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ADDRESSING MENTAL HEALTH STIGMA IN NURSING
National Summit Report
October 2022
The COVID-19 pandemic brought greater attention to the frequency and severity of stress and burnout and the impact they have on mental health in nurses. This increased awareness has resulted in growing cross-sector calls to action. Numerous roadmaps outline both the complexity of the way forward and the need for many organizations to play a role serving as catalysts for change. For the American Nurses Foundation (the Foundation), the philanthropic entity of the ANA Enterprise, the commitment to lead work that supports the mental health and well-being of the nation’s nurses began early in the pandemic (see Appendix B) and has now evolved to include addressing the stigma associated with seeking mental health support. While the barriers to seeking and receiving mental health and well-being support are an issue for the entire healthcare workforce, the Foundation is focusing on nurses, the largest group within the healthcare workforce. Recognizing the complexity of identifying actionable steps forward, the Foundation hosted the Summit to Address Mental Health Stigma in Nursing in February and March 2022. The sessions brought together a diverse group of experts with the purpose of creating a blueprint for national action and guiding philanthropic investments in addressing stigma in mental health in nursing. These 26 national leaders in mental health and well-being (see Appendix C) identified a future state for clinical practice where culture is transformed and all stakeholders play a role in addressing the continuum of well-being, mental health, and mental illness to ensure the offering and asking for help is normalized, encouraged, and done so without stigma. A detailed report of the Summit is shared in Appendix D. The following highlights the outcomes from the Summit, including the key actions to move towards the desired future state. FUTURE STATE PRINCIPLES Transitioning towards the desired future state will require intentionally adopting foundational principles that reflect the social-ecological model, requiring commitments from individuals, peers, organizations, policy, and society. The following principles were identified by the Summit attendees.
- Nurses can bring their whole self to work or to the care environment.
- Peers within nursing and other disciplines have the resources, responsibility, and skill to address mental health in a way that does not further stigmatize those seeking help.
- Offering help and asking for help are normalized.
- Nurses can recognize stress injury in themselves and others.
- “Nurse heroism” is challenged to address the everyday norms and perceptions that lead to stigma.
- Organizations are led by leaders who are equipped to support their staff, empowered to talk about their own experiences, and create a culture of well-being.
- Policy surrounding licensure, accreditation, and certification does not serve as a potential source of stigma, while still maintaining public safety.
- Society is a place where nurses are role models to destigmatize seeking mental health support for peers, colleagues, and patients.
- A new vision is created to reflect a renegotiated nursing social contract.
- Models are developed and disseminated that create a common language of definition and intervention planning that unites the national conversation about stigma. ACTIONS TOWARDS THE FUTURE STATE While bold, the principles are aspirational without action. Summit attendees identified five actions that incorporate the principles which, when adopted, would create measurable progress towards the desired future state. The Summit attendees identified the following actions in order of priority:
- Build a nurse-led alliance to convene, communicate, and collaborate on reducing stigma related to well-being and mental health.
- Create structural and regulatory changes that leverage existing systems to eliminate/reduce stigma.
- Build a culture across the profession (students through leaders) that is based on culturally appropriate, equitable, and inclusive education, tools, and resources to understand and respond to the stress continuum.
- Use an appreciative inquiry approach to create a resource compendium of programs that effectively reduce stigma.
