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pandemic's immense impact on mental health, lack of proper per- sonal protective equipment, and outbreaks, which meant that units could not admit new patients at a time when every bed was needed. Nevertheless, the patients needed to go somewhere, which is another reason why some patients get sent to facilities far from home. And if staff were out sick, units were left extremely short staffed. When the BHU at Glendale Memorial Hospital had outbreaks, despite patients initially having a negative PCR test, Weiss said they would stop admitting patients, test everyone again, keep them iso- lated in their rooms, and try to discharge them as soon as possible. Meanwhile, staff would be floated to other units as sitters for patients who needed one-to-one care. Once the unit was cleared, then they would start admitting patients again. The lack of beds means patients languish in the ED for days, weeks, or longer, wait- ing for an open bed. At San Bernardino Community Hospital's BHU, Clayton Dezan noticed many more young people being admitted, especially in the beginning of the pandemic, 18- to 24-year-olds, a far younger group than he was used to seeing. "They had a lot of fear and depression," said Dezan, an RN who has been working in the BHU for a decade. "They didn't have the same support as they did before the pandemic. They weren't seeing other people and missed face-to-face contact." Dezan says many of the patients in his unit are unhoused and for some, their mental illness is drug-induced. Nearly all the patients in his unit are there on a 72-hour involuntary psychiatric hold, known in California as a 5150, for people who are a danger to themselves or others. He has also encountered patients who could barely breathe and even someone who complained of extreme pain but instead of being treated, was put on a 5150 hold. He says this can happen when patients say things like, "the pain is so bad I just want to die" or who are so agitated and screaming due to pain. When patients arrive with medical conditions that must be addressed immediately, Dezan contacts the house manager and advocates to move the patient to the appropriate unit. Some of the 5150 patients get converted to a voluntary hold and remain longer if it is not safe to discharge them. If someone cannot care for themselves or is very violent, then they could be put under a conservatorship and then transferred to a locked facility for long- term care. However, it can take a long time to find an open bed. "Some have been in our unit for more than a year because we can't find them a placement," said Dezan. In North Carolina, Beekman also encounters patients who need to be placed elsewhere because they can no longer function 20 N A T I O N A L N U R S E 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 J U LY | A U G U S T | S E P T E M B E R 2 0 2 2 VA Mental Health Nurses Lisa Harris, a primary care and mental health RN at the Tusca- loosa VA Medical Center, sees veterans from Alabama as well as the neighboring states of Georgia, Tennessee, Mississippi, and Louisi- ana. Some are traveling a couple of hours because there is nowhere else for them to go. She assesses veterans' mental health and refers them to the appropriate care, which could be a therapist, medication, inpatient acute mental health unit, or other VA programs. Her caseload includes patients who are suffering from depression, substance abuse, stress, high anxiety transitioning to civilian life, or having relationship or anger issues. Sometimes she discovers that a patient is unhoused and living in their car. "I will make sure that they get the help that they need," said Harris, who has been an RN for four years and an LVN for 18, including 15 years at the VA. That could mean Harris is coordinating their care with primary care, mental health, the social worker, and the homeless coordinator. Daphne James has worked at the Tuscaloosa VA for 23 years, including the past seven years as a psychiatric nurse practitioner. She sees patients who are dealing with post-traumatic stress dis- order and sexual trauma. James has about an hour to spend with new patients and 30 minutes for follow-up appointments. But a patient in crisis can throw the whole day off, especially because the outpatient clinic is chronically short staffed. "I need adequate time to care for my patients," said James, who sees stable patients once every three months, and others more frequently. "We are feeling the short staffing, RNs, LPNs. And we only have two psychiatrists for the whole mental health outpatient clinic. It's just not safe staffing when you're trying to deal with sui- cides." Harris said that due to short staffing, she sometimes gets pulled to work in another clinic. She was even assigned to work in acute mental health inpatient care for four weeks. When she was working in the inpatient unit, the clinic psychologist did the intakes for the outpatients in her stead as well as his own work. Tuscaloosa VA nurses and their colleagues at NNU-represented VA facilities across the country have been speaking out and protest- ing about patient safety, short staffing, and RN retention. They refuse to be silent and continue to demand that leadership address their ongoing concerns (see page 9 for their recent actions). — C.S. "These patients are the most misunderstood patients that we have. These are patients with illnesses. They are not completely aware of what's going on. We need to treat them like any other patient. They need help." Lisa Harris, RN Daphne James, NP