Author(s): Bernadette Mazurek Melnyk, PhD, APRN-CNP, FAANP, FNAP, FAAN; Andreanna Pavan Hsieh, MPH; Judy Davidson, DNP RN MCCM FAAN; Holly Carpenter, BSN, RN; Amanda Choflet, DNP, RN, OCN; Janie Heath, APRN-BC, FAAN, FNAP, FAANP; Marianne E. Hess, MSN, RN, CCRN-K; P
An urgent call to shift from crisis intervention to long-term prevention
Takeaways:
- Nurses are experiencing an unprecedented amount of burnout, depression, and anxiety.
- Stressful work environments, workplace bullying, and workplace cultures unsupportive of personal well-being play a role in the nurse mental health crisis.
- System-level mental health promotion can reduce the mental health burden on nurses.
Editor’s note: This article is the first in a three-part series that aims to highlight the work of the American Nurses Association (ANA) Building Strength through Resilience Committee. To promote the mental health of nurses, the committee has developed web content that focuses on mental health promotion and prevention, suicide prevention, and grief. These resources are free, and a full list of the committee’s work can be found at nursingworld.org/practice-policy/nurse-suicide-prevention. This first article provides background on the state of mental health in nursing and reviews system-level interventions for nurse mental health promotion and prevention.
A paradigm shift from crisis intervention to mental health promotion and prevention is urgently needed in nursing. For many years, leaders didn’t properly address high rates of healthcare workforce burnout (emotional exhaustion, depersonalization, job detachment, and a sense of ineffectiveness) and unhealthy lifestyle behaviors. Instead, burnout was believed to be an individual, not a systemic, issue. Individual nurses were left to figure it out, resulting in a crisis situation. Even the World Health Organization now classifies burnout as an “occupational phenomenon” that must be addressed to maintain mental well-being in the workplace.
When burnout occurs, depression, anxiety, risky substance use, physical fatigue, and workplace incivility tend to follow. According to Davidson and colleagues, the prevalence of depression, anxiety, and suicide is now higher in nurses than in the general U.S. population. A national study by Melnyk and colleagues reported that half of 1,790 nurses from 19 healthcare systems indicated poor mental and physical health, and approximately one-third reported depression. Study analysis determined that depression was the leading predictor of self-reported medical errors. In addition to worsening nurse population health outcomes, the mental health crisis also has created costly job turnover rates and increased risks to patient care and safety.
The problem has reached an even higher level of urgency as the COVID-19 pandemic continues to exacerbate the rate of mental health issues in nurses as they suffer from more burnout, depression, and anxiety, as well as acute stress disorder and post-traumatic stress disorder. At its most extreme, the lack of system-level preparation to protect nurses against COVID-19 and the resulting secondary mental health effects has resulted in nurse and physician suicide. These outcomes highlight the need to provide interventions for those who are suffering from acute mental health problems and to intensify mental health prevention and promotion efforts. Focusing on prevention at the system level may reduce the number of nurses who reach a state of burnout or experience an acute mental health crisis. (See Contributing factors.)
Contributing factors
Nurse burnout and other mental health concerns—such as compassion fatigue (similar to burnout, but more severe as it involves trauma, a decrease in the ability to sympathize, and a change in worldview), depression, anxiety, and risky substance use—are symptoms of a larger issue endemic within the nursing profession. Mental health issues are complex. They arise from genetic predisposition and environmental factors such as stressful work environments, workplace bullying, and workplace cultures that don’t support personal wellbeing. These environmental factors may prevent nurses from prioritizing their own self-care.
Self-care habits include getting 30 minutes of physical activity 5 days a week, eating five servings of fruits and vegetables per day, not smoking, limiting alcohol intake to one drink a day, getting 7 to 9 hours of sleep per day, and regularly practicing a preferred stress reduction technique, such as mindfulness. According to the Centers for Disease Control and Prevention, such practices can help prevent chronic disease and aid in reducing mental health condition symptoms. In addition, those struggling with a mental health issue can benefit from working with a mental health professional.
