By Greg Freeman
Stress has long been a serious problem for physicians and nurses, but the added burden of COVID-19 is bringing attention to a particular challenge: All too often, clinicians are reluctant to seek the support of their employee assistance programs (EAPs) and other mental health resources available to them.
A primary reason they avoid seeking help is that they fear they will face negative repercussions at work, even losing their jobs, according to recent research.1
A survey conducted by the American College of Emergency Physicians (ACEP) revealed 45% of emergency physicians do not feel comfortable seeking mental health treatment. Most emergency physicians (87%) said they have felt more stress since the start of the COVID-19 pandemic, citing a lack of personal protective equipment (PPE) and other resources as key reasons.
“These new data add real urgency to the need for emergency physicians, policymakers, and clinical leaders to work together to change our approach to mental health. Every healthcare professional, especially those on the frontlines of the pandemic, should be able to address their mental health without fear of judgment or consequences,” Mark Rosenberg, DO, MBA, FACEP, president of ACEP, said in a statement.2
ACEP reports physicians avoid seeking help because they fear being asked about mental health treatment at some future point in their careers. Specifically, the poll revealed stigma in the workplace (73%) and fear of professional reprisal (57%) as the top reasons for avoiding mental healthcare. Additionally, many state medical boards require disclosure of mental health problems on physician licensing applications, although there appears to be ongoing debates and evolution about these policies.3,4
In the early stage of the pandemic, an emergency physician serving as medical director at a New York City hospital committed suicide. Her family cited the stress of treating COVID-19 patients as a primary cause. In the same week, a paramedic in New York City also killed himself; the family cited COVID-19 stress.
It is important to separate the mental health resource from the place of employment, says Charles Rothberg, MD, chair of the Physician Wellness and Resilience Committee at the Medical Society of the State of New York (MSSNY). “Physicians in general are in one of the high-stress professions, like law enforcement and the military. Like both of those professions, there is a culture where physicians don’t seek help because of certain cultural and professional hurdles,” Rothberg says. “Layered on that is the stress related to COVID-19. That stress is extraordinary.”
Medical students and residents suffer the same stress. The additional burden of feeling like they are not ready for the COVID-19 pandemic exacerbates the problem.
“When you combine that with the social isolation, particularly for people like residents who have traveled to a new city and don’t have the support of local family and friends, all of that disrupts a person’s natural ability to cope,” Rothberg says.
In July 2020, the MSSNY launched a program to assist physicians, residents, and medical students who may be contemplating suicide. The week the MSSNY P2P started, three physicians reached out requesting support.
The program can offer independent support that may appeal to physicians who do not want to reach out to their own institution for help.
“The idea of peer-to-peer is that it is a nonjudgmental, nonthreatening, noninstitutional encounter that calms people, reassures them, validates their thoughts and feelings, and supports people by telling them that what they are feeling is normal and not extraordinary,” Rothberg says. “Or, if it’s not normal, they provide resources to pursue a remedy.”
There are similar peer-to-peer programs that are institutionally driven, Rothberg notes, but the MSSNY program is not tied to any healthcare institutions. The program ensures the peer supporters do not have an employee-employer relationship or supervisory control over the person seeking support, Rothberg notes.
The goal of the program is to assist physicians before their stress reaches a critical point and affects their performance at work or leads to related issues like substance abuse. Those seeking help are matched confidentially with a peer physician through email and a toll-free phone number. The program matches the physician in need with a peer in similar professional standing, but not necessarily in the same geographical area. For confidentiality, physicians seeking help do not want to talk with someone in their immediate community.
Some hospital systems have expressed interest in adopting an approach like the MSSNY program as part of existing EAPs. However, Rothberg urges caution to leaders considering this path.
“There needs to be a firewall. An in-house program, no matter how well intentioned and designed, is not going to work as well as something that is separate from the institution,” Rothberg says. “They want to set it up through human resources because it is an employee benefit, but I don’t think that any system in house can be as effective as a [external] physician-run program.”
