Overcoming Stigma: Asking for and Receiving Mental Health Support.

Critical care nurses have borne a significant burden during the pandemic. Studies indicate that the COVID-19 pandemic has seriously degraded critical care nurses’ physical, psychological, and emotional well-being.1-3 The mental health consequences of the pandemic on nurses include increased rates of depression,4,5 anxiety,4,5 posttraumatic stress disorder (PTSD),4-6 and burnout.4,6 Suicide rates among nurses have long been higher than rates for the general population,7,8 and high-stress clinical scenarios such as disease outbreaks are well-recognized risk factors for nurse suicide.8 Unsurprisingly, 41.8% of nurses report that they have witnessed or experienced an “extremely stressful, disturbing, or traumatic event” related to the COVID-19 pandemic.8 This is especially true of younger members of the profession, with 51% of nurses under the age of 25 reporting depression within the past 14 days.8 If we are to maintain a healthy and robust workforce to support patients through this and future periods of increased care needs, we must protect the emotional and psychological health of those called to care.Stigma is a significant barrier to nurses seeking mental health care and other support services.9 The American Nurses Foundation found that more than 36% of nurses report stigma related to mental health care seeking.10 Stigma is defined as an undesirable attribute that has negative identity consequences as well as impediments to social standing.11 Within the nursing profession, stigma related to mental health care seeking may create barriers to peer acceptance and occupational success and may delay or prevent care seeking altogether. Mental health stigma is well documented and stems in part from stereotypes that people with mental illness are irrational, incompetent, and undependable.12 These negative stereotypes are in direct conflict with professional and occupational norms. As members of the most-trusted profession, nurses are sometimes seen as morally infallible; this assumption is incongruent with negative stereotypes about who experiences depression and anxiety. Stigma has rooted itself in the norms and practices of the nursing profession, stemming from a culture of health care where nurses are seen as caregivers rather than those in need of care themselves. This creates an identity discordance between the nurse as caregiver and the nurse as a person who requires care and support.Tasha is an experienced critical care nurse. During the long haul of the pandemic, she often worked more than her assigned hours because of staff shortages. Midway through the third surge she started to notice that she was chronically exhausted and had little energy for activities outside of work. She had developed poor sleep habits that resulted in her getting less than 6 hours of sleep per day. When she did sleep, her sleep was often disrupted by nightmares involving patients she had cared for. She felt guilty and sad about the patients she might have been able to help in different circumstances. When she was at work, the intensity of her patient load left her on sympathetic overload for the duration of her shift. She began to worry that she was depressed and could be experiencing PTSD. Tasha always prided herself as having a “thick skin”—she was regarded by her colleagues as a person who could handle anything. But now, she felt like she was drowning. Her health care organization regularly communicated the array of services that were available to support nurses like her, but she heard that the Employee Assistance Program wasn’t very responsive, and her supervisor was likely to find out that she was seeking help. Plus, if she had to admit she was seeking mental health support she would need to disclose it on her license renewal. She was concerned about what others would think if she admitted she was struggling. She had overheard other nurses making fun of those who sought counseling as “weaklings.” One of her close friends approached her manager about concerns about her own mental health needs and was told, “We are so short-staffed, I can’t afford to give you any time off. Can’t you manage it on your day off?” Besides, Tasha wasn’t convinced anything would help anyway. She ought to be able to manage this herself.There are 4 classically defined domains that fall under the larger umbrella of stigma: perceived, internalized, anticipated, and enacted. All 4 have the potential to negatively impact the physical and emotional health of nurses but they can especially impact mental health. Perceived stigma involves general perceptions of mental illness and how the public at large feels about people who endorse mental health needs.13 Prejudice is one example of perceived stigma.13 Nurses who perceive stigma may begin to internalize these negative feelings and view themselves as somehow lacking or “less than.” Internalized stigma reduces self-esteem and self-concept and may reduce individual goals and aspirations.13 Nurses may also anticipate negative reactions from others if their mental health status is known. Finally, enacted stigma is how people treat the stigmatized person. Enacted stigma includes gossip, insults, discrimination, and other behaviors.13 Stigma, in all its forms, makes it more difficult for people with mental health needs to engage in professional mental health care and self-care.12 See the Figure for a depiction of perceived, internalized, anticipated, and enacted stigma.Stress and diagnoses of depression and anxiety are extremely common in the general population. Over the course of a lifetime, 8.4% of adults in the United States will experience a major depressive episode,14 and 31.1% will endorse an anxiety disorder.15 Prepandemic studies estimated that at any given time, approximately 10% of the workforce is actively battling depression.16 Experts believe that this number has only increased as a result of the stresses of the COVID-19 pandemic. These stressors are particularly acute for the nursing workforce as we respond to increased patient volumes, high patient acuity, staff shortages, and increased caregiving