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Evaluation of mental health support and needs for emergency department providers

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Evaluation of mental health support and needs for emergency department providers

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Evaluation of Mental Health Support and Needs for Emergency Department Providers

Angie Crystal Palmer Simonson

Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education

May 2023

© Copyright by Angie Crystal Palmer Simonson 2023
All Rights Reserved

The Committee for Angie Crystal Palmer Simonson certifies the approval of this Dissertation

Kimberly Hirabayashi
Courtney Malloy
Eric Canny, Committee Chair

Rossier School of Education
University of Southern California
2023
iv
Abstract
This study applies the social cognitive theory (SCT) from Bandura’s research on the person,
behavior, and environment concerning accessing mental health resources for emergency
department providers. The purpose of the study was to identify what if any, mental health
support resources emergency department providers currently use. Also, this study reviewed
what resources emergency department providers would find helpful to support their mental
health, decreasing career attrition and suicide. The interview participants included providers
who work in the Formation Healthcare emergency departments, have been employed for 2
or more years, and have been licensed for over 3 years. Out of this population, eleven
providers completed interviews. The interviews were analyzed to discover themes on the
current mental health resources and recommended future resources. Findings from the study
indicated providers do not use the mental health resources available today due to two
fundamental issues: time constraints and concerns with the stigma related to asking for help.
Analysis revealed that increased structured peer support, paid time off, telehealth services,
and unique support offerings would reduce the use barriers and increase participation in
mental health preventative maintenance and support. The study found low-cost, high-reward
opportunities to keep providers and reduce suicide in the emergency department provider
population.

v
Dedication
To Mom and Dad, without your unwavering belief in education and instilling in me knowledge is
power at any stage of your life; I would not be here today. Your unconditional love has given me
the power to chase my dreams without fear of failure.

To my Hubby- Jason, you indeed are my rock and the LOML! There is no challenge,
opportunity, or adventure we cannot tackle with our love. This degree would not have happened
without you and your incredible understanding when school had to come first, vacations
postponed, and life had to become school, work, and repeat. Endless appreciation for all you did
to support this dream every step of the way.

To Clayton, I will never forget you and your impact on this world; we must do better with mental
health support, and I promise to advocate for this compelling cause! Those in healthcare, only
you know what you go through each day and the toll it takes on your life-support each other with
kindness- remember life is a short journey, always lead with compassion.

To Kissy, Mambo, Palmer, McKenzie and McCallister: Your snuggles, love and commitment to
being with me made this journey possible.
vi
Acknowledgments
To my study group Richard, Nancy, and Chris are three individuals whom I not only look
up to; but count as friends. Thank you for holding me accountable while giving grace, always
being a text message away, and for your unwavering compassion.
To my committee members and my chair, you are incredible scholars, teachers, and an
inspiration; each of you change the lives you touch daily and the many who read the works of
those you support. Thank you all for being a fierce, supportive influence.

vii
Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ....................................................................................................................................... v
Acknowledgments.......................................................................................................................... vi
List of Tables .................................................................................................................................. x
List of Figures ................................................................................................................................ xi
Chapter One: Introduction to the Study .......................................................................................... 1
Background of the Problem ................................................................................................ 1
Purpose of the Study ........................................................................................................... 2
Significance of the Study .................................................................................................... 2
Overview of Theoretical Foundation .................................................................................. 5
Definition of Terms............................................................................................................. 5
Organization of the Study ................................................................................................... 6
Chapter Two: Review of the Literature .......................................................................................... 8
Environmental Factors Influencing Mental Health............................................................. 8
Theoretical Foundation ..................................................................................................... 22
Summary ........................................................................................................................... 26
Chapter Three: Methodology ........................................................................................................ 27
Overview of Design .......................................................................................................... 27
Instrumentation ................................................................................................................. 31
Data Collection ................................................................................................................. 32
Data Analysis .................................................................................................................... 34
Credibility and Trustworthiness ........................................................................................ 34
Summary ........................................................................................................................... 35
Chapter Four: Findings ................................................................................................................. 37
viii
Participants ........................................................................................................................ 38
Results for Research Question 1 ....................................................................................... 39
Results for Research Question 2 ....................................................................................... 45
Summary ........................................................................................................................... 56
Chapter Five: Recommendations .................................................................................................. 58
Discussion of Findings ...................................................................................................... 58
Theoretical Framework ..................................................................................................... 61
Recommendations for Practice ......................................................................................... 62
Resources .......................................................................................................................... 72
Company ........................................................................................................................... 72
Days available ................................................................................................................... 72
Time available ................................................................................................................... 72
Cost ................................................................................................................................... 72
TBD................................................................................................................................... 72
Monday thru Sat ................................................................................................................ 72
Noon/noon......................................................................................................................... 72
$5/item .............................................................................................................................. 72
Oil change ......................................................................................................................... 72
TBD................................................................................................................................... 72
Tuesday, Thursday, Friday ............................................................................................... 72
8am/2pm ........................................................................................................................... 72
$35..................................................................................................................................... 72
Meal delivery .................................................................................................................... 72
TBD................................................................................................................................... 72
Monday, Wednesday Friday ............................................................................................. 72
ix
10am/ 8pm ........................................................................................................................ 72
$9/Meal ............................................................................................................................. 72
Limitations and Delimitations ........................................................................................... 73
Recommendations for Future Research ............................................................................ 73
Conclusion ........................................................................................................................ 74
Appendix A: Interview Protocol ................................................................................................... 87
Introduction to the Interview ............................................................................................ 87
Conclusion to the Interview .............................................................................................. 88
Appendix B: Information Sheet for Exempt Research ................................................................. 89

x
List of Tables
Table 1: Responses to the Questions Asking About Years of Experience,
Role, Location and Gender 39
Table 2: Responses to the Questions Asking Understanding of Resources 41
Table 3: Opportunities for Support Scheduling 72

xi
List of Figures
Figure 1: Social Cognitive Theory, Access to Mental Health Resources
for Emergency Department Providers 25
Figure 2: Sample Resources, Ready Set Wellness 42
Figure 3: Physician Wellness Individual to Institutional Practices 64
Figure 4: Top Mental Health Priorities 69

1

Chapter One: Introduction to the Study
Emergency department providers lack the proper mental health resources and support.
Increased patient load, amplified hours, and lack of support staff increase work stress
(Mamidipalli et al., 2020). The continuous stress and lack of mental health resources lead to
career attrition and suicide (Wilkinson et al., 2017). A physician’s death by self-harm is 2.5
times more likely without peer support than the public (Najjar, 2020). Research from
Panagopoulou et al. (2019) states healthcare organizations place the ownness of mental health
and attrition on providers with a lack of self-care opportunities, overburdening of roles, and
increasing demands. Wong et al. (2020) agree the increase in mental health concerns develop
from life’s tragedies where healthcare teams are continually a frontline audience. Through
Vigil’s (2021) research, the mental health numbers shown are greater in the provider population
by 23.3% for providers with suicidal ideations, 15.7% for suicidal plans, and 10.9% for
attempted suicide in comparison to the public. In support of strong mental health, Hooper et al.
(2021) argue mental health interventions create a safe space for workers to develop strong habits
supporting self-efficacy. The critical need to understand these healthcare providers’ current
mental health landscape will ensure future resources decrease career attrition and the risk of
provider suicide.
Background of the Problem
To examine the current state of healthcare and provider needs and analyze what resources
are available, Formation Healthcare (pseudonyms used) was the organization of the study.
Formation Healthcare is a system comprised of double-digit hospitals and affiliate locations in
the western United States, including in-patient, outpatient, and support services. The mission of
the organization is religious in nature, using the teachings of Christ to serve their communities
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through healthcare. This organization is rooted in solid values, which led to the creation of a
strategy to align the past with the future of healthcare in growth, alignment, and patient safety.
Staffing these locations is 30,000 caregivers with varying levels of education, ability, and
responsibilities. This study’s selected field of focus is approximately 250 emergency department
providers working at hospital facilities, not free-standing emergency departments or urgent care
sites. The Formation Healthcare organization has not previously taken part in any provider-
focused mental health resource studies increasing the importance of this study and the research.
Purpose of the Study
The purpose of the study is to review the current mental healthcare resources available
for providers, the day-to-day behaviors which affect the use of these resources, and the barriers
the system needs to remove to ensure mental health support for emergency department providers.
This problem of practice has been studied; with a focused lens on training, global pandemics,
and lack of resources, but for this study, a micro lens will focus on mental health resources at a
local level.
Two research questions guided this study:
1. What mental health resources are emergency department providers aware of and use,
if any?
2. What services and resources do emergency department providers need to support
their mental health?
Significance of the Study
The Formation Healthcare organization’s recruitment needs for emergency department
providers continue to increase in conjunction with the increased patient volume, retirement, and
attrition from the system. With all healthcare institutions often vying for the same providers,
3

