A day in the life of a mental health nurse

The CHOC Children’s Mental Health Inpatient Center is an inpatient psychiatric center exclusively dedicated to the treatment of children ages 3-17 with mental illness who are in immediate risk of hurting themselves or others. It is the only inpatient facility in Orange County that can treat patients younger than 12. Our doctors and care team are all specially trained to treat children and provide the very best patient- and family-centered care 24 hours a day, seven days a week.

During a child’s stay, he or she engages in daily multidisciplinary therapeutic groups and receives individual therapy, family therapy, brief psychological testing and psychiatric care.

In observance of Mental Health Month, follow along for a day in the life of Madeline, a clinical nurse in CHOC’s Mental Health Inpatient Center.

5:15 a.m. – After fighting my snooze button, I wake up, shower, and drink some much-needed coffee.

6:30 a.m. – My cat yells his goodbyes to me as I give him a treat and leave for work. On the way, I vibe out to music to get pumped up for the day. I’ve worked at CHOC for over a year now. Last year, I was accepted into CHOC’s Registered Nurse Residency program. As a new nurse, I felt called to work in a mental health setting. I am beyond proud to stand alongside the brilliant CHOC team on the frontlines of mental healthcare.  

7:00 a.m. – I join my team in our conference room for a daily briefing report. Together, we review any newly admitted patients, our current population of patients, and any safety concerns. One of the ways we keep kids safe is through trauma-informed care. Upon admission, we work with patients and their families to determine any triggering situations or actions the patients may have, and then learn how strong emotions may manifest outwardly; such as pacing, shaking, or becoming very quiet. This information helps us to rapidly identify when patients are struggling and may need extra support or encouragement to utilize their coping skills. One of my favorite environmental adaptations we can provide for patients is our sensory room. It helps stimulate a few of our five senses to help kids cope and be more present in the moment. Sometimes, just hearing the rhythmic movements of the bubbles can be soothing and have a great calming effect.

7:30 a.m. – Once I have an understanding of our environment, I walk the unit to check on the patients. Most are still asleep, so I then look up my patient’s medications, while verifying medication consents. All pediatric psychiatric medications need parental consent obtained by the patient’s psychiatrist.

8:15 a.m. — Our medication room has a barn door, so I can efficiently and safely administer patients’ morning medications, preform a quick mental status check-in, and obtain vitals.

9:30 a.m. — One of my patients is currently taking a new medication. In order to better understand her body’s acceptance and tolerance of the drug, we need to run labs. Before drawing her blood, I numb a small area of her skin using a J-Tip®. During the blood draw, a child life specialist and I help the patient cope by offering her modeling clay and a hide-and-seek activity book.

10:00 a.m. — Throughout the day, our patients are divided into groups based on age to attend group sessions. This creates a structured environment that promotes the development of coping and social skills they can utilize when they go home. The sessions focus on our various themes of the day that can range from problem solving or emotional regulation to nutrition and wellness. These sessions are led by our team of nurses, social workers, child life specialists, plus art and music therapists. This morning’s group session is focused on gross motor skills. Our group leaders soak up some sunshine in our beautiful outdoor area while supervising patients socializing and joining in on a game of handball.

11:00 a.m. — I sit down with one of my patients to discuss their day so far and check in on any thoughts of self-harm that we can work through together. Afterwards, as part of the patient care team, I meet with that patient’s psychiatrist Dr. Lavanya Wusirika, and social worker Gaby, to discuss the patient’s care plan.

12:30 p.m. – It’s time for the patients to have lunch. Our patients eat together, so I assist with passing out lunch trays and pouring drinks. One of our licensed vocational nurses, Brenda, has become our unofficial DJ, and she plays music during lunch to help create a fun, therapeutic environment.

1:00 p.m. – I receive a call from a patient’s parent. After addressing their questions, I update them on their child’s plan of care, medications and current temperament.

2:00 p.m. – I use my own lunch break to catch up with my coworkers. We spend a lot of time together, and I’m lucky to have such an amazing work family.

3:00 p.m. – It’s time for one of our patients to head home. Upon admission to the unit, our team begins organizing outside resources and planning ways to increase safety and support at home. This information is built upon throughout their stay and is incorporated into an individualized safety and coping plan. After our social workers discuss the plan for home with the patient and their parent, I review current medication information and additional discharge instructions. Staff members and fellow patients send off their peer with warm wishes and words of encouragement.

4:30 p.m. –As a nurse, it’s my turn to lead one of our nursing groups. After the patients participate in a discussion about favorite coping skills and we do a check-in of their current emotions, we follow a painting tutorial to practice our theme of the day, mindfulness.

6:00 p.m. – I spend time updating my patients’ charts, including their mental status assessments and treatment plans. This way our whole team can see the patient’s progress and any concerns.

