Virginia is going “all in” statewide with an effort to improve and protect the mental and emotional well-being of healthcare workers by removing invasive questions in licensing reviews so they can seek counseling without fear of stigma and job loss.
Jointly supporting the initiative are the Virginia Hospital and Healthcare Association, the Virginia Nurses Association, and the Medical Society of Virginia. The statewide effort comes out of partnership with All In: WellBeing First for Healthcare, and the Dr. Lorna Breen Heroes’ Foundation.
“The two goals are to eliminate barriers to mental health access that apply to licensed healthcare workers, and to scale solutions to professional well-being across the health systems and communities,” says Corey Feist, JD, co-founder of All In and president of the Dr. Lorna Breen Heroes’ Foundation.
Last year, Feist and colleagues were instrumental in lobbying for a federal bill to provide grants to facilities that pursue credentialing changes and provide training for preventing burnout and suicide. Virginia is the first state to embrace the All In initiative, but Feist is in discussions with several other states, including Arizona, Delaware, Georgia, Maryland, Massachusetts, and North Carolina.
“By working together and changing licensing questions at the state level, credentialing questions at the hospital level, and then going through the rest of our curriculum, we believe that Virginia will become a model for the rest of the country to follow,” Feist says.
The Flaw in the System
The pandemic exposed a huge flaw in much of the medical profession and nursing: Traumatized healthcare workers largely avoided therapy and could not fully process the stress, burnout, and moral injury they suffered, particularly during the early onslaught of SARS-CoV-2.
Imagine holding a smartphone to the face of a dying patient so he or she can say goodbye to their family. Some patients who refused the vaccines begged for them as they lay dying. “It’s too late to use the vaccine,” they were told. Defiant to the end, another COVID-19 patient told his physician, “I would rather die than take the vaccine.” He got his wish. Bearing witness to such traumatizing events were healthcare workers, who already experienced higher burnout and suicide rates than the public.
“When clinicians are afraid to seek the mental healthcare they need, they may find themselves unable to work due to burnout or behavioral health disorders,” Feist explains. “Some, like my sister-in-law Lorna, may turn to suicide.”
On April 26, 2020, the singular tragedy of suicide brought down the emergency physician — who by all accounts was whip-smart and outgoing socially yet demanded excellence of herself and colleagues while on duty.1
Lorna Breen, MD, a classic overachiever who exuded confidence, was helming the NewYork-Presbyterian Allen Hospital emergency department in New York City when wave after wave of COVID-19 patients arrived for treatment in March 2020. The city was hit with one of the first huge outbreaks of COVID-19, at one point sending 800 patients a day to the morgue. Breen’s ED was at triple capacity even as ambulances waited outside. Some of those who died waiting for treatment were put in a radiology room.
Breen and her colleagues were becoming overwhelmed as she worked 15-hour days, contracting COVID-19 herself in mid-March. Breen quarantined at home, still trying to fix anything she could over the phone. Feeling like she was letting down her colleagues, Breen returned to work after a couple of weeks, but there is some question whether she had completely recovered from COVID-19, which is now known to produce lingering symptoms of fatigue and brain fog as well as a panoply of other symptoms.1
“Lorna was always tough and smart and very active,” said Jennifer Breen Feist, JD, who formed the Heroes’ Foundation in her sister’s name. “She always wanted to be an emergency physician in Manhattan. For the first 49 years and six months of her life, she showed no signs of depression or anxiety. That changed after she got COVID.”2
This was compounded by the stigma of seeking mental help, which Jennifer Feist and husband Corey Feist are trying to remove in states like Virginia. Virginia hospitals and health systems joining the voluntary All In initiative must commit to:
- Use the All In Licensure and Credentialing Toolkit3 to eliminate barriers to mental health access. The hospitals and health systems that audit and change language on credentialing applications will be recognized as All In for prioritizing clinician well-being and recognized as a WellBeing First Champion.
- Publicly declare an organizational commitment to workforce well-being and invest in and cultivate an environment where health workers feel valued and supported. “The American Medical Association has found that less than half of the healthcare workers in the country felt valued and supported by their employer,” Corey Feist explains. “The AMA ties feeling of value to individual resilience — you’re more resilient if you feel valued and supported. We have learned through working with hospitals and health workers across the country that there’s a big gap between what healthcare leaders are doing and what healthcare workers are observing and experiencing. That visible commitment is key.”
- Define at least one organizational goal to improve workforce well-being drawn from the National Academy of Medicine’s National Plan for Health Workforce Well-Being.
- Use initiative programming and resources offered and contribute to the community of shared learning and improvement.
- Identify and remove low-value work, such as reducing electronic health records clicks for common workflows and minimizing inbox notifications. “One of the biggest drivers of healthcare worker burnout is administrative burden,” Corey Feist says. “About 70% of a physician’s time and 50% of a nurse’s time is spent in administrative processes, not in care. There are a number of ways that hospital systems can remove that administrative burden completely. But we got to get that off them.”
- Appoint a “Well-Being Executive” to lead clinician well-being efforts.
- Go beyond employee assistance programs (EAPs) to ensure adequate mental healthcare. This includes access to quality mental health counseling, a peer-support program, and psychological first aid training.
Find the “Trusted Other”
One hospital that joined the initiative and has a head start in this kind of work is the Wisdom and Wellbeing Program at UVA Health Charlottesville. Hospital Employee Health spoke with Richard Westphal, PhD, RN, PMHCNS-BC, PMHNP-BC, FAAN, co-director of the program, in the following interview, which has been lightly edited for length and clarity.