To find our way out of this crisis, organizations must support employee self-care by providing wellness cultures, addressing system problems, and providing evidence-based interventions to improve nurse mental and physical health. Such interventions include teaching and promoting mindfulness (staying present in the moment and being aware of your feelings and environment), enhancing resiliency (building personal attributes, including forgiveness, gratitude, and compassion), and practicing cognitive-behavioral skills (identifying how a person’s thought patterns impact their emotions and behaviors, and overturning negative with positive thinking).
Systems solution resources
Consider the following evidence-based resources for establishing a preventive program that is integrated into a wellness culture and engaging state and federal representatives.
HEAR and MINDBODYSTRONGprograms
Evidence-based interventions must be translated more rapidly into clinical settings to improve clinician mental health and well-being. For example, all nurses should have access to free anonymous depression and suicide screening. The University of California at San Diego’s evidence-based Healer Education Assessment and Referral (HEAR) program, which provides screenings and referrals to mental health services, has successfully identified and provided care to healthcare workers struggling with suicidal thoughts, substance use disorder, and other mental health conditions.
Another successful evidence-based program that can be delivered by nurses and other nonpsychiatric mental health providers is the MINDBODYSTRONG program, which provides a workbook-based, seven-session cognitive behavior therapy program for nurses and other clinicians. A study with new nurse residents showed that those who received access to the program as part of their orientation had higher job satisfaction and less depression, anxiety, and stress up to 6 months after completion.
National initiatives
In addition to ANA’s Building Strength through Resilience Committee, other relevant initiatives include ANA Enterprise’s Healthy Nurse, Healthy Nation™ (www.hnhn.org), the Well-Being Initiative launched by the American Nurses Foundation (bit.ly/36nChTP), and the National Academy of Medicine’s (NAM) Action Collaborative on Clinician WellBeing and Resilience (nam.edu/initiatives/clinician-resilience-and-well-being).
These national programs support the research needed to establish evidence-based preventive strategies, provide resources, and demonstrate that nursing leadership supports and prioritizes mental health and well-being. For sustainable improvements in nurse well-being to occur, a multi-stakeholder approach is required. In addition to direct nursing professional leadership, state policymakers, health professional licensing boards, and health professional colleges and schools must provide indirect leadership.
State policy briefs
States can issue policy briefs that promote clinician mental health and well-being. For example, the Health Policy Institute of Ohio partnered with The Ohio State University Helene Fuld Health Trust National Institute for Evidence-Based Practice in Nursing and Healthcare to create a policy brief (A Call to Action: Improving Clinician Wellbeing and Patient Care and Safety) that describes the state of clinician well-being; defines the framework for the relationship between clinician well-being and patient care; reviews evidence-based policies and programs that improve clinician well-being; and establishes a set of evidence-based state policy recommendations. The brief identifies three key takeaways for policymakers and healthcare leaders:
- A bidirectional relationship exists between clinician well-being and patient care.
- Clinicians are encountering serious problems related to their health and well-being (high burnout, depression, addiction, suicide).
- Improvement requires a comprehensive approach that provides a continuum of prevention, treatment, and recovery support.
The full report can be accessed at healthpolicyohio.org/a-call-to-action.
Six goals and actions to prevent burnout and promote mental health
Stigma and fear of professional consequences continue to be barriers for clinicians seeking help for mental health conditions. According to the Health Policy Institute of Ohio policy brief, this stigma typically begins during school and continues as clinicians begin working in environments without a strong wellness culture. To combat these barriers, The National Academies of Sciences, Engineering, and Medicine proposed six goals and system-wide actions to prevent burnout and promote the mental health of clinicians.
- Create positive work environments.
- Create positive learning environments.
- Reduce administrative burden.
- Enable technology solutions.
- Provide support to clinicians and learners.
- Invest in research.