reviewing providers’ mental and physical well-being and the system’s wellness support
resources is imperative. In the 2021 –2022 fiscal year, Formation Healthcare’s attrition of
emergency department providers has doubled compared to the past five fiscal years (Formation
Healthcare, 2022). Upon delivery of exit interviews, the stress of healthcare and the increasing
demand for physicians is the most significant reason for leaving the organization (Formation
Healthcare, 2022). Brooks’s (2018) research posits upwards of 16% of providers surveyed are
leaving the workforce or reducing their hours due to stress and concerns about the future of
healthcare support. This loss is 1 million (U.S.) dollars per physician based on revenue,
recruitment, relocation, and sign-on dollars (Brooks, 2018). This out-migration trend of
providers is not sustainable while continuing to supply emergency services in every community
Formation Healthcare serves. The importance of physician wellness is stressed, but often at odds
with provider professionalism and the Hippocratic Oath at which patient care should come above
all else (Lemaire, 2018). The continued shift in physician mental health is associated with
increased patient-care demands, payment issues, amplified accountability, and conflicts between
systematic healthcare and patients.
Wallace (2008) posits these barriers lead to a decline in physicians’ autonomy,
snowballing stress. Without daily fulfillment, healthcare workers display signs of mental health
stress, decreasing their ability to act with understanding and empathy amongst their peers and
patients and increasing stress levels (Wilkinson et al., 2017). According to Papathanasiou (2015),
burnout syndrome includes the ramifications of exhaustion hindering work performance,
negatively reflecting on patient care, leading to career attrition and mental health concerns.
Perfectionism coupled with the high performance of emergency department providers and the
attention to detail, the responsibility of making swift life-altering decisions, longer hours, and
4

decreased time with patients increase the risk of stress and depression (Wilkinson et al., 2017). In
addition to the cost of loss and recruitment, career attrition of medical providers is also costly
due to relocation, training, and time without coverage.
The accessibility and presence of resources when offered, Choudhury et al. (2021) say,
reduces healthcare workers’ stress and develops coping strategies, psychological safety, and
evaluation habits. Moll (2014) argues a provider’s positionality is rooted in being in control and
invincible; to ask for mental health support or use resources is in opposition to their training. In
Wallace’s (2009) study, of the physicians surveyed, 17% described their mental health as fair or
poor leading to mental health concerns and career attrition estimated at 25 –60% of all providers.
This oversight of personal care can be detrimental. Koninis et al. (2015) agree on professions
where human contact is paramount, there can be grave consequences to continually bypassing
your personal needs.
Emergency department providers in high-trauma and high-stress low, control professions
have increased impacts of PTSD due to repetitive work stressors (Carmassi et al., 2020).
Choudhury (2021) contends more than half of healthcare workers who have mental health needs
after the pandemic has increased anxiety or depressive characteristics. Chang et al. (2018) posit
being in healthcare is a daily assessment and building of needs, not a one-time cost and-benefit
analysis compounding overtime leading to attrition. Hawton’s (2000) research states emergency
department providers are more likely than the general population to commit suicide by 1.4 times
for males and 2.3 times for women. The most severe of the provider outcomes is the decision of
an emergency department provider to take their life by suicide; per Hawton et al. (2000),
research states doctors committing suicide with drugs was more common than the public by
5

31%. Providers are not invincible and often do not recognize their mental needs, which makes
healthcare wellness resources increasingly important.
Overview of Theoretical Foundation
Utilizing the social cognitive theory (Bandura, 2020) supports the need for research
between people, their environment, and their behavior as the structure for this research. The
fundamental concepts of the relationship between patient, provider, and system have significance
in finding why providers are leaving a “calling” profession due to their mental health, burnout,
stress, and anxiety. Social cognitive theory (Bandura, 2020) stresses the interaction between a
person’s motivation, behavior, and cognition leading to control over their actions, thoughts, and
feelings. The social cognitive theory is well aligned to help understand how a career in
emergency department medicine affects the mental well-being of providers. Godin et al. (2008)
research argues social cognitive theory in healthcare workers includes beliefs about social
influences, moral norms, personal capability, intention, and habits ending in behavior. A
quantitative study with interviews was completed to understand providers and their relationship
to their past, the work environment, and mental health.
Definition of Terms
Below are the words and phrases included in this study. To ensure an agreed-upon
understanding, the definitions used in this paper are as follows.
Attrition from the Nursing Standard (2000) is the number of healthcare workers leaving
the workforce through action or process of gradual reduction.
Advanced practice providers per Sarzynski and Barry (2019) state advanced practice
providers are nurse practitioners, physician assistants, certified nurse midwives, clinical nurse
specialists, certified registered nurse anesthetists, and other licensed non-physician providers.
6

Burnout is considered the combination of emotional exhaustion decreased personal
accomplishment and depersonalization, creating burnout syndrome, including depressive
symptoms (Bianchi & Schonfeld, 2017).
COVID-19 or known as Coronavirus Disease (COVID)-19 is present when respiratory
illness is present and at least one symptom of respiratory disease by contact with a confirmed or
probable COVID-19 case. (Tanno et al., 2020).
Emergency department (ED) or Emergency Room (ER) of a hospital is open 365 days, 24
hours a to anyone seeking emergency care. A hospital location that handles acute emergency
care, public health surveillance, occupational care, and disaster support (Moskop et al., 2008)
Mental health according to the World Health Organization ([WHO], 2004), mental health
is a state where the ability to cope, be productive, and live well with a contribution to their
community are realized by an individual.
Organization of the Study
The overview of this five-chapter study started with an introduction to the problem of
practice and the importance of the problem in chapter one. The second chapter will review the
literature and research to continue the review of providers’ mental health support and outcomes.
Beginning with the past and present effects of mental health concerns, leading to suicide and
career attrition on emergency department-trained providers, the environmental factors affecting
providers, the barriers to using healthcare, and strategies to support positive mental health with
wellness resources. Subsequently, the framework of social cognitive theory is used with
alignment to this research study. Chapter three reviews the methodology and the background for
qualitative research through interviews. In chapter four, the findings from the research study via
interviews are presented and reviewed, and themes are identified from emergency department
7

providers in Formation Healthcare. This research study concludes with chapter five
recommendations for improving healthcare providers’ mental health by reducing attrition and
provider suicide through robust mental health resources.

8

Chapter Two: Review of the Literature
The literature review examines the past and present mental health landscape for
healthcare providers in emergency departments of in-patient hospital facilities. The research
questions and paper sections are organized by mental health resources, organizational
environmental effects, and barriers to using wellness resources. Each section presents literature
from the provider and health system perspective, as tackling mental health support for
emergency department providers is collaborative.
Environmental Factors Influencing Mental Health
An emergency department provider’s mental health is shaped by the environment in
which they work in conjunction with their background and training. Moskop et al. (2008)
research reinforced the repetitive stress of this subset of providers and its adverse effects on their
mental health, including depression, anger, and sadness. The history of providers pushing their
mental health so extensively, leading to taking their lives, is impactful in need for change
(Najjar, 2020). The research Najjar (2020) did in conjunction with the review from the Center for
Disease Control shows a disproportionate mortality ratio, suggesting physicians are 2.5 times
more likely in comparison to other occupation groups to die by suicide due to their environment.
The research presented by Kishor et al. (2021) said more than 50% of the providers who
committed suicide had diagnosed mental health concerns without treatment or system support.
The research on providers’ suicidal ideations from Brooks et al. (2018) states reviewing this data
can help review and protect providers who are currently struggling with mental health and other
providers in the profession dealing with environmental effects. When untreated, these amplified
concerns, coupled with the increased access to self-soothing medications at work and decreased
access or willingness to seek care, increase the likelihood of physician suicide (Kõlves & De
9

