Nurses suffering in silence: Addressing the stigma of mental health in nursing and healthcare.

Abstract

FigurePrior to the pandemic, there were alarmingly high numbers of healthcare professionals suffering from burnout, with some studies indicating numbers as high as 45 to 55%.1 Burnout remains an enigma that's difficult to define adequately and accurately. It has been described as a “basic tenet of fatigue” and “the intolerance of any effort,” or as a combination of the inability and the unwillingness to expend the necessary effort at work for proper task completion, leading to lack of energy, reduced commitment, or disengagement.2 Evidence of burnout and understated suffering in nurses pre-dates the COVID-19 pandemic by decades.3 Data are replete documenting burnout in nurses exposed to stressors associated with high patient acuity, lack of resources, technology overload, and exposure to morally distressing situations.4 Burnout correlates with higher rates of anxiety disorders, depression, alcohol and substance use disorders, and suicide. Sixty percent of nurses reported feelings of burnout.5 Of greater alarm for the future of an aging nursing workforce, 66% of nurses under 35 reported feeling anxious; 47% reported feelings of depression or having experienced an extremely stressful, violent, or traumatic event due to COVID-19, indicating a need for a large swathe of our nurses to be further evaluated for potential posttraumatic stress and suicide risk.4 The stigma phenomenon Nurses who have admitted to not seeking mental health support (even after they determine that they need it) indicated reasons such as lack of time, feeling that they should be able to handle their own mental health, and cost or lack of financial resources.4 Stigma, defined as a social process characterized by exclusion, rejection, blame, or devaluation that results from anticipation of an adverse social judgment, likely contributes to nurses' hesitancy or resistance to ask for or receive support or services.6 The anticipation of an adverse social judgment isn't imagined or purely based on perception; it's based on experience and founded in history. Stigma is bred in actions and behaviors and embedded in structures and policies. Disciplinary responses and policies that are applied inequitably to some but not others breed gossip, alienation, and shame and create a culture for nurses to suffer in silence. Historically, nursing has cultivated a “survival of the fittest” culture and a belief that the profession is not for the meek and mild. A pattern of perfectionism driven by quality and high standards creates barriers to revealing human frailties. Nursing has also been known to normalize some of the suffering that comes with being a nurse and perpetuate the notion that showing emotions or asking for help are signs of weakness.6 These patterns of nurses not supporting each other or judging others harshly likely arises from unacknowledged responses to patterns of oppression within the profession and healthcare. As much as nurses have championed efforts to destigmatize the public's social stigma related to mental health, more attention and effort are needed to destigmatize mental health within nursing ranks. Stigma associated with mental health issues can be exacerbated when mental health and mental illness are consciously or unconsciously conflated. Within nursing there are opportunities to address these implicit biases and to make distinctions that normalize mental health as part of overall well-being. Gaps in nurses seeking services With the burgeoning prevalence of mental health consequences related to the pandemic, many healthcare organizations have attempted to intensify mental health resources but use by nurses is deficient. The divide between what organizational leaders provide to support mental well-being and what nurses feel is needed to address their declining mental health has come into sharp focus during the pandemic.5 Employee-assistance programs (EAPs), hotlines, and peer recovery programs have been made available to nurses to take part in services when needed, but they're clearly not enough. There's an increasing negative perception from nurses that their employers really don't care about their well-being.4 Sixty-eight percent of nurses don't seek mental health support; however, it's encouraging to see that more than 50% of nurses under 35 have sought mental health support since the start of the pandemic.4 What isn't clear is whether mental health services are sought out by nurses or provided preventively, and whether support and treatment are provided and sustained over time for efficacy and improved mental health. Pitfalls of EAPs EAPs have long been seen as the solution to provide social, emotional, and mental support in healthcare. EAPs are “voluntary work-based programs that offer free and confidential assessments, short-term counseling, referrals, and follow-up services to employees who have personal and/or work-related problems that impact mental and emotional well-being (such as alcohol and other substance abuse, stress, grief, family problems, and psychological disorders).”7 Despite their widespread availability, only 5% of respondents to the survey question, “What has been most helpful in strengthening your well-being?” felt that EAPs or counseling services were helpful, and 4% of nurses not seeking mental health support expressed concerns with EAP confidentiality.5 Furthermore, most EAPs have been historically housed and intertwined with human resources departments, which certainly validates nurses' concerns about privacy. EAPs and peer recovery programs have been offered and used reactively