Should Every Nurse Have a Modicum of Mental-Behavioral Health Skills?

Recognizing when someone needs help is probably the most basic need of nurturing, yet not all providers are trained the same.

For the last 10 weeks, nurses in the continental United States have been working in various stages of lockdown, as a furious battle is waged with the worst pandemic any of us have witnessed. Soon, states will begin the process of easing back restrictions, and nurses will face an unknown future. Hospitals are experiencing extraordinary financial hardship, as elective procedures and appointments were canceled. Nurses not working in clinical hotspots have been furloughed as more than 36.5 million U.S. jobs have been eliminated from the economy.

What has not changed has been the potential for mental and behavioral health needs during the crisis.

In fact, ABC News has stated that calls to a U.S. helpline during the month of March in 2020 have increased over 891% compared to the same time period from 2019 (1). What is frightening is the fact that nurses are stressed now more than ever during the pandemic. They are supporting friends and family, answering calls about the latest CDC, WHO (World Health Organization) information related to the transmission of the coronavirus, and trying to obtain necessary PPE for themselves and their colleagues. Recognizing the signs of stress and the need for mental health assistance may not be at the top of their list, but unfortunately, it needs to be.

As states begin to “open up”, the controversy over the how and why to proceed has begun, with nurses in scrubs silently confronting civilians hurling messages of frustration and anger. So far, most of the demonstrations have been peaceful, although violence has begun to escalate. Incidence after incidence has been reported of people being harmed regarding the usage of masks, from spitting to broken arms, and even murder. With the intensifying emotional toll on nurses’ mental and behavioral health, one must wonder…

Should every nurse have a modicum of mental-behavioral health skills?

Defining the Problem

The words behavioral and mental health have been used interchangeably by healthcare, and either may have stigma and/or bias associated with their use. Nurses working in the field understand that behavioral health disorders are the leading cause of disability in both the United States and Canada and affect up to one of every five adults >18 in America, or approximately 17.9 percent of that age group. Not even nurses are immune. “Behavioral health patients can be complex.” The issue with behavioral health problems is they very seldom present as an isolated concern. Instead, they may be accompanied by or associated with complicated physiological problems, such as diabetes, hypertension, or cardiovascular disease. (5)

Additionally, mental or behavioral illnesses may not appear as a single entity. Patients prone to behavioral illness may develop more than one disorder, such as depression and anxiety, or a mood disorder complicated by a substance abuse problem. According to the National Alliance on Mental Illness (, this is when confusion and misunderstanding may occur in a healthcare setting. Nurses need to realize when their own biases, hesitancy, prejudice, or stigma might compromise the care patients need, even if it is our own health. We should not be afraid to speak up or seek assistance or fear reprisal if/when we need care. (5)

Could it be we need to learn much more about behavioral health, especially when needs are skyrocketing?

Understanding the Basics

Recognizing when someone needs help is probably the most basic need of nurturing, yet not all providers are trained the same. Nurses working in general practice environments and those working in mental health facilities work in entirely different settings, yet in recent years, patients have begun to seek behavioral assistance through emergency rooms and clinics, blurring the lines between general practice and behavioral health. It has become important that all nurses gain a modicum of skill in dealing with mental-behavioral health issues, whether through de-escalation skills, or by the recognition of potential illness that requires appropriate referral/physician follow-through. (4)

For example, Psychiatric NP Emma Mangano, working at the ED at Johns Hopkins Hospital, has grown used to the 60 percent increase in patient volume since 2012. She rounds on patients in the Emergency Psychiatric Unit, where ~400 patients/month are examined with conditions from schizophrenia, bipolar disorder, autism, dementia, depression, or substance abuse disorder. As Emma has learned, patients may arrive voluntarily or with police in tow. They may be violent and require security to keep them safe. Staff learns how to listen without judgment, without being condescending or dismissive, as well as how to restrain those needing it. Sharp objects such as keys and jewelry, as well as shoelaces, are removed from patients when they are admitted. (3)

Some patients may be admitted for inpatient care, until referrals may be obtained. At Johns Hopkins, 83 inpatient beds for behavioral health exist, but as nurses know, resources for inpatient and outpatient mental-behavioral health are scarce, so finding the appropriate referral/medication may take time. (3)

Five Warning Signs to Know

Since the outbreak of the pandemic, it has been difficult to know how our colleagues and family members are doing, as many of us have been sheltering in place, or working in isolation from peers. This has been an incredibly difficult time, with families grieving the loss of loved ones, and professionals mourning the passing of close friends. It has been impossible to know who is vulnerable to mental distress until another life is tragically lost, e.g. Dr. Lorna M. Breen, who died by suicide at the end of a grueling Covid-19 shift.

As such, nurses should be on the alert for these five warning signs of a possible need for mental-behavioral follow-up:

  1. Long-lasting irritability or sadness
  2. Extremely low or high moods
  3. Excessive anxiety, worry, or fear
  4. Social withdrawal
  5. Dramatic changes in sleeping or eating habits

If you or someone you know has two or more of these symptoms, it is a reason for concern and follow-up with a professional in the field. Remember, there should be no need for stigma, bias, or judgment attached to a need for behavioral health follow-up, especially during this time of extreme stress. This time, above all, is when you should check on your quiet friends; they may need assistance the most.

Are they handling the stress as they should? Are they able to verbalize what they find worrisome? Do they have appropriate support?

Remember, for the 18th year in a row Nursing has been the most trusted profession. For mental-behavioral health issues, we should trust one another when we need help, whenever that might occur, especially in the middle of a pandemic.

National Suicide Prevention Lifeline:



  1. “Calls to US helpline jump 891%, as white House is warned of a mental health crisis.”, Levine, M., April 7, 2020, ABC News.
  2. “7 things you should know about mental health nursing.”, October 2, 2018, Nurse Practitioner Career Guide.
  3. “The changing dynamics of emergency psychiatric care.” Nitkin, K., 10-19-2018, John Hopkins Medicine, News, and Publications.
  4. “A comparison of the nursing practice environment in mental health and medical-surgical settings.”, Roche, M. et al, June 2010, Journal of Nursing Scholarship.
  5. “Behavioral health considerations.”, Maryniak, K., 2019, AMN Healthcare, Inc.