American Academy of Nursing on Policy

Promoting the mental health of familiesGeraldine S. Pearson, PhD, PMHCNS, BC, FAAN*, Lois K. Evans, PhD, RN, FAAN,

Vicki P. Hines-Martin, PhD, RN, FAAN, Edilma L. Yearwood, PhD, PMHCNS, BC, FAAN,Janet A. York, PhD, PMHCNS, BC, FAAN, Catherine F. Kane, PhD, RN, FAAN

Psychiatric Nursing and Substance Use Disorders Expert Panel for the American Academy of Nursing

The American Academy of Nursing has identified thedevelopment of healthy families, particularly thosethat are underserved, as one of its priorities. This is abroad mandate that focuses on physical and mentalhealth promotion, maintenance, and treatment,recognizing that physical and mental health is inter-twined. Mental health status is particularly precariousin families living in poverty and those confronted withchronic health problems, limited access to care, andthe stigma associated with mental health problems.This brief focuses on fosteringmental health in diverseand underserved families.

Background

Underserved populations from diverse cultural andracial backgrounds across the life span experiencehigher rates of exposure to factors that put them at riskfor poor mental health. The U.S. Surgeon General’sReport on Mental Health identified that “even morethan other areas of health and medicine, the mentalhealth field is plagued by disparities in the availabilityof and access to its services. These disparities areviewed readily through the lenses of racial and culturaldiversity, age, and gender” (U.S. Department of Healthand Human Services, 1999, p. vi).

The World Health Organization identified mentalhealth as “a state of well-being in which an individualrealizes his or her own abilities, can cope with thenormal stresses of life, can work productively, and isable tomake a contribution to his or her community. Inthis positive sense, mental health is the foundation forindividual well-being and the effective functioning of acommunity” (World Health Organization, 2007, p. 1). Inthe United States, underserved racial and ethnicgroups experience numerous disparities in health andhealth care that adversely influence their mentalhealth. This includes higher illness risks, diminishedaccess to care, and lower-quality treatment (Smedley,Stith, & Nelson, 2003). Disparities in mental health

* Corresponding author: Geraldine S. Pearson, Associate Professor Uchiatry - Child and Adolescent Division 263 Farmington Avenue, MC2

E-mail address: gpearson@uchc.edu (G.S. Pearson).

0029-6554/$ - see front matter � 2014 Elsevier Inc. All rights reservedhttp://dx.doi.org/10.1016/j.outlook.2014.04.003

care are even more pronounced in underserved racialand ethnic groups and residents of rural communities.These disparities in care result in poor engagementand, ultimately, poor health outcomes.

Engagement is seen as pivotal to reducing mentalhealth disparities and improving mental health(Interian, Lewis-Fernandez, & Dixon, 2013). Engage-ment has been defined as occurring on a continuum,beginning with the decision to seek care and followedby a series of decisions about remaining involved incare. The process of obtainingmental health services iscomplex and includesmany “linked steps: encouragingtreatment seeking when there is a need, continuity invarious aspects of care (including visit participation),treatment retention, and medication adherence”(Interian et al., 2013, p. 212). Engagement is facilitatedwhen there is comfort with the health care providerand a belief that the provider is sensitive to and flexiblewith culturally diverse, vulnerable, and underservedindividuals.

The Mental Health Parity and Addiction Equity Act(2008) entitles Americans to a full range of mentalhealth and substance use disorder services on a parwith physical and medical health care. Implementa-tion of the Affordable Care Act dramatically improvesaccess to care pathways. Yet, the issue of engagementis more complex and involves the willingness of in-dividuals and families to actively participate in careand maintain a relationship with the health careprovider.

Nursing is in a pivotal position for leadership in themovement towardmental health parity. Nurses at boththe generalist and specialty levels of practice under-stand the nuances of the engagement process, whichinvolves getting underserved families to health careservices and then supporting them to remain involvedin their care.

Individuals and families often seek treatment for amental health issue that could have been addressedmuch earlier, before a worsening crisis, with targetedprevention of more serious problems. With improvedaccessibility of services, the challenge will be in

niversity of Connecticut School of Medicine Department of Psy-103, Farmington, CT 06030.

.

Nur s Out l o o k 6 2 ( 2 0 1 4 ) 2 2 5e 2 2 7226

engaging patients, fostering trust, and ensuring thatpatients believe they are being heard and cared for ina respectful, nonjudgmental manner. Psychiatric/mental health nursing specialists can be the driversof mental health services integrated into primarycare and embedded in the care provided by nursegeneralists and other health professionals in a vari-ety of settings. Nurses have also developed innova-tive models of care that integrate primary care andbehavioral health services for the severely mentallyill (e.g., Integrated Health Care of the University ofIllinois School of Nursing). Nursing is well positionedfor leadership in fostering patient engagement,addressing the treatment needs for diverse and un-derserved populations, driving the treatment process,and reducing the harm of unmet mental healthneeds.

The following recommendations for mental healthplans, programs, and researchwill foster resilience andhealth for vulnerable families:

1. The Administration should convene a multi-sectoral task force to develop a national action planfor promoting mental health that will encompassapproaches that address the strengths and vul-nerabilities of individuals, families, and commu-nities; target access to mental health services thatare integrated into primary care; and focus on pa-tient engagement. An updated Surgeon General’sReport on Mental Health can serve as the founda-tion for the development of this action plan.

