By Gary Evans
The National Institute for Occupational Safety and Health (NIOSH) is making good on its promise to restore the battered medical workforce, which is threatening an exodus from the bedside after suffering years of moral injury, belligerent patients, and declining mental health.
“Survey data have indicated high levels of exhaustion and thoughts of self-harm among health workers,” Thomas Cunningham, PhD, a senior scientist at NIOSH, tells Hospital Employee Health. “Media reports have described cases of physicians and nurses who died by suicide, who were afraid to seek help as they feared doing so would jeopardize their licensure.”
A recently published survey of 20,000 nurses and physicians who work in Magnet hospitals — a nursing designation for a good place of employment — reported unsettling findings. “High burnout was common among hospital physicians (32%) and nurses (47%),” the authors noted.1
Overall, 32% of physicians said there were not enough nurses at their facility, while 54% of nurses said their work site was shorthanded. Physicians and nurses reported “having a poor work environment (20% and 34%, respectively), and lacked confidence in management (42% and 46%, respectively). Fewer than 10% of clinicians described their workplace as joyful.”1
Indeed, we are a far and painful cry from joy, so much so that last year NIOSH launched Impact Wellbeing to address the mental health of healthcare workers.2 The ongoing program is providing tools and advancing research to address the healthcare worker mental health crisis.
These issues are not new. They preceded the pandemic but were inestimably intensified by it, as healthcare workers saw patients dying while fearing for their own lives and worried about exposing their families at home. (For more information, see the related story in the December 2023 issue of Hospital Employee Health.)
New Research Published
The latest iteration of the NIOSH campaign is a special supplement issue of the American Journal of Public Health with 15 articles focusing on healthcare worker mental health. This step moves the campaign beyond the “raise awareness” stage with several articles proposing solutions that healthcare administrators should address to attack the problem.
“There is a need for more investment in primary prevention of poor mental health outcomes at the organizational and systems levels,” Cunningham says. “This supplement can serve as a critical resource in supporting organizational change.”
In the introduction to the supplement, Cunningham and co-authors said NIOSH is trying to “rapidly communicate the latest science guiding the development of responsive mental health and well-being resources for health workers. There is a growing body of science supporting the improvement of workplace mental health through healthy work design and systems-level well-being efforts within organizations.”3
For example, one study in the supplement reviewed how 44 organizations were using federal grants they received under the Dr. Lorna Breen Health Care Provider Protection Act. Named for a New York City emergency physician who died by suicide after developing COVID-19 in 2020, the funds are issued in the form of grants to hospitals and other healthcare settings to address the mental health needs of their employees. The various grant recipients were looking at the mental health of their workplace from a variety of perspectives, including substance use screening and assistance, stress and trauma services, and resilience training.
“During an interview, one program director shared that it was the suicide of a former colleague that led her to engage in well-being work,” the authors reported. “When asked what she hopes to accomplish with this grant, she shared, ‘Nobody else should die because of this.’”4
Yet, many nurses and physicians may avoid critically needed mental health counseling for fear of being branded by some diagnosis or documentation of therapy. In what amounts to a bitter paradox, those stable enough to seek treatment and improve their day-to-day mental health balk at this barrier and might continue to deteriorate. Considering the old engineering adage that every system is perfectly designed to produce the results it yields, medical licensing systems seem perversely wired to drive mental health problems underground.
However, another study in the collection reported there has been success in removing stigmatizing language from license exams in Virginia and ongoing efforts to do so nationwide.
“The Federation of State Medical Boards, the American Medical Association, and the American Psychiatric Association recommend against overly broad and invasive mental health questions,” the authors emphasized. “Such questions on licensing and credentialing applications are shown to be ineffective at protecting the public and may violate the Americans with Disabilities Act. Moreover, these disclosures result in a pervasive and well-documented stigma that prevents clinicians from seeking mental healthcare.”5
Casting a Wide Net
Some of the tactics described in the articles include expanding screening and mental health services through in-person and virtual offerings and ensuring worker privacy to encourage uptake. Stress and trauma services included training in the psychological effects of stress, mental health first aid, peer-to-peer support systems, and crisis response teams.
Given the scope of the problem, the supplement cast a wide net, extending to the psychological pressures experienced by caregivers of family or friends in the community. In general, “caregiving distress” is reported by those helping people in the community with dementia or long-term chronic conditions. These effects might be more frequent and severe in immigrants, who may lack community support and face barriers interacting with the healthcare system.
“Caregivers and their distinct circumstances should also be considered further in the healthcare delivery context,” the authors recommended. “For instance, caregivers are often tasked with communicating with providers and navigating health and social services.”6
Some hospitals are using so-called “Schwartz rounds,” which generally involve a monthly meeting on site to allow healthcare workers to share their personal stories around some traumatic theme. Clinicians, social workers, and chaplains briefly present the topic and invite healthcare workers in the audience to share their feelings about the case or issue in question.
