National Plan for Health Workforce Well-Being (2022)

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3 Priority Area: Support Mental Health and Reduce Stigma Provide support to health workers by eliminating barriers and reducing stigma associated with seeking services to address mental health challenges. “We need investment in mental health in the long term, funding and access to care, and change in barriers to access like conversations about care and stigma in our culture.” - Frontline Health Worker1 Mental health is a “state of mental well-being that enables peo- ple to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community” (WHO, 2022). Mental health disorders affect 15 to 20 percent of U.S. adults in any given year and are the leading cause of disability in the country (U.S. Burden of Disease Collaborators, 2013). For health care work- ers specifically, the nature of their clinical training and work is linked to substantial increases in depression, anxiety, suicidal ide- ation, and other mental health conditions upon entering the pro- fession, with high rates persisting through their careers (Bellini et al., 2018; Mata et al., 2015; Melnyk et al., 2020). There is a contin- uum of stress in the environment with multiple phases and impli- cations (Nash et al., 2010). Past pandemics and emerging evidence suggest that many health workers will have experiences along the stress continuum, which could include COVID-19-related trauma, 1 For background on this quote and those in other chapters, visit the NAM’s Clinician Burnout Crisis in the Era of COVID-19: Insights from the Frontlines of Care webpage at: https://nam.edu/initiatives/ clinician-resilience-and-well-being/clinician-burnout-crisis-in-the-era-of-covid-19/. 25 

26 | National Plan for Health Workforce Well-Being posttraumatic stress disorder (PTSD), risk for substance use, and depression (McKay and Asmundson, 2020). Ultimately, if health workers are not well, health care delivery and patient safety may suffer (Fahrenkopf et al., 2008). There is robust evidence that mental health disorders can be pre- vented, and prevention approaches have the potential to substan- tially reduce the public health burden of these disorders (Munoz et al., 2012). It should be noted that prevention strategies and treat- ments differ for mental health challenges and problems that are potentially linked with substance use and addiction. Prevention ef- forts should be aimed at populations, such as health workers and other professionals, where the prevalence of disorders are high and important drivers of poor mental health have been identified. To decrease the number of health workers and learners who develop depression, anxiety, and other mental health issues, it is criti- cal that health systems address the structural challenges that are driving some of their employees’ poor mental health, such as high workload, administrative burden, and work-family conflict (Fang et al., 2022; Guille et al., 2017). When mental health issues arise, these upstream drivers must be addressed, in addition to the pro- vision of appropriate mental health resources and referrals. This requires appropriate triage by skilled mental health professionals at the individual level who can distinguish between burnout and mental and behavioral health issues and make an accurate refer- ral for treatment. Health workers struggling with addiction and fearful of losing their licenses should have assistance, since there are significant consequences—not only to themselves but also for their patients—if they remain untreated (Butler Center for Re- search, 2015). In the United States, stigma associated with seeking support for emotional and mental health and substance use is widespread in the general population (NASEM, 2019). Negative perceptions, at- titudes, and discrimination regarding help-seeking are entrenched in the health professions’ culture and training, as well as individual perceptions of and the actual expectations and responses of health systems, licensing bodies, and other governing forces (NASEM, 2019). As such, many mental health programs, even when imple- mented, face resistance from health workers, so planning for psy- PREPUBLICATION COPY - Uncorrected Proofs 

Support Mental Health and Reduce Stigma | 27 chological intervention programs should include promotion and awareness campaigns at the organizational level (Buselli et al., 2021). At the state level, despite progress in recent years on updat- ed licensing applications to encourage treatment-seeking among health workers, this stigma continues to be pervasive (FSMB, 2018; Halter et al., 2019).2 In practice, health workers may still internal- ize shame, avoid speaking up and getting care, or avoid fully shar- ing their experiences with their employers. Continuing to eliminate both policy barriers to care and cultural stigma are foundational to the professional well-being of health workers and learners. 2 In 2018, the Federation of State Medical Boards released recommendations for licensing applica- tions to ask only about current impairments to practicing—not all conditions—that might undermine a physician’s ability to work safely (FSMB, 2018). These licensing updates would be consistent with the Americans with Disabilities Act, which prohibits discrimination against those with mental health condi- tions. Many state boards of nursing are also modifying their licensing applications (Halter et al., 2019). PREPUBLICATION COPY - Uncorrected Proofs 

28 | National Plan for Health Workforce Well-Being Priority Area: Support mental health and reduce stigma. The mental health workforce is strengthened with Goal 1 increased numbers of practitioners. Academic Institutions, Clinical Training Programs, and Accreditation Bodies Federal, State, and Local Governments Actors Health Systems Insurers and Payers Professional and Specialty Societies 1A. Train, recruit, and retain additional mental health professionals (e.g. mental health nurse practitioners, occu- pational therapists, psychiatrists, psychologists, physician assistants, and social workers) to provide care for the health workforce. 1B. Increase resources to support individuals seeking educa- tion to become mental health professionals. Actions 1C. Continue to address the lack of pay parity between health professionals providing mental health services and those who provide other forms of treatment. 1D. Establish debt forgiveness programs and pathways to increase the interest of learners in mental health professions. 1E. Integrate training on referral pathways from primary care to specialty mental health care. PREPUBLICATION COPY - Uncorrected Proofs 

