It’s OK not to be OK … really … it is! Confronting Mental Health Stigma in Nursing

This catchphrase has embedded itself in the zeitgeist in recent years. A personal favorite is a song by Demi Lovato and Marshmello. Yet, despite the recent cultural shift toward recognizing that everyone struggles sometimes, we as a profession and the broader society still face the challenge of moving from lip service (or song) to action.

According to the American Psychological Association, stigma is "the negative social attitude attached to a characteristic of an individual that may be regarded as a mental, physical or social deficiency. A stigma implies social disapproval and can lead unfairly to discrimination against and exclusion of the individual." In the context of mental health, it can be both a public bias toward those who are experiencing a mental health condition, or internalized by an individual, often as a feeling of shame. In both cases, stigma often discourages individuals from seeking help and talking about their experiences, and it contributes to feelings of isolation.

Stigma is, by its very nature, difficult to address. The fact that people may experience stigma both from those around them and from themselves means ending stigma requires societal shifts and a level of personal awareness. Due to the vastness of these goals, organizations such as Huntsman Mental Health Institute at the University of Utah have approached it the same way previous generations brought about social change movements such as using seat belts, recycling and breastfeeding. In December 2021, the institute announced a Grand Challenge to end the stigma of mental illness.

The healthcare workforce is also leading the charge in addressing stigma. The National Academy of Medicine's National Plan for Health Workforce Well-Being, released in October 2022, is a prime example. It identifies supporting mental health and reducing stigma as a priority area with five associated goals:

• The mental health workforce is strengthened with increased numbers of practitioners.
• dequate mental health services are available, easily accessible, confidential, dignified, paid for, and health workers and learners are encouraged to use them.
• Stigma and barriers are reduced for health workers and learners to disclose mental health issues and utilize mental health services.
• Health workers and learners do not experience unnecessary punitive actions when seeking mental health services.
• Access to mental health resources is correlated with improved health worker well-being.

The May 2022 Surgeon General's Advisory on Addressing Health Worker Burnout recognized, albeit briefly, that reducing stigma is important. It advocated for actions that can contribute to reducing stigma, including reviewing and changing policies that may deter workers from seeking help, building cultures in academic and practice settings that support the well-being of the workforce, and promoting ways that individuals can support their peers and themselves.

While these healthcare workforce approaches to destigmatization are welcomed, it is important to look at the unique ways that nurses can impact and be impacted by stigma in mental health. One article describes three perspectives nurses can encounter - the stigmatized, the stigmatizer and the destigmatizer. We know nurses are not exempt from mental health conditions. According to the American Nurses Foundation's Pulse on the Nation's Nurses survey, conducted in August 2021, just 31% of respondents had sought professional mental health support since March 2020. Among the 68% who had not sought support, the two primary reasons were lack of time (20%) and feeling they should be able to handle their own mental health (15%). These rationales aren't surprising and support years of findings that nurses put the well-being of their patients ahead of their own. Nurses also encounter stigma. In the same August 2021 survey, over one-third of respondents acknowledged feeling stigma in seeking mental health support from family or colleagues and, perhaps most concerning, the largest proportion of those experiencing stigma felt it within themselves (17%).

The complexity of this issue and the immediate needs of nurses inspired the American Nurses Foundation to host the Summit to Address Mental Health Stigma in Nursing in February and March 2022. The sessions brought together a diverse group of 26 nursing and non-nursing experts with the purpose of creating a blueprint for national action and guiding philanthropic investments to address stigma in mental health in nursing. The group identified an ideal future state in nursing as one where the culture is transformed and all stakeholders play a role in addressing the continuum of well-being, mental health and mental illness, to ensure asking for help is normalized, encouraged and done without stigma. This ambitious vision requires action. The summit attendees identified five actions that if implemented have the potential to make measurable progress toward a better future:

• Build a nurse-led alliance to convene, communicate and collaborate on reducing stigma related to well-being and mental health.
• Create structural and regulatory changes that leverage existing systems to eliminate/reduce stigma.
• Build a culture across the profession (students through leaders) that is based on culturally appropriate, equitable and inclusive education, tools and resources to understand and respond to the stress continuum.
• Use an appreciative inquiry approach to create a resource compendium of programs that effectively reduce stigma.
• Create a recognition program to bring attention to and increase the number of individuals/organizations successfully addressing mental health stigma.

These actions, and those referenced in the National Academy of Medicine's National Plan and the Surgeon General's Advisory, primarily focus on changes that are led by organizations and policymakers, and they may feel out of reach for many individual nurses. But that doesn't mean you can't be part of the movement to destigmatize mental health conditions. Many small actions can have a meaningful effect on you, your peers and your wider community.

For example:

• If you are experiencing a mental health condition, recognize that you are not alone, and that it is important to seek help. Your employer likely has resources available through your employee assistance program. You can also access support through external resources noted in the Well-Being Initiative, which includes a guide for finding a mental health professional.
• Look for opportunities to educate yourself about actions you can take to be a destigmatizer. The National Alliance on Mental Illness has a Pledge to Be StigmaFree campaign with many resources, including tips to change the language we unintentionally use every day that may promote stigma.
• Normalize the language of mental health and advocate for change. There are many frameworks you can bring to your team, such as Stress First Aid, which focus on recognizing when you or your colleagues are experiencing a stress reaction and creating space to address it.

As the largest segment of the healthcare workforce and the Gallup Poll’s most trusted profession for 20 consecutive years, nurses are positioned to influence culture in powerful ways. While destigmatizing mental health issues will require large structural changes in society and healthcare, such as addressing discriminatory barriers in licensure and increasing the availability of mental health resources, it also relies on each of us to take action in our daily lives.

How will each of you step into the role of a destigmatizer with your patients, peers and community, and uphold the Code of Ethics for Nurses to promote personal health, safety and well-being for yourself and others?