Leo, 2013). These risks have continued to increase over time without meaningful environmental
solutions and safety nets.
Medical School Training
Medical school training must include a provider’s mental health landscape to combat and
create a basis for coping skills. Currently, the medical school curriculum is light on mental health
awareness for providers. Without training to have a keen eye for signs of mental health distress,
there is often a miss in identifying personal or peers’ mental health needs (Dutheil et al., 2019).
Research in addition to Dutheil et al. (2019) and Rubin (2014) states medical schools lack
information on students’ reasons for attrition out of the workforce or schooling, specifically
those who died by suicide. In addition, often schools and employers do not want to report this
data as it could affect their recruitment. Schernhammer and Colditz (2004) review the long-
standing evidence supporting the type of person who chooses to join the medical community as
an altruistic profession absent of the long-standing increased risk for suicide. Medical schools
must continually review the training on mental health support; understanding ways to reduce the
stigma is imperative to improve the usage of mental health resources for emergency department
providers.
Access to Mental Health Resources
Available mental health resources can help support positive outcomes and decrease
mental health concerns, although this is only a part of history. According to Downs et al. (2013)
study, in the past decade, there has been increased work in finding providers who are positively
affected by mental health support; but less has been done to create platforms and interventional
resources. Although changes in the environment do not prove to be a complete solution,
Manning et al. (2015) confirm the usage of wellness resources and decreased access to
10

medication does protect a provider’s mental health. Mental health support is ongoing and starts
with creating a resiliency foundation during schooling and continues to be critical throughout a
career, with a review often needed based on the current environment’s underlying healthcare
concerns.
Today’s mental health solutions are typically two-pronged, an assessment and face-to-
face educational programs focused on: destigmatizing, finding, treating, and educating on the
profession’s risks. Downs et al. (2013) research states this typically takes place prior to full-time
employment. Since the assessment is completed before employment, it considers the lack of
time, stigma of needing help, privacy, and career impact Downs et al. (2013), which takes place
in a career setting. These environmental factors decrease the glamor often associated with being
a provider or being in healthcare. Brooks et al. (2018) emphasize the importance of providers
understanding their health needs, improving patient care, and encouraging providers to own their
mental health with or without a supportive environment. In turn, this ownership in a physician’s
well-being helps drive positivity in using resources supplied or seeking resources available,
creating an environment of support for other providers. The overarching concern was not simply
about suicide and attrition in the physician population; this population, surrounded by other
caregivers, is seeking an environment where it is safe to ask for help without judgment (Najjar,
2020).
Stigma of Behavioral Help
In the research study presented by Schernhammer and Colditz (2004), they say
physicians in the medical field have a higher rate of death by suicide than other professions
exceeding the general population by four times. Even when mental health needs are identified,
there is an unwillingness to seek treatment due to stigma and fear, and treatment could lead to
11

changes in employment, shame, or suspension of a medical license (Rubin, 2014). In the region
of the United States, Formation Healthcare has facilities; there is no reporting requirement if
emergency department providers use mental health resources unless they rise to the level where
patients are in danger (Formation Healthcare, 2022). A physician’s reluctance to seek help is one
of the factors hindering healthcare institutions from spending money and resources on physician
wellness; it often looks as though resources are not needed or not used, as suicide rates are often
not reported (Dutheil et al., 2019). Some reluctance could be improved with training, ensuring
physicians are aware of resources and their protections to stay anonymous and the importance of
seeking help early and often (Fish & Steinert, 1995).
The suicide rate among physicians is higher than the general population, and due to their
avoidance of seeking help, it is often more concerning when providers ask for help (Rubin,
2014). Fish and Steinert (1995) posit there are connections to physicians’ being in the role of
caretaker, and by being a healthcare provider, they feel precluded from asking for help for
themselves. In addition, there is a fear of losing the confidence of their peers, increasing the lag
time for providers to seek help. According to Daskivich et al. (2015), their systematic review
found statistically significantly higher suicide rates among practicing medical professionals
compared with the general population due to the lag time in care. According to Rubin (2014), the
statistics are striking each year, 300 to 400 physicians take their lives in the United States, which
equals the approximate graduation of three medical schools yearly. Cornette et al. (2009)
research suggests physician suicide is 2.45 times more than non-physicians. Notably, the overall
mortality rate among physicians is lower in comparison with the general population, apart from
the suicide rate, where the mortality rate is significantly higher in this population (Harvey et al.,
2021). As aforementioned, Harvey et al. (2021) research on depression and anxiety proves it is
12

higher in emergency department physicians than reported in other occupations leading to a
higher risk of suicide. Many of these basic physician needs are addressed by closer
communication and collaboration with providers early in their careers using psychological safety
to speak up for mental health.
Physician Mental Health
Hippocrates wrote the Hippocratic Oath to implore physicians to answer to a higher
calling for their profession and do no harm to their patients. Although full effectiveness could be
argued, this Oath has created a shared responsibility amongst providers for their patients; but it
has undermined their responsibility to themselves. There is an acute need to put physicians’ well-
being or self-first by transforming the workplace attention to education on emotional well-being,
psychological safety, and mental health support of emergency department providers. Dutheil et
al. (2019) explored the reasons behind the high physician suicide rate being two times more
likely than the outside population. They found it is explained by reviewing the social work
environment for its lack of psychological safety. With continued conflict or lack of teamwork
when unresolved issues arise, there is a decrease in work satisfaction and increased stress
(Dutheil et al., 2019). Decreased work satisfaction and the implications of requiring providers to
deliver tragic news to patients and families daily amplify the need for perfection, leading to
increased depression, anxiety, and mental health concerns (Dutheil et al., 2019). The rudimentary
foundation of being a doctor is caring for others, implying the culture is not to ask for personal
help (Fish & Steinert, 1995). The increased demand for providers is partly due to the constant
changes in healthcare compounded by provider attrition and suicide rate.
13

Provider Habits
There are significant barriers to making a change in the space of physician attrition and
mental health. Kuhn and Flanagan (2017) argue as the basis of burnout leading to attrition is not
only the barriers of current healthcare delivery, but also the medical school teachings of
excellence, competence, and compassion. These teachings, layered by the Hippocratic Oath, can
be powerful; but also create dangerous habits for physicians to deny needs such as sleep and
recovery time, further burdening mental health (Wilkie et al., 2022). Physicians often deny their
most basic needs, including the need to discuss work, patients, and tragedy, removing the ability
for peer support (Kuhn & Flanagan, 2017). The concept of a physician well-being program as a
one size fits all approach does not find success in changing an emergency department physician
environment. In turn, the cost of physician burnout is highly associated with increased medical
errors, physician distress, career attrition, and increased suicide rates for this subset of providers
(Schwartz et al., 2019). It is essential to note the past structure of physician personnel initiatives
for mental health support has not been working; in turn, organizational support mechanisms are
needed by healthcare systems to promote physician well-being (Dyrbye et al., 2010).
The continual time and mental exhaustion providers spend consulting on patients’
diagnoses and outcomes affects providers’ long-term mental health. There are mixed emotions
for providers in creating connections with patients while seeing continued patient tragedy leading
to mental health decline and burnout (Redinbaugh et al., 2003; Lökman et al., 2011). Providers
aim to provide quality care, but their ability to do this objectively with increased pressures from
patients and the profession proves challenging, increasing daily levels of anxiety and depression
(Lökman et al., 2011). Lökman et al. (2011) research says the constant impending crisis
environment in a hospital setting creates unpredictability, leading to anxiety and depression.
14

There must be a “why” behind physician attrition and mental health decline; at the core, it is
work-related concerns: changes in autonomy, increased administrative needs, decreased support,
and perfectionism which can haunt a high achiever without good coping strategies (Wilkie et al.,
2022). The increased emphasis on patient satisfaction also continues the stress of decision
making leading to depression (Cornette et al., 2009). Furthering this thought, Wilkie et al. (2022)
and Schrijver (2016) research state the absent support of peers leads to higher provider burnout,
career attrition, and suicide from disengaged leadership, undefined strategic alignment of the
healthcare system, decreased resources, limited accessibility, and unclear communication tactics.
System Working Conditions
The healthcare system’s environment plays a significant role in a provider’s mental
health and is critical to understanding the background of a physician’s usage of resources.
Brooks et al. (2018) research reviews the personality baseline of physicians who typically have
traits of perfectionism, which aids in beneficial patient care; but hinders the willingness to be
vulnerable. In addition, personality traits significantly influence how a person navigates work
stress and uses available resources (Manning et al., 2015). Being team-focused can hinder and
help the environmental factors in an emergency department based on the people in these roles
and how they support their medical team (Brookes et al., 2018). The unknown daily support team
for emergency department providers continues to pressure providers to put others before
themselves, increasing the stress on their mental health.
Correlation of Emotional Intelligence and Provider Judgement
Research from Rosenstein et al. (2021) supports that mental health awareness begins with
the emotional intelligence of having providers self-awareness of their needs, what help is
necessary for their physical and mental state, and attention to their current emotions. Although
15