6:45 p.m. – During daily community meetings, all of our patients join together, and our staff leads a check-in to summarize what has been learned from our theme of the day. Patients take turns sharing their high and low of the day and how we can build on these experiences for tomorrow.

7:00 p.m. – As our night shift nurses arrive, we take turns giving a report of their patient’s day and mental status. We share new triggers that we have learned from the patients as well as new coping skills that were helpful. Knowing how we can best care for patients before, during and after a crisis or stressful situation is fundamental for trauma-informed care. By caring for every patient as a whole, not as a diagnosis or as someone defined by their trauma or maladaptive behaviors, we are able to better understand and care for them.

8:00 p.m. ― Get home and share a delicious meal with my husband. A long hug and many kisses are bestowed unto my cat Boots. The three of us will cuddle up and watch a show before we head to sleep and start again.

From the Nursing Frontline of the Batten Disease Battle

When the neuroscience unit nurses at CHOC Children’s Hospital discovered that teen patient Maya loved to crack people up, they knew a joke book would be the perfect gift.

Compared to the life-changing treatment Maya is receiving at CHOC Children’s Hospital, a book is a very small token. But as partners in this journey, CHOC nurses say it’s the very least they can do.

Maya is among nine patients receiving a novel treatment for CLN2 disease, or late infantile Batten disease at CHOC. The group comes every two weeks for an infusion of Brineura, a drug that replaces a deficient enzyme.

The CHOC team has just celebrated the second anniversary of the first infusion, having clocked more than 300 procedures in the last 24 months. Since CHOC began offering the treatment in spring 2017, the number of patients has more than doubled, says Dr. Raymond Wang, a pediatric metabolic specialist and the program’s medical director.

Dr. Raymond Wang, medical director, and Susan See, Neuroscience nurse manager
Dr. Raymond Wang, medical director of the Batten disease treatment program, and Susan See, neuroscience unit nurse manager

Among the handful of institutions nationwide offering the treatment, CHOC’s program is the largest.

Despite the juggling act of placing patients, made especially tough during high wintertime patient census, CHOC nursing leadership has helped ensure these patients have never missed a procedure.

Nurses play an integral role in the procedure, assisting pediatric neurosurgeon Dr. Joffre Olaya in inserting a needle through the skin of the patient’s skull and into an Ommaya reservoir implanted beneath the flesh to reach the fluid surrounding the brain.

The procedure is conducted inside the patient’s room on CHOC’s neuroscience floor. During the procedure and afterward as they monitor the patients, the nursing team is in frequent, close contact with the children – and their parents.

“Because of this, we know how some parents take their coffee, which brand of diapers they prefer, and how the families gather to talk after treatments,” says Alison Cubacub, a clinical nurse II in CHOC’s neuroscience unit.

They also know how life-changing the treatment is for families.

Before Brineura clinical trials and its ultimate approval by the U.S. Food and Drug Administration, this small group of patients and their families endured a long odyssey of poring over Internet pages, making endless phone calls, and traveling the country in hopes of finding treatment for the devastating diagnosis that is Batten disease.

The rare and fatal neurologic condition typically begins with language delays and seizures before age 3, and rapidly progresses to dementia, blindness, loss of the ability to walk and talk, and death in childhood.

But Brineura has shown to slow the disease’s progression. Over a three-year period, patients treated during clinical trials showed no advancement of the disease, which was radically different from the disorder’s natural course. The medication improves quality of life and buys patients critical time as researchers continue to search for a cure.

Before, Southern California patients traveled every 10 days from their homes to Columbus, Ohio, to receive treatment as part of a clinical trial. Aside from the inconvenience, the process split apart families. But now, they need only drive a few miles to CHOC for a few hours of treatment.

And while it can’t compare to the relief felt by patients and families, CHOC’s neuroscience nursing team is invigorated by the professional growth that’s been afforded to them as a result of CHOC offering the treatment.

“The science and research that went into developing this treatment is fascinating,” says Melissa Rodriguez, RN, BSN, CPN, a clinical nurse III in CHOC’s neuroscience unit. “To assist in its administration, we participated in an in-depth study that included literature about the procedure and the condition, as well as extensive training in the sterile procedure required to infuse the medication.”

Nurses Week Q&A With CHOC’s Chief Nursing Officer Melanie Patterson

In honor of National Nurses Week (May 6-12), Melanie Patterson, DNP, MHA, RN, vice president, patient care services and chief nursing officer of CHOC Children’s Hospital, shared a few nursing highlights from the past year. CHOC nurses work in a variety of roles, from direct patient care to informatics. They partner with our pediatricians and pediatric specialists, as well as other staff, to advance care and safety for our patients and their families. Learn more about their most recent contributions in this Q&A with Melanie.

