April 27, 2021

Episode 55: Why we need a paradigm shift when it comes to nurse mental health

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Description

Our guest for this episode is one of the leading voices in the conversation around clinician mental health. Dr. Bernadette Melnyk is the Vice President for Health Promotion, the University Chief Wellness Officer, and the dean of the College of Nursing at The Ohio State University. She is nationally recognized as an expert on evidence-based approaches to a wide range of healthcare and wellness challenges.

She and Dr. Nurse Dan talk about how nurses are coping as the COVID-19 pandemic passes the one year mark, and why Dr. Melnyk thinks there is a mental health crisis lurking in our healthcare workforce. She shares her thoughts on the evidence-based techniques that can improve nurses’ well-being, the role of skills building and cognitive behavioral therapy in treating anxiety and depression, and why the idea that resiliency is an innate trait is a myth. 

Dr. Melnyk also shares her thoughts on why wellness leadership is so important in healthcare, academia and corporate America, and why we need to change our healthcare paradigm from sick care to well care. 

Links to recommended reading: 

Podcast

Transcript

Dan:
Bern, welcome to the show.

Bernadette:
Thanks, Dan, and I have to share this with the audience. I always look for the people with a twinkle in their eye and a fire in their belly. And you walked in as a senior nursing student to my dean's office, not even a month after I started in Arizona. I was so impressed that, one, you had the guts to come to me as a brand new dean at Arizona State. But, two, I just saw the innovation in the twinkle in your eye and a fire in your belly. But I tell other leaders, there's going to be resistors out there everywhere, no matter where you are and what you do. Don't spend a lot of time and energy on those people. You run with the people with a twinkle in their eye and a fire in their belly.

Dan:
That's something I think you're an expert at. You find those people, you rally them around, and you get stuff done in a world where, especially academia, where things move very slowly, there's a lot of bureaucracy, a lot of politics that have to be played, but you've been able to do that. I think your term for the resistors are the negatoids, right?

Bernadette:
Yes.

Dan:
What's some advice, how do you find that twinkle? Can you put words around how you find those high performers, those people that are willing to buck the system and move forward with you?

Bernadette:
I see those people, you just can palpate their energy and their enthusiasm. These people also tend to be the dreamers. Dan, you and I both were really big dreamers. I think sometimes leaders get really stuck in process and they forget how critical it is to build dreams in people. Because if people don't have dreams and purpose and passion, it's going to be really, really tough to create good momentum. When I interview a faculty candidate, say I've interviewed so many over the course of my career and have been blessed to attract just great people now for the last nine years to Ohio State, to Buckeye Nation. But I ask everybody when I interview them, if I could be your fairy godmother in the next 5 to 10 years, what will you do if you know you cannot fail?

Bernadette:
What still surprises me to this day is the majority of people can't immediately give me an answer. To me, that's sad. So many people have lost their ability to dream. And even through the pandemic, we need a dream and innovate more than ever right now. Probably the top answer I get from people is, people will say, "I want to get tenure," or "I want to get a big NIH grant." I always tell people, try not to have those things as your big dream. Think about the impact you want to make. Who do you want to help? What difference do you want to make in the world? If you focus on those things, the tenure will come. The grants will come.

Dan:
Yeah, those are all process things. Tenure and the grants are kind of processed, but the outcome you're trying to achieve isn't to get funding from NIH, the outcome is to find the answer to some big clinical problem or something you're passionate about, or to have established a career where you've made an impact that it's worthy of the tenure status. Those other things, they'll come as the byproduct.

Dan:
We talk about the same thing with operational leaders. They say, "My goal is to get magnet status." No, your goal is not to get magnet status; your goal is to build a culture that's worthy of magnet status. I think reframing out of the process or that end game to the outcome and the impact I think is really good.

Bernadette:
Absolutely.

Dan:
Bern, I know you have lots of dreams, and I want to dive into a couple of them, one being your passion and work around mental health, specifically for nurses. Your whole career has been dedicated to the mental health of both patients and kids, as well as nurses. What are you seeing now in the profession since COVID has been here? What kind of burnout, what kind of symptoms are you seeing in the profession related to their mental health?

