Nurse Practitioner Uses Patience to Help Mentally Ill

When nurse practitioner Dawn Howley, M.S.N., takes on a new patient at Spencer Psychiatry, a clinic in Spencer, Iowa, she is prepared to commit as much time as necessary to help that individual get better. And sometimes that can be a very long time. Howley still sees a few patients she first met as a new psychiatric nurse nearly 30 years ago.

“In the mental health field, relationships with patients are different than for general health care because these illnesses are so chronic,” she observes. “You tend to establish relationships for a long period of time, and to see people through real change and growth.” That’s especially true in small town settings that allow clinicians to establish closer, lasting connections with patients, she notes.

Howley, an NHSC Loan Repayment alumna, recalls one case with special satisfaction. One of her patients was a young man with schizophrenia. He also suffered from substance abuse problems and was frequently hospitalized. Eventually placing this patient in residential care, for a year and a half, afforded him the opportunity to turn himself around, Howley explains. “He worked on rehabilitation for his alcohol problem and learned that controlling his illness required compliance with his medication regimen.”

With patience and determination, she and her colleagues transitioned the patient back into the community with structured work activity. He is now a very active member of Alcoholics Anonymous, Howley reports, “and is working in competitive employment, part-time at a hardware store.” She still sees the man periodically “to help keep him on track,” and to update the treatment team about his progress. The success with this difficult case, “has been a very rewarding thing for me,” she says. Patience is key because, “sometimes you go through setbacks several times before it works.”

Growing up in Sioux City, Iowa, Howley became interested in a nursing career at an early age. She enrolled in a community college program, where she was introduced to psychiatric practice during her clinical training at a large state institution—Cherokee Mental Health Institute in Cherokee, Iowa. Her interest and imagination piqued, Howley ended up working at Cherokee for 5 years after graduation.

She pursued further education in her profession, earning a bachelor’s degree from Briar Cliff University in Sioux City. In 1999, she received her M.S.N. in psychiatric mental health nursing from the University of Nebraska.

In 1983, while pursuing her master’s degree, Howley moved to Spencer, Iowa, to help start up the therapy program in a new mental health unit at the local community hospital. In 1987, she moved to Spencer Psychiatry, a private practice directed by a former NHSC Scholar, Paul Anderson, D.O.

Spencer is located in a rural area with a population of around 13,000. Howley’s clinic serves a large area within roughly a 60-mile radius of the town. It’s still primarily a white population, she explains, but more Hispanics have moved to the area, and there have been some Vietnamese and Laotian immigrants living in the vicinity for many years. Both ethnic groups came to work in the local meatpacking plants, she explains.

Howley’s rural practice requires her to do a lot of traveling to reach her patients, putting her on the road 2 to 3 days a week. “There’s no public transportation here,” so the only way she is able to see some patients is if she goes to them. “I make some home visits. Our office also has six satellite clinics, and we go to various nursing homes and residential care facilities.”

She treats people of all ages ranging from 2 to 98 “and everyone in between.” Most are on Medicaid (25 percent) or Medicare (25 percent), and many are on long-term disability. “We’re an older state with quite a few seniors,” Howley adds. For the elderly, mental problems are often complicated or caused by physical illnesses, such as Alzheimer’s and stroke.

In addition to Howley and Dr. Anderson, the clinical team at Spencer Psychiatry includes another nurse practitioner, three social workers (two full-time and one part-time), and one clinical psychologist. “We have a team approach where we work within our facility and the inpatient hospital to ensure continuity of care.” Regular staff meetings foster this team approach, she says.

According to Howley, one of the toughest challenges is finding ways to meet the full spectrum of patient needs for other support programs, such as heating assistance and subsidies for medicines. “Sometimes you need to go beyond the usual limits of health care practice,” Howley notes. “For example, you may have to go to the drug manufacturers to obtain free medications.” Spencer Psychiatry’s sliding scale fee system for its lower income patients is yet another way patient needs are supported.

Howley derives the most satisfaction from developing relationships with her patients, “just being able to see them evolve, take control of their illness, and make a life for themselves.”

No matter how desperate her patients’ lives may sometimes be, Howley believes that “you need to treat your patients like you would anyone else in your life—with a lot of respect and admiration for what these people go through, and the work they have to put into maintaining their lives, and getting better.”