research states dying patients and outcomes lead to depression, anxiety, and, if repetitive, could
lead to suicide; the more common emotion is guilt and stress linked to career attrition
(Redinbaugh et al., 2003). In addition, there is an identified need for more mental health
resources, specifically counseling and emotional preparedness to combat the stress stemming
from emotional anticipation, self-efficacy with weathering the daily storm, and the baseline
contextual concerns of medical decision-making (Kranke et al., 2021). The complexities of the
emergency department make this role and this work location even more intense and unknown.
Emergency department providers must help with urgent medical issues, given limited
support. This, coupled with the demanding- long hours, high volumes, and lack of job clarity,
increases the risk of attrition, stress, and anxiety (Chatzittofis, 2021). In addition, the COVID-19
pandemic further increased the stress and the negative impacts on mental and physical health
with the added fear of physical safety (Al- Jumaili, 2021). In many cases, the cognitive load of
providers is teetering towards overload. However, they could have the opportunity to balance
with debriefing after a catastrophic event, where the emotional toll on the individual provider or
team could be affected psychologically long term (Harder et al., 2020). The unknowns and
compounding stress of a provider’s shift led to continual stress stemming from decision-making,
trauma, and stress. Navigating a provider’s feelings and environmental support can help balance
the challenges a provider faces at work with any personal underlying mental health and wellness
concerns.
Adequate understanding of a provider’s judgment is essential to appreciate the quick toll
decision-making has on patient outcomes, lives saved, care navigation, and, conversely, on a
provider’s physical and mental health (White et al., 2016). The increased stress of decision-
making amplified during the pandemic, where the unknowns outweighed the knowns in
16

medicine, further affecting the mental health effects of providers (Al-Jumaili, 2021). Quick
decision-making creates lasting environmental effects on the culture in an emergency department
as stress, raw humor, and deflection become coping mechanisms. In addition, Ching et al. (2021)
find the psychological distress of a pandemic led to increased provider resignations and
reluctance to work due to their and their family’s health on top of increased emergency
department change. The emergency department setting is unknown and often unstable, with the
requirement of providers to be present leading to exhaustion from the environmental and
emotional impacts of the role.
Care Barriers
The background supporting Harvey et al. (2021) research concludes the number of
physicians with mental health support needs is between 13% and 36% as physicians are
unwilling to seek help due to concerns with confidentiality, consequences to their career or
license, and time constraints. A provider’s vulnerability to mental health can be challenging
when coupled with fear of seeking help and the cultural stigma, but there are distinct proof
providers are not immune to mental health concerns (Harvey et al., 2021). Allowing physicians,
the time to receive self-care is one side to the problem but breaking down the barriers to
physicians’ willingness to seek care is another. Hull et al. (2008) contend physicians must heal
others, supporting the notion that physicians should seek care and peer support. Due to these
underlying pressures, physicians and their peer group are likelier to have a higher rate of
depression, suicide, and substance abuse (Hull et al., 2008). In concurrence with the harmful
effects of not seeking mental healthcare, this lack of support affects personal and professional
relationships decreasing connection and furthering the struggles of wellness.
17

There are many barriers to a physician’s mental health due to career contentment, as
reviews of cost structures, quality improvement, and progressions of patient experience increase
pressures and stress on providers (Schrijver, 2016). To track the changes in mental health
concerns, Rubin (2014) reviewed the statistics on mental health for medical students entering
school compared to their physician counterparts who have been practicing. In this research,
Rubin (2014) found lower levels of burnout and depression for new providers than seasoned
providers if they joined a medical school emphasizing positive provider mental health. As a
physician’s career progresses and they become a productive practitioner, the stressors of the job
and constant changes become more burdensome due to habits formed (Fish & Steinert, 1995). In
turn, leading to a higher instance of suicide and attrition or, at a minimum personal conflicts and
emotional distress, which can lead to increased substance abuse, of which physicians have a 12%
higher risk than the general population (Schrijver, 2016). The problem of physician mental
health is not new but also is not getting better with current resources, so action from the
individual, their behaviors, and the environment will need to match the barriers from personal
views, job design, leadership behavior, and organizational attitudes.
Medical School Strategies to Address Gaps
The need for mental health support for providers has been staggering for years but
increasing physician suicide research requires prompt and vigorous action. Stergiopoulos et al.
(2020) research noted a significant shift in 2018 when the International Conference on Physician
Health invited physicians and healthcare systems to discuss and develop physician mental health
support plans. This presentation increased awareness of wellness needs, specifically ensuring
physician competency in baseline coping skills upon graduation from medical school
(Stergiopoulos et al., 2020). As recent as, 2015 was the first opportunity for medical students to
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report a disability and ask for support during their schooling; this included mental health support,
taking time off for self-care, and removing the stigma (Stergiopoulos et al., 2020). Execution of
this outcome was preceded by changing the medical school curriculum and requiring more
information before joining medical school, including added support for persons notating a
disability (Stergiopoulos et al., 2020). The creation of a baseline structure and timing of
implementation in schools aided in collecting the exact numbers of suicides from emergency
department providers and, in turn, the correlation to increased patient safety and outcomes
(Schrijver, 2016). Developing the coping skills in school to ask for help and understanding
physician needs will ensure baseline phycological safety is supported by emergency departments
and effectively woven through the providers’ health system.
Physician Behavior
Although the rigor and commitment to create avenues for change might be a newer
concept, some of these parameters were set forth as early as 1999 when the Accreditation
Council for Graduate Education (ACGME) met and created core competencies for providers
(Stergiopoulos et al., 2020). These competencies stemmed from the understanding of the mental
toll decreased professionalism in the workplace takes on providers, and with increased
collegiality, psychological safety increased (Dyrbye et al., 2010). Once a provider is employed,
there is agreement from Wilkie et al. (2022) and Stergiopoulos et al. (2020) on the increased
awareness of physician professionalism and how this can shape the work environment and
improve peer support. The renewed focus on reviewing physician behavior will increase
openness, transparency, and teamwork (Deutsch et al., 2021). To ensure commitment to this
change and understanding the current barriers, the structure of identifying unprofessional
behavior and clearly defining roles for future dialogue on professionalism is important
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(Schrijver, 2016). Compassion and kindness as the foundation of an environment of
psychological safety for providers in the healthcare setting are imperative to have beneficial peer
support.
Commitment to Mental Health
Deutsch et al. (2021) reviewed the development of mental health programs and the needs
for success based on six themes: ensuring the basic needs of the workforce are met, there is a
structure of shift needs, leaders supply feedback, providers are valued for the care they provide,
there is a development of a community within the clinical team and personal ownership of a
provider’s needs are addressed. For health systems to commit to developing more support
services in physician wellness, physicians must also commit to their and other physicians' well-
being, requiring self-regulation (Stergiopoulos et al., 2020). The lack of commitment to
collegiality training and understanding the resources available stifles the adoption of widespread
wellness programs from healthcare systems (Dyrbye, 2010). Furthermore, the lack of provider
commitment to cultivating their understanding of mental health both personally and
professionally has led to limited progress in behavioral health.
Decision Making
To successfully promote a provider’s mental health, which has been tried, but based on
the research not being successful, there needs to be a global approach starting with training,
continuing with expectations, and concluding with ongoing resources (Downs et al., 2013). Most
notably, providers want inclusive decision-making and do not want decisions made about them
without them. Due to various shift times and the unknown cadence of patients, their participation
at meetings is sparse, so it is challenging to ensure all physician voices are heard (Downs et al.,
2013). The reported physician satisfaction completed by Schwartz et al. (2020) says the positive
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attributes of an emergency department physician’s role are compounded by their relationships
with patients. With the shift in healthcare to an increase in physician leadership, control, and
decision-making, the time at the bedside has decreased, leading to distress, frustration, and
demoralization (Schwartz et al., 2020). This gap increases physicians’ frustration when there is
an adverse patient outcome, and they feel their competing priorities are to blame (Schwartz et al.,
2019). In addition to supporting the needs of providers at work, there is an emphasis on career
growth as physicians transition to leadership roles, prioritize self-care, and balance community
(Deutsch et al., 2021). In Jennings et al. (2022) research, the findings support the challenges with
work hours while balancing volumes and objectively being the sole person responsible for a
patient’s outcome. Finding the balance is crucial, although difficult with the ever-changing needs
of the physician population in conjunction with the fast pace of healthcare.
Work Structure
Concerns over time have surfaced, and solutions have been created for medical providers
working long hours or too many consecutive days, leading to career attrition and suicide. In the
mid-1990s, a safe hour-to-work versus days off ratio was included in most medical staff bylaws,
employment agreements, and policies (Carpenter & Swerdlow, 1997). Jennings et al. (2022) state
parameters around hours and high patient load expectations were also identified as a trigger to
mental health stress. The formalized expectations set in the 1990s improved patient safety,
outcomes, and employee wellness Carpenter and Swerdlow (1997); the same rigor must be used
to change the landscape in physician self-care and patient volume restrictions today. Fish and
Steinert (1995) believe there should be a robust physician support team to make meaningful
improvements in mental health support for providers. A team responsible for ensuring mental
health support is available out of the workplace in a safe and anonymous location, providing
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training programs to increase awareness and advocacy in the mental health space, and
developing a diagnostic group that can complete virtual checks for high-risk physician groups
(Fish & Steinert, 1995). In addition to these tactics, there should be a development of educational
programs shared with providers and their spouses for early awareness and support, as well as
mandatory peer support groups (Fish & Steinert, 1995). Including families in self-care can help
reduce the stigma and support early awareness of mental health concerns with support,
consistency, and set expectations of follow-through and commitment.
Behavioral Health Support Reform
To improve physician wellness and to supply resources needed for positive employee
mental health, according to Daskivich et al. (2015), behavioral health support is a tiered
approach of discussion, mentorship, and personal support, in an inclusive learning environment.
Importantly, as found in the research, wellness support will only be effective if there is a safety
net of outside support Fish and Steinert (1995); the net includes faculty, peers, staff, and family.
Baird et al. (1995) reviewed best practices to support physicians’ mental health prevention: the
creation of effective communication channels, physician support groups, online learning, and
monthly newsletters with information on mental health resources and support. Bolstered wellness
programs can help subside some mental health needs (Fish & Steinert, 1995). Healthcare is a
team sport, according to Cornette et al. (2009), and the research of Harvey et al. (2021) says the
ability to have a healthy workplace and workforce is crucial to patient outcomes. Harvey et al.
(2021) argue that the most significant current concerns are the increased burdens of
administrative duties, decreased autonomy, and increased demands in physician roles today
implicating mental health. These structural stressors lead to attrition and suicide in emergency
22