Another study in the supplement found positive results by using cognitive behavioral therapy (CBT) to help workers overcome trauma and recenter themselves. According to the American Psychological Association, two of the basic tenets of CBT are that mental health problems are based in part on negative or faulty thinking and that they are expressed in learned and perpetuating behavior. An essential element is to break this cycle by changing the negative thinking patterns and the subsequent behavior by “learning to recognize one’s distortions in thinking that are creating problems, and then to re-evaluate them in light of reality.”7
Other areas of focus include:
- gaining a better understanding of the behavior and motivation of others;
- learning to develop a greater sense of confidence in one’s abilities;
- facing fears instead of avoiding them;
- using role-playing to prepare for potentially problematic interactions with others;
- learning to calm one’s mind and relax one’s body.
“Our results demonstrate high commitment to care, as evidenced by low dropout and no-show rates,” the authors reported. “After 14 visits, HCW patients evidenced significant decreases in reported symptoms of depression, suicidality, anxiety, PTSD, and alcohol use and increased psychological well-being. These findings suggest that immediately accessible short-term CBT is effective in this population, with effect sizes comparable to those found in randomized controlled trials.”8
Individual efforts to foster personal resilience through mindfulness training, yoga, and the like often are dismissed — perhaps a bit unfairly — as a way for the powers that be to avoid addressing the larger healthcare system problems that create stress and erode mental health.
“Research suggests the way that work is organized and managed can contribute significantly to worker mental health and well-being,” Cunningham tells HEH. “However, the majority of efforts to improve worker mental health have relied on individually focused intervention approaches. As suggested across several articles in this collection, there is a clear need for leaders in the health sector to take more of a primary prevention approach to supporting worker mental health and well-being — to implement interventions at the organizational and systems levels to affect long-term, sustainable improvements.”
For example, another study in the supplement underscores how “healthcare leaders are challenged by financial and regulatory pressures, rapidly developing technologies, workforce shortages, high demand for services, and an aging population with complex chronic diseases.”9
Yet ultimately, the physical organization and design of work falls within their bailiwick, tying them to the health of frontline staff through the appointment and management of supervisors. This delegation of managerial duties seems to be able to make or break morale.
“Cross-sectional and longitudinal studies with thousands of health workers demonstrate that the leadership behaviors of immediate supervisors are associated with well-being, safety climate, teamwork climate, burnout, job satisfaction, and intent to leave,” the authors noted. “This suggests that leadership development is a possible primary prevention approach to mitigate health worker stress and optimize work environments.”
For this process to thrive, top management must be engaged and willing to provide the support and resources for leadership development. “If leaders are not empowered, trained, and supported, it is unlikely that any [substantive improvements] will be realized,” the authors concluded.
On the other hand, if support for leadership development is backed up and funded from the top down, a different picture emerges.
“Healthcare administrators are well-positioned to implement needed operational and cultural changes,” Cunningham says. “They are also able to reach a large population of health workers across all levels, departments, and job titles.”
REFERENCES
- Aiken LH, Lasater KB, Sloane DM, et al. Physician and nurse well-being and preferred interventions to address burnout in hospital practice: Factors associated with turnover, outcomes, and patient safety. JAMA Health Forum 2023;4:e231809.
- National Institute for Occupational Safety and Health. Impact Wellbeing. Last reviewed Jan. 9, 2024. https://www.cdc.gov/niosh/impa...
- Cunningham TR, Chosewood LC, Garcia Davis J, Rochel de Camargo K. Health worker mental health: Addressing the current crisis and building a sustainable future. Am J Public Health 2024;114:132-133.
- Chen C, Strasser J, Dent R, et al. How can health care organizations address burnout? A description of the Dr. Lorna Breen Act grantees. Am J Public Health 2024;114: 148-151.
- Simmons S, Feist JC, Segres A. Changing licensing and credentialing applications to promote health workers’ mental health, Virginia, December 2022-September 2023. Am J Public Health 2024;114:152-155.
- Zhou S, Ogunjesa BA, Raj M. Mental health outcomes of immigrant- and US-born caregivers: California health interview survey, 2019-2020. Am J Public Health 2024;114:189-199.
- American Psychological Association. What is Cognitive Behavioral Therapy? Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder. 2017. https://www.apa.org/ptsd-guide...
- Doukas AM, Sharma V, DePierro JM, et al. Effectiveness of CBT-informed behavioral health interventions for health care workers in a specialized clinical service during the COVID-19 pandemic. Am J Public Health 2024;114:167-170.
- Schwatka NV, Burden M, Dyrbye LN. An organizational leadership development approach to support health worker mental health. Am J Public Health 2024;114:142-147.
The National Institute for Occupational Safety and Health is making good on its promise to restore the battered medical workforce, which is threatening an exodus from the bedside after suffering years of moral injury, belligerent patients, and declining mental health.
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