waking up

My dreams last night were a little strange. I drank a mug of chai tea at like 1900 to boost me through a Reiki treatment and massage that I gave to my new love interest. It was a successful treatment because sleepy time came for him swiftly! I adore providing healing touch to people, especially love interests. I feel like that is my one sort of super power that I have to offer, I just haven’t found the right man to accept my talents and want to make them a permanent part of his life. I have hope for this one. I have hope for all of them, who I am kidding? I try to give my all every time. Well, as much of my all as I have left after having my heart shattered into at least a million pieces.

Anyway, back to my dreams. I ended up home sooner than I thought I would last night and slightly amped on chai tea and the success of my Reiki and massage treatments. So I decided to write in my journal for awhile and then I blogged for the first time in forever and actually published it. I’ve been doing this thing a lot lately where I write but then I get worried about who might read it and that I might shock or hurt feelings or cause political turmoil at work or whatever and I’m over it. Blogging is so helpful for me. So I’m just gonna do it. As I sailed into sleep last night it was one of those into sleep transitions where I felt myself soaring above for a good long while. I was relaxed and ready to sleep, it’s just the chai tea had me more aware than I would be normally. The dreams that I remember were with my new love interest at his home. This is the strange part: there was a dead body in one of the bedrooms, like someone had died that we all expected to die, like they had been on hospice or something, and he hadn’t called the hospice people yet because he wasn’t ready to. He was waiting for someone who wanted to say goodbye privately. And then my mom came into the picture to bathe the body. Why I wasn’t involved in this I have no idea since I am a registered nurse and have bathed my fair share of dead bodies. I did, however, make the suggestion to add clove essential oil to the bath to help with the smell. My love interest and my mom agreed that was a good idea. My love interest even said that was something that used to be done before modern day chemical embalming… whether or not that is true I have no idea… this was a dream!

Analyzing a dream like this is so interesting. Obviously, my subconscious is sifting through some shit. The smell of a dead body. That was the main concern. Not let’s get the person we are waiting for here sooner than later so we can call the hospice people and the funeral home. The smell is a big part of my trauma with Nick’s death. He wasn’t found until days after he died. The neighbors called a wellness check to the local authorities because of the smell coming from his place. My heart absolutely crushes in on itself every time I think about that. This is definitely something I haven’t worked through completely. I just put it in a box and tucked it away. Time to get it out and work it through. I dreamt about Nick the night of September 11, 2018, which was death day number 3 and what we suspect is the day that Nick died that year. He was found on the Sunday after that, which I think was the 16th. He left a note with my name and contact information on it. I hadn’t attempted to get in touch with him for months except through the court because of how he had behaved the last time he had Pierce and Ryan over, which was Father’s Day weekend that year. He had started drinking again and being very emotionally and verbally abusive. Ryan had called me crying because he was so scared. Pierce had taken over Oscar’s old role of attempting to be the mediator between drunk and unreasonably angry Nick and the younger kids, kid in this case. That’s when I decided to take action and file for a safety focused parenting plan. Nick texted me once around the Fourth of July to ask to have the kids, and I texted back that any arrangements to see the kids needed to go through my lawyer. He never took it further. All I ever heard from him again was that he wanted to push the court date out to October so he had more time to find and pay for a lawyer.

My heart really hurts for how completely fractured our relationship became. When we started out together I was so young and he was so experienced (or maybe traumatized?) and pretending (?) to have hope and see the possibility for joy. Nick never really talked about what had happened to him and his family. His brother Jimmy had been murdered and his favorite sister, LouAnn, had died of suicide a number of years after that. Not to mention whatever happened when he was growing up in a too small house for 7 kids and 2 parents who sort of got along, but not really. He used to say the 7 kids came from Catholic guilt and not love. He would make it a joke. He made lots of things jokes. I think that was his main coping mechanism besides drinking and smoking pot. All of his unprocessed and unresolved feelings surrounding the trauma he had been through came out in all sorts of negative and destructive ways. That is what happens to people when they don’t work through to the bottom.

Now I’m working through to the bottom with Nick. His death has been so hard to process. I think because we were estranged when he died, but also because I have such a deep and profound love for him, still. He is around all the time. I feel him more than I feel Oscar. He always has something to say and he is in my dreams all the time! Maybe the dream I had last night is Nick. And the one they are waiting for is me. I haven’t said proper goodbyes. I hold a piece of him in my mind that is when we first met. I was so enamored by his charm and his brilliant mind. I’ve never met a man like Nick. It was so easy for us to fall in love. Looking back on old pictures on Oscar’s birthday I realized how hard we tried. I’m not sure what went wrong. I guess the active addiction is really what came between us. Neither one of us could relate to the other because we were never in our right minds if we could help it. I remember how he used to hold my hand. And the way that he would look at me. His goofy grin. And the sex was great. We had an excellent time in bed. It’s honestly one of the reasons I stayed as long as I did. It was really hard to let that go. And to learn to live without it has been so tough!!

