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independently. "They have absolutely nowhere to go," said Beek- man who has been a nurse since 1991, including a decade in the Navy as a medical-surgical RN. "They are elderly so we have to find a nursing home or assisted living facility. Sometimes they end up staying in the behavioral health unit long-term because we need to have a place to send them to. You can't send them to a shelter." When patients are discharged, a social worker should have a plan in place, including a place for them to go if they do not have a place to live. In California, they could go to a board-and-care home, which is a licensed adult residential facility for people with mental illness. However, many of these homes have been closing and some are in poor condition so people do not stay and are back on the streets, and then the cycle begins again. "I had one patient 36 times in three months," said Dezan. "They go out and come back. The police bring them in." Patients keep getting readmitted due to the broken health care system, lack of resources, lack of affordable housing, and inadequate funding of programs and services. "We need more case managers to make sure that care is continued," observed Dezan. "But if a patient is homeless, we can't follow up with them until they come back. It's hard to get them to see a psychiatrist on a regular basis. They have to have insurance, a place where they can be contacted, and they need to make time to go see them." Linda Rucker acknowledges that at Chicago's Jackson Park Hos- pital, behavioral health patients have few options after discharge because there are no available outpatient services or board of health clinics anymore. Consequently, she sees many repeat patients, too. Sometimes they are people who are unhoused or who refuse to go to a facility. They have a psychotic break, get arrested, and end up in the ER again and again. A t the same time that Covid drove intense demand for BHU beds when there were fewer of them than ever, NNU behavioral health nurses faced new pandemic-related threats to their health and safety at work. Because all BHU patients were supposed to test negative for Covid, some facilities did not give staff N95 respirators until much later in the pandemic because other hospital units, such as the ICU and ED, were prioritized. Beekman in North Carolina said her unit only had surgical masks for the first year and a half of the pandemic. Then management announced in the fall of 2021 that part of her unit was going to care for Covid-positive behavioral health patients the next day. But they weren't ready. Her unit did not have any negative pressure rooms and no one had been fit-tested for N95s. Beekman immediately asked her manager if the nurses were going to hear from infection control and they were fit tested that day. The Covid section of her unit only lasted a few months because Beekman said it was not set up for Covid patients. "We would be with these Covid patients wearing our masks and everything," recalled Beekman. "Then we'd have to go get some- thing from the supply room and there's just one supply room on the unit. There was a lot of cross-contamination going on." Nowadays, Beekman said that if a patient does test positive, they have been good about staying in their room, which is important because behavioral health units typically have a common shared space with a TV. Patients in her unit are supposed to wear a mask, but not all of them comply. That's the situation Weiss faces in Glen- dale, too. "It is difficult to keep people compliant wearing a mask depending on their situation," said Weiss. Weiss said BHU nurses at Glendale Memorial Hospital got N95s fairly quickly, but management was rationing PPE for more than a year and a half. Sometimes the PPE that nurses were fit-tested for were not available. Now, they have plenty of PPE but protections are still not optimal. Weiss, who has a beard, should wear a powered air- purifying respirator (PAPR) but still does not have one. He said PAPRs were prioritized for other units. Dixon said that the bigger Sutter facilities got the majority of the PPE and that the nurses at Sutter Center for Psychiatry felt like they were the outlier. They were initially reusing N95s and getting substandard gloves. "We used to have to hunt down our manager to get an N95," recalls Dixon who brought her own N95 at times because she lives with her 92-year-old mother and wanted to keep her safe. "Now they're available at the door and we can get them whenever we want." W hen people find out that Laura Dixon works in behavioral health, she says the majority respond, "Wow. How can you do that?" because they think of the stereotype: patients who are unpredictable, highly psychotic, violent, wearing restraints, or who are criminally insane. Sadly, these stigmatizing descriptions and images are still prevalent. "A lot of people have the idea from Holly- wood that everyone's gonna come and jump you and just attack you out of the blue," said Weiss. "But people could be attacked on the streets or in the subway more than they would be in my unit." The reality of workplace violence in behavioral health units is very different. Yes, workplace violence is still a problem—as it is throughout the entire hospital—and there is much that employers can improve—such as boosting staffing levels—to prevent it from happening in the first place. Nurses know that workplace violence and behavioral health issues can occur in any unit in the hospital, not just the BHU. RNs encounter patients or visitors who react violently to different situ- ations, whether it's a furious family member in the emergency department, a confused patient in med-surg, a psychotic patient with J U LY | A U G U S T | S E P T E M B E R 2 0 2 2 W W W . N A T I O N A L N U R S E S U N I T E D . O R G N A T I O N A L N U R S E 21 Linda Rucker, behavioral health RN, emergency department, Jackson Park Hospital, Chicago