department physicians, and the development of meaningful solutions can be aligned with the
social cognitive theory.
Theoretical Foundation
The social cognitive theory formed the relationship between individuals, environment,
and behaviors (Bandura, 2020). This model has a triadic relationship with the mental process,
which develops a person’s beliefs based on their environment. Social cognitive theory has
relevance to the research on emergency department providers’ mental health resources as in the
function between the individual provider, their healthcare system, and their beliefs which aid or
hinder the use of mental health resources. The social cognitive theory allows for assessing
behavior, person, and environment where motivation, knowledge, and organization can be used
to review successes and opportunities (Bandura, 2020). The fundamental concepts of the
relationship between patient, provider, and system are important as research is completed to find
why providers leave a “calling” profession due to their mental health, burnout, stress, and
anxiety. Mental health support resources as a foundation are only helpful if they are in an
environment where providers are willing to seek help and are motivated to seek resources as
offered (Bandura, 2020). As Clark and Estes (2008) research say, improved motivation correlates
to behavioral indicators of active choice, mental effort, and determination. These traits are
needed to seek mental health support in trying times. The knowledge and motivation to look for
and use mental health resources are needed to support providers in their ongoing personal and
professional mental health journey.
Human Agency
In the constructs of the social cognitive theory and its relationship to a person’s mental
health is the importance of human agency showing a person’s degree of control over their
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actions, thoughts, and feelings; according to Schunk (2012), this starts by understanding support
mechanisms available. Locke and Sadler’s (2007) research supports the social cognitive theory
and its emphasis on ever-changing cognitive variables, including self-efficacy and values. In
reviewing the social cognitive theory and its relationship and grounding to the social
environment, there is a reciprocal relationship between the influences of a group on individuals.
Understanding the peer pressures that aid or hinder admitting the need for mental health support
and seeking this support is vital to developing successful resources. Jennings et al. (2022)
challenge chasing levels of professional achievement in conjunction with changed patient
attitudes, the risk of malpractice, and reduced autonomy leading to burnout, depression, and
suicide. The pressures of competition reduce the ability for camaraderie or support amongst
providers and, conversely, a willingness to ask for help or lean on a colleague.
SCT Identities
The social cognitive theory (SCT) is the proper lens to review mental health concerns in
healthcare; because it supplies ideas to influence actions, experiences, environmental factors, and
behaviors surrounding accessing resources. These parameters are solidified through expectations,
learnings, change management, and personal commitment. Godin et al. (2008) found past
behavior creates future habits. This leads to the social cognitive theory of self-efficacy,
controlling and executing one’s behavior. Manjarres-Posada et al. (2020) contend SCT highlights
the interactional relationships in healthcare, where a single person can affect their life with
reflection, regulation, and flexibility, all needed when seeking mental health resources. Chang et
al. (2018) state healthcare workers can make decisions to improve their well-being and mental
health. However, because of the high attrition rate of this workforce population, it will take the
triadic approach of person, behavior, and environment of the social cognitive theory to help
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develop resources. Additionally, Dos Santos (2020) supports this notion of a required framework
to analyze healthcare providers’ mental health using the lens of Triadic Reciprocity. These
connections create the work environment and its sustainability for healthcare workers.
It is through the lens of reinforcements, observational change, self-control, and self-
efficacy which drive this theory and the successful relationship in decreasing mental health
concerns among emergency department providers. Emergency department providers are tasked
with identifying patient concerns and making quick decisions requiring a provider to be well-
rounded in medicine and firm in chaos. Williams and Rucker’s (2015) research proves the
practicality of SCT in healthcare and the vast prospects it has in complex systems helping to
challenge momentous change. In solving a problem of this substantial size, it is necessary to
have a solid foundation, as in the social cognitive theory, to review the past and present barriers
to seeking mental health support for the emergency department provider population.
Social Cognitive Theory
This research uses Bandura’s (2020) social cognitive theory to review the personal,
environmental, and behavioral factors as the structure of the study. Providers need assurance the
healthcare environment supports and can recognize their mental health needs allowing for
collaborative sharing of mental health concerns without punitive measures. Moll (2014) states
healthcare providers spend endless hours pushing themselves and others to perform their job; this
perfectionism then creates an intolerance for those peers who are struggling with their mental
health, creating mental health support avoidance. Chirico et al. (2021) research reviews the
difficulties of training providers in healthcare as time is limited, stress is high, one-on-one
support is scarce and online resources often lack effectiveness. At the same time, organizations
are trying to be adaptive, creative, and supportive of providers’ mental health needs which is an
25

environmental, structural, and personnel challenge. To create positive mental health reform and
sustainment, there needs to be equal parts person acknowledging there is a need, behavior willing
to seek help, and proper environmental resources.

Figure 1
Social Cognitive Theory

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Summary
To change the current environment and the rate of physician attrition, systems need to
prove supportive of whole-person care of the emergency physician population. Ness et al. (2021)
challenge the current concern is the limited resources available for mental health support,
including psychologists and therapists, making access to these resources more difficult even if
available (Chen et al., 2020). With the increased mental health needs of emergency departments,
creative solutions with personal understanding, support of peers, and system resources will need
to be developed for healthcare (Ghazali et al., 2019). Mental health and wellness in the provider
population is a significant problem with many underlying explanations; to structure valuable
resources and solutions, the social cognitive theory is a valuable framework for understanding
and process improvement.