Bernadette:
Well, right now, Dan, we have a mental health pandemic going on inside of the COVID-19 pandemic. Even before the pandemic, I conducted two national studies on the health and wellbeing of nurses. The first one, almost 2000 nurses from 19 healthcare systems throughout the country, more than 50% of the nurses reported poor physical or mental health. A third of the nurses met the cutoff on the depression scale that we used in that study. And we were the first study to show that depression was the leading predictor of medical errors that the nurses made.

Bernadette:
Now think about this: 250 to 400,000 people die in the United States every year from preventable medical errors that are made by well-meaning caring nurses, physicians, that are just totally burnt-out and depressed. With a pandemic, these issues have escalated even more, rates of depression, anxiety, post-traumatic stress disorder, and burnout. So our country, our healthcare systems, they have got to invest in the health and wellbeing of their nurses, their doctors, and all their healthcare providers. Sadly, the C-suite doesn't often make those connections. So what we've got to do, Dan, is help our C-suites to make those connections. If their clinicians are not well, their healthcare quality safety's going to go down and their costs are going to rise.

Dan:
That's such a good point to make. In one of the organizations I worked early on when burnout was kind of coming up through the physician lens, I was like, well, burnout's been around forever for nurses, but now that physicians are calling it out, now it's kind of becoming a thing sometimes. We were talking about it, and a lot of their early interventions were like, well, you need to take a day off, or you need to go do yoga. Or if you're just more resilient, you'd be fine.

Dan:
I would talk to my frontline colleagues, whether nurses or some of the physicians, and they're like, "Listen, if I'm told to do yoga one more time, I'm going to punch somebody." That's not the intervention I need. Number one, I need systemic changes around workflow and workload and expectations there, but also like yoga doesn't fix the underlying problem here. I wonder what you've heard, and I know you're very passionate about CBT therapy. What are some of the solutions that the C-suite could consider to support their mental health on a daily basis?

Bernadette:
I have been blessed to be one of 60 leaders that were appointed in 2017 to serve on the National Academy of Medicine's Action Collaborative on Clinician Well-Being and Resilience. We had a consensus study that came out last November, and that consensus report really focuses on what you were just talking about. And that is, one, we got to fix systems problems, because systems issues are a major contributor to clinician burnout, stress, and anxiety depression. So we've got to do that. We've got to build wellness cultures.

Bernadette:
In my studies, the two that I had mentioned before, nurses who perceived that their organization supported their health and wellbeing had less depression, had less anxiety, and were physically healthier. So perception of wellness support in an organization is critical, but culture eats strategy, we know that, for breakfast, lunch, and dinner. So you're not going to change culture overnight in an organization that hasn't had an investment in wellness. They got to be patient. You got to start somewhere. You got to appoint a leader to be a chief wellness officer like myself, who's going to spearhead your initiatives, who's going to improve your population health and wellbeing outcomes.

Bernadette:
It also has to start with our learning environments, academic settings. We have to grow up our students to learn how to take good self-care, to build wellness cultures, because they're often too in shock when they get out into the real world, and they're not equipped to handle the stressors that come from being in the real world.

Dan:
One of the issues that I see, too, is that we've just not normalized checking in with people, especially nurses, on a regular basis as part of the shift that they work. I think we expect them to come ready to work. We do maybe a huddle in the morning or that night, depending on what shift you're on, you do your work, and then you go home. But you could have seen a bad code, watched a family member cry, hold a person's hand, watch them die. Then we kind of normalize all that as, well, that's just normal part of work, then. See you tomorrow. Are there ways that we can embed 5- to 10-minute strategies in the normal workflow of a nurse that could support them and help them just reframe, like you mentioned?

Bernadette:
Absolutely. There's been a strategy called Pause, that I think you probably have heard of. That is, after a patient dies, for the team to come together and pause and respect that person's life and share their emotions and feelings. I always focus on these brief evidence-based interventions. I think sometimes, Dan, we make this whole thing too complicated.

