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Mental health in nursing

A student's perspective

Halsted, Candis DNP-PMHNP, RN; Hart, Virginia T. DNP, RN, PMHNP-BC

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doi: 10.1097/01.NURSE.0000694764.76416.f9
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I DECIDED TO RETURN to school in 2015 after practicing as a nurse in various settings for 7 years. I subscribe to the adage that knowledge is power. My drive for additional education and experience was based on my desire to achieve a higher status, assume more control over my practice, and to garner more respect from other healthcare professionals. As I immersed myself in my graduate studies, however, I found my desires, self-image, and professional viewpoint had changed.

I have always endeavored to be the best student, greatest employee, and most dependable teammate. Those efforts took on a feverish intensity during periods of transition—student to nurse, nurse to working mother, mother and nurse to professional student. Good was not good enough, and my drive to be the best and greatest was an integral part of my self-worth. Unfortunately, it led to anxiety, depression, hopelessness, and isolation that negatively impacted my education, practice, and personal life.

It was not until my clinical rotations as a psychiatric-mental health NP student that I came to realize the magnitude of the situation. There I was, taking courses on trauma-informed care and giving my patients tools for building self-efficacy, self-compassion, and coping skills while simultaneously ignoring my own needs.

Having left the workplace to focus on my online studies, I was isolated, lacking confidence, feeling overwhelmed, and overcompensating for some perceived shortcoming that I could not even define. I felt hopeless and defeated. I experienced bouts of anxiety and depression so intense I lost my sense of purpose. I considered dropping out of school many times, but I gave in to the expectations of others. I forced myself to continue pushing aside my own needs, persisting despite my growing depression and anxiety.

Looking back, I had so many chances to speak up and reach out for help. I could have spoken with nurse managers, coworkers, fellow students, and faculty a hundred different ways on so many occasions. Instead, I allowed the culture of silence and my own perfectionism to rule.

At my lowest point, I made the life-altering decision to reach out for help—first to my husband, then a therapist, a fellow student, and finally my school faculty. With their assistance, some serious self-reflection, and a lot of self-help reading, I am working to address my mental illness and establish a sense of well-being.

That is not to say that I have it all figured out. I still struggle many days to keep faith in my strengths and abilities. The things I have learned and witnessed, the obstacles I have encountered and overcome, whether academic, professional, or personal, have humbled me and restored my desire to return to the love, service, and justice at the core of my professional drive and practice. I am once again prioritizing my values and making sure my actions reflect them. Among those values is the desire to work toward the unification of our profession and to advocate for policy changes that support the mental health of all nurses. Inspired by my personal experiences, this article explores mental health issues many nurses confront today.

A pervasive problem

Although mental health and suicide among nurses have emerged as areas of professional concern in recent years, little research or literature exists regarding profession-specific risk factors, prevalence of mental illness, and suicide rates. With little to no concrete statistics to draw from, the true incidence of mental illness within the nursing profession is unknown. Furthermore, little has been done to bring these problems to the attention of the general public or to acquire the recognition and support of the professional community.1-3

What can be found are decades of research stating that nursing is psychologically demanding and can contribute to poor mental health in a variety of ways, such as depression, anxiety, secondary trauma, compassion fatigue, and burnout.1-7 The occupational hazards of nursing can also compromise work-life balance. Add to this various individual risk factors such as genetic predisposition or history of personal trauma, as well as the fact that academic standards for the profession favor those who are exacting and high-performing. It stands to reason that nurses are in jeopardy of significantly elevated levels of stress and maladaptive coping.5,8 When ongoing, this can lead to impaired functioning. In the professional setting, impairment has been correlated with increased risk for errors, patient harm, and clinical ineffectiveness.9

Mental illness can be defined as clinically significant impairment in social, conceptual, and practical functioning.9,10 Although very common, mental illness is often untreated.11 One in five adults will have some experience with mental illness each year, but less than half will receive treatment.11

Nursing has a hidden culture of stigma and silence regarding mental illness, which serves to minimize and overshadow those experiencing clinically significant distress.6,12 Competition, intimidation, and bullying among nurses are pervasive across practice and in academic settings.13,14 These behaviors can breed psychologically hazardous and hostile environments. Fear of becoming a target may result in blame, shame, self-stigmatization, isolation, and suffering in any individual with potentially undesirable characteristics in such settings, regardless of his or her mental health status. Such abuses and fear can promote conformity and negatively impact disclosure and help-seeking behaviors in stressed, distressed, and impaired individuals.1,2,5,13