or as part of disciplinary action plans. Any positive outcomes from EAPs are understandably unknown and hidden for privacy reasons, but there's awareness that in some cases when nurses or other peers have been referred to EAPs by their managers, some of those individuals have returned with silence, shared negative experiences, or haven't returned to the department or workplace postreferral. New paradigms for EAPs customized with nurse-sensitive approaches to services and delivery are urgently needed. Key strategies to address stigma Look within. The first step to addressing stigma in nursing is to look within. Intentionally or unintentionally, the culture of nursing has adopted norms surrounding asking for and receiving help, support, or resources that undermine nurses' willingness to use them. When the message communicated is “good nurses don't need help,” we activate a predictable human response of shame, guilt, denial, or resistance. Often within nursing, especially in high-stakes environments like critical care, asking for help can be viewed as deficiency or failure. Enduring judgment and risking being ostracized carries significant burdens that many nurses are unwilling to risk. These factors are intensified when asking for help or support is focused on mental health issues. Leaders must understand their biases and consequences and adopt a teachable spirit by accepting that human beings are fallible, and that resilience isn't missing when limits are met. View asking for support as an act of integrity and self-stewardship. One shift to reduce stigma and help nurses to seek support and resources to address their mental health concerns is to connect these actions to fundamental ethical values of the profession. The ANA Code of Ethics is clear: Nurses have the same responsibility to themselves as they do to others—including preserving health, well-being, and integrity.8 Integrity requires self-stewardship, “demonstrating a commitment to know oneself, to responsibly and mindfully manage one's personal resources, to recognize and compassionately respect one's limitations, and to choose actions that are wholesome and life-affirming.”9 Instead of harshly judging those who need mental health support, nurses can individually and collectively shift the narrative from “there's something wrong with me” to “I'm exercising self-stewardship by recognizing and honoring my limitations and needs.” When we can intentionally reframe these situations and respond with understanding and compassion, we begin to create a more supportive and healthier ecosystem for nursing practice. Distinguish mental health from mental illness. Many nurses, as well as the public, conflate mental health with mental illness. When this occurs, it amplifies the cultural patterns within the profession that intensify shame or denial. Differentiating these terms helps to open the door to normalizing our humanity and the limits of our ability to respond to challenges or setbacks in ways that are healthy and wholesome. Likewise, these distinctions must be communicated in learning and practice environments to create a coherent message within the profession. Integrate strategic initiatives with the Pathway to Excellence® framework. In recent American Nurses Foundation listening sessions, participants were asked about their perceptions of stigma in mental health.10Figure 1 includes six recommendations to combat mental and emotional health stigmas. These recommendations align with the six standards of the ANCC Pathway to Excellence Framework for positive practice environments (see Figure 2).11Figure 1:: Six strategies to combat mental and emotional health stigma in nursing10Figure 2:: ANCC Pathway to Excellence® Framework for Positive Practice Environments.1. Shared decision-making: “Communication must be clear, frequent, prominent, and specific.” Changing the mental health narrative for nurses is critical. Aligning values of integrity, transparency, humility, and courage to how you view people with mental health needs begins the process of culture change.12 Overcommunicating values and the overriding philosophy about health and mental well-being is key. Letting people know “it's okay to not be okay” and creating trustworthy mechanisms to ask for and receive support and services is vital. 2. Leadership: “It must come from the top.” Leaders serve a vital role in setting the tone around mental health in an organization. Leaders are human beings too. When leaders demonstrate their humanity and show their vulnerabilities and frailties, they disrupt the perception that perfection or immutable strength is required to lead. Change begins when leaders shift their philosophical approach and behaviors and implement sustainable structural changes in policies, procedures, and priorities that destigmatize and normalize asking for and receiving support or resources. 3. Safety: “Mental health must become a requirement for all employers of nurses.” Many organizations have invested in and implemented high reliability and just culture programs to reset team approaches to safety. These programs are typically built on the premise that being human means that errors will occur, even after all types of training and education. These programs are designed to mitigate our human frailties by learning how we make mistakes, the differences between system or human errors, and ways to reduce the likelihood of making these errors. Intentional alignment of safety initiatives with mental health and well-being structures creates synergy that supports a holistic culture. 