2. Nursing’s participation in all aspects of developingand implementing the action plan, formulatingadditional policies, and redesigning mental healthservices is essential. State government boards,commissions, and councils must include nursingleadership in policy decisions influencing mentalhealth services. The American Academy of Nursingwill work with other national nursing organiza-tions to assist the administration and others inidentifying nurses with expertise in mental healthcare who can lend their important perspectives tothis work.

3. The National Institutes of Health, the Patient-Centered Outcomes Research Institute, and theSubstance Abuse and Mental Health ServicesAdministration, along with relevant nongovern-mental organizations, should prioritize researchthat addresses access, patient engagement, andmental health interventions within the context ofcultural and ethnic differences in populationsacross the life span.

4. Federal and nongovernmental agencies thatdevelop research guidelines and provide fundingshould emphasize community-based participatoryresearch methods for studies of mental healthcare.

5. The federal and state governments should partnerwith payers and providers to developmental health

promotion programs that build on intrinsic com-munity and family strengths such as spirituality,identity, values, educational attainment, and localleadership.

6. The Academy will engage nursing and other keystakeholders in raising public awareness of andsupporting multisectoral initiatives that addressthe broad range of conditions in communities thatcan undermine the mental health of individualsand families, such as joblessness, poverty,violence, and racism. The Academy will also workwith the American Organization of Nurse Execu-tives and other leading nursing organizations toencourage chief nursing officers and other nurseleaders in nonprofit hospitals to integrate this focusinto their institutions’ community benefit assess-ment and improvement plans.

7. Congress must appropriate funding for the expan-sion of nurse-managed clinics, as authorized underthe Affordable Care Act, that integrate behavioralhealth services and focus on individual, family, andsocial network strengths tomediate risks tomentalhealth while supporting resilience.

8. The Department of Health and Human Services,Health Resources and Services Administration,should prioritize funding nursing and other healthprofessions’ educational programs that will buildthe capacity of the nursing and health care work-force to integrate mental health care into primarycare, school health, and other health care services.Health Resources and Services Administration ini-tiatives should seek to ensure that generalistnurses are trained to provide mental healthscreening and nursing interventions to diverse andunderserved families across the life span andwithin multiple treatment settings.

9. Organizations and agencies that approve and ac-credit nursing schools and programs shouldinclude standards to ensure that these include op-portunities for students to develop the evidence-based knowledge and skills that they will need tobe able to address the mental health concerns ofunderserved and diverse populations.

10. National nursing specialty organizations shouldtake the lead to encourage the development of andprovide a model of collaborative practices andpractice agreements between advanced practicegeneralist and specialty nurses.

11. Increased funding must be secured for advancedpsychiatric and mental health education by aca-demic nursing programs in order to (1) ensure thatnurses have the evidence-based skills to addressmental health issues in underserved and diversepopulations and to (2) expand the supply ofadvanced practice nurses with a specialty in child,adolescent, family, and adult mental health.

12. The Centers for Disease Control and Preventionshould collaborate with the Surgeon General’s Of-fice to develop an initiative for promoting public

Nur s Ou t l o o k 6 2 ( 2 0 1 4 ) 2 2 5e 2 2 7 227

awareness of mental health across the life spanand across cultures and ethnic/racial groups as away of moving the nation forward on the HealthyPeople 2020 goals and reducing the stigma associ-ated with mental illness. This initiative shouldinclude engaging consumers; local, state, and na-tional entities; and health care providers tocollaborate on improving print literature, onlineresources, and social media that focus on mentalhealth messaging.

13. The Department of Health and Human Services,Center for Medicare and Medicaid Innovation,should develop a grant program for exploringmodels of care that effectively use primary careproviders as the first line of mental healthassessment for all populations followed by asupport network of mental health providers whocan offer more intensive psychiatric in-terventions. This program could encourage thedevelopment of primary care/mental health res-idencies to increase the number of cost-effectiveproviders who are proficient in such colla-borations.

14. Advocacy groups such as the National Alliance onMental Illness and other consumer-focused orga-nizations and health care providers should collab-orate on developing a model of consumerempowerment and patient- and family-centeredmental health care.

Acknowledgments

This policy brief was developed by the PsychiatricNursing and Substance Use Disorders Expert Panel forthe American Academy of Nursing. The authors wishto thank Mary D. Moller, DNP, APRN, PNHCNS-BC,CPRP, FAAN for her editorial assistance.

r e f e r e n c e s

Interian, A., Lewis-Fernandez, R., & Dixon, L. B. (2013). Improvingtreatment engagement of underserved U.S. racial-ethnicgroups: A review of recent interventions. Psychiatric Services,64. Retrieved from http://journal.psychiatryonline.org. http://dx.doi.org/10.1176/appi.ps.201100136.

Smedley, B. D., Stith, A. Y., & Nelson, A. R. (2004). The healthcareenvironment and its relation to disparities (pp. 80-124). In B. D.Smedley, Stith, A. Y., & Nelson, A. R. (Eds.). Unequaltreatment: Confronting racial and ethnic disparities inhealthcare. Washington, D.C.: National Academy Press.

U.S. Department of Health and Human Services. Mental health: Areport of the Surgeon General. Rockville, MD: U.S. Departmentof Health and Human Services, Substance Abuse and MentalHealth Services Administration, Center for Mental HealthServices, National Institutes of Health, National Institute ofMental Health, 1999.

World Health Organization. (2007). What Is Mental Health? OnlineQ7A. Retrieved from http://www.who.int/features/qa/62/en/index.html.