When Your Patient Has a Mental Illness

It can be a challenge when your patient has a co-morbid mental illness.

People with severe mental illness may be socially inappropriate, may practice poor hygiene (part of the illness), may be morbidly obese (due to medication side effects), and many are bereft of common social skills.  

Often not beautiful people, they are shunned, blamed, and feared, both outside and inside the acute care setting. 


When Your Patient has a mental illnessThe National Alliance on Mental Illnesses (NAMI) Stigmabusters fact sheet tells us that:

  •  One in five people worldwide have a mental or neurological disorder at some point in their lives.
  •  Some 450 million people currently suffer from such conditions

Even though mental health is an important topic in our country, severe mental illness is not well treated or understood.

Not My Role

Some nurses protest having a patient with mental illness. “Behavioral health is not my chosen speciality. If I had wanted to work with mentally ill  patients, I would have gone into psychiatric nursing.”

But people with mental illness can be found on any nursing unit because they, too, have heart failure, broken bones, and COPD.

The need for medical care among patients with mental illness has increased.

Due to lifestyle choices, health care access disparity, side effects of antipsychotic meds- and multiple other socio-economic reasons, people with mental illness are highly prone to many medical disorders such as obesity and diabetes Type II.

For these reasons, the life expectancy of a person with a severe mental illness is 15-30 years shorter than that of the general population.


To be mentally ill is to suffer shame, and to be blamed for having a severe neuro-biological disorder that they neither caused nor deserved.

In many cultures, a family member with mental illness may be cared for at home but kept out of public view. In American society, stigma and ignorance still exist, even among health care providers and within the healthcare system.

The American Psychiatric Nurses Association (APNA), an organizational affiliate of ANA,  has identified stigma as one of the biggest barriers to mental health care and steadfastly works to educate and overcome stigma.

Nurses themselves have mixed attitudes and responses towards patients with severe mental illness.

These  include avoidance and fear all the way up to expressing a dislike for caring for these patients.


Without training, nurses may find it difficult to communicate to their patients with severe mental illness. No nurse likes to feel inadequate. Feelings of inadequacy take you back to being a new nurse and being uncomfortable in your practice. The key is to acknowledge the feelings, own them, and move forward, while being respectful and professional.

Fear of Personal Safety

Nurses express concern  about personal safety due to fear of unpredictable behavior and a perception of increased violent behavior in this population along with a lack of support in the hospital environment.

In reality, and according to a large study,  “The prevalence of violence among those with a major mental disorder who did not abuse substances was indistinguishable from their non-substance abusing neighbourhood controls. A concurrent substance abuse disorder doubled the risk of violence. Those with schizophrenia had the lowest occurrence of violence over the course of the year (14.8%), compared to those with a bipolar disorder (22.0%) or major depression (28.5%). Delusions were not associated with violence, even ‘threat control override’ delusions that cause an individual to think that someone is out to harm them or that someone can control their thoughts. “

and…”Second, members of the public undoubtedly exaggerate both the strength of the relationship between major mental disorders and violence, as well as their own personal risk from the severely mentally ill. It is far more likely that people with a serious mental illness will be the victim of violence.”

Time Constraints

When patients have both high physical and mental needs, the time constrained nurse will prioritize physical care and is more comfortable doing so.

Allot more time for care to allow for patient education.

Extra time may be needed for treatments and procedures and to repeat instructions.

Don’t React

A wise psychiatric nurse I know says, “Don’t get flipped out over the behaviors”.

You may feel scared, inadequate,  shocked, impatient, frustrated -don’t react. Remain calm, matter-of-fact, and professional.

 Can’t Fix it

Acute care nurses are accustomed to seeing a progression towards wellness or healing.

By contrast, severe  mental health disorders do not heal. They can be managed in the same way that diabetes can be managed, but not fixed in the way that a fracture can be fixed.

Understand that there is no magic bullet. Just listen instead of solving or fixing or changing.

Be Present

Avoid avoidance and make every effort to be present.

Being present has been described by Dr. John-Kabat Zinn as “ paying attention in the moment on purpose without judgment.”

Do not offer platitudes but do provide acceptance, compassion and presence. Use mirroring and reflective responses to establish communication.

Refocus and Distract

If a conversation is looping, redirecting can often be effective. If available, adult coloring and connect the dots workbooks can help focus patients. Consider other means of re-focusing, such as suggesting a short walk in the hall.


Give short, simple directions or explanations. Be prepared to repeat the same information if needed. For example, be patient and repeat “I’m sorry you can’t have ice chips right now,  I will check with the doctor at 6pm.” Offering a concrete goal is very helpful and typically will be accepted.

If your patient is perseverating, they’ll tire out and exhaust themselves if they keep getting the same response.

Use respectful language

NAMI urges us to see the person, not the illness.

Put the person before the illness – use phrases such as “the patient with bipolar disorder” and not “ the bipolar patient”.  Never use terms like crazy, lunatic, psycho, retarded;  and correct people who do so.


Patients with severe mental illness are people- someone else’s son or daughter, someone else’s loved one.

As their nurse, you may be the only person to communicate the caring and respect that every patient deserves, regardless of their illness and diagnosis.


Until next time,

Nurse Beth

Come visit me at Ask Nurse Beth career column at allnurses.com for all kinds of  entertaining and informative career questions and answers, and to submit your own question :) Or visit me at nursecode.com and StaffGarden where I also blog. Buzzzzzz…I’m a busy little bee !



NAMI Fact Sheet retrieved July 2016 http://www.nami.org/Search?searchtext=violence+in+mentally+ill&searchmode=anyword

Stuart, H. 2003. Violence and Mental Illness. retrieved July 2016 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1525086/

About Beth Hawkes

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Nurse Beth (Beth Hawkes, MSN, RN-BC), is a nursing career specialist and blogs at nursecode.com. She's also the author of Your Last Nursing Class: How to Land Your First Nursing Job. If you have ever submitted a resume or interviewed and never heard back, this book is for you. You will learn why never to say “I’m a perfectionist” when asked “What’s your greatest weakness?” You will be given insider tips and discover what nurse managers are really looking for in a candidate. Filled with real life examples and testimonials, “Your Last Nursing Class: How to Land Your First Nursing Job” truly is the ultimate guide to composing winning cover letters, essays, resumes-and landing a nursing job. Available at Amazon.