Nick would make xmess a fun and joyful holiday. He’d always make it special. I don’t have that kind of talent or desire since my people have died. This year my mom and Ryan decorated together, thank God. I genuinely hate all of it. It takes so much emotional energy. I feel like I dip into my already drained reserve tanks every year since Oscar died and especially so since Nick has died.

What am I to do with this dream? I don’t want Nick to go. Maybe it is time, though, whether I want it to be or not. I have to let go to let a new man in. It’s that simple. Simple; not easy.

cocoon

Over the past several months I have written and then not published. Because I was worried about work politics or hurting someone’s feelings or some other such similar reason. At the beginning of September I went into what feels like a cocoon. I have been avoiding all social media and focusing on me, the now, my kids, my home, my work. I thought it would be just September that I avoided social media, and, in fact, for the entire month of September I was completely and totally absent from social media. It felt so good I didn’t check it out again until late October. I don’t think I’ve had any personal posts, except to thank people for the birthday wishes, which was hilarious because people responded as if my birthday was recent and not in September.

While I’ve been in this cocoon and considering the break that I have been taking from social media and also from blogging and the reasons for that I have come to the conclusion that I am done censoring myself.

I left Luke’s for a number of different reasons, not the least of which was politics, yet again. So sick of work politics. I tried to go back to the CVOR when I realized for sure that the clinic wasn’t going to be anything but me working as a medical assistant (!!!) and the director couldn’t make a spot for me. Too bad, because they are down nurses now. I ended up interviewing for a spot as a staff nurse to open a new OR in south Overland Park. The commute is about 10 minutes less than to Luke’s. And it is a main OR, so the cases are all super chill. We are like one step above a surgery center as far as acuity goes, so I am on cloud nine compared to CV acuity. I do miss the CV, though. I really really miss my CT surgeons. It really really sucks that the director of the CVOR couldn’t make a spot for me. Oh well. The incredibly awesome thing about my new gig is that I am primarily scrubbing! I feel like a duck to water I love it so much. I am considering pursuing my first assist so I can stay in the scrub role for the remainder of my nursing career.

So, yeah, career is chill. Not what I thought I would end up doing, I guess, but whatever.

My grief feels sort of like it is on ice. Sort of. It has definitely morphed this year. That really started over death day six and three. It was Oscar’s sixth death day and Nick’s third death day. Me and Pierce and Ryan went to Vail to see Death Cab for Cutie and it was completely different. I feel like I came to a new understanding that my years turn on death day, not New Year’s. I have also begun to reach a new distance from the trauma where I see that everyone, well, most everyone, has their own trauma. Most people don’t deal with it as well as I do, though, and it causes them real personality issues. Negative ones. I have shit I am dealing with in my personality, don’t get me wrong, it’s just that what I have been through has really forced me to change so I can get through my days with the least amount of discomfort as possible. My pain, my broken heart, is too much to bear and not be as healthy as I can be. I think the fact that Nick died of suicide three years after Oscar died of suicide is very telling regarding how painful it is to have one of your babies die of suicide.

And then there’s dating. Oh my goodness. What a freaking roller coaster ride. I wish I didn’t love sex so much. For real. I am hopeful that I may have finally met my match. It seems promising so far, but man, I’ve been here before. Countless times it seems like. I am attempting not to have any expectations, but goddamn that is so fucking hard. So, more like reasonable expectations. Still, my emotions throw me around without my permission, like, a lot. Learning how to rise above that noise is one of the hardest things. Bottom line, I try to be responsible. Hopefully this rocky road will finally start to smooth out.

My kids all really inspire me. Ryan has been amazing to learn from and be around and chill out with. He is learning guitar and piano, and writing lyrics, so it is absolutely inspiring to be around him. Pierce is a fucking rock star. I still cannot believe how well he has weathered the storm. Almost done with the first semester of KU. He absolutely thrives. Then there’s my firecracker, Phoenix. He and I are on a nutrition journey together. Finally gave into the PCP’s advice to trial a gluten free diet for him to help with his chronic constipation. He is so much better! Now if we can get his immune system to kick in so he stops picking up every bug from the preschool. We are going to see a naturopath to help us with that. And Oscar. He and I see each other in my dreams. I feel his presence often and we have a relationship even through death. He is wise and guides all of his brothers and me. I feel his energy helping us to see the way. He knows that I am inspired by him to become a better mother, a better person. He is my light. I miss him beyond words. Always.

