Nurses' perceptions of barriers to accessing mental health care

A HEALTHY WORKFORCE is essential for safe, compassionate patient care. However, nurses are experiencing a mental health crisis, with unprecedented rates of burnout and poor mental health contributing to workforce shortages and impacting patients' access to timely, quality care.1 Nurses navigate unique physical, emotional, and ethical challenges daily, including: long, irregular hours and unsafe, difficult work environments; routine exposure to suffering and emotionally difficult situations; resource shortages and high clinical demands; payment models and technologies that complicate patient care delivery; and policies that interfere with clinical decision-making with patients. Stigmatizing policies and practices often discourage nurses from seeking mental health care, based on the misguided belief that identifying nurses who have been diagnosed or treated with a mental health condition protects patient safety. But the reality is starkly different: when nurses fear seeking help because of privacy concerns, the quality of care declines, poor mental health and burnout intensify, workforce shortages grow, and lives are lost. UNDERSTANDING NURSES' PERCEPTIONS More than 2000 nurse practitioners (NPs), physician assistants, physicians, and registered nurses (RNs) participated in a survey that informed a new research report, Clinician Perceptions of Barriers to Access Mental Health Care, to understand individual, structural, and cultural barriers that prevent clinicians from seeking mental health care.2 Specifically for NPs and RNs, the survey results included the following. Structural barriers to mental health care access. The cost of mental health services without insurance and lack of schedule flexibility created the greatest logistical barriers to accessing mental health care for NPs and RNs. Female RNs and those under age 40 were significantly more likely to cite schedule barriers to accessing mental health care than their male and older counterparts. For example, one oncology nurse shared, “As a night shift nurse, getting help at a time that doesn't cause me to be even more sleep deprived than I already am [is a barrier]. Also scheduling issues are barriers. I don't work the same nights 2 weeks in a row and often don't get my work schedule more than 2 weeks in advance, which makes planning for appointments difficult.” Institutional stigma and perceived discrimination. One of the barriers that may limit nurses' ability to access mental health care is the real or perceived impact on their professional license or ability to get credentialed and/or hired to practice in certain health systems, hospitals, clinics, and other settings. This fear arises because many of these applications ask broad questions about clinicians' past mental health history without specifying whether the clinician has a current, unmanaged condition or symptoms that would impair their ability to practice in a competent, ethical, and professional manner. In fact, more than 40% of NPs and RNs expressed concerns about impacts on their jobs/credentials/privileges to practice. A primary care nurse shared, “I don't seek mental health care because I often have to apply for a nursing license in a non-compact state. There are often questions about past or current treatment for mental health issues.” Internal and external attitudes and judgment. Nurses also reported personal and interpersonal attitudes and judgment that create cultural barriers to mental health care access and increase privacy concerns. One in 20 NPs and RNs said they would have concerns about a colleague's ability to practice in a competent, ethical, and professional manner if they learned that colleague had accessed mental health care. However, the overwhelming majority of NPs and RNs (95%) are neutral or positive about their colleagues accessing mental health care. An OB/GYN nurse shared, “Feeling like everyone else can handle the daily stresses of inpatient care just fine, and I'm the one who stresses the most. I have a lot of anxiety leaving work, usually feeling like I've forgotten something, even when nothing is brought up at all in a later shift. I do hold on to memories of many bad outcomes patients had. But all that to say, I look around and think, ‘Why would I need to look for help when everyone else seems to be fine?’”FIGURE 1:: Factors that create barriers to seeking mental health careELIMINATE SYSTEMIC CULTURAL BARRIERS TO MENTAL HEALTH CARE FOR NURSES Changing systems and culture can be complex, but we believe that improving nurses' access to mental health care without fear of bias, judgment, or discrimination is both necessary and possible. There are evidence-based, evidence-informed, and emerging resources that leaders, employers, policymakers, and other decision-makers can use to help remove the structural and cultural barriers to accessing mental health care. Actions and approaches for eliminating these barriers include but aren't limited to the following. Ensure accessible and affordable mental health care. Health care is a 24/7 environment, and standard business hours often don't work for health workers. Mental health care must be available during off-hours and weekends, or employers must provide unpenalized time off for care. Mental health screenings and treatment should be free, affordable, or covered by insurance. Commit to equal privacy in mental health care. Nurses' mental health diagnoses or treatments must remain private unless disclosure is necessary to protect patient or public safety or to prevent harm to others. Licensure bodies, credentialing organizations, and