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Chapter Three: Methodology
The methodology section of the research was completed through virtual interviews to
answer the research questions formed from the purpose of the study. These questions meant
understanding why providers’ mental health affects their career longevity and the needed
wellness resources. This chapter begins with the research question and the study’s design,
explaining the researcher’s decisions based on their positionality in relation to the interviewee
group. Specific attention was given to how the interviews were structured, data reviewed, and
reflections on validity and reliability. Consistent, inclusive, and thoughtful research practices
were considered at every juncture to protect the interviewees and the research findings.
presidential leaders, you can set up why yours will be a qualitative one.
Two research questions guided this study:
1. What mental health resources are emergency department providers aware of and use,
if any?
2. What services and resources do emergency department providers need to support
their mental health?
Overview of Design
The interview questions were crafted to review the current state of emergency department
providers’ understanding of the mental health resources available and identify what future
resources would be helpful. The research questions align with the social cognitive theory in the
behavior, person, and organizational environment, which supports or hinders positive mental
health for emergency department providers. The study was designed to be thorough enough to
understand where the emergency department providers’ mental health opportunities and barriers
are based on the resources provided. The research design was qualitative positivist research in an
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interview format. The qualitative review is an investigative process where research is used to
understand a particular event, role, group of people, or instance (Creswell & Creswell, 2018).
This study design allowed for an in-depth discussion of mental health concerns for healthcare
providers today, focusing on the usage, awareness, and acceptance of available resources. The
inquiry strategy was qualitative interviews, Creswell, and Creswell (2018) suggest open-ended
questions help solicit truthful backgrounds and opinions. These interviews inquired about a
provider’s experience, stress triggers, understanding of mental health resources, and barriers to
use.
Research Setting
The pool of providers was 250 emergency department providers in the healthcare
organization of study serving both rural and urban communities. Each provider worked at a
facility with a patient load of 30 –50 patients a day with different acuity levels from Trauma
Level I to Trauma Level IV. Salkind’s (2014) research supports the need to ensure the data
requested is what you need for your research; respondent selection and participation are crucial.
The sample criteria ensured there was consistency in resources by only interviewing providers in
one organization but allowing for varied application of these resources and needs based on the
person, years of experience, and facility location.
The first criteria were set to ensure a provider has been on the job long enough to
experience repetitive stress (3 years) and employed with the health system long enough to
understand the resources available and have time for use (2 years). To ensure an ample sample
size, recruitment started with an e-mail ask, explaining the reason for the research, the time it
would take to complete the interview, and the safety measures used to protect respondents. Next,
the researcher used their professional network to reach out to providers to schedule interviews.
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According to Rosenberg (2017), participants feel more comfortable contributing when they know
how they will be protected, how the data will be used, and what benefits there are to them. All e-
mails sent to providers spelled out the confidentiality measures of the study for emergency
department providers willing to give up their time.
The Researcher
The U.S. population’s healthcare needs are becoming increasingly more diverse, while
opposite to this, the diversity of the populations employed in healthcare is less than 20% (Pitt et
al., 2020). As the researcher in this study, I fall into the less diverse category as a white female
with a business background who has the luxury of time and resources to access mental health
support. I am an executive leader within Formation Healthcare; no providers who work at my
facility were included in the interviews for this study. Over the years, I have been on many
committees with emergency department providers who have shared the increased stress,
decreased understanding, and usage of resources, leading to their career attrition. These realities
have created a biased belief in the importance of supporting the creation of mental health
resources and empowering the access and use of these tools. To combat these biases based on my
earlier experiences, I have asked each provider about their experiences with their barriers to
accessing these resources and insight into the resources needed.
Positionality although the heart of who we are; also builds the foundation for our blind
spots and prejudices. As a scholar, it was my responsibility to know how my healthcare
colleague’s loss due to mental health has shaped my understanding of the research question. As a
researcher, I am mindful of how my background, upbringing, position, and experience with
mental health can precede my thoughts on available resources and reasons for usage. To ensure
fair and just practices during the interviews, consistent interview questions were used, ensuring
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my background as a researcher shaped the importance of the topic. However, the outcomes were
driven by emergency department providers who experience these needs daily.
Data Source
All data was sourced from interviews and a literature review. The interviews and
observation took place in the Winter of 2022, while the literature review was completed during
the Summer of 2022. The data size was eleven interviewees out of an original pool of 250
emergency department providers.
Structure
The method used to answer the research questions was thirty-minute or fewer virtual
interviews with emergency department providers. Virtual interviews allowed providers time and
comfort to give background and the researcher’s ability to inquire about career stressors,
availability of resources, and how both affect mental health outcomes. This media method
allowed for the conducive nature of sensitivity surrounding a person’s mental health as it could
occur in the provider’s chosen location. All providers interviewed stated their comfort in sharing
in a virtual setting. The ability to set a preparation time for the interviews allowed providers to
focus entirely on the research taking place, as emergency department providers rarely know the
cadence of their days.
Participants
The target population for the interview study was emergency department providers who
work in Formation Healthcare based in the Western United States, excluding the facility where
the PI is an executive. To be included in the interview, emergency department providers must
have been a provider for more than 3 years and worked for the organization for more than 2
years. Participants were all employees of a contracted emergency department provider group
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with Formation Healthcare; to supply services within their emergency departments. All providers
had the same years of schooling, specializing in emergency care with or without fellowship
training years. These providers are considered affluent as their pay scale is in the top quartile of
doctor compensation. There was careful consideration in creating a diverse, equitable, and
inclusive environment in how participants were recruited for the interviews.
Instrumentation
For the formalized process, a planned semi-structured approach for interviews was used
in the hopes of receiving consistent baseline information, as in the suggestion from Merriam and
Tisdell’s (2016) research to use probing questions to help inform conclusions. As mentioned, all
interview participants felt comfortable discussing the topic in a recorded interview. The
interview structure was seven questions; although each interview varied in length based on
responses and the need for follow-up, all interviews were sub thirty minutes in length. Caution
was applied in question creation to ensure no leading questions were utilized, understanding the
researcher has a greater awareness of the resources available for providers in the organization.
The format of using other clarifying and probing questions after a response was used only
at the end of the interview; to ask if there was anything that should have been asked in the
interview or would be helpful for the research. Per Merriam and Tisdell (2016), interpretive
questions check the researcher’s understanding and help collect more information to support the
research. One of the tools used for reflection during this process was, at the suggestion of
research from Burkholder (2019), the use of reflexive journaling to help create an ongoing look
into the researcher’s rationale. This practice was started during the pilot phase of interviews, and
journaling was completed before and after all interviews. This tactic, in conjunction with the
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proper sampling, recruitment, and comparison between the two methods, ensured unbiased
research considering the literature and the researcher’s positionality.
Data Collection
Interviews were sourced after institutional review board (IRB) approval through the
University of Southern California Rossier School of Education in the Fall of 2022. All 250
emergency department providers in Formation Healthcare were considered candidates for the
interview. At the time of the study, the PI is associated with Formation Healthcare and is an
executive for one of the hospitals. Therefore, all providers working at this location were
excluded. The PI does not have any supervisory, hiring, human resources, payment, or
contracting authority with these providers. All these actions are performed at a corporate level
with the contracting company Central ED (a pseudonym used). Formation Healthcare is a multi-
hospital system across the Western United States. The interview recruitment was conducted
electronically via emails to Formation Health and Central ED providers utilizing the PI’s
professional network. No e-mails were sent directly to the providers by the PI instead were sent
from the PI’s USC e-mail to their network sent out the e-mails on their behalf and aided with
scheduling. The first questions in the interview determined if participants met the criteria for
participation in the study. The interviewer asked participants if they were working in a
Formation Healthcare hospital emergency department, working at Formation Healthcare for
more than 2 years or if they have been a practicing emergency department provider for more than
3 years. All providers completed this study outside of working hours and were able to devote the
needed time for the interview. All interviewees understood the confidentiality measures in place
and allowed for recordings of the interviews and to be contacted again if needed for this study.
However, secondary contact was not needed.
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Interviews
Each interview starts with an appreciation for the provider’s time; Bogdan and Biklen
(2007) state it is helpful to start with building rapport to create a space for a productive
interview. The interview structure was set up to obtain consent before any questions were asked,
followed by five minutes of background and demographic gathering before the semi-structured
and probing questions. Thirteen responses were received for interview scheduling; upon
completion, one interviewee canceled, and another did not show up or respond to a follow-up.
Throughout the study, the structured questions were based solely on a provider’s mental health;
but a patient’s acuity, mental health, and interactions with a patient can affect a provider’s
mental health as well. After interview number three, specificity was added to interview questions
three and four to ensure participants understood the response should be related to providers’
mental health only and not include a patient’s mental health. To ensure consistent results, all
interviews used a transcription service Descript during the live interview, and all transcripts were
reviewed within 24 hours after the live interview. Directly following each interview, one hour
was set aside to review the events before listening to the transcript to add notations. Each
transcript was saved with the time and date of the interview and numbered to ensure the
interviewee’s anonymity. In addition, all participants agreed to be recorded for transcription;
names were not used during any of the recordings. Therefore, all identifying information was not
saved with the transcripts. Recorded interviews are available only to the PI through a password-
protected Zoom account and will be deleted upon completion of the research. Interview
transcripts are saved in a password-protected computer and a password-protected cloud server.
Control in time, location, and planning was essential for successful interview completion;
according to Patton (2002), control is vital in this process to ensure clarity by asking focused
34