Xmess sucks. Holidays suck. Half of my family is dead. It is what it is. The point is that I keep going. I keep moving forward. Even when it feels like I am slogging through mud. Some days are better than others. I try to enjoy every moment for what it is and be in it. Fully present.

Hopefully it won’t be so long before the next time I write and publish. I might just go back and publish some of the drafts that I have saved up from over the past couple of years. I’m cocooned, but I’m done hiding.

let’s get into it

For real I keep dreaming about Nick. I really don’t understand it. I know there is a lot that I still need to process about our abusive marriage and it is a lot different working through it while he is dead, but seriously, what gives? My psychologist and I spoke about it a few weeks ago. I told her that I keep dreaming about him and I know I need to work through some of the roughness between us, so she suggested that I write about it. She suggested I write him a letter, which is so cliche, but it is a very common tool when you are working through problems that you have with dead people, I have discovered on my grief journey. Kind of funny, right? But, hey, it must work, or it wouldn’t be a cliche. I know after Oscar died I wrote a letter to him almost immediately. I was so distraught and raw. Just raw. Nothing felt like I thought it would. After Oscar died it was like my feelings got turned inside out. Completely strange how deep grief changes you. Anyway, back to Nick. I keep dreaming about him. I dreamt a lot about him when he first died. I actually dreamt that he died before I knew he was dead. That was weird. And we’ve had other dream time sessions, too. We made quite a bit of progress, actually, but now I feel like we are stuck. So after my psychologist recommended that I write to him, I actually started just writing about what happened between us. A historical account. It is funny because during my session when my doc and I talked about this I immediately said, “Oh, it could be the start of my memoir!” Goes to show you how I am always trying to make something out of nothing. She brought me back to reality by reminding me that I just needed to let it flow. After that first (and only) time I have written about my life then I was so exhausted!

And I keep dreaming the same sort of dream. We are together, even though we shouldn’t be, and he is his happy-go-lucky-I-want-to-have-fun-and-get-laid self. Nick loved sex. It was one of the things that kept us together for so incredibly long even though the abuse and dysfunction was so uncomfortable. It isn’t like we did too much that was wild and crazy, we just had a routine that worked for both of us that we would always fall into. And when we first met it was like fireworks between us. Our chemistry was like no chemistry I have ever felt before or since. That is what I though was love between us. We didn’t really know how to love. On my journey following Jesus (this is sort of new- it has been a push pull my entire life, it is just that about three months ago I finally really committed to Him) I have learned that love is so much more than a feeling. It is an action. A choice that you make to accept someone despite all of their faults and do positive things for them. Nick and I had trouble with that. And he would sometimes seemingly flaunt his faults. Looking back with what I know now and my own experience with grief and how incredible hard it is for me to maintain my okay with a lot a lot of self-care I can see how grief shaped Nick into the reluctant-to-change addict that he was. He used to tell me that the deaths of his brother and sister felt like emotional amputations. I was so cruel. I would tell him he needed to make a choice to move on and get healthy. That is so easy for someone who had never been bereaved to say. I have learned through my own grief that you never really move on. There is always a piece of you that is in the moment that someone you love dies. You are changed irrevocably forever. For the duration. Never the same.

In my dream that is the same, yet slightly different every time, Nick and I are together and we shouldn’t be and we are hiding out from our families trying to have sex. There is always some reason that we need to hide. In the dream I am always adamant that no one see us or know that we are together and he isn’t really worried about it at all. He is so focused on taking my mind off of being worried so I can relax and let him have his way. Our marriage and our home life was a lot like that. We hid our drug use from a lot of people. I wanted to quit from the time that we got pregnant with Oscar in 1999, but he plain told me that he would never stop using, that it was a deep part of who he was and how he managed to deal with the trauma that he had packed away. What would have been more accurate would have been for him to say that his using kept him from having to deal with the trauma that he had packed away. He stuffed it deep down and avoided it for as long as I knew him. It was so rare for him to talk about Jimmy or LouAnn. He was always passing me a beer or a pipe and telling me to relax.