Bernadette:
My team did a systematic review of the interventions to improve the mental health wellbeing, healthy lifestyle behaviors of nurses and physicians. There's a couple really simple evidence-based techniques that we can use that also decrease stress and improve mood. For instance, one is vitamin G. I tell everybody to take vitamin G every day. That's for gratitude. Not only be thankful and kind to yourself, but to others. We have so many studies that show a daily practice of gratitude, getting up every morning saying two or three people or things we're grateful for, creating that gratitude board on all our clinical units. We've done that here at Ohio State. So then when people come in to work, they write one thing on the board they're grateful for as a reminder that every day is a gift. Even through hard times, we can find silver linings and learn to appreciate those things.

Dan:
I love that. This is the ER nurse humor. A lot of people said, well, just give them vitamin A, which was code word for Ativan, but that's obviously not a great tool, either, longterm.

Bernadette:
I'm not going to endorse vitamin A. I'm going to stick with vitamin G for sure.

Dan:
We used to joke that walking into the ER, we should just have a shower, like a mist you walked through, and it was an Ativan mist, and then everyone just calm down and we could all just get our stuff together. But I think the gratitude is a much better tool there. I think you're right. It's a lot of reframing, and then it's support networks. I think nurses sometimes feel like they're on islands, and they don't have that support network. One thing we're excited about is building that community around health, normalizing that it's okay to not be okay, and then help direct people to the resources that they can learn about this stuff, or trainings, or even just to talk to somebody. I think we can do more of that throughout the entire workforce.

Bernadette:
Absolutely. You know, Dan, a lot of people, there's been so much research around resiliency and how it does help to protect us against both chronic disease, physical and mental health problems. A lot of people think you're either blessed you were born with resiliency or you're not. That couldn't be further from the truth. We can build resiliency skills throughout our lifetime.

Bernadette:
As a researcher, I have worked for all of my career to develop an evidence-based cognitive behavior therapy program, known as COPE in the literature. It's CBT. We know through tons of research, cognitive behavioral therapy, or skills building, is the best first-line treatment for mild to moderate depression or anxiety. But so few people get it, in large part because of the shortage of mental health counselors throughout the United States. But as a psychiatric nurse practitioner myself, I developed expertise in CBT, and 25 years ago, I said, this isn't rocket science. These are really good coping skills. So why don't I manualize CBT so that nurses, social workers, teachers in schools could deliver this seven-session CBT program.

Bernadette:
I tell you, Dan, so many researchers never get a chance to see what they developed be used. It is so awesome that my CBT program is being used now in all 50 states to bring help to children, teens, young adults, who wouldn't otherwise get treatment, and they're getting reimbursed for that.

Bernadette:
We just adapted that program for nurses, for physicians, for other clinicians, and we call it MINDBODYSTRONG. With that program, we are hoping to build these mental resiliency skills, because the root of so much depression, stress, and anxiety is negative patterns of thinking or cognitive distortions that people don't even realize they have because they have formed over so many years. So if we can help people when they're feeling stressed, anxious, depressed, to stop themselves and to say, "What was just going through my mind? Is it true? Is it helpful? Do I have the evidence to back this up?" Because they're going to find 99% of the time, no, what they're thinking was not helpful, was not true. So if you learn to stop those negative thoughts, turn them around to positive, you will feel so much more emotionally better.

Dan:
That's a great overview of the CBT and work, and I can attest that it's awesome. My wife Kim was on one of the research teams there and we got to see firsthand how impactful it was to the high school population and the young adult population, which is awesome.

Dan:
One of the things that we've heard from our nurses, too, and we saw this when Ohio State entrusted, built the crisis support line, that nurses have a armor around them, kind of the battle armor on, and it's hard to take that down and for them to reach out for help or acknowledge that there might be something brewing that maybe they need to talk to somebody about or get some resources around. What's your strategy on breaking that down a little bit, or making it okay for the nurses to reach out when they may feel like that's a weakness in the profession?