questions and listening to create meaningful dialogue. All interviews were completed via Zoom,
so the interviewees could choose the setting where this conversation took place. The interviews
were structured to ensure timing, cadence, and understanding were the responsibility of the
researcher and not the interviewee. Bogdan and Biklen’s (2007) research stresses the importance
of ensuring an interviewer controls their reactions and perspectives. As a researcher, there is the
responsibility to learn; while being mindful not to display personal positionality or instruct your
subjects. Careful consideration was placed on the interview questions, the building of rapport,
the reduction of emotions from the researcher, and receiving consent due to the sensitive nature
of the research topic.
Data Analysis
The data from the interviews were analyzed by first reviewing the transcripts for trends,
questions, and thematic content. This required a narrative analysis to ensure as a researcher, there
was a thoughtful analysis of each interview. Next, thematic coding was completed to analyze the
interviews for similarities in data frequencies using qualitative values. This qualitative analysis
allowed for linking the common themes from all interview responses, where the text responses
were indexed into categories to develop a framework of thematic ideas (Gibbs, 2007). The
coding aided in interview reflection, thoughtful consideration of the data, and a reflexive review
of the researcher’s self-awareness during the data collection process. Lastly, the data was
segmented for themes, analyzed for trends, and the results were written and reviewed.
Credibility and Trustworthiness
To ensure the research credibility and trustworthiness of the findings, Merriam and
Tisdell (2016) research says the researcher’s understanding of the world continues to change the
constructs of their reality. To ensure the credibility and trustworthiness of the research,
35

triangulation was used to compare the information received from the interviewees, findings from
the literature and careful review and follow-up of the respondent validation. To further ensure
the data collected and the conclusions created for the research are aligned, Merriam and Tisdell
(2016) state you can use the respondent validation to seek feedback on your findings from the
people you interviewed. The respondent validation ensured no misinterpretation of findings,
conclusions, or themes developed from the researcher’s personal bias and positionality. To
further ensure credibility and trustworthiness, Robinson, and Leonard (2019) state there needs
yto be diligence around response effects, ensuring decreased response variations based on the
way questions were stated to participants. The questions were reviewed in a pilot setting,
ensuring that clarity and understating were similar across the participant populations. The
questions were delivered in the same order. The only change was to questions three and four to
increase clarity. To ensure data reliability, there was strict adherence to the interview protocols
and inclusion of the interviewee population.
Summary
The research performed for the proposed study will benefit the mental health and well-
being of healthcare providers and their patients, families, communities, and the connected
healthcare system. The underlying position of the study is to create value, understanding, and
acceptance of the mental health needs of providers with the proper resources. As Greenberg et al.
(2020) say, ethics in healthcare underly every decision, and the spoken truth is only sometimes
evidence based. This requires changes to psychological safety to truly support healthcare
workers needing care within their system. By creating a safe space for interviews with
confidentiality protocols, participants felt comfortable answering questions based on their
experiences, backgrounds, and beliefs. As a researcher, the concern with interviews and their
36

validity was bridged by including a diverse interviewee population. The addition of the probing
question at the end of the interview helped bridge the gap between credibility and trustworthiness
(Merriam & Tisdell, 2016).
Both psychological safety and physical safety were addressed in the first e-mail as well
the format of the interviews. All participants received an information sheet with the agreement
and understanding they could stop the interview at any time or skip over questions that were too
sensitive. The research study did not have any affiliation with the health system in the researcher
and interviewees were employed. Although the employer approved the research study, no
individual answers or results will be shared with the organization. All interview transcriptions
will be on a locked drive for research purposes only. To ensure safe, equitable, and legal
interview practices for this study, we started with the University of Southern California IRB
approval. Findings and results will be documented in the researcher’s doctoral dissertation. After
the final defense and submission of the dissertation to USC, a summary of the findings will also
be provided to the interview participants upon request.

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Chapter Four: Findings
The study aimed to conduct interviews to analyze the mental health resources available in
the Formation Healthcare organization for emergency department providers and their use of
these resources. The conceptual framework is the social cognitive theory (Bandura, 2020), as a
systematic approach to reviewing the interaction between a person’s motivation, behavior, and
cognition with their mental health. The research study assumed, with the support of the literature,
that there are inadequate resources for emergency department providers and barriers to accessing
these resources. With the addition of resources, providers would stay in the field longer and be
happier and healthier. All eleven interview participants indicated changes would be helpful, as
the current mental health resources are not easily accessible within their provider schedule, they
lack an understanding of the resources, and longevity in the field is hindered without the proper
institutional changes.
Two research questions guided this study:
1. What mental health resources are emergency department providers aware of and use,
if any?
2. What services and resources do emergency department providers need to support
their mental health?
The method used for this study was qualitative design; interviews were conducted via
Zoom in an informal and semi-structured protocol with the intent of receiving background on the
current usage of mental health resources, the understanding of the resources available and future
resources, which would be more helpful. Wilkinson et al. (2017) research posits lack of mental
health resources leads to career attrition and suicide. The structure of this chapter is a
background on the participants, an overview of the findings, and a summary of key themes.
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Participants
The providers interviewed for this study span the entire Formation Healthcare system,
including multiple states and communities, both rural and urban. The interviews were conducted
with eleven emergency department providers who practice only in Formation Healthcare and do
not moonlight at other healthcare systems. Each provider interviewed has been practicing as an
emergency department provider for more than 3 years and practicing in the Formation
Healthcare system for more than 2 years. With a collective experience as an emergency
department provider of 151.5 years, an average year at Formation Healthcare of 9.3 years, and in
the role as a board-certified emergency department provider of 13.7 years. There were four
female and seven male interviewees. Although the interview inclusion criteria included mid-level
providers and doctors, only providers with a doctor’s education completed interviews (Table 1).
The background of providers prior to their current role ranged from the military, another form of
patient care, engineering, and information technology, all ending up in the emergency
department as their primary career. No participants declined to answer any questions. The only
clarification asked by interviewees was, “Did the study questions focus on the patient’s mental
health or only the providers’ mental health” (3P)? Table 1 notates the interview participants,
years in the company, experience, role, gender, and geographic setting. The participant
identification number will be used throughout the paper to identify the individual responses in
the interviews.

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Table 1
Responses to the Questions Asking About Years of Experience, Role, Location and Gender
Participants Leadership Years in
organization
Years
licensed
Gender Geographic
area
1P Director 7 10 F Urban
2P Director 6 6 F Urban
3P None 3 3 F Rural
4P None 2.5 15 M Rural
5P Director 9 13 M Rural
8P CMO 5 14 F Rural
9P None 3.5 3.5 M Rural
10P CMO 19 23 M Urban
11P None 22 30 M Rural
12P None 14 18 M Rural
13P CMO 12 16 M Urban

Note. The roles column indicates if a provider also maintains leadership responsibilities either
medical director (director) or chief medical officer (CMO).

Results for Research Question 1
The providers interviewed identified the resources available in Formation Healthcare and
believe many resources are available. Although, more than half of the providers could not
identify where to find the resources. Within the participants interviewed, there was no trend in
years of experience or years with the organization to improve the use or understanding of
resources.
Resources
The results and findings from the interviews answer the two research questions for the
study. There was no link found between years of service or years of experience in whether
resources were known or used; there were also no themes between genders. The rural versus
urban markets did have some more prominent themes based on resources. To understand the
40

findings concerning the interviews, the current resources were discussed, the access to resources
was reviewed, and the needed resources were identified.
Available Resources
The overarching theme received from interviewees is there are resources available,
although accessing these resources is the barrier to utilization. All eleven interviewees were
aware there are resources available to support their mental health. Out of the eleven who were
aware of resources, only four providers knew where to find resources (1P, 2P, 4P & 13P). Table
2 is the collective understanding of the providers interviewed with their awareness of mental
health resources available in Formation Healthcare and the providers’ understanding of access to
the resources.

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Table 2
Responses to the Questions Asking Understanding of Resources
Participant Resources awareness Resources
accessed

1P

Learning management, peer review, telehealth Learning
management

2P

Learning management, peer review, telehealth, state
programs
Training, peer
review

3P

Phone applications, learning management None
4P Telehealth Telehealth
counseling

5P

Learning management, peer review, telehealth None
8P

Aware of resources no specifics None
9P

Learning management, peer review, telehealth, phone
applications
None
10P

Learning management, peer review, telehealth, meditation None
11P

Aware of resources no specifics None
12P

Peer review, phone applications, team meetings None
13P Learning management, peer review, telehealth, phone
applications, meditation
Peer reviews

There were differing responses on what resources the interviewees believed were
available: each of the providers interviewed were able to give at least one example of the
resources available. Although, out of the eleven providers interviewed, only four of them have
used the resources available through the health system to support their mental health 1P, 2P, 4P,
13P even those providers who have used the resources did not know where to find them if
42

needed again. Providers 9P and 12P have used resources outside the health system; interviewee
12P states, “Accessing resources outside of the health system allows for increased flexibility and
decreased stress as you are able to choose your support.” Within the Formation Healthcare
system, all providers interviewed have access to the same resources; but the theme of the
interviews supports resources that were known and used differently by each provider.
Figure 2 notates examples of the learning opportunities in the Formation Healthcare system, the
generic online learning programs. These pieces of training range from opportunities of
completion in one sitting, or others that are ongoing. These resources can aid in support, change
management, and endorse healthy behaviors.