4. Quality: “Emphasize wellness, be proactive, and make resources accessible.” It takes courage to ask for or seek services when you're struggling. Anecdotally nurses report that their organizations say that they have mental health services but, when they're needed, they find that they're not easily accessible, timely, or effective. Support systems must be designed with nurses' input. Otherwise, leaders and system processes can inadvertently erode trust and intensify their distress. 5. Well-being: “We must normalize mental health in nursing.” Every leader must assess what policies, plans, and procedures exist to provide mental health support and identify ways to dismantle the impediments to accessing mental health services in licensure, regulations, and employment. This is the “put your money where your mouth is” part of leading this change that's long overdue. 6. Professional development: “More education and awareness about the importance of mental health in nursing are needed (early and often).” An important leverage point for change is to create a multipronged educational strategy to raise awareness, competence in recognizing signals of mental health needs, and confidence in accessing support and resources. These offerings should begin on the first day of nursing school and extend into nurse residency and continuing-education programs.13 Table 1 includes promising directions that nurse leaders can explore to begin the cultural shift within their workforce, organization, and the profession. Table 1: - Strategies for implementing recommendations to address stigma in nursing Pathway Standard Stigma Element Promising Approaches 1 Shared decision-making Allowing clinical nurse input into decision-making influences all aspects of care delivery. “Communication must be clear, frequent, prominent, and specific.” Trust is broken if promises made aren't fulfilled. Setting up council structures that monitor and report trends related to mental health and use of services to an organizational decision-making body is critical for sustainment and success. This will bring organizations closer to the vision of creating a healthy work environment where mental health is viewed as a norm rather than an exception. 2 Leadership Leaders continuously strive to increase their core knowledge and role competency through leadership development activities along with feedback from colleagues and nursing staff. “It must come from the top.” Demonstrate your commitment to destigmatizing mental health by allocating meaningful and substantial resources to a multipronged approach to foster mental, emotional, and moral health and asking for support. 3 Safety Protect the safety and well-being of nurses, staff, and patients through safety policies and procedures. “Mental health must become a requirement for all employers of nurses.” Strategically investing in systems to support access to and use of mental health services is a tangible way that healthcare leaders and organizations can build a foundation of trust. This includes having robust and sustainable insurance coverage for mental health services. Inflexible limits on the type and frequency of services or undue administrative barriers to access must be dismantled so nurses can get services in a timely and comprehensive manner. 4 Quality Quality initiatives are evidence-based, focused on improving outcomes based on benchmarking. “Emphasize wellness, be proactive, and make resources accessible.” Instead of waiting for an emotional or mental health issue to become a problem, proactive monitoring and assessment is needed to help nurses and their employers recognize early signals of stress or distress. Normalizing a routine, proactive check-in process creates a culture of openness and support. 5 Well-being Providing staff with the opportunity to develop an integrated work and personal life balance. “We must normalize mental health in nursing.” Numerous processes must be created to forge seamless pathways for nurses and team members to share emotions and experiences that threaten their integrity and well-being. A reallocation or new infusion of leave hours for mental health days helps break the stigma. Health benefits must be reviewed, and a separate section should be designed focused on support for mental health and well-being. A public relations campaign with a slogan about nurses' mental health should resonate throughout the entire department or organization. 6 Professional development Pathway to Excellence organizations recognize the importance of staff orientation, collaboration, and development in the delivery of safe and effective patient care. “More education and awareness about the importance of mental health in nursing are needed (early and often).” Create academic practice partnerships to align the new competencies for nursing education with nurse residency and continuing-education requirements and offerings.14 Together create continuity in messaging and expectations for nonpunitive responses across settings and roles. An urgent priority Nurses' mental and emotional health has been significantly degraded during the pandemic, exacerbating long-standing barriers to accessing support and resources. Stigma surrounding mental and emotional health has intensified nurses' reluctance to seek services and resources. Individuals and organizations have a pivotal role in creating a destigmatizing ecosystem surrounding mental health within nursing and the organizations where they serve. Focused attention on the barriers to access and the culture of the profession that contributes to this reality is an urgent priority. Implementing the recommendations outlined above, and leveraging the pathways criteria, offers organizational leaders a roadmap for beginning the culture change.