- Create a recognition program to bring attention to and amplify the spread of individuals/organizations successfully addressing mental health stigma. ALIGNMENT WITH OTHER INITIATIVES The focus on mental health, well-being, and burnout within the healthcare workforce has grown. Notable examples include the passage of the Dr. Lorna Breen Health Care Provider Protection Act, the release of Addressing Health Worker Burnout: The U.S. Surgeon General’s Advisory on Building a Thriving Health Workforce, and the announcement of the National Academy of Medicine Clinician Well- Being Collaborative’s National Plan for Health Workforce Well-Being. These reports and their recommendations are a comprehensive call to action to improve the of mental health and well-being of the healthcare workforce. Additionally, calls to address stigma are interwoven throughout. While the Stigma Summit occurred before the passage of the legislation and release of the reports, the actions are reflected in many of the reports’ recommendations. The alignment between the Stigma Summit Actions and the recommendations from the legislation and reports highlight the breadth and depth of the work ahead and the many stakeholders who will need to be involved. It is essential that nursing be at the center of this important work. Not only are nurses the largest segment of the healthcare workforce and their mental health and well-being have been impacted throughout the course of the pandemic, but as healthcare evolves, nursing is positioned to change culture and step into the role of the “de-stigmatizer,” with their patients, peers, and wider community. Appendix A is a crosswalk between the Stigma Summit Actions and the recommendations from the legislation and reports illustrating how they intersect. NEXT STEP The recommendation to create a nurse-led alliance will be the driver of the next phase of work. In 2023 the Foundation will host a series of convenings, with each session focusing on a different topic related to
Appendix A Crosswalk of Stigma Summit Actions & National Healthcare Workforce Reports Summit Action Item Dr. Lorna Breen Act U.S. Surgeon General’s Advisory NAM National Plan Build a nurse-led alliance to convene, communicate, and collaborate on reducing stigma related to well-being and mental health. Convene conferences and symposia to share strategies for improving well- being and preventing and reducing burnout and distress. Establish a national platform or network that can rapidly share, implement, and test models or solutions for transitioning from acute COVID-19 care to institutionalizing long-term well-being. Create structural and regulatory changes (licensure, Joint Commission, certification, AACN Healthy Work Environment, Magnet, Pathway to Excellence etc.) to eliminate/reduce stigma. … the Secretary, in consultation with relevant stakeholders, shall- (1) conduct a review on improving health care professional mental health and the outcomes of programs authorized under this Act…The review under subsection (a) shall take into account … barriers to seeking and accessing mental health care for health care professionals, which may include consideration of stigma and licensing concerns, and actions taken by State licensing boards, schools for health professionals, health care professional training associations, hospital associations, or other organizations, as Eliminate punitive policies for seeking mental health and substance use care…and eliminate punitive language in the licensing, accreditation, and credentialing of health professionals. Examine questions on applications and renewal forms for jobs and hospital credentialing so that health workers are not deterred from seeking mental health and substance use care. Convene state licensing and certification boards to accelerate appropriate changes to mental health reporting requirements, reduce stigma, and normalize the process for health workers to seek help for workplace-related stresses. Align questions about personal health information with the Americans with Disabilities Act to inquire only about current impairments that may affect their ability to provide care due to a health condition rather than a past or current diagnosis or treatment for a mental health condition. Track whether state-level barriers have been removed.
appropriate, to address such barriers… Build a culture across the profession (students through leaders) that is based on culturally appropriate, equitable, and inclusive education, tools, and resources to understand and respond to the stress continuum. Learning environments should promote inclusive policies, mitigate stigma and discrimination, and prioritize diversity efforts among faculty, students, and trainees. Transform workplace culture to empower health workers and be responsive to their voices and needs. Normalize conversation about the use of mental health and substance use care for health workers. Leaders at every level of an organization should be trained in these programs, address barriers for use, and periodically promote these services to their health workers. Instill approaches to decrease workplace stress and burnout and improve health worker and learner well-being in strategic plans, organizational values, and human resources policies and procedures. Facilitate adequate time off and mental health resources without stigma or punishment. Use an appreciative inquiry approach to create a resource compendium of programs that effectively reduce stigma. The Secretary [of HHS], in consultation with relevant stakeholders, including medical professional associations, shall establish a national evidence-based or evidence-informed education and awareness initiative… to address stigma associated with seeking Enhance wide-scale uptake of implementation best practices and approaches to improve well-being and decrease burnout across various stakeholder groups.
Appendix B ABOUT THE AMERICAN NURSES FOUNDATION’S PANDEMIC MENTAL HEALTH INITIATIVES At the beginning of the COVID-19 pandemic, the American Nurses Foundation (Foundation) established the Well-Being Initiative as part of its four-component Coronavirus Response Fund for Nurses. The Well- Being Initiative was created to support the mental health and well-being of all nurses by providing a suite of free evidence-based programs and resources created for nurses by nurses. Programs and resources align with a three-stage response framework:
- Relief - Providing immediate assistance for nurses impacted by the pandemic.
- Recovery - Listening to nurses and increasing their strengths and resilience.