That was what I needed to see. In my dreams Nick is trying to get me to relax so he can have his way. There is something he wants to show me. And here I thought that he was the one not letting me get through to him. I wonder if the next time I dream about him if I can let myself go back to the Jes who would let Nick completely dominate her? That is a scary thought. Makes me want to run. If I can just sort of allow myself to go down that path enough with him I wonder if we can get to the deeper level we need to get to in order to sort through some more of the rough between us?

Working through issues with dead people is hard.

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.

 

Long time coming

In December I finished my BSN. What a relief. I showed up to the  Avila University Administration Building to pick up my diploma the day campus re-opened after Xmess break and when the nice lady behind the counter handed it to me and asked me to check the spelling of my name to make sure it was correct the tears started flowing. Joy, sadness, relief, pride. It was all in those tears. And the missing. Missing Oscar, missing Nick. I can hear Nick telling me how proud he is of me. I can feel Oscar’s arms around me squeezing me tight in hugs only he could give. Thinking of that moment brings the tears to my eyes and goosebumps to my flesh even now.

My life seems to have been moving a million miles an hour for the past several years. Really since I got clean eight years ago. Change is always constant. Not just subtle changes like needing to change the brand of your coffee because the one that you like has gotten too pricey or your usual store has stopped carrying it. My changes have been life or death, literally. Navigating big change is hard. Nothing easy about it. I have found that the way to stay (mostly) productive is to focus on the small bits that make up the everyday. Breathing. Breathing is a big deal for me. Meditation daily is part of my routine, but it hasn’t always been. At first, it was simply remembering to take deep cleansing breaths whenever the uncomfortable vibrations of emotional pain would start creeping in. Then drinking enough water. For real. Water is a big deal. After that comes nourishing foods. All with a focus on mindfulness. Staying square in the middle of the moment you are in.

In the last semester of my BSN, I had a realization. The truth of my realization is that I am a nurse whose calling is surgery. This has been a difficult truth for me to embrace since Oscar’s death.

I studied mental health- depression, and suicidality- for all of my individual projects while completing my BSN. How confusing to study mental health so intensely if your calling is surgery. I thought for a while that I should try to change my specialty area and I did for about three months beginning in the late summer of 2018. I worked in primary care for those three months and I learned very quickly that it wasn’t for me. Nick died in September of that year and I couldn’t try to make the transition to primary care work any longer. Thankfully, I was welcomed back to the OR at Menorah I had been working in since I left KU in 2016. It was really good to go back to surgery after trying something different. This was a big clue to me that my calling is truly surgery.

Fast forward to last summer, 2019. It became glaringly clear to me that Menorah was no longer a good fit for me. Not because I was grating with personalities or anything like that. Menorah OR has been a wonderful family for me. I love all of the staff there dearly and it took me over six months to make the final decision to leave for another OR. I was not aligning with the foundational ethics of HCA. Over and over again I would see the same problems happening and I was powerless to do anything about it. I had ended up back in a board running position and was denied the opportunity to advance to management, so I was in this strange and very uncomfortable position of seeing exactly what needed to change to make our department more efficient and safer for staff and patients with no power to make change happen.

I applied for other OR staff nurse positions after I was denied the promotion to OR Manager at Menorah- and I turned down two very strong offers from organizations with very positive reputations. I wasn’t sure if my motivation to leave Menorah was coming from a place that was purely emotionally reactionary. What if this just meant that I really did need to change my specialty area? That was the lingering question. I felt like I wanted to try a little longer at Menorah (and finish my BSN). Ensure that I was truly doing everything I could to continue my career at Menorah. There were several conversations with my director about burning out in my board running position. That it was too stressful to make an impossible schedule run smoothly every day. What we needed to change to make our department more efficient. My concerns fell on deaf ears. I tried at Menorah. I really did.

I explored the question of whether I was really meant for surgery because of all of the heart and soul that I gave to Menorah with no reciprocation. I decided to apply for any and every job that sounded interesting to me that wasn’t in surgery. Looking back I feel like I was testing God. My job hunt included many different community health type positions from school nurse to county emergency coordinator to public health. I applied at UMKC, Cerner, Johnson County, Shawnee Mission School District, even Tyson Foods! ZERO interest from these employers. My resume went nowhere.

Swirling in the back of my mind, the entire time since I had turned the offer down in September, I kept thinking of one OR staff nurse position in particular: CVOR at Saint Luke’s Hospital. When I had interviewed there in late summer last year I was so impressed. I asked the manager more questions than she asked me. All of her answers were spot on. I shadowed there and was completely enthralled. The way the nurses practiced, the care I saw given, it was all world-class. Truly world-class. And the cases themselves! I had always had a little piece of me that wanted to learn CVOR, but I felt like I wasn’t good enough.