Bernadette:
I think you're so right. It's that kind of macho framework. We can go 12 hours without going to the bathroom and not eat the whole time, and that's been inculturated in people. So mental health stigma is still very alive and well in our profession, unfortunately. I think the more that we can say to people, it's okay to admit that you're tired. It's okay to admit you're having issues with some depression or stress. It's a strength, not a weakness, to be able to recognize those issues and to seek help for them.

Bernadette:
Again, if people feel guilt, I should be a better working mother, I should be a better working dad, or nurse, or whatever it is. Guilt and worry, I always tell people are the two most wasted emotions, which is why if we can teach people along with the CBT skills how to be more mindful in the present moment, that will also go leaps and bounds to help them. Plus, Dan, we have got to change the language of licensing boards and the questions they ask, because so many people don't admit when they've had an issue in the past, because a lot of licensing medical boards, nursing boards, still ask about past mental health issues. So we've got to change that language, and I'm currently working on that.

Dan:
That's great. I think that if we can break through that and normalize it as part of the professional practice, even, of nursing, I think that's just going to serve us even more. I want to pivot a little bit to some of the changes you've seen from your perspective as a dean with the pandemic. I spoke recently with Dr. Ernest Grant from the ANA about his view of things. He mentioned there was an uptick in nursing school enrollments that he's hearing about because of the pandemic. I'm wondering if you've seen something similar around nursing school enrollment or inquiries about going to nursing school. And what has really changed for you since the pandemic has started?

Bernadette:
Well, we get slammed with applications at Ohio State, we really do. Unfortunately, due to limitations in clinical sites, we can't take all well-qualified applicants, which break my heart, because we need nurses so desperately. So the pandemic has not blunted applications at all. In fact, our applications are up. We are a very large college of nursing with about 2400 students now. As far as our faculty, I think, again, we were so blessed, because in a lot of other colleges who weren't experts in online education, we certainly were. I will tell you, Dan, I'm seeing this across the country, faculty are tired. I call this COVID-19 Zoom fatigue, because we're often on Zoom from first thing in the morning until six o'clock at night. What I've advised our faculty to do is take these micro recovery breaks during the day.

Bernadette:
Like for one, cut the length of your meetings down even by 10 minutes, so you have 10 minutes to do some physical activity or mindfulness. Those micro recovery breaks are important. Then the amount of sitting that people are doing right now is killing us, literally. Sitting is the new smoking. Even if we sit three hours a day, we increase our cardiac risk by 30%, and it zaps our energy. Bottom line, we've got to stand more, move more, and sit less. We also have to let go a little bit of these very high expectations we have of ourselves and our students. I tell our faculty, look at assignments. Do you really need all of these assignments?

Dan:
I know.

Bernadette:
We still want to put out highly qualified nurses, but we've got to recognize this pandemic has caused problems with even more burnout, more depression, more anxiety, and we got to lighten up just a little bit for our own sake and for our students.

Dan:
Yeah. That's a good point. Being faculty at Ohio State and teaching in the MHI program, and then this semester I'm teaching in the APRN program in their leadership course. For the last two semesters, at least in the first month of each semester, it's been, hey, something, life has come up. Either I've got COVID, or I have a family member issue or just something. And I think just being flexible around that. My view is, ultimately, all those due dates and things are sort of arbitrary. At the end of the day, you got to complete the semester, but there's flexibility that both faculty can have and students can have that just allows people to better fit things into their chaotic world at the moment. That seems to help and lower the stress levels even to the point where...

Dan:
Last semester we had a conversation with a student who had to withdraw and things for some life issues. It took a weight off her shoulders to know she was welcome back the next semester and it wasn't going to hurt her chances to ever graduate with a degree. I think just having that positive attitude and talking and being real about what's happening in the world, I think is also a great step that we could do there.

Bernadette:
Dan, before we ended up signing off today, I really want to give a pitch for nurses in chief wellness officer positions. These positions are growing like crazy throughout the country right now, because the institutions, medical centers, hospitals, are recognizing that they do need to invest more in the health and wellbeing of their people. But there are very, very few, I don't know another nurse right now who was in a chief wellness officer position like myself. I was so fortunate when I came to Ohio State. It was actually a negotiated role for me. I was heavily recruited by Ohio State to throw my hat in the ring for the nursing deanship. But I said, "I'm humbled you thought of me, but I have no intention of making a lateral move. However, if there were an opportunity to combine the dean's job with the university-wide leadership role as the chief wellness officer, I might talk with you all."