- Rebuilding - Evolving the practice of nursing to transform healthcare. To date, more than 4 20,000 nurses have participated in a Well-Being Initiative programs that address needs related to the relief and recovery component of the framework. While programs to support the well-being of individual nurses will be necessary for the foreseeable future, it is essential that creating structural and cultural transformation is prioritized. The Foundation is prioritizing addressing stigma following an assessment of survey data and literature resulting in an article in Nurse Leader^1. The Foundation’s Pulse on the Nation’s Nurses Survey Series focuses heavily on the mental health and well-being of nurses and recent findings highlight several instances where stigma was a concern for nurses when considering seeking mental health support. In the third Mental Health and Wellness Survey from August 2021^2 , even as over two-thirds of respondents reported feeling exhausted, overwhelmed, and frustrated, and three-in-four reported feeling stressed, many nurses were still resistant to using resources provided to them. Three percent said Employee Assistance Programs (EAPs) strengthened their well-being, and just 31 percent reported seeking professional mental health support. However, of the 68 percent of nurses who did not seek mental health support, only 45 percent reported not needing it. Twenty percent said that they lacked the time, and 16 percent felt they should be able to handle their own mental health. The cultural assumption that nurses need to just “deal with” the difficulties of the job and that if they need help, they potentially are not “cut out for nursing” is a form of stigma.^34 In the same mental health survey, respondents were asked about experiences of stigma. Nearly one- third experienced stigma somewhere – from themselves, with colleagues, friends, or family. Interestingly, while younger nurses, those 34 and under, were much more likely to have sought professional mental health support – nearly 45 percent had sought it, compared to 31 percent of all respondents – 51 percent still acknowledged experiencing stigma somewhere. These survey results; combined with available research and findings from focus groups, prompted the Foundation to bring together experts for the Summit to Address Mental Health Stigma in Nursing to create an action plan. (^1) https://www.nurseleader.com/article/S1541-4612(21)00231-7/fulltext (^2) https://www.nursingworld.org/practice-policy/work-environment/health-safety/disaster- preparedness/coronavirus/what-you-need-to-know/pulse-on-the-nations-nurses-covid- 19 - survey-series-mental- health-and-wellness-survey- 3 - september-2021/ (^3) https://journals.sagepub.com/doi/abs/10.1177/ (^4) https://www.nurseleader.com/article/S1541-4612(21)00231-7/fulltext
Appendix C
Summit to Address Mental Health Stigma in Nursing
February 16, 2022 & March 3, 2022
Attendees
▪ Robyn Begley, DNP, RN, NEA-BC, FAAN – Chief Executive Officer, American Organization of Nursing Leadership ▪ Derek Bell, MS, CWP – Director of Wellbeing & Joy of Practice, Ascension ▪ Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, CCTP – Director of Nursing Programs, American Nurses Association ▪ Michelle Buck, MS, APRN, CNS – APRN Senior Policy Advisor, National Council of State Boards of Nursing ▪ Allison Burfield Byler, RN, MSN, PhD – Senior Manager, Health Care Initiatives, NAMI ▪ Lisa DiBlasi Moorehead, EdD, MSN, RN, CENP, CJCP – Associate Nurse Executive, The Joint Commission ▪ Tari Dilks, DNP, APRN, PMHNP-BC, FAANP - Professor and Co-Coordinator of Graduate Nursing, McNeese State University ▪ Aaron Eagan, RN, MPH – Director, Community-Based Suicide Prevention, VHA Office of Mental Health and Suicide Prevention ▪ Corey Feist, JD, MBA – President & Co-Founder, Dr. Lorna Breen Heroes’ Foundation ▪ Trina Geyer, PhD, RN, NPD-BC, NEA-BC – Director, Nursing Leadership and Development, Emory Healthcare ▪ Esther Golda Lozano Otis, BSN, RN, IBCLC, CYT - Staff Resiliency Coordinator, Sentara Martha Jefferson Hospital ▪ Janie Heath, PhD, APRN-BC, FAAN – Dean and Warwick Professor of Nursing, University of Kentucky College of Nursing ▪ Stephen Hernandez, PhD, RN – Associate Professor, University of New Mexico College of Nursing ▪ Coretta Jenerette, PhD, RN, AOCN, CNE, ANEF, FAAN – Associate Dean for Diversity, Equity, and Inclusivity and Professor, University of South Carolina School of Nursing ▪ Kate Judge – Executive Director, American Nurses Foundation ▪ Allison Nordberg – Program Director, American Nurses Foundation ▪ AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN, FAAN – Vice President & Chief Nursing Officer, Einstein Medical Center Montgomery ▪ Mijung Park, PhD, MPH, RN – Associate Professor, Department of Family Health Care Nursing, University of California San Francisco ▪ Phyllis Quinlan, PhD, RN, NPD-BC – MFW Consultants ▪ Caesar Rangel, BSN, RN – Psychiatric Registered Nurse, Delta-T Group ▪ Cynda Rushton, PhD, MSN, RN, FAAN – Anne and George L. Bunting Professor of Clinical Ethics, Johns Hopkins University ▪ Tait Shanafelt, MD – Chief Wellness Officer, Stanford Medicine, Director, WellMD & WellPhD Center, Stanford University ▪ Britt Sinha, MBA, RD, SHRM-CP – Corporate Director, Benefits, Health & Wellbeing, NewYork- Presbyterian ▪ Pam Thompson, MS, RN, CENP, FAAN – Facilitator ▪ Yolanda Walsh – Program Administrator, American Nurses Foundation