I had first been exposed to CVOR at KU. One of our robot rooms for main was in the CVOR and I would peek in the windows of those heart cases and I remember saying to my work wife at the time how much I wish I could just be a fly on the wall in those rooms. What if I was meant to grow as an OR nurse in a way that I never thought I would have the opportunity to? What if I could grow my OR nursing practice to include this pinnacle of OR nursing knowledge- open hearts? Those were the questions that began to make themselves regulars as I would contemplate my next career move.

The day after I finished my BSN course work in December 2019 I looked to see if the position at Saint Luke’s CVOR was still open. It was! I immediately reached out to the manager and to the HR recruiter I had worked with previously. I went through another round of interviews. I felt a sense of home during those interviews. I was extended a second offer that I accepted.

I have been in my new position learning the rooms as a CVOR staff nurse for about a month now. I’m not going to lie, it was pretty rough at first. The cases are the highest acuity and that is challenging to me because of my own personal trauma, but I feel confident that I am able to process these new experiences appropriately and bring my highest level of professional performance to the table. Also, fitting in with such a tight-knit team… They are the tightest-knit team I have ever seen, and each and every one of them holds each other to the highest practice standard. And me, coming from a leadership position where I had been on the outside of staff camaraderie- I am sure it seemed like I was either super stand-offish or a snob. Transitions have always been hard for me, but I feel like especially over the past two weeks or so I have started figuring out my spot on this team. I feel like I have so much to learn even though I have been an OR nurse for the better part of ten years. This specialty area should not see me bored for a very very long time, if ever!

I have been feeling so much of myself change since I started at Luke’s. The organizational atmosphere at Saint Luke’s is amazing. I have never felt so supported in my nursing practice. What I have had the blessing to witness caring for our patients is truly humbling. Somehow being with these patients is different than all of the other surgical patients I have cared for. It has been very powerful for me on the deepest level of spirit.

My career finally feels like it is exactly where it needs to be. And that has been a long time coming. My new understanding is that I can pursue the career that I have always dreamed of and simultaneously honor my firstborn son, Oscar. I don’t need to fundamentally change what has always excited me about nursing in order to fully honor his memory. The way that I carry myself as I do the work that I love is what matters. That I keep talking and keep sharing openly and honestly about my experience and all that I have learned about mental wellness is the purest way for me to honor my beautiful boy, Oscar.

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Suicide Grief is Complicated Grief

Well. Here I am on the other side of Thanksgiving. Many wonderful things have happened to me in the past week. I met someone. (I met someone!) My Lane kids and I celebrated Oscar’s birthday in a natural flow. It was truly a joy-filled day, which feels so good. I love that I was able to celebrate Oscar and all of the things that made him so incredible, so special, and not be completely overwhelmed by grief. Thanksgiving was unconventional and very chill (this was due to me being so focused on exercising healthy boundaries in all of my relationships this year). We had a day filled with meeting our new dog (who is also a suicide loss survivor- I am sure I will talk more about her at a later time) and eating fried chicken for dinner before I spent a few hours in the later evening with my new love interest on a very unique first date. We vibe on so many different levels, even the really deep ones. It is a new feeling to be truly seen by a man who is interested in me romantically. I have hope for this budding new relationship, but I am also scared. Scared because I don’t have a track record of positive outcomes in this arena for various reasons, not the least of which is grief. Which leads me to last night.

Through a set of circumstances and motivation that was of purest intent, I found myself listening to live music at a bar. It was so much fun to see all of the people up dancing and having a good time, so many smiles. I found myself smiling and bopping around in my seat, which was enough for two different older gentlemen to ask me to dance. I accepted, mostly because I wanted to allow a full experience of the environment, but also to get closer to the stage in order to see the musicians with increased clarity. I danced two or three times with the younger of the two gentlemen to the point that he wanted to start a conversation. He started that conversation by asking my age. Then he told me he was fifty-two. 52. That’s how old Nick would have been if he were still alive. The gentleman asked if he could sit with me and I politely declined, telling him I was with someone. (Working those healthy boundaries again!) We had a bit more conversation. He told me he doesn’t ever go out, but he did tonight because when he got home from having drinks downtown with friends he didn’t want to be home alone, that he lives just around the corner, but he never comes here and he should come here more often. Then he sat back in his seat, which was just in front of me. And I couldn’t help but watch him drink beer after beer after beer. I did what I could energetically to surround myself in a shielding bubble and send whatever energy-sucking tentacles he had sunk into me back to him, but it was too late.