Support Mental Health and Reduce Stigma | 29 Adequate mental health services are available, easily Goal 2 accessible, confidential, dignified, paid for, and health workers and learners are encouraged to use them. Federal, State, and Local Governments Health Systems Health Workers Actors Insurers and Payers Private and Non-Profit Organizations Professional and Specialty Societies 2A. Provide supportive mental health services for health workers involved in safety events and other traumatic events as part of a system’s layered protections against medical er- rors. 2B. Support the use of faith leaders, coaches, peer sup- porters, and other trusted resources due to the shortage of licensed mental health professionals. 2C. Provide quality mental health services, offer telemedi- cine and virtual care options where appropriate, and expand hours of availability to when health workers are not at work. 2D. Offer external providers of mental health services to em- Actions phasize confidentiality. 2E. Arrange coverage and/or flexible schedules for health workers to participate in mental health appointments. 2F. Establish peer-support programs and offer psychologi- cal and/or stress first-aid training for all health workers and trainees, in addition to Employee Assistance Programs. 2G. Guarantee mental health parity with other medical con- ditions for the coverage of health care costs. 2H. Increase reimbursement and reform prior authoriza- tion for mental health services to ensure health workers and trainees receive the care they need. PREPUBLICATION COPY - Uncorrected Proofs 

30 | National Plan for Health Workforce Well-Being Stigma and barriers are reduced for health workers and Goal 3 learners to disclose mental health issues and utilize mental health services. Academic Institutions, Clinical Training Programs, and Accreditation Bodies Federal, State, and Local Governments Health Systems Actors Health Workers Media and Communications Private and Non-Profit Organizations Professional and Specialty Societies 3A. Increase awareness of mental health issues and services through routine communications, such as rounds or regu- larly scheduled meetings, and other dissemination efforts. 3B. Develop policies and exemplar practices regarding re- quirements for privileging and credentialing in health care delivery organizations. Actions 3C. Convene state licensing and certification boards to ac- celerate appropriate changes to mental health reporting requirements, reduce stigma, and normalize the process for health workers to seek help for workplace-related stresses. 3D. Educate the public and health workforce about the ben- efits of mentally healthy workers. PREPUBLICATION COPY - Uncorrected Proofs 

Support Mental Health and Reduce Stigma | 31 Health workers and learners do not experience Goal 4 unnecessary punitive actions when seeking mental health services. Academic Institutions, Clinical Training Programs, and Accreditation Bodies Federal, State, and Local Governments Actors Health Systems Insurers and Payers 4A. Align questions about personal health information with the Americans with Disabilities Act to inquire only about current impairments that may affect their ability to provide care due to a health condition rather than a past or current diagnosis or treatment for a mental health condition. Actions 4B. Establish accountability frameworks for ensuring psy- chologically safe working and learning environments that prevent discrimination, such as inappropriate retaliation or termination, against health workers and learners disclosing mental health challenges. PREPUBLICATION COPY - Uncorrected Proofs 

32 | National Plan for Health Workforce Well-Being Access to mental health resources is correlated with Goal 5 improved health worker well-being. Academic Institutions, Clinical Training Programs, and Accreditation Bodies Federal, State, and Local Governments Actors Health Systems Professional and Specialty Societies 5A. Track the use of mental health services and programs (e.g., Employee Assistance Program) to ensure programs are designed to meet the needs of health workers, whether efforts to seek assistance and treatment have increased, and Actions whether organizational barriers (such as stigma, lack of con- fidentiality, fear of punitive consequences, etc.) have been removed. NOTE: Data should be de-identified. 5B. Track whether state-level barriers have been removed. NOTE: The list of actors in this table is not exhaustive. Many of the actors named in this table will need to plan and coordinate their actions with each other as part of a systems approach to health workforce well-being. RELATED RESOURCES3 1 Cultivate a Culture of Connection and Support • Organizational Guide: 2022 Healthcare Workforce Rescue Package (National Academy of Medicine-All In) • Organizational Guide: Conversation and Action Guide to Sup- port Staff Well-Being and Joy in Work During and After the COVID-19 Pandemic (Institute for Healthcare Improvement) • Organizational Graphic: Psychological PPE: Promote Health Care Workforce Mental Health and Well-Being (Institute for Healthcare Improvement) 3 For additional resources, visit the NAM’s Resource Compendium for Health Care Worker Well-Being webpage at: https://nam.edu/compendium-of-key-resources-for-improving-clinician-well-being/. PREPUBLICATION COPY - Uncorrected Proofs 

Support Mental Health and Reduce Stigma | 33 • Organizational Guide: Peer Support Programs for Physicians (American Medical Association) • Organizational Guide: At the Heart of the Pandemic: Nursing Peer Support (Godfrey et al., 2020) • Organizational Guide: Preventing Physician Suicide: Identify and Support At-Risk Physicians (American Medical Associa- tion) • Individual Support Guide: Provider Well-Being for Behavior- al Health Professionals (Mental Health Technology Transfer Center Network) • Individual Support Guide: Health Care Professionals (Nation- al Alliance on Mental Illness) • Resource Compilation: COVID Resources (American Psychi- atric Nurses Association) PREPUBLICATION COPY - Uncorrected Proofs