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Obstacles to Mental Health Care

Depression, anxiety and burnout among nurses skyrocketed during the pandemic. Getting help is not always so easy.

The Fall of 2020 wasn’t the first time I’d sought professional mental health support, but it was undoubtedly the most urgent. As the pandemic surged through our nation and the ICU where I worked became overwhelmed with COVID-19 patients, anxiety, insomnia and hopelessness were my dark shadows. I was burned out and needed help immediately.

Though I was initially optimistic about finding a qualified therapist, my confidence sank as I encountered one hurdle after another: Their schedules were full, the waitlists were long or their skill sets didn’t match my needs (trauma-informed, competent in treating moral injury).

It took months and a few unsuccessful sessions before I found a therapist who met most of my criteria. Unfortunately, she was not an “in-network” provider under my insurance plan, and the out-of-pocket cost was prohibitive.

My experience isn’t unique.

Nurses everywhere have encountered similar frustration and disappointment while seeking relief from the emotional and physical exhaustion brought on by working through an international crisis. Rates of anxiety and depression in the U.S. have tripled over the last two years.

By some estimates, up to 40 percent of healthcare professionals will experience post-traumatic stress following the pandemic. Severe burnout among nurses has more than doubled.

More than ever, nurses need access to comprehensive, effective mental health care. Unfortunately, this seems harder than ever to obtain, and even when services are available, they’re not necessarily used by those who most urgently need them.

Common Obstacles

There are many factors that can keep nurses from accessing the help they need. Here are some of the most common:

Stigma

The stigmatization of mental health disorders (including self-stigmatization) is a powerful deterrent to seeking help, particularly in nursing. Some of us buy into the misconception that self-care takes away from our ability to care for others. We avoid or deny our issues, and our shame and embarrassment prevent us from admitting that we can’t do it alone.

The truth is that nurses are not immune to mental illness, substance use disorder or suicidal ideation. Thanks to the pandemic, we are more likely than the general population to suffer these conditions.

Destigmatization demands that we normalize conversations about mental health, advocate for ourselves and share our collective experience of stress and the need for support.

Managers and supervisors can also help to decrease stigma by educating staff and by promoting and participating in self-care. When leaders role-model adaptive coping skills, it sends a powerful message to employees: that mental wellness is of utmost import, and no one is above needing help.

Fear of losing a job or licensure

Nurses often avoid acknowledging their problems or seeking help out of fear of suffering professional consequences.

For example, while most healthcare organizations offer some form of an employee assistance program (EAP) that provides free access to counseling, legal assistance and financial advice, among other benefits, research suggests that fewer than 10 percent of employees across the U.S. use these programs, often for fear that sensitive, confidential information may be disclosed to their employers.

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In reality, EAPs are subject to strict confidentiality laws. Employers are not aware of which specific employees contact the program, nor can they obtain information discussed in sessions between an employee and a service provider.

(The main exception is when an employee’s use of an EAP is through a mandated referral by management or H.R. In those cases, the nurse would be asked to sign a release allowing the employer to receive feedback regarding the nurse’s participation in or completion of assigned counseling.)

Similar concerns apply to nurses’ use of health insurance. Some insurers require a mental health diagnosis before they will cover treatment, and the thought of the damage such a label could do to a staff member’s reputation or career is terrifying, even if it’s only hypothetical.

Please know that licensed mental health providers are obligated to uphold client confidentiality, and mental health disorders are often covered by federal and state laws prohibiting discrimination based on medical condition or disability. There are exceptions if patient safety is at risk, but if that’s the case, receiving adequate help for yourself is all the more urgent.

Other confidential mental health services are available. At the UC San Diego HEAR program (medschool.ucsd.edu/som/hear), healthcare professionals can complete anonymous screenings for burnout, depression, anxiety and suicidal ideation, and then receive feedback and follow-up suggestions from trained counselors.

Cost and availability

Locating a mental health provider who’s available and affordable can be like finding a needle in a haystack.

In California, the median rate for one session with a licensed therapist is $120. With many in-network providers fully booked, nurses might pay anywhere from 50 to 100 percent of the full hourly rate to receive treatment.