My world began crumbling into a wave of grief. Nick would have been fifty-two if he were still alive. I haven’t quite learned how to negotiate my Nick-sized grief. Our relationship was so incredibly dysfunctional and he was abusive. Terribly abusive. I have just begun working through that in therapy. I feel like sometimes with the grief that I feel as a suicide loss survivor I cannot help but feel a glimpse of the pain that my loved one was feeling when they died. And that really hurts. That is hard to allow. It is very difficult for other people to be around, as well, when I am feeling that way.

There is so much in that environment- the bar- that I haven’t really dealt with, as well. I haven’t been to a bar since before Oscar died in 2015 and even then I was going to the Green Lady Lounge to listen to jazz, which is a much different environment. Nick’s natural environment was the bar. I remember when we first met he was a regular at the Manette Saloon. Everyone knew him. Everyone called him “Nicky the Mayor”. The mayor of Manette. That was the little neighborhood we lived in East Bremerton, right down on the water there. Looking back, hindsight being what it is, that should have been a red flag for me- that he was a regular at the local bar, but his charm and his smile and his eyes outweighed any red flags you could throw at me. Even the shower of red flags that happened the night before we got married was not enough. There was something in Nick Lane that wrapped itself up tight around my heart and my soul. I fell deeply and madly in love with him.

Our first date was a drive to the ocean. He used to tell me that he could see how incredible I was and he knew he would have to plan something really really special to get my undivided attention. We had such a whirlwind romance. He sucked me right into his orbit. He was so smart. I used to tell him he had a sexy brain. Our good times didn’t last long. His true colors came out the night before our wedding. Then the next thirteen years of my life were spent trying to figure out how to get out. We had three beautiful children during that time. I’ve talked before about how each pregnancy I had hope would be catalyst enough for him to change, to quit using and get healthy with me. It was never enough. He only had glimpses of recovery after our divorce. The pain of the grief that he carried was too much for him and he died of suicide just last year. Just last year. That first wave of holidays was tolerated on a wave of adrenaline and shock. This year it is settling in.

So this is the grief that I carry that is Nick-size. This grief doesn’t feel like an old friend yet. This grief feels like unresolved business mixed with deep disappointment and the only truly madly deeply romantic love I have known to this point in my life mixed with the stark realization that it was a farce. Truly madly deeply romantic love does not verbally, emotionally and sexually abuse you. This grief that I carry surrounding Nick is forever complicated. If I have learned anything about grief the past four years I have learned that the only way to accept it is to allow it. Pain like this is hard to allow. Especially this time of year when we are supposed to be joyous and happy, always looking on the bright side. I wish it could be different, but it isn’t. This is my journey. And I will honor it to the best of my ability. I will keep talking and I will keep sharing. I will continue to have the conversation that no one wants to have, the one about suicide.

So I’ve made it through September, and almost all of October, but…

It just doesn’t really get any easier, not at the base, at the foundation of it all. I still feel his absence to the absolute marrow of my bones, all the way down to the molecular structure of my DNA. I keep dreaming about him and his dad and Washington- the other night I dreamt that I was with him, close to him, touching his beautiful face and staring into those incredible deeply perceptive eyes. I woke up and picked a huge wound on my own face, which I haven’t done in years. Great. I have been keenly missing his dad lately, too. All I ever wanted was to be happy with Nick. To get along with the most amazing partner I had ever had- but to do that he would have had to completely change. Addiction is a cunning enemy of life, goddamnit. And it sure was a destructive force on my life, on our lives, all the way around. The root cause of all of the tragedy that I have endured in my life is addiction. I work hard, daily, to make peace with that fact. To accept it, to let it be. And to never let it happen again. This Lane family curse stops with me, stops with this generation. No more. Enough.

Here I am almost through October. This year has actually been pretty okay. I have been utilizing a mental wellness product that is all-natural and it has been helping me to be pretty okay, which is tremendously improved from my typical level of functioning this time of year. It helped me get through Nick’s funeral- of that, I am certain- and helped me to make the most of my time in Kitsap County. It was so incredibly healing. We called it #healingweek. And it lived up to its name in every way. I realized during my time in Washington that the geography there, the land there, the people there, the rain there, the trees there, the water there, the everything there is always going to be half of who I am. Half of who I am. I felt a mission in my life, a pull that was beyond words when I was a teenager running from everything I knew in the Midwest. And it took me straight to Nick Lane in Bremerton, Washington. What a journey it has been. There are so many things that I would have done differently, of course.

