face-to-face for clinicians and via phone for patients.  The results of this study also support the integration of mental health services in the primary care setting, but with one important caveat: tending appropriately to the mental healthcare of the registered nurses who are the leaders in providing and coordinating that level of patient care. 

The third article reviewed was a mixed methods study authored by Brenda Reiss-Brennan, “Mental health integration: Normalizing team care.”  This study was published in 2014 and focuses on nine primary care clinics of Intermountain Healthcare in Salt Lake City, Utah.  Three clinics from each phase of mental health integration were included: potential, adoption and routinized.  Even though this study utilized a mixed methods approach, it is primarily a qualitative study.  The sample included both clinicians and patients.  Fifty clinical staff were selected for balance among team members including physicians, clinic managers, nurse care managers, mental health specialists and medical support staff.  Patients were randomly selected who had received care for depression from their primary care provider (PCP) in the previous twelve months, for a total of 59.  This study tested the effectiveness based on objective and subjective criteria of mental health integration (MHI) which is “a team-based approach where complementary roles include the patient and family and are operationalized at the clinic improving both physician and staff communication” (Reiss-Brennan).  MHI is a standardized approach to incorporating mental healthcare into the primary care setting.  The data collected was longitudinal and was collected via self-report, observation and interview.  Again, the data collected, which included a decrease in emergency department visits and patient-reported decrease in mental illness symptomatology, as well as positive provider reported reactions to MHI, support implementation of mental healthcare via the primary care setting. 

The fourth and final article analyzed was a meta-analysis authored by Kathleen Barrett and Yu-Ping Chang, “Behavioral interventions targeting chronic pain, depression, and substance use disorder in primary care.”  The study was published in 2016 and reviewed a total of six articles with a total of 696 participants.  Four electronic databases were searched including CINAHL, Medline, PsycInfo and Google scholar.  Key words included in the search were as follows: chronic pain, depression, depressive disorders, behavioral interventions and primary care.  Limitations set on the search included articles published during the years 1995 to 2015, available in English, original randomized controlled trials (RCT), adult population and studies that contained a behavioral health intervention.  Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used.  The patients in the study had an average age of 45, with 316 men and 380 women.  Three of the six studies were conducted in the United States, two in Australia and one in England.  All study participants had at least two of the three diagnoses (depression, chronic pain and substance used disorder) during the time of the study.  Two of the six studies were conducted strictly in primary care.  The results of this meta-analysis showed, again, that integrating behavioral healthcare in the primary care setting had a positive impact on patient care through decreased mental illness symptomatology. 

Discussion 

The changes that need to happen to better serve our country’s mental health patient population revolve around nurse-led mental health integration of primary care.  The resources it would take to influence the people who could make this change are tremendous.  The changes that need to be made to standardize mental health integration have already been successfully implemented by Intermountain Healthcare in Salt Lake City, Utah.  To make these changes across the country there will need to be a change in healthcare law.  This begins with one EMR that acts as an umbrella for all EMRs.  There needs to be a way for each of the many pieces of the care puzzle to fit together so that each piece of a patient’s records from different providers can be viewed by each of the team members on the patient’s care team.  This would also allow application of machine learning algorithms to accurately predict suicidality in patients.  In some cases, before the patient is aware of the imminent danger facing them.  “In an effort to contribute to the development of one such method, we applied machine learning (ML) to electronic health record (EHR) data.  Our major findings included the following: (a) This method produced more accurate prediction of suicide attempts than traditional methods, with notable lead time (up to 2 years) prior to attempts; (b) model performance steadily improved as the suicide attempt became more imminent; (c)model performance was similar for single and repeat attempters; and (d) predictor importance within algorithms shifted over time” (Walsh, Ribeiro, Franklin). 

The changes that are needed are possible, but only with the help of big money to lobby lawmakers in the community on a local, state and federal level.  To find funding for this type of initiative nurses would need to contact major non-profit organizations that study mental illness such as the American Foundation for Suicide Prevention (AFSP), the National Alliance for Mental Illness (NAMI) and perhaps the countless of other small non-profits started by parents, family members and friends of those who have died of suicide.  Bringing these voices together as one voice would provide the power needed to move legislation.  This is the tip of the iceberg and would eventually lead to a massive healthcare system reformation.  The first step, though, is to have one medical record that unites them all.  Ideally this medical record would be fluid enough to communicate with most of the EMRs already in existence.  

So many lives are lost every day to suicide.  If the resources were in place to address mental illness where it meets primary care, it is certain that the number of sons, daughters, husbands, wives, ex-husbands, ex-wives, mothers, fathers, brothers, sisters, cousins, aunts, uncles, friends, neighbors and other community members that we lose to suicide would drastically decrease.  The evidence uncovered in this research review supports this without a shadow of a doubt.  “Most patients with behavioral health needs use the primary care office as their main source of care, and given the nation’s shortage or behavioral health providers, this may be the only setting in which behavioral health problems can be broadly recognized and treated” (Crowley, Kirschner).  Bottom line is there is a huge need for nurses in primary care who are able and willing to implement changes once they are legislated either as part of health care law or part of their health care entity’s updated care standards at the place where primary care nursing and mental health nursing meet.   

References 

Ashman, J. J., Rui, P., & Okeyode, T., (2017). Characteristics of office-based physician visits 2014. National Center for Health Statistics Data Brief (no 292). Hyattsville, MD. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db292.htm 

Barrett, K., & Chang, Y. (2016). Behavioral interventions targeting chronic pain, depression, and substance use disorder in primary care. Journal of Nursing Scholarship,48(4), 345-353. doi:10.1111/jnu.12213 

Cherry, D., Albert, M., & McCaig, L. F., (2018). Mental health-related physician office visits by adults aged 18 and over: United States, 2012–2014. National Center for Health Statistics Data Brief (no 311). Hyattsville, MD. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db311.htm 

Crowley, R. A., & Kirschner, N., (2015). The integration of care for mental health, substance abuse, and other behavioral health conditions into primary care: Executive summary of an American college of physicians position paper. Annals of Internal Medicine,163(4), 298. doi:10.7326/m15-0510 

National Center for Health Statistics., (2016). Depression. Retrieved from https://www.cdc.gov/nchs/fastats/depression.html 

Office of the Associate Director for Communications., (2018). Vital Signs: Suicide rising across the US, more than a mental health concern. Retrieved from https://www.cdc.gov/vitalsigns/suicide/index.html 

Reiss-Brennan, B., (2014). Mental health integration: Normalizing team care. Journal of Primary Care & Community Health, 5(1), 55-60. doi:10.11/2150131913508983 

Walsh, C. G., Ribeiro, J. D., & Franklin, J. C., (2017). Predicting risk of suicide attempts over time through machine learning. Clinical Psychological Science,5(3), 457-469. doi:10.1177/2167702617691560 

Webster, L. A. D., Ekers, D., & Chew-Graham, C. A. (2016). Feasibility of training practice nurses to deliver a psychosocial intervention within a collaborative care framework for people with depression and long-term conditions. BMC Nursing,15(1). doi:10.1186/s12912-016-0190-2 

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