Rothberg notes physicians in a peer-to-peer program remain obligated to report impaired physicians and misconduct. If either party learns of misconduct or that substance abuse has affected the other physician’s work, that must be reported to the proper authorities.
“This program is not made for someone who is already impaired. A physician who is impaired might be reluctant to seek help for fear of being reported, so we are sensitive to that and have mechanisms to avoid getting into that situation,” Rothberg says. “An employer might not feel the same way about that sensitivity.”
The greatest difficulty in treating frontline healthcare workers for their COVID-19-amplified stress is their resources for help are tied so closely to their employers, says Wilfred G. van Gorp, PhD, ABPP, who offers neuropsychology testing in New York City and Chicago.
“That is a huge hurdle for healthcare institutions to overcome, especially with doctors,” he says. “The very act of acknowledging you have a problem and asking for help could derail your career. It’s a quandary that is very problematic for some professions and difficult to overcome.”
Van Gorp advocates for strong barriers between the EAP and the employer. Confidentiality must be absolute and promoted effectively to employees and physicians.
“The confidentiality must be explained, guaranteed, and agreed to by hospital administration. Otherwise, no one would avail themselves of this resource,” van Gorp says. “This has to be widely endorsed by hospital administration because the repercussions could be quite serious if the employer is not serious about it. You need to be physically distant from the hospital, and available off hours, not on the second floor where everyone sees the chief of surgery going in to the therapist’s office.”
Nurses deal with the same reluctance to seek help for stress, says Mike Hastings, MSN, RN, CEN, president of the Emergency Nurses Association (ENA).
“We are the caretakers. Historically, we just don’t do a good job of taking care of ourselves,” he says. “With COVID, we have seen some hospitals focus more on wellness issues and pushing out more resources for healthcare workers. Convincing nurses to take full advantage of those resources can still be a challenge.” Many nurses fear they might lose their license to practice nursing or lose their employment if they seek mental healthcare, according to Holly Carpenter, BSN, RN, senior policy advisor for the Nursing Practice and Work Environment and Innovation departments with the American Nurses Association (ANA).
Hospitals should offer mental health screenings and crisis response protocols, according to Carpenter. She also says mental health treatment should be covered by employee health plans — and that information should remain private. State laws and boards of nursing regulations concerning mental healthcare treatment, substance abuse treatment, disclosure, and possible penalties are not uniform. This prevents nurses from knowing exactly how to proceed if they think they need help.
“Those fears can be a reality if the care was not confidential and there was not a program in place to safely transition them back to work,” Carpenter explains. “Patient safety, nurse safety, and the employer obligations all have to be taken into account. It’s not as cut and dried as you might think when nurses ask about how this can affect their careers.”
ENA has encouraged the use of peer support groups in which nurses can talk about their struggles and find healthy ways to cope.5
“It’s a good chance for them to realize they are not alone. For nurses, that can be critical. A lot of times, when you only know what’s happening in your one institution, there can be a mindset that you’re the only one facing these problems,” Hastings explains. “When we’re able to reach out to others, we realize that the problem is more global than just your own institution. It at least allows you to understand you’re not alone in what you’re facing. Together, you’ll get through this.”
Hastings says talking about stress in the workplace regularly can help remove stigma about the subject. “This is something that everyone in our world experiences sometimes,” he adds. “It’s important to establish that it’s OK to talk about it and get help.”
“We really want to see the assessment and screening so they don’t get to the point of crisis, and then a form of help that doesn’t threaten their license, their confidentiality, or their employment,” Carpenter says. “Optimal staffing is a big help. It would be great if a nurse could actually take her breaks as scheduled. If you don’t have time to eat or go to the bathroom in a 12-hour shift, that’s not going to help anybody.”
Nurses need time and space to decompress after a patient death. Avoid mandatory overtime, and provide resources like float nurses so colleagues can take these breaks. Effective and enforced workplace bullying and violence prevention policies help, too.