One of the things that I have learned just recently is that the people that I had hoped I could rely on for support don’t get it. When the people that you thought supported you no matter what tell you that you are not trying hard enough when your grief overwhelms you with such force that it takes your breath away it is time to find new people. So I took that truth and have been looking for my tribe. I am very hopeful that I will find it in yoga. And I am very grateful that I have the opening of a new studio to look forward to next month. November is hard because it is Oscar’s birthday, so having something to look forward to next month is key.

Something wonderful did happen to me at the end of September- while I was at Pierce’s home debate tournament- I literally felt my holiday spirit float back into my body. At the exact spot where my heart is. This is huge for my family. When I asked Viv and Pierce if they would be okay with staying home for Christmas and decorating the house together they were both very excited! I usually take the kids and run away somewhere for Christmas because it is just too hard to tolerate. Great Wolf Lodge has been key for those getaways. I am not ready for any family ornaments yet- I don’t know when I will be- so this year we are decorating with a beach theme! It is fun to look forward to the happiness it brings to Viv especially. I am certain my youngest little spitfire, Phoenix, will appreciate it, as well. He is only two.

Viv and I had a lot of fun decorating for Halloween- Halloween used to be my absolute favorite holiday with Oscar. He loved to carve pumpkins. The year that he died I had been so looking forward to sharing Halloween with him because we hadn’t carved pumpkins together for two years… he was always so good at carving pumpkins. I took pictures the last time we carved pumpkins together in Bremerton, the year before the divorce. The problem is, I don’t know where those pictures are… I am almost ready to start going through the old pictures. I have so many from when he was little, thank God. They are waiting patiently for me in the hutch where I keep all that is left of him. There will never be enough of him. Not ever.

All of these feelings and all of my experiences spill over into my professional life. How could they not when I am a nurse? Since Oscar died I have felt a need to affect change on a larger scale than I do in my current position. I have experimented with all kinds of different ideas: working in primary care (that was a no-go), having my own intuitive healing arts business (still too small), staying in surgery and working my way “up the ladder” (my current director doesn’t agree that I should advance to manager), simply staying in surgery as a staff nurse somewhere other than where I work now (surgery just doesn’t feel right anymore). Over and over again I feel like I am not fitting. I keep working over all these different scenarios in my mind about how I could stay where I am and just volunteer more, I would very much like to be more involved with the Johnson County Suicide Prevention Coalition, but I am so tired after working shifts at my current position. It is so incredibly draining. The hours are so long and I see how it affects Viv negatively. Another good reason for a different path- different hours.

And I am still finishing school- it is almost over!!! December is my graduation date. I keep thinking maybe when I am done with school it will be different. And it will, but it won’t change how tired I am after a shift running the board in my OR. So I have started applying for positions in public health-related environments as they come up. Basically, if it looks interesting to me and it is something I have never done before as a nurse because it is on a macro-level instead of a micro-level I am applying. It is scary to think about leaving the specialty area that I wanted so much to be apart of for so long when I first started as a registered nurse fourteen years ago. Scary for a variety of reasons. Not the least of which is money. I am finally making more now than I did on the west coast- it took several years to get here. But just how important is money? Very. Sure. But so is affecting change to a system that is broken. And I can’t do that from the boardrunner position in surgery. I really want to work with healthcare issues on a larger scale- so perhaps at Cerner working on developing solutions for population health electronic medical records or working for the Johnson County Government to coordinate and manage emergency preparedness or how about as a middle school nurse?

My point is these are all things I think about, that I experience, that I face on a daily that I never would have if Oscar hadn’t died. I was happy at KU in the Main OR working as a circulator. It was all I ever wanted. The life I was building was going so well, I had finally gotten custody of all three of my Lane kids and everything was finally going to be okay. We were all going to be happy because we were finally going to be together. And it was going to be everything we ever wanted, our family life was because I had gotten clean and was doing the work to heal and be healthy. To be the best mom I could be. But then Oscar died and my world disintegrated. Our world disintegrated. Here we are four years later and it only sort of looks “normal” again. Because I am sort of okay and can decorate for the holidays again. I miss him. More than I have ever missed anything in my life. And it hurts. More than words could ever describe. And it always will. Period.

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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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Christmas 2018

Christmas sucks.

This is Christmas number four without Oscar and Christmas number one without Nick. There was no way I could bear the thought of being at home today, so a few weeks ago I did what Nick would have liked for me to do: book a room at Great Wolf Lodge. We have an incredible room! We got an upgrade, so I have my own room. So wonderful. I am so grateful to be able to do this for the kids and for me. But this is one of the conundrums of grief: feeling two opposite feelings equally as strongly at the same time. I am grateful for the now, spending this time with my kids and having a break from it all, but the pain of loss is especially poignant right now.