Chief wellness officers
Appointing a chief wellness officer (CWO) can help organizations meet the National Academies of Sciences, Engineering, and Medicine goals. The CWO, ideally a member of the organization’s senior leadership team, should have access to the necessary resources to support wellness initiatives. Their work should focus on building a strong wellness culture where healthy behaviors are the norm in an organization. A CWO can provide a voice for openly acknowledging and discussing clinician well-being as a shared organizational value and help establish and promote confidential mental health and addiction screenings and treatment services for clinicians. During COVID-19, or any future crisis, the CWO can serve as a “command center” for organizational wellness decision-making. According to an Ohio State University case study, for every dollar invested in wellness, the return on investment ranges from $3 to $4. An increase in value on investment also rises as morale and clinician engagement improve.
Engaging with the federal government
We must call upon our federal government—the highest system level—and its representatives to allocate funding for clinicians who’ve experienced negative physical and mental health effects as a result of the pandemic. Such resources could provide a national epidemiologic tracking program to monitor clinician well-being as a quality indicator. The urgent need for this request became apparent with the tragic loss of Dr. Lorna Breen to suicide. Dr. Breen worked in emergency medicine and was described as outgoing and extroverted, but her mental health was substantially affected by the trauma of caring for patients with COVID-19. Accordingly, the S.4349 – Dr. Lorna Breen Health Care Provider Act was introduced on July 29, 2020. If passed, the legislation will provide behavioral health and well-being training programs to healthcare professionals, launch a national campaign to promote seeking mental health support and treatment, initiate a federal study to assess mental health and burnout in healthcare professionals, and provide grants for establishing and expanding mental health services for those providing care to patients with COVID-19.
Building a foundation of prevention
Promoting the mental health and well-being of nurses must be considered a foundational necessity. A preventive approach is necessary to improve the population health of nurses, enhance patient outcomes, and decrease healthcare costs. As Benjamin Franklin once said, “An ounce of prevention is worth a pound of cure.” AN
To view a list of references, visit myamericannurse.com/?p=70264.
Bernadette Mazurek Melnyk is vice president for health promotion, university chief wellness officer, dean, and Helene Fuld Health Trust professor of evidence-based practice in the college of nursing at The Ohio State University in Columbus. Andreanna Pavan Hsieh is a science writer in the college of nursing at The Ohio State University. Judy Davidson is a nurse scientist at the University of California San Diego School of Medicine. Holly Carpenter is a senior policy advisor for Innovation Nursing Practice & Work Environment at ANA Enterprise in Silver Spring, Maryland. Amanda Choflet is an assistant professor and leadership concentration chair at San Diego State University’s College of Health and Human Service. Janie Heath is dean and Warwick professor of nursing at the University of Kentucky College of Nursing in Lexington. Marianne E. Hess is education coordinator at George Washington University Hospital in Washington, DC. Peggy Lee is a critical care RN at University Medical Center in Las Vegas, Nevada. Terri Link is a product manager for guideline implementation tools for the Association of periOperative Registered Nurses in Denver, Colorado. Jalma Marcus is a board-certified private practice holistic nurse in Perkiomenville, Pennsylvania and author of the Space that Surrounds Theory and 4 C’s Alignment System. Christine Pabico is director of the Pathway to Excellence® Program at the American Nurses Credentialing Center in Silver Spring, Maryland. Kathleen Poindexter is an associate professor and assistant dean of undergraduate programs and faculty development at Michigan State University college of nursing in East Lansing. Lisa Stand is a senior policy advisor for policy and government affairs at the American Nurses Association.
References
Cappelucci K, Zindel M, Knight HC, Busis N, Alexander C. Improving clinician well-being at Ohio State University: A case study. National Academy of Medicine. August 26, 2019. nam.edu/clinicianwellbeing/case-study/ohio-state-university
Centers for Disease Control and Prevention. How you can prevent chronic disease. September 15, 2020. cdc.gov/chronicdisease/about/prevent/index.htm
Crawford CL, Chu F, Judson LH, et al. An integrative review of nurse-to-nurse incivility, hostility, and workplace violence: A GPS for nurse leaders. Nurs Adm Q. 2019;43(2):138-56.