“I’m a nurse working at the ANA office. If we had a death at the ANA, we’d probably all be given time off and have people calling to check in on us. But for most nurses, they have to prepare the body for the morgue and get ready for the next patient,” Carpenter says. “They may have known that patient for days, and they need a nice, serene place where they can decompress for five to 15 minutes. Nurses are used to death, but they’re not inured to it — nor do we want them to be.”
The most important thing is for nurses to know they are not alone, Carpenter adds. Hospitals should offer some type of free, confidential, and easily acceptable mental health screening, she says. The goal is for people to obtain help before the stress leads to a more serious condition.
The symptoms of stress can manifest in many ways, including headaches, lethargy, emotional outbursts, and sleep disorders, says Jorge Palacios, MD, clinical researcher at SilverCloud Health, a digital mental health company with offices in Boston, London, and Dublin.
“The more experienced the healthcare workers are, the less likely they are to experience mental health issues related to work. It’s the new people who have been on the job for less time that are at higher risk,” he says. “Adequate training and support also have been identified in scientific studies as lowering the risk. Healthcare workers who don’t feel they have enough training to deal with these situations, and who don’t have the support to deal with their own problems, are at greater risk.”
On top of everything else, healthcare workers have been anxious about bringing COVID-19 home and transmitting it to loved ones. This leaves workers feeling even more vulnerable. “There is a loss of control, even though they have been trained and know more than most about the virus. They worry about the unknowns, the symptoms and the mutations, whether the vaccine will work,” Palacios says. “That has an effect on mental health.”
On the bright side, Palacios says research has indicated some healthcare workers feel an increased sense of meaning and purpose because of the pandemic.6 Exercise, talk therapy, meditation, yoga, in-person support groups, and online therapy tools all could help healthcare workers cope, according to Palacios.
Physicians or nurses seeking mental healthcare are making themselves vulnerable, not just professionally but on a personal level. Any program seeking to help them must acknowledge that vulnerability and assure users of confidentiality.
“It’s important to understand the needs of your frontline healthcare workers and provide the kind of assistance they need in the form that makes them most comfortable accepting it,” Palacios says. “It’s not enough to say that you have these resources within the hospital or health system and you should make use of them. If the help is not provided in a way that makes them feel safe, they will not use it.”
(Editor’s Note: For those in need, contact your state’s medical society or medical board to identify resources in your area.)
- American College of Emergency Physicians. Poll: Workplace stigma, fear of professional consequences prevent emergency physicians from seeking mental health care. Oct. 26, 2020. https://www.emergencyphysicians.org/article/mental-health/poll-workplace-stigma-fear-of-professional-consequences-prevent-emergency-physicians-from-seeking-mental-health-care
- American College of Emergency Physicians. As stress during the pandemic grows, nearly half of nation’s emergency physicians uncomfortable seeking mental health care. Oct. 26, 2020. https://www.emergencyphysicians.org/press-releases/2020/10-26-20-as-stress-during-the-pandemic-grows-nearly-half-of-nations-emergency-physicians-uncomfortable-seeking-mental-health-care
- American Medical Association. AMA adopts policy to improve physician access to mental health care. June 13, 2018. https://www.ama-assn.org/press-center/press-releases/ama-adopts-policy-improve-physician-access-mental-health-care-0#:~:text=Specifically,%20the%20policy%20encourages%20state,when%20the%20physician%20presents%20a
- House Committee on Energy & Commerce. Hearing on high anxiety and stress: Legislation to improve mental health during crisis. June 30, 2020. https://energycommerce.house.gov/committee-activity/hearings/hearing-on-high-anxiety-and-stress-legislation-to-improve-mental-health
- American Psychiatric Nurses Association. Well-Being Initiative. Nurses’ guide to mental health support services. https://www.ena.org/docs/default-source/resource-library/practice-resources/covidresources/nurses-guide-pdf-003-(1).pdf?sfvrsn=8fe8a48_2
- Shreffler J, Petrey J, Huecker M. The impact of COVID-19 on healthcare worker wellness: A scoping review. West J Emerg Med 2020;21:1059-1066.