Breaking the silence

FigureRNs AND CLINICAL SUPPORT technicians are among the subcategories of healthcare workers at the highest risk for suicide.1 Healthcare workers face unique challenges, including long work hours, difficult work conditions, high stress levels, compassion fatigue, workplace violence, and repeated exposure to trauma, all of which can have profound effects on their mental health.2 These factors not only impact nurses' personal well-being but also influence their ability to provide safe, high-quality patient care. Leaders in healthcare organizations play a critical role in fostering an environment that prioritizes the mental health and well-being of healthcare workers.3 Thus, it's critical for healthcare leaders to understand what's necessary to create a supportive culture that both promotes and improves nurses' mental health.3 OVERVIEW OF MENTAL HEALTH CHALLENGES IN NURSING Nurses represent the largest percentage of the workforce for most healthcare systems, yet their mental health needs are often overlooked and left unaddressed.2 High workloads, chronic stress, moral distress, and secondary traumatic stress contribute to significant mental health challenges.2 The data surrounding nurses' mental health are alarming. Burnout. Characterized by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment, burnout can impact nurses across all settings. Studies estimate that up to 56% of nurses experience burnout symptoms, with rates even higher in high-acuity settings such as the ED and ICU.4 Compassion fatigue—the emotional strain of caring for others who are suffering—further exacerbates these issues. Depression and anxiety. Recent statistics indicate that around 46% of nurses experience symptoms of depression and anxiety.5 Research suggests that nurses don't seek professional mental health support for a variety of reasons, including a lack of time and financial resources.4 But perhaps more alarming, 86% of nurses don't utilize employer-provided counseling services.5 Suicide. Nurses have significantly higher suicide rates compared with the general population. According to research, nurses are 18% more likely to attempt suicide than the general population, and female nurses are at nearly double the risk of suicide compared with females in the general workforce.6 FACTORS CONTRIBUTING TO NURSES' MENTAL HEALTH BURDEN A variety of factors contribute to the mental health crisis among nurses. Workplace stressors. Staffing shortages, high patient-to-nurse ratios, and long working hours are among the most common on-the-job stressors for nurses.2,4,5 Exposure to trauma. Repeated exposure to patient suffering and death, especially in high-stress environments such as CCUs and EDs, can lead to mental health decline.1,2 Stigma. Reluctance to seek help due to fear of judgment or professional repercussions is common among nurses.2,4 Organizational culture. Some organizations lack adequate mental health support systems and haven't fully developed a culture of psychological safety, which can negatively impact nurses' well-being.2,5 These issues highlight the urgent need for systemic solutions that target the root causes of poor mental health among nurses. Addressing this complex challenge requires a multifaceted approach that not only meets the immediate needs of nurses during an acute crisis but also focuses on implementing systemic organizational changes to further support recovery, resilience, and return to work for the impacted nursing workforce. In 2020, the Healthy Nurse, Healthy Nation® (HNHN) Strength Through Resiliency Committee examined, developed, and collected mental health resources for nurses, including those for suicide prevention.7 The committee, composed of mental health subject matter experts, representatives from professional associations, invested nurses, and staff from across the American Nurses Enterprise, developed a collection of resources to explain the risk factors for suicide, share evidence-based support strategies, and raise awareness of available resources.7 OVERVIEW OF THE PATHWAY TO EXCELLENCE® FRAMEWORK Given the complexity of the challenges to nurses' mental well-being, a structured, organization-wide framework is essential to ensuring long-term improvements in nurses' mental health. The American Nurses Credentialing Center's (ANCC's) Pathway to Excellence® framework is a globally recognized, evidence-based framework for cultivating positive practice environments where nurses can thrive. The Pathway framework emphasizes six key standards that promote nursing excellence: Shared Decision-Making, Leadership, Safety, Quality, Well-Being, and Professional Development (see Table 1).TABLE 1.: ANCC Pathway to Excellence® FrameworkPathway's Well-Being standard emphasizes the importance of fostering a psychologically safe work environment, normalizing the dialogue about mental health struggles, and reducing barriers to seeking help for mental health issues among healthcare workers.8 Further, Pathway focuses on culture changes and broader resource awareness to normalize mental health help-seeking behavior, emphasizing the importance of integrating well-being into the organization's long-term strategic planning and continuously assessing the well-being of the workforce to identify opportunities to improve. Leaders at Pathway organizations fulfill a key role in fostering a positive practice environment by raising awareness of mental health issues prevalent among nurses and offering evidence-based mental health and support services to address those issues. LEVERAGING THE PATHWAY FRAMEWORK TO MAXIMIZE MENTAL HEALTH PROMOTION Although the Pathway framework sets the foundation for a supportive work culture, it's the practical application of its principles that leads to cultural transformation and meaningful outcomes. Therefore, addressing mental health challenges and preventing suicide among nurses requires a multifaceted approach that combines individual-focused strategies with organization-level interventions. By leveraging the Pathway framework to foster a positive practice environment where nurses feel valued and supported, organizations demonstrate their commitment to improving the mental health