HEH: Does the Wisdom and Wellbeing Program address this issue of medical licensing as a barrier to mental health therapy?
Westphal: Yes. That’s one of the concerns that we have. We have three pillars of activities. The first pillar is what we call “growing the green” and building resilience capacities — it’s wisdom practices. The second pillar is addressing unnecessary stressors within the work environment. The third pillar is when a colleague has an occupational stress injury, how do we connect them with services? That would also include how [to] help a colleague who has depression, anxiety, and underlying mental disorder. Under that umbrella, any barrier, be it from stigma or policies or procedures, would be fair game for the Wisdom and Wellbeing Program to engage in a dialogue.
HEH: The program was launched in 2016. Did you get into this field early compared to some hospitals?
Westphal: Our team was really early and on board with talking with our credentialing committee and asking, “What are the questions about mental capacity, and are they stigmatizing?” Well, they were. We said, “Let’s work on changing that.” The UVA credentialing team rapidly agreed and said, “That’s not a fair question, let’s revise that.” Then they did so on the credentialing form. Now, we are finding what I call second- and third-order policies that would have echoes of that [stigmatizing] credentialing language embedded in them. As we’re reviewing policies, we’re looking for statements within personnel policies that would create a barrier to seeking help.
HEH: You use both a team approach and peer support concepts. Could you speak a little to each of those and how they work together to keep your employees healthy?
Westphal: What we know about first responder culture — and that includes healthcare workers, fire, EMS, military members, law enforcement — is that this is a group of professionals that focus on the needs of other people. That means they rarely focus on their own needs, and so just saying, “remember to take care of yourself” doesn’t resonate with this culture. It really is about peer support and team support. We teach the use of using a stress continuum — green, yellow, orange, and red zones. Green being your resilience and wisdom practices, and yellow zone tactics for addressing stress reactions in the moment.
HEH: The Wisdom and Wellbeing Program website notes orange represents injured or impaired, and red represents mental disorders, including depression and anxiety.
Westphal: If you think of this, it doesn’t matter what your job is, it doesn’t matter what your role is. These are universal human needs. We find that by using the stress continuum, we can reduce a sense of hierarchy between physicians and nurses. It creates a shared space that doesn’t contain the same power dynamic. For example, if I’m a nurse working in a clinic with a physician and I say, “Dr. Smith, you and I have been working together for a while. You’re looking a little orange, and I don’t mean jaundice. What is going on?” That’s how colleagues will talk with each other. Our approach absolutely is for the entire health workforce, independent of professional standing, licensure, or role within the organization.
HEH: What about the peer support aspect?
Westphal: When we think about employee assistance and well-being in an institution like a large academic medical center, there are organizational entities that have a primary mission, like an EAP or a clinician wellness program, which tends to focus only on physicians. We have more than 14 different subgroups that intersect with well-being — chaplains, population health, the Compassionate Care Initiative in UVA’s School of Nursing, and other programs within the school of medicine and the university.
We have a well-being collaborative. We invite them into the space. The reason why we do this is that this is part of the safety net for the employee. When employees are distressed or they’re trying to help a peer who is distressed, they are going to go to what’s called a “trusted other.” For some employees, going to the EAP program is a trusted other. For many employees, that’s the last thing they’re going to do. What’s really important here is that when someone is in distress, can we break the code of silence? Can we get them connected with at least one supportive resource through the Wisdom and Wellbeing program and the collaborative?
We try to make sure all of these different entities are aware of each other. If I’m a chaplain and I’m having a dialogue with a team member who’s really distressed, I can say, “I’m really glad you trust me enough to talk about this. I’ve got to let you know, there’s someone else that I think can help you even more, and that’s Sally in the EAP. I’ve talked with her. She’s really good.” Notice what happens in this first responder culture — be it healthcare, military, fire — is that often, we rely upon the opinion of a peer to say, “This is a trusted resource. As a friend, I’ll go there with you.” When we developed Stress First Aid for the Department of the Navy, that was a key piece of it. It was about a peer knowing a trusted resource, not that you went to the mental health clinic. When we talk about team members and peers, it’s the entire workforce. [For example], the person who’s doing valet parking at the front of the medical center is a peer to the CEO. They have different roles, but we are all peers in this endeavor.
HEH: Since your Wisdom and Wellness program was created before COVID-19 emerged, can you comment on how well your system worked through the stress during the early days of the pandemic?
Westphal: We were lucky in that we had this framework and we had been working to get buy-in and dialogue going. But there was kind of a passive resistance — you know, “Work is stressful, but that’s nothing new.” COVID comes along and strips bare the illusion that the workforce is OK. Now, we have a mechanism and a process for at least talking about the work we do and the challenges that we have. Some units invited us in, took the information in, and started using it. Other units would call for help, and they’d say, “Come do that thing you do” We’d come in, start the process, but you know, this is about culture change. For whatever reason, they weren’t ready to change their culture or their narrative. They were looking for someone to come in and fix them, or fix the system, rather than empower them to support each other.
REFERENCES
- Dr. Lorna Breen Heroes’ Foundation. Dr. Lorna Breen: Sister, daughter, friend, physician. 2023.
- Evans G. Emergency physicians are suffering as COVID-19 resurges. Hospital Employee Health. Dec. 1, 2020.
- All In: WellBeing First for Healthcare Workers. Remove Intrusive Mental Health Questions from Licensure and Credentialing Applications: A Toolkit to Audit, Change, and Communicate. 2022.
Virginia is going “all in” statewide with an effort to improve and protect the mental and emotional well-being of healthcare workers by removing invasive questions in licensing reviews so they can seek counseling without fear of stigma and job loss.
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