Christmas used to always be proceeded by a sleepless night for me and Nick when the Lane kids were all little. I remember Nick used to say, “Christmas should be a good time for us, we deserve to have one good time a year, Jes.” And so every year we would splurge on the kiddos. So many gifts! The tree would always be bursting and the stockings overflowing with all sorts of fun stuff. We went broke each year a little more at Christmas, but the smiles on the kids’ faces were so worth it. I didn’t know that then. The crushing debt was one of the issues that broke our marriage. There were lots of reasons we were dysfunctional and needed a divorce, don’t get me wrong, but the debt added a level of stress that was smothering.

This year, since Nick died, I have been struggling. Truly. Just to see what his death has done to our kids and to feel that heartbreak and also my own in a world that will. not. give. has been exceptionally exhausting. All of the same levels and types of emotion and pain as when Oscar died, but without any grace. None. The world shrugged it’s shoulders and laughed while saying, “let’s see how you make it through this one.” So many emotions. How do you stay focused on the good in a set of circumstances like that?

Lots of ways. I see Oscar everywhere, and this helps me. Sometimes it is unbelievably sad and painful, but mostly it makes me smile and fills my heart with warmth. I stay connected spiritually by taking care of myself. Aromatherapy every single day if nothing else. It’s funny, I take that shit to work and sometimes I feel like I am pedaling drugs because I offer to share my aromatherapy with co-workers who are stressed out. Lately I have been taking aromatherapy and a crystal of some sort to work. And it helps. Oh does it help.

I have also been working with my shadow self to understand what she needs. First I had to free her (see my starsprae intuitive healing arts blog for more about my day to day healing work). Now I am working with her to help her find her voice again. Lots of years of suppression has not worn well on her. She is wild and free, full of inspiration and amazing life. I have seen glimmers, we are working to make it easy for her to be seen. A morning routine of a tarot reading has been part of my healing process for about a month or so now. I love tarot! It is fun and intuitive and it is helping me stay focused.

The hardest work I have had to do recently is in the area of romantic relationships. I think Nick’s death has influenced this quite a bit if I am completely honest. Since he died I have been mourning the loss of so much- the potential of a healthy father for my older children, the only other parent to Oscar (all of those memories that Nick was the only other person who was apart of!- now I am the only bearer of them), the potential for healing our relationship- I would have liked to be friends with Nick again. The feelings are complicated and deep. It will take quite a long time to get through them. Years and years. All of this has made it harder to tolerate relationships in general, let alone the romantic relationship with my youngest’s father that I have been trying to heal. I gave myself permission to set a healthy boundary with him a couple of weeks ago. I could hear Nick’s voice in my head- “The timing, Jessica, the timing! You always have the worst timing!” Yes, just a couple weeks before Christmas and I set a strong friendship-only boundary. I cannot try for anything else right now. I need space.

Space to remember. Space to be the mother to my children that I feel I need to be. Space to grow my talents as an energy healer. Space to make my own home. Space to spread out. Mostly space to remember. So much remembering lately. I love my psychologist. At our last session she encouraged me with this idea, “You are ready when you are ready.” This applies to so many different things! I am ready to remember. I am ready to let myself go to those spaces. I am ready to stand up for my needs. I am ready to forgive (even though that is going to take me a long time to do completely, Nick!) I am ready to live as who I am.

I cannot believe we have to do Christmas this year without you, Nick. I do wish you were here to spoil the kids and share your jolly Christmas spirit with them. It was the one time of year that you always made into the best for us, for them. I know you tried so so hard.

Oscar, there was a three pound Hershey chocolate bar at Walmart this year! I would have bought it for you if you were still alive, no doubt! I miss you so so much. You would have been on your first winter break from college. I wonder what you would have been studying? You would be here with us. On the pull out sofa. Ready to splash and play and have fun with your brothers and sister. You were always my mother hen. Taking care of everybody. I wish I could have done better teaching you to take care of yourself. I know you are still here with us, I feel you here with me right now, but that doesn’t change how much I miss you.

Christmas sucks as much as it is wonderful when you are a bereaved mama and divorced widow.

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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 

Zimmermann, T., Puschmann, E., Bussche, H. V., Wiese, B., Ernst, A., Porzelt, S., Daubmann, A., Scherer, M. (2016). 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). International Journal of Nursing Studies,63, 101-111. doi:10.1016/j.ijnurstu.2016.08.007