Bernadette:
The next thing, our former president Gordon Gee called me and said, "Bern Melnyk, what's all this hype about a chief wellness officer? And what would you do if you came to Ohio State in that role on top of what we already do?" That's how the first CWO position at a university came to be. There were already CWOs in corporate America, because corporate America realized, one, before academia did how important that wellness leadership role was. But now, because of the National Academy of Medicine Action Collaborative, we've really been publishing and promoting the role of CWOs.

Bernadette:
I'm in a network now of about 30 of us. The majority are physicians, and that's fine, but I really want to encourage nurses who have always been proponents of health promotion and wellbeing. We are so skilled to be able to step up in these leadership roles to improve population health all throughout the country, and I'm not sure why our profession hasn't really caught on to this role yet.

Dan:
We just held an event recently, an online event, where we talked about roles beyond the bedside. And there was a fair amount... We had over 150 nurses sign up and show up online. And the questions in the chat really revolved around this wellness or wellness coach role, which is the entry to that track of chief wellness officer. So I think there's a lot of energy around it, and I see it on social media, I see it on LinkedIn. I think there's a lot of nurses who see that the profession needs somebody like that to support. What's the track to become a chief wellness officer? What kind of training should you have? What kind of degrees are there? Or is it really just a passion that you take and figure out where you can fit within an organization and grow it from there?

Bernadette:
That's a great question. I think honestly that physicians, nurses, nurse practitioners, are ideally suited to this particular role. In terms of track, I think there needs to be some good experience in this whole field of health promotion, behavior change, population health improvement. Again, there's such a need for so many of us CWOs out there. I personally talk to university presidents, the C-suite of medical centers, who they call me and ask for my opinion in what should the job description look like, how many years of experience. There's going to be more growth in wellness coaches. There's going to be more growth.

Bernadette:
Dan, I believe, and I keep pounding the drum, that we need to change our paradigm in the United States healthcare system from sick care to well care and focus on prevention. We'll always need good management, evidence-based, of chronic conditions. But right now, our healthcare system only invests 8% in prevention and wellness. It's no wonder why we rank so low in health outcomes amongst other Western world countries.

Bernadette:
Unless we boost what we're doing in prevention and wellness, we're going to continue to have one out of two people in this country affected by chronic disease, when 80% of chronic disease is totally preventable with just a few healthy lifestyle behaviors. The behavior change is what I call character building. It's not easy. That's where cultures, wellness cultures, that makes healthy behaviors the norm, are so critical.

Dan:
Yeah. And I know Ohio State has a number of degree tracks that focus on that, as well, related to wellness and even embedded in the nursing program and the other professions, so check those out.

Dan:
Bern, it was great to have you on the show. One thing we like to do at the end is share that one nugget, that handoff to the listeners, about what they can do and take tomorrow to be awesome in their roles. What would you like to hand off to our listeners?

Bernadette:
I think I would like to tell people to focus first on their self-care. It is not selfish to build in self-care every day, because we cannot continue to pour from an empty cup. So even if it's 5 to 10 minutes a day, do something that brings you joy and improves your wellbeing. If you don't take the time to do this now, you'll have to make the time for illness at far too young of an age.

Dan:
That's such an important point. And that's everything from taking a break to the things we talked about today, to just reaching out and opening up about anything that you're feeling about. I think you're right. We got to take care of it now, or it just builds on itself for later.

Dan:
Bern, thank you so much for being here. I know you're on Twitter, on LinkedIn. You can look at Ohio State's nursing program. You're all over the web and speak frequently. So check Dr. Melnyk out wherever you can find her. If you ever have a chance to work with her, it's the best experience you could have. So Bern, thanks so much for being on the show.

Bernadette:
Thanks, Dan. I'm so proud of you, honestly, and you keep dreaming, discovering, and delivering.

Thank you and welcome to the Trusted Community!
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