responsibilities at home. Despite increasing evidence in the literature about the negative impacts of mental health stigma on care-seeking behaviors, media portrayals of mental health struggles are rife with stereotypes about mental illness and violence, perceived danger to the community, and associations with gun violence.17 Community perceptions of mental illness also include unfounded stereotypes about incompetence, intellectual deficits, and amorality.18 There is also a tendency to conflate normal mental health stressors with mental illness and thereby attach labels that contribute to stigma. Unfortunately, segments of the general community continue to believe that mental illness is controllable by will and therefore believe people suffering from mental illnesses don’t deserve compassion and support.18 For example, there is a perception that depression and anxiety are “all in your head,” and that people with mental illness should be able to “shake it off.” In contrast, we would never expect someone with pneumonia or heart failure to push through their illness, because we recognize that the individual has no control over how the illness occurred or the time it takes to recover.Anticipated stigma may be a major barrier to nurses reporting burnout, depression, and anxiety. Nurses who endorse higher mental health needs may fear negative repercussions from their coworkers and supervisors. They may fear gossip or anticipate a loss of their professional reputation as a capable and dependable team member, and they may expect to lose the camaraderie and support of colleagues as a result of disclosure. Others fear that their privacy will not be protected when they seek mental health services or share their struggles with others. From supervisors, nurses may fear loss of respect, seniority, and opportunities for professional growth such as promotions. Nurses may even fear loss of livelihood should their supervisor pass them up for extra shifts or overtime because of depression or anxiety. These concerns are not without merit. Research shows that both coworkers and supervisors question the reliability of workers with mental illness.16 The majority of state boards of nursing (30 of 50 states) ask questions about mental and psychiatric health during initial licensure and renewals.19 These questions are variably compliant with regulations set forth by the Americans with Disabilities Act19 and certainly give nurses pause about the professional costs of seeking care.Provision 5 of the American Nurses Association (ANA) Code of Ethics states, Nurses have the duty to care for themselves and each other as they do for their patients. The ANA specifically addresses the damage done when nurses hold themselves and one another to a “hero” standard. The ANA affirms that we as nurses are not called to place the needs of the public above our needs as individuals. Beyond physical risk, the hero standard also undermines the mental health of the nurse. The hero standard perpetuates stereotypes about mental toughness among nurses and reinforces self-stigma when a nurse feels conflicted by the pull between self and patient. Provision 5 is the official statement that should put to rest the debate about the ethics of self-preservation in the face of undue stress and mental distress. Self-stewardship is not selfishness.21 Asking for and receiving support is an act of integrity. It protects the nurse as an individual, protects today’s patients by ensuring that their caregiver has the emotional and mental capacity to deliver physical care with empathy, and protects tomorrow’s patients by promoting a healthy nursing workforce.Nursing leaders, institutions, and even individuals can take small steps toward reducing the stigma associated with mental health and occupational burnout. Even small actions such as prioritizing uninterrupted staff breaks off the nursing unit communicate to staff that their mental wellness is a priority and that patient care should not come at the expense of their mental and emotional health. Creating open and honest dialogue about the prevalence of burnout and mental illness is a great way to combat occupational mental health stigma. The Table outlines specific steps nurses and their leaders can take to make visible their commitments to destigmatizing access and use of mental health services and to creating healthy workplaces. If nurses know that they are not alone, and that they will not be penalized for self-stewardship related to mental health, then they can be empowered to prioritize their mental wellness. In addition to institutional supports, the ANA is working to support the mental health and well-being of nurses during the COVID-19 pandemic. Nursing leaders can guide staff toward resources such as mental health self-assessments, apps, toolkits, free meditation and relaxation exercises, and referrals to immediate help.The pandemic has exacerbated long-standing organizational and structural issues that have degraded the mental health and well-being of critical care nurses. Stigma is another barrier that stands in the way of optimal mental health among nurses. Fortunately, there are tangible steps that nursing leaders and organizations can take to promote mental health and reduce the stigma surrounding mental health and self-stewardship.23 In challenging times, it is essential to communicate to nurses on the front lines that patient care does not come at the expense of our own mental health. Positioning self-stewardship as an essential nursing duty removes the stigma associated with mental health care. Committing to a path of self-stewardship encourages nurses to engage in healthy behaviors rather than hiding or pushing down feelings of stress, burnout, depression, or anxiety. Nurses must be empowered to care for their mental health for their own benefit and for that of our patients. When leaders and organizational structures support nurses’ individual commitment to their own well-being, healthy workplaces become reliable and effective resources for nurses. Together we can dismantle stigmatizing norms and instead develop practices and conditions for nurses to thrive and serve.