APPENDIX D
SUMMIT SUMMARY
The purpose of the summit was to assist the Foundation in determining what direction and actions are needed to address the stigma associated with accessing support for mental well-being. To accomplish this, a group of 26 national leaders in mental health and well-being individuals (see Appendix A) met for two virtual sessions, each four hours long and a week apart. These individuals are national leaders in mental health and well-being. This group represented mental health practice, academia, advocates and allies for mental health/mental illness, and regulatory perspectives. These sessions were the formal kick- off to the Foundation’s commitment to removing the stigma associated with seeking help for mental well-being. The structure of the sessions is detailed in the following outline of activities. SESSION ONE: The session began with background presentations focusing on data about nurses’ current state of well- being, an overview of stigma, and examples of evidence-based programs that focus on mental health and well-being and included a component of addressing stigma. One notable response from one participant was this session was the first time they had participated or engaged in such a conversation with such a diverse group of professionals working on the issues of stigma. There was a sense that perhaps this group could identify actions to move the field forward. For the second half of the session, participants were placed in breakout rooms to discuss and decide 1) What would a desired state where stigma is addressed look like? 2) What in our current state prevents the desired state?, and 3) What steps (that we control) can we take to achieve the desired state? Themes emerged through the dialogue of maintaining a focus on a desired state. After this session, the Foundation staff and consultants organized the major themes and created a proposed description of the desired state being a “future state for clinical practice where culture is transformed and all stakeholders play a role in addressing the continuum of well-being, mental health, and mental illness to ensure the offering and asking for help is normalized, encouraged, and done so without stigma.” SESSION TWO: The group began by identifying the “aha” moment from the first session. One example was the new understanding that future work must focus on the continuum of mental health and well-being and that individuals can move across the continuum. The clarifying issue was that reaching nurses impacted by the stress of COVID-19 and other trauma was different from the issues of mental illness. The development and use of language will be critically important. The group was presented with the desired state which was adopted after the first summit session for the next steps in the process. Break out groups were given the following questions to identify next steps and high impact tactics to move toward the desired state. These questions included: 1) What is already being done that works? 2) What could we do with the resources we have? 3) What could be done with additional resources and where might we find those resources? And 4) What are the one or two most impactful action steps to pursue? The outcomes of the fourth breakout group were then prioritized by the participants after the session by way of electronic voting and ranking. The end results were five action items.
- Build a nurse-led alliance to convene, communicate, and collaborate on reducing stigma related to well-being and mental health.
- Create structural and regulatory changes that leverage existing systems to eliminate/reduce stigma.
- Build a culture across the profession (students through leaders) that is based on culturally appropriate, equitable, and inclusive education, tools, and resources to understand and respond to the stress continuum.
- Use an appreciative inquiry approach to create a resource compendium of programs that effectively reduce stigma.
- Create a recognition program to bring attention to and amplify the spread of individuals/organizations successfully addressing mental health stigma.