Fortunately, in the past two years, there’s been a considerable increase in the availability of free or discounted mental health services for healthcare professionals.

One example is Heroes Health Initiative (heroeshealth.unc.edu), a collaborative project of the University of North Carolina at Chapel Hill that advertises a 24-hour hotline, reduced-cost teletherapy and links to coping skills courses via web and mobile apps.

You can also improve your chances of finding more affordable and immediate care by looking outside the box of typical professionals and also considering spiritual care advisors, peer support groups, health and wellness or life coaches, and mindfulness courses as possibilities.

As an adjunct to individual counseling sessions, I frequently attend a meditation group and an online meeting for healthcare and allied professionals.

Just keep in mind that programs like these may have different confidentiality rules than would apply to a licensed psychologist or psychiatrist. Be sure to read the fine print.

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Lack of awareness

Despite our nursing expertise, not all of us are familiar with mental health disorders, and even if we are, we may neglect to apply what we know to our own circumstances.

Unmanageable stress may manifest as persistent anxiety and depression, but those aren’t the only indications of an imminent crisis. Chronic headaches, IBS and musculoskeletal pain can also be physical barometers of mental or emotional distress.

Pay attention to your own feelings and be proactive about seeking the help you need, before you reach the breaking point.

In some cases, nurses who need help may be unaware of the resources offered by their employers. Every healthcare facility should make sure that the contact information for supportive resources is visible and accessible. Managers should communicate that information to staff both verbally and in written form.

Leadership should also take steps to include mental health education in new employee orientation, residency courses and annual skills training for clinicians. Mindfulness-based stress reduction (MBSR), resiliency training and substance use disorder courses should be offered regularly and taught sensitively.

I’m a clinical instructor, and I always discuss these issues with students early in their education. I tell them that a high-quality therapist is as much of a career essential for nurses as scrubs and a stethoscope.

Building a Supportive Organization

Supporting nurses’ emotional and psychological wellbeing is a collaborative process. Authentic, approachable leadership is an important factor in cultivating a culture of wellness.

For example, Hannah, an assistant nurse manager in a community hospital, has an open-door policy; her staff knows they are welcome to stop in her office to cry, laugh or vent their frustrations.

If you’re in management, you should also make time to highlight positive moments during periods of hardship and uncertainty. Celebrate the successes of individuals, your department and your organization.

Simple, constructive changes to the environment can have a valuable impact. My ICU department established a “Zen-Den”: a small room, free from work-related paraphernalia, where staff can sit, meditate, breathe and relax.

Another strategy for organizational success is to appoint a chief wellness officer (CWO) who supports all employees by evaluating and promoting organizational wellbeing through individual and system-wide interventions.

Institutions can also join ANA’s Healthy Nurse Healthy Nation initiative (www.healthynursehealthynation.org), which assists hospitals and nurses in health promotion.

Individually, we can each commit to kindness toward self and others, acting from a place of compassion and empathy — and remembering that caring for ourselves is an indicator of our capacity to care for others, not a hindrance.

A Multifaceted Approach

It’s been almost two years since I reached out for professional help with my burnout. After deciding the out-of-network therapist wasn’t affordable, I placed myself on the waitlists of two practitioners covered by my insurance. Until an opening became available, I took advantage of my facility’s EAP-sponsored three free counseling sessions.

My mental health has significantly improved with expert guidance and fresh coping tools, and the foreboding specter of emotional distress has faded into the past. I can only imagine what the consequences might have been if I had continued to work without seeking the support I so desperately needed.

Our approach to the challenge of mental health in the workplace needs to be multifaceted. Both individual actions and systemic changes are necessary to make wellness an organizational value. By increasing awareness and education, eradicating stigma and adopting innovative strategies, we can eliminate the barriers to accessing mental health care.

It’s a win-win scenario: When staff morale and engagement improve, patient care outcomes do as well.


TIFFANY SWEDEEN, RN, MSN, CPRC/CPC, works in critical care and as a clinical instructor. Follow her on Instagram @scrubbedcleanrn or at www.recoverandrise.com.


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