Davidson JE, Accardi R, Sanchez C, Zisook S, Hoffman LA. Sustainability and outcomes of a suicide prevention program for nurses [published correction appears in Worldviews Evid Based Nurs. 2020;17(2):179]. Worldviews Evid Based Nurs. 2020;17(1):24-31.
Davidson JE, Proudfoot J, Lee K, Terterian G, Zisook S. A longitudinal analysis of nurse suicide in the United States (2005-2016) with recommendations for action [published correction appears in Worldviews Evid Based Nurs. 2020;17(2):180]. Worldviews Evid Based Nurs. 2020;17(1):6-15.
Dr. Lorna Breen Health Care Provider Protection Act, S 4349, 116th Cong (2019-2020). congress.gov/bill/116th-congress/senate-bill/4349?q=%7B%22search%22%3A%5B%22d%22%5D%7D&s=1&r=3
Dzau VJ, Kirch D, Nasca T. Preventing a parallel pandemic – A national strategy to protect clinicians’ well-being. N Engl J Med. 2020;383(6):513-5.
Foli KJ, Reddick B, Zhang L, Krcelich K. Substance use in registered nurses: “I Heard About a Nurse Who…” J Am Psychiatr Nurses Assoc. 2020;26(1):65-76.
Health Policy Institute of Ohio and The Ohio State College of Nursing Helene Fuld Trust National Institute for Evidence-based Practice in Nursing and Health Care. A Call to Action: Improving Clinician Wellbeing and Patient care and Safety. February 2020. healthpolicyohio.org/wp-content/uploads/2020/02/CallToAction_Brief.pdf.
Melnyk BM, Kelly SA, Stephens J, et al. Interventions to improve mental health, well-being, physical health, and lifestyle behaviors in physicians and nurses: A systematic review. Am J Health Promot. 2020;34(8):929-41.
Melnyk BM, Orsolini L, Tan A, et al. A national study links nurses’ physical and mental health to medical errors and perceived worksite wellness. J Occup Environ Med. 2018;60(2):126-31.
National Academies of Sciences, Engineering, and Medicine. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: The National Academies Press; 2019.
Pheko MM, Monteiro NM, Segopolo MT. When work hurts: A conceptual framework explaining how organizational culture may perpetuate workplace bullying. J Hum Behav Soc Environ. 2017;27(6):571-88.
Rahman A, Plummer V. COVID-19 related suicide among hospital nurses; case study evidence from worldwide media reports. Psychiatry Res. 2020;291:113272.
Rogers A. Nurses’ work schedules, quality of care, and the health of the nurse workforce remain significant issues. Washington State Nurses Association. 2019. cdn.wsna.org/assets/entry-assets/3215/Nurses-work-schedules-quality-of-care-and-fatigue_200622_172628.pdf
Sampson M, Melnyk BM, Hoying J. Intervention effects of the MINDBODYSTRONG cognitive behavioral skills building program on newly licensed registered nurses’ mental health, healthy lifestyle behaviors, and job satisfaction. J Nurs Adm. 2019;49(10):487-95.
Sampson M, Melnyk BM, Hoying J. The MINDBODYSTRONG intervention for new nurse residents: 6-month effects on mental health outcomes, healthy lifestyle behaviors, and job satisfaction. Worldviews Evid Based Nurs. 2020;17(1):16-23.
Starr KT. The sneaky prevalence of substance abuse in nursing. Nursing. 2015;45(3):16-7.
Tawfik DS, Scheid A, Profit J, et al. Evidence relating health care provider burnout and quality of care: A systematic review and meta-analysis. Ann Intern Med. 2019;171(8):555-67.
Watkins A, Rothfeld M, Rashbaum WK, Rosenthal B. Top E.R. doctor who treated virus patients dies by suicide. The New York Times. April 27, 2020. nytimes.com/2020/04/27/nyregion/new-york-city-doctor-suicide-coronavirus.html
World Health Organization. Burn-out an “occupational phenomenon”: International classification of diseases. May 28, 2019. who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases
Worley J. Nurses with substance use disorders: Where we are and what needs to be done. J Psychosoc Nurs Ment Health Serv. 2017;55(12):11-4.