liability carriers should only request disclosure of current impairment. Past mental health care must also be protected from discovery in malpractice or other legal cases unless required to ensure patient safety. Additionally, health employers must provide or contract with health plans that include expanded insurance networks or telehealth options, ensuring health workers aren't forced to seek care within their own organizations. Guarantee confidential peer support. Nurses face unique stressors that impact their mental health. The daily realities of health care—unexpected patient outcomes, constant exposure to suffering, and high-pressure environments—can deeply affect mental health and well-being. Nurses must have access to confidential peer support programs and trained supporters to process these challenges safely. Peer support programs bridge a crucial gap, offering something unique: the ability to talk with colleagues who've walked the same path. These programs complement professional mental health services by providing immediate, accessible support from peers who understand the realities of clinical practice firsthand. Encourage education and training on mental health and well-being. Continuing education and certification for nurses must include evidence-based training on mental health care and professional well-being. Employers should also provide best-practice resources to support ongoing education on available mental health resources. Undergraduate, graduate, and postgraduate training programs must prepare nurses to manage the stressors of patient care, recognize when stress poses risks to mental health, and know how to access health worker–specific mental health resources. Strengthen access to confidential professional health program support. Almost every state has a Federation of State Physician Health Programs (FSPHP)-recognized Professional or Physicians Health Program (PHP).3 These programs provide confidential assessment, referral to treatment, resources, and monitoring for health care professionals and those in training when there's a concern that a health condition may be negatively affecting their ability to provide safe, effective care. As long as no patient harm occurred, nurses must be offered the option to participate in a PHP as an alternative to negative employment, credentialing, or regulatory actions. PHPs must be well funded and properly staffed to fulfill their mission of improving the health of the health care community and protecting patient safety. PHPs should be run by knowledgeable professionals and follow supportive best practices, including choices of approved evaluation and treatment providers, processes for appeal or reconsideration of PHP recommendations, and opportunities for participants to get a second opinion when there are disagreements about diagnosis or treatment. Advance a supportive pathway for reentry. Nurses who may have been unable to practice because of a health condition must be offered a transparent, structured, and reasonable reentry process that balances nurses' needs while maintaining patient safety. PHPs, health care regulators, insurers, employers, and credentialing bodies all must have a role and collaborate in this reentry process. Nurses' treatment and care during their pathway for reentry should be affordable or financial assistance and support should be made available.FIGURE 2:: Attitudes toward colleagues who have accessed mental health careFRAMEWORK FOR POSITIVE PRACTICE ENVIRONMENTS The American Nurses Credentialing Center's Pathway to Excellence Framework for Creating Positive Practice Environments fosters organizational cultures that prioritize nurse well-being and raise awareness of mental health issues prevalent among nurses. Nurses are given a voice; safeguarded from physical, psychological, and compassion fatigue; and staff well-being is at the forefront of the organizational strategic plan—elements that result in a healthy, engaged, and resilient workforce. Support strategies are also in place to address the well-being needs of senior nursing leaders and nurse managers, who play a critical role in supporting their teams.4 The evidence-based framework is grounded in six key pillars: shared decision-making, leadership, safety, quality, well-being, and professional development. The framework addresses common barriers to accessing mental health care by promoting strategies such as: organizational approaches to compassion fatigue, real-time support for staff involved in adverse events, a culture of psychological safety for self-reporting errors, flexible scheduling to support well-being, mental health awareness initiatives, access to mental health services, and evidence-based practices to enhance well-being during work hours. REMOVING BARRIERS BENEFITS ALL Many nurses who seek help receive effective and potentially lifesaving mental health care. This care may come in the form of peer support, counseling, therapy, medication or a myriad of other modalities that help people process difficult experiences, build skills, create community, or manage a mental health condition. When nurses are afraid to seek mental health care, they can suffer, and so can the people around them, including patients and team members. Barriers to mental health care for nurses, whether cultural or structural, can have widespread implications that affect cultures of safety, quality of care, staff retention, system resilience, and more. By working together, we can build a system that prioritizes mental health for those who care for us, ensuring nurses and all health workers can access mental health care without fear of repercussions.