Who Cares for the Caregivers? The Push for Laws to Protect Nurses’ Mental Health

The alarm blares at 5:00 AM, and before the coffee kicks in, you step onto the hospital floor. Chaos is in full swing — you’re short-staffed again, with twice as many patients as possible. A patient in room 406 is crashing, alarm bells shriek, and is that another patient shouting for meds across the hall. Family members need updates, a doctor has multiple orders for you, and two admits are in the hallway. More than 67% of nurses reported feeling depressed or anxious, and two thirds said they were not receiving mental health support.

Nurses cite lack of time and financial resources among the reasons for not seeking treatment, but fears about losing their jobs and the impact on their nursing licenses were also top issues.

Registered nurses (RN) and advanced practice RN (APRNs) can be required to answer invasive questions about their mental health as part of their state licensure and advanced credentialing applications. The questions can be stigmatizing and could require nurses to submit letters from their healthcare providers addressing their mental health status.

“Nurses aren’t seeking help…because they are so fearful about losing their licensure,” said Bernadette Mazurek Melnyk, PhD, APRN–certified nurse practitioner, study author and professor emeritus at The Ohio State University, Columbus, Ohio. “We need to be putting real emphasis on getting help for the nurses who need help.”

Advocating for Change

Staffing shortages, high patient loads, poor leadership, and increased workplace violence have contributed to high rates of burnout in the nursing workforce. Nurses also deal with high rates of compassion fatigue, poor work-life balance, and higher-than-average suicide rates.

Nursing licensing boards in 30 states ask questions about mental illness on their applications, including 22 boards that ask about past mental health diagnoses and require predictions of future impairment.

“The workforce in healthcare has got the worst mental health, but they’re also uniquely penalized…by this same system,” said Corey Feist, JD, MBA, co-founder, and CEO of the Dr Lorna Breen Heroes’ Foundation. “There are very specific actions that licensing boards and others need to take to make explicit that the workforce is valued, seen, heard, and cared about.”

There is a movement to urge licensing and credentialing organizations to remove invasive and stigmatizing mental health questions from their applications. The National Council of State Boards of Nursing is working on national recommendations for the removal of invasive mental health questions from nursing licensure applications, according to Feist.

To date, nursing boards in Mississippi, Missouri, Nebraska, and Oklahoma have updated their applications to remove invasive questions about mental health. The Dr Lorna Breen Heroes’ Foundation has created a free toolkit to support their efforts.

Virginia passed Safe Haven legislation that made it easier for physicians and physician associates to seek mental health support without fear that it would impact their licenses; it was extended to include nurses. Other states, including Georgia and Montana, are exploring similar legislation.

The efforts are part of a national trend to make it easier for healthcare professionals to seek mental health care. Anthony Papa, PhD, associate professor, and director of clinical training at University of Hawaiʻi at Mānoa, Honolulu, Hawaii, calls these changes a “trend in the right direction” but notes that more work must be done.

“The penalties involved with reporting that you have a mental health problem are such that…people are ignoring them or not reporting them,” he said. “We need to allow people to get the care they need and not feel like they need to hide it.”

Help for the Helpers

The costs of untreated mental health issues are high. Nursing turnover rates are 18%, and some studies have reported that as many as 40% of nurses could leave their current positions in the next 6 months. Nurses who remain on the job are also at risk.

“Nurses, like many other healthcare professionals in the United States, have to navigate a minefield of questions about prior mental health treatment and diagnosis, which reinforce institutionalized stigma around mental health treatment,” Feist told Medscape Medical News. “It not only impacts their ability to get care…but it also compromises patient care in that the healthcare workers are not able to show up to work doing their best because of whatever that medical condition might be that is untreated.”

In addition, depression has been associated with higher rates of absenteeism, lower productivity, and reduced quality of patient care. Moreover, untreated mental health issues were linked to higher rates of self-reported medical errors.

Feist believes that a combination of inertia and competing priorities have prevented state boards from auditing and editing their applications to be free of intrusive questions and stigmatizing language that make it harder for healthcare professionals to seek help for mental health concerns. Culture also plays a role.

“The part of all of this, which is reinforced in so many healthcare professional training and in licensure, is [the mentality] that getting treatment for a mental health condition is a sign of weakness,” said Feist. “It’s an old way of thinking about mental illness, and yet it is still something that is visible in healthcare.”

In addition to removing questions about mental health diagnoses from licensure applications, Papa advocates for a culture shift within healthcare to reduce the stigma and make it easier for nurses to seek care. Continued conversations about changing legislation are also essential, he added.

“I would like to see support for treatment of mental health issues being talked about at the state level, within state licensing boards, and [among] regulators in every state,” Papa said. “We see the [American Nurses Association, National Institute of Mental Health, National Institutes of Health, and the Centers for Disease Control and Prevention] coming around, but more people need to be vocal and start working to change some of the legislation to get the word out that if you seek care [for mental health issues], you’ll be able to stay a nurse.”

Jodi Helmer is a freelance journalist who writes about health and wellness for Fortune, AARP, WebMD, Fitbit, and GE HealthCare.