outcomes of their nursing workforce. Examples of Pathway-aligned strategies that organizations can implement to address mental health challenges and prevent suicide among nurses include the following. Assess the health of your workforce. Organizations should regularly assess the unique mental wellness needs of their workforce, and then implement staff-selected, targeted initiatives to address those needs. HNHN is an American Nurses Enterprise program that's designed to improve the health of the nation's nurses. HNHN offers an IRB-reviewed, comprehensive health assessment survey that includes questions on work environment, physical activity, nutrition, quality of life, safety, and more. After completing the survey, participants are provided with an interactive health heat map.9 Use facts to demonstrate the return on investment. Without a strong executive leadership commitment, mental health initiatives may not receive adequate human and financial resources to ensure long-term sustainability. Engaging nurse leaders and executives in mental health discussions ensures these initiatives are prioritized within the organization's strategic plan and goals. Leaders should develop and present data-driven evidence that demonstrates the return on investment of mental health programs, including improvements in nurse retention, engagement, and patient outcomes.8 Foster open communication channels. Fostering safe, bidirectional communication between leadership and frontline nurses empowers nurses to openly communicate about issues or concerns that impact their well-being. When nurses feel that they can discuss their issues or concerns in a safe space and that their well-being is a priority, engagement improves, and nurses are more likely to seek help when they feel overwhelmed or in distress.8 Operationalize shared decision-making to address workplace stressors. Leaders must partner with nurses to address workplace stressors. Pathway organizations foster a culture of interprofessional shared decision-making and demonstrate a commitment to enhancing the overall well-being of their workforce. By involving the workforce in these discussions and decisions, organizations increase the likelihood that the result will have a meaningful impact.8 Enhance existing mental health support programs. Staff often report that employee-assistance programs and employer-provided counseling don't provide the level of comprehensive support needed for nurses to fully acknowledge the importance of self-care and personal wellness interventions.2 Further development of mental health support programs should focus on developing real-time support for staff involved in adverse work-related situations, highlighting the importance of taking breaks, and developing peer support groups where nurses can share their lived experiences.3 Remove mental health stigmas to normalize seeking help. Despite increasing awareness, mental health stigma remains a major obstacle. For individual nurses, a larger problem is suffering in silence, which can often be attributed to either a lack of awareness of the severity of nurses' personal mental health issues or fear of judgment due to stigmatization of mental health disorders.6 Increasing awareness of mental health issues and promoting available organizational resources contribute to enhancing the overall well-being of healthcare teams. Integrating mental health discussions into routine staff meetings can help make seeking support a cultural norm. Pathway engages in the ALL IN: WellBeing First for Healthcare coalition to drive systemic change, advocating for policies and practices that dismantle stigma and prioritize workforce well-being. Healthcare organizations should also evaluate and consider removing intrusive mental health-related questions from job applications and credentialing processes, as these can further reinforce stigma and discourage nurses from seeking the support they need.10 Consider implementing an evidence-based suicide training prevention program. Organizations should provide suicide prevention education for all employees to improve their skills and capability to respond to colleagues who need behavioral health support. For example, consider implementing the University of California San Diego's Healer Education Assessment & Referral (HEAR) suicide prevention program.11 The HEAR program includes education to eliminate the stigma of seeking help; conducts proactive, anonymous screening to identify at-risk individuals; organizes debriefings after stressful incidents; and provides counseling and connections to treatment as a necessary follow-up. A COMPREHENSIVE APPROACH TO PROTECTING NURSES' MENTAL HEALTH Nurse leaders play a pivotal role in championing mental health initiatives, ensuring that mental health and well-being are prioritized within their teams. Addressing the mental health crisis among nurses requires a comprehensive, evidence-based approach that integrates an organization-wide shared vision for well-being, executive leadership commitment, supportive workplace cultures, and targeted interventions. Embedding well-being into an organization's strategic goals ensures that leadership and frontline staff are aligned in fostering a culture in which mental health is prioritized, sustained, and continuously improved. The Pathway to Excellence framework provides a structured, evidence-based model for fostering positive practice environments where nurses feel valued, supported, and empowered to prioritize their own well-being. By assessing workforce health, fostering open communication, operationalizing shared decision-making, enhancing mental health support programs, removing stigmas, and implementing evidence-based suicide prevention training, healthcare organizations can make meaningful strides toward protecting the mental health of their nursing workforce. Don't suffer in silence. Help is available 24/7. If you or someone you know is struggling, call or text 988 or text TALK to 741741. Well-Being Excellence™ offers an evidence-based approach to evaluate and enhance your organization's well-being efforts. Additional information is available atwww.nursingworld.org/organizational-programs/well-being-excellence.