Melanie Patterson, DNP, MHA, RN, vice president, patient care services and chief nursing officer
Melanie Patterson, Chief Nursing Officer

CHOC received numerous accolades for patient care and safety; among them Magnet® recognition. What does this honor really mean?

This is our third time achieving Magnet recognition, reflecting our commitment to high-quality nursing practice. This is truly an honor and places us in an elite group of healthcare organizations; fewer than 500 (out of more than 6,300) hospitals in the country have achieved Magnet recognition.

Official green flag Magnet logo from the American Nurses Credentialing Center
CHOC received Magnet recognition for the third time

To earn this distinction, we passed a rigorous and lengthy process that required widespread participation from leadership and staff. We are a much better organization because of our Magnet recognition, which raised the bar for patient care and inspired every member of our team to achieve excellence every day.

CHOC has taken a leadership role in developing a pediatric system of mental health care in Orange County, with an inpatient center as its centerpiece. Do you have any updates to share?

Our Mental Health Inpatient Center opened last April, filling a gap in a fragmented system that left children younger than 12 with no inpatient services in Orange County. The innovative facility, which features a warm, healing environment, is the only one in the state to offer all private rooms and an option for parents to stay overnight with their child, as appropriate. We’ve admitted more than 600 children since we opened and achieved an 86 percent positive rating in our patient experience survey. In addition, our restraint and seclusion rates are far below the national average, as is nurse turnover. The Center’s team has worked hard to create the right combination of “people, place and practice” to promote the best outcomes for our patients and their families.

How has nursing contributed to evidence-based practices?

Evidence-based practice (EBP) is a dynamic process of integrating research, credible sources of knowledge, clinical expertise, and patient and family preferences and values to achieve optimal patient outcomes, enhance practice, and manage health care costs. We developed an EBP Scholars program that is a formal six-month long program funded in part by the Walden and Jean Young Shaw Foundation. Scholars receive education about the EBP process and guidance in developing their own projects focused on improving outcomes. Results have included an increased number of external poster and podium presentations, and nurse-led projects submitted for research consideration and peer-reviewed nursing publications. In addition, six nurse-led projects were awarded grants for projects that resulted in meaningful change, increased patient safety, and decreased cost of care.

A nurse and patient play with a stuffed animal.

How involved have nurses been in research projects?

We encourage a culture of inquiry among our nurses. Our Nursing Research and Innovation Council promotes the integration of research, and innovation into practice, and facilitates nurse involvement in related activities across the organization. Our Nursing Research Associate Training Program provides a meaningful and relatable approach to empower nurses, at all levels, to participate in multidisciplinary research. Participants attend classes and receive hands-on training with a clinical research coordinator.

One example of nurse-led research was focused on pupillary assessment (examining pupils’ reaction to light). This is important in neurological evaluations because changes in the size, equality and reactivity of the pupils can provide vital diagnostic information. Evidence suggests that the traditional pen-light pupil examination is subjective and has low precision and reproducibility. Automated hand-held pupillometers have recently been used to provide more objective measurements of pupillary size and reactivity. Studies suggest early detection of subtle changes using pupillometers may improve patient outcomes in adults, yet there is not much literature on its use in children.

Over the past few years, our nurses have established an organizational database of automated pupillometry to provide evidence for the use of pupillometers in children. Findings from a preliminary study were presented at the American Association of Neuroscience Nurses national conference in Denver, Colorado this past March and demonstrate a statistically significant inverse relationship between pupillometer readings and increased intracranial (inside the skull) pressure. We have since expanded the use of pupillometers in our emergency department and started additional multidisciplinary studies.

How have your nurses taken leadership roles in advancing patient safety throughout the hospital?

CHOC nurses have initiated and/or been asked to participate in numerous quality improvement projects focused on enhancing patient safety. I am especially proud of our team of safety coaches whose roles are to reinforce ― often through real-time feedback ― safe practices. This team now consists of 88 clinicians from more than 25 different areas across our entire healthcare system.

A group of CHOC nurses laugh while posing for a photo

Additionally, we recently created the role of discharge nurse navigator whose focus is on successfully transitioning patients from the hospital to their homes. This includes educating families on after-care instructions and any other follow-up recommended by their physicians. The ultimate goals are decreasing readmission rates and improving patient and family satisfaction. We’ve seen our seven and 30-day readmission rates decrease beyond our initial goals and patient/parent satisfaction regarding nurse communications increase.

What makes CHOC nurses so unique?

Obviously, I am biased and think our nurses are the best in the profession. Every day, I have the privilege of witnessing the countless ways they preserve the magic of childhood. They are compassionate advocates for our patients and families, and proactive in implementing positive change that improves the care and service we provide. They are also collaborative, partnering with our physicians, each other and staff from across the entire healthcare system. They are committed to nursing excellence in everything they do, and selflessly dedicated to advancing our mission and our vision. I am incredibly fortunate to lead such an amazing team.