The issue is exacerbated by a lack of respect and recognition for nursing that is still present within the healthcare culture at large. The traditional hierarchy holds physicians as experts, not nurses. Even advanced practice nurses are diminished, often referred to as “mid-level providers” and “physician extenders.”15 These attitudes undermine the autonomy and dignity of nurses, especially when they collaborate with other healthcare disciplines.14

In addition, while healthcare entities and societies champion the rights of the patient, the need to protect the basic human dignity and professional image of nurses is often overlooked.14 Fundamental protections and rights for nurses are being compromised every day when we are expected to tolerate long hours, interrupted (or nonexistent) breaks, heavy patient caseloads, incivility, and even violence in the workplace. Nurse unions across the country are threatening walkouts and going on strike because of the failure of hospitals to address these issues.16,17 The situation is not helped by the fact that guiding and governing bodies for nursing practice are numerous yet, in my opinion, self-segregated.

Systemic change

Although some organizations have created emotional wellness programs, a cohesive or public effort to address systemic problems is lacking.1-3 Until employers, boards of nursing, and nursing organizations place the same importance on the well-being of nurses and risk mitigation, nurses may continue to suffer in silence. Within the currently disjointed system, we cannot hope to make substantive changes without offering our passion and expertise as well as identifying and supporting means for promoting self-care and wellness among the thousands of practicing nurses and preprofessionals experiencing distress or symptoms of mental illness.

Pressures and barriers to mental health and help-seeking extend to the academic setting.4-5 For professional nurses returning to school, the pressure associated with practice and professional expectations may be exacerbated by their increased need to balance a variety of personal and/or family responsibilities, deadlines, financial obligations, leisure time, and peer competitiveness. Despite these contributory risk factors, I have seen few—if any—educational programs for health and helping disciplines, such as nursing, medicine, and social work, place value on assessing students' stress and distress. In commiserative discussions with others doing graduate work in nursing, social work, occupational therapy, and physical therapy, I have yet to meet anyone who felt the faculty took action to address the genuine difficulties many of them faced in balancing their lives. In short, students (myself included) feel devalued by the lack of respect, holistic consideration, and mentorship they encounter. Academic learning environments have a great need to support improvement of the emotional well-being and psychological resiliency of students and for improving the accessibility of support, counseling, and mental health resources.4,5

I encourage you to take a long, hard look at yourself and those around you. If you are struggling, please reach out to someone you trust and let them know you are not okay. If you are not sure that what you are experiencing is normal or cause for concern, there are many websites that provide education and information on how to identify mental health problems, as well as hotline crisis intervention services and referrals to local counseling. These websites often have articles and tips on how to improve your mental health through physical, spiritual, and psychological self-care. (See Mental health resources.)

No mental health concern is too big or too small. If you are not well, talk to a friend, family member, professional, or help hotline. If you suspect a coworker, colleague, or student needs help, please reach out. Something as simple as asking if they are okay and giving them the space and time to express their feelings can make all the difference. As Edward Everett Hale once said, “I am only one, but still I am one. I cannot do everything, but still I can do something. And because I cannot do everything, I will not refuse to do the something that I can do.”18 We owe it to ourselves, our profession, our patients, and their families to seek help and to offer help to our fellow nurses in need.

For anyone requiring immediate crisis intervention or assistance finding a local mental health provider, the following resources are available:

  • Mental Health America: 1-866-400-6428 for referrals, 1-800-273-8255 for crisis
  • National Alliance on Mental Illness HelpLine 1-800-950-6264
  • National Suicide Prevention Helpline 1-800-273-8255

Crisis Text Line available 24 hours a day, text “HOME” to 741741

Mental health resources


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13. Arnetz JE, Sudan S, Fitzpatrick L, et al. Organizational determinants of bullying and work disengagement among hospital nurses. J Adv Nurs. 2019;75(6):1229–1238.
14. Sabatino L, Kangasniemi MK, Rocco G, Alvaro R, Stievano A. Nurses' perceptions of professional dignity in hospital settings. Nurs Ethics. 2016;23(3):277–293.
15. American Association of Nurse Practitioners. Position statement: use of terms such as mid-level provider and physician extender. 2015.
16. Associated Press Wire Service Content. Nurses, caregivers announce strike at Swedish Hospital. U.S. News & World Report. 2020.
17. Lardieri A. Thousands of nurses strike for more staffing, better patient ratios. U.S. News & World Report. 2019.
18. Morrison JD. Masterpieces of Religious Verse. New York, NY: HarperCollins; 1948.

anxiety; compassion fatigue; depression; emotional wellness; mental health; nursing; suicide prevention

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