Figure 2
Sample Resources: Ready Set Wellness (Pseudonym Used)

Note. From “Navigate, Navigate Wellbeing Solutions,” navigatewell.com. In the public domain.

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Resources Utilization
For providers who could access the resources available, there was agreement that the
resources needed more practical and applicable support. Of the four providers who have used the
available resources, only one believed the applications were helpful and said, “Meditation was
easy to use, did not take planning, and could be stopped at any time” (4P). Provider 4 said,
“Resources are short of what is currently needed to support positive mental health” (4P). The
remaining nine providers were aware of resources; but have yet to use the mental health
resources provided. Interviewee 9P, who was aware of the resources, specified what had been
ineffective. His belief is “the wellness stuff” is counterproductive, “as it would seem you are
offering a band-aid to someone’s arm who was cut off” (9P). The discussion surrounding the
quote from interviewee number nine was based on his concerns with the depth and breadth of the
current mental health support needs and the offerings simply being “quick, canned support
mechanisms and breathing techniques, which will not solve the personal or professional burden
of providers” (9P). The four providers who have accessed resources echoed the same theme,
“when mental health support is not presented the right way, it is insulting or demeaning” (9P).
The current array of support resources indicated by all eleven interviewees is not meeting the
mental health support demands of emergency department providers in Formation Healthcare.
Furthermore, “when there are no testimonials, it can be a waste of time” (11P). Using
precious time to use resources that do not work is worse than doing nothing (12P). Providers 4P,
9P, and 12P have each tried more than one of the resources and report they needed the support
due to the ongoing stress of the job, not a one-time event, but the resources, “did not meet the
need” (4P). Provider 9P posed, “The support is helpful if it is surface level, not if ongoing
support is needed.” Provider’s 4P and 12P stated that providers needed to go outside the
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healthcare system to receive the robust mental health support needed, “sharing with someone
affiliated with your health system may or may not be safe” (4P). The information regarding
seeking mental help derived from the interviews does not necessarily mean the other providers
have not sought mental health resources, but other providers did not report this as part of their
interview.
Accessing Resources
Providers interviewed, as a majority were aware of resources, although there was a
shared concern of where to locate the appropriate resources to use when and if needed. Seven
out of eleven interviewees did not know how to find resources, supporting the notion that access
and understanding is a hindrance to being able to support mental health (Figure 2, pg. 44).
Interview participants indicated a need for training on how to find mental health resource
accessible to them; as resources might be more commonly used if knowing where to find them
and access was simple (1P, 2P, 4P, 9P, 12P, 13P). Interviewee 1P stated the best way to find
resources is “ask someone who knows someone to ask.” Provider 2P stated she would not call a
peer as “peer support feels forced” (2P). Interviewee 2P stated the quickest improvement could
be “setting peer mentors or sharing contact lists.” Increased access to contact lists with work
location and hours would help bridge the gap and “have the ability to establish relationships with
your peers earlier” (2P). Interviewee 5P did not know how to access resources but was “sure I
could figure out where to find them if needed” (5P). The other remaining providers said they
would need to ask someone, reference training materials or “spend time poking around on the
website” (1P). Interviewee 13P said, “Providers do not consider the need for resources or looking
for them till they absolutely need them,” which “hinders their commitment to being prepared”
(2P). Interviewee 13P also said he had not accessed resources before; but “might have on a
45

distressing day if he would have taken the time to access these before a triggering event and had
awareness on how to find them.” Although interviewee 1P stated the best way to find resources
is to ask 4P, 5P, 8P, and 13P said having to ask where to find resources or “not knowing where
to go for resources would be a hindrance to using resources as this breaks confidentiality and
admits weakness” (8P). The current hunt for resources requires persistence, courage, and time
which is limited or lacking for emergency department providers.
The use of resources would increase if the “onboarding was more robust and consistent training
included access to mental health resources” (2P). The origin of access did not come up in any
interviews concerning phone versus computer or home versus office, but the simplicity of access
was important. Interviewee 10P suggests, “it takes effort to engage with yourself in a way to be
true to your mental health, and sometimes it is easier to push it down,”; further reducing the
access to resources. Interviewees 5P, 8P, 9P, and 10P stated lack of accessing resources is the
foundation of their barriers, and providers’ lack of trust in resources exasperates this concern.
Results for Research Question 2
The use of resources has variability based on an individual provider’s concerns with the
stigma associated with utilizing resources and the confidentiality of the resources provided.
Reducing these barriers creates the foundation for finding resources to support a provider’s
mental health. The providers interviewed identified peer support, work schedules, and traumatic
events as barriers to sustained mental health and offered resource solutions to support providers’
mental health in the future. methodologies and topics to see how they presented their findings.
Stigma of Utilizing Resources
The current stigma surrounding mental health was a congruent theme in the interviews.
The word stigma was used at some point in all eleven interviews, each saying it is a barrier to
46

understanding, using, asking, and receiving help. Using “stigma” to “state there is disgrace,
shame or a negative connotation” (9P) is aligned with seeking mental health support in any
format (4P, 9P, 13P). Interviewee 4P was very honest about the struggles in finding help, “being
comfortable with whom you are and talking is the largest roadblock to receiving useful help if
you are afraid of being judged.” Interviewee 2P felt more training would reduce the stigma
saying, “All providers should, could, and would need mental health support at some time during
their employment, and talking about the why, how, and what would be helpful.” Help can be
needed for many things both, “personal or professional needs and mental health resources should
support both, and both should be equally as important” (2P). The concerns with seeking
treatment or the stigma of seeking treatment was an identified barrier by the interviewees to
utilizing mental health resources.
Three interviewees said the stigma was attached to mental health needs in all its forms
(4P, 9P, 12P). Interviewee 12P specifically said why he believes providers do not seek mental
health resources, “with our egos, we tend not to ask for ask for help; we fix other people’s
problems, we do not have problems” (12P). The fear of others looking at you as weak came up as
a reason there is a stigma attached to asking for help or support (3P, 5P, 10P). One of the
providers said he sees a therapist, is “open about it, and still feels a bit of a stigma, and I feel it is
putting my cards on the table saying I am weak” (9P). This provider stated the fear of mental
health leading as a sign of weakness not only inhibits seeking help; but also talks about specific
instances which might lead to increased emotion, need for support, or questioning their role (9P).
Interviewee 3P said stigma is “the silent barrier creating a fence between healthy, human and
connection with loneliness and emotion.”
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Although a theme in the interviews, there were no suggested solutions given of services
or resources which would help decrease the stigma related to mental health. Although
interviewee 13P stated “an opportunity within the health system to reduce the stigma,” as well as
9P stated, “in the medical community at each facility to feel safe sharing, asking for help or
supporting peers in need will reduce the stigma.” Continued awareness of all people on mental
health issues is the grassroots of reducing the stigma in healthcare and beyond.
Decreased Confidentiality of Resources
The providers interviewed for the study cover emergency department shifts across the
entire Formation Healthcare network, inclusive of multiple states and communities of varying
sizes; based on the size and location of the facility, the breadth of confidentiality concerns was
mixed. Confidentiality concerns were shared amongst all providers apart from provider 9P, who
felt comfortable speaking to any professional about mental health needs. Other providers said
they wish to have telehealth opportunities 3P, 4P, and 12P stated as “not to have to access
resources within their community as these were limited” (3P). Providers 10P and 13P felt that
even living in a big city precluded their ability to find “confidential support as they know many
of the providers in the community” (13P). Although confidentiality was a perceived barrier, there
was no discussion from any of the eleven providers concerning their personal information being
shared without consent; 4P stated, “It was the fear of sharing their information with someone
they might know as a provider and have to interact within their community.” Interviewee 3P
agreed, “Getting help with mental health when you work in healthcare is hard when you do not
want to run into someone you work with or have a collegial relationship, as this could be
awkward.” Not only was the barrier stated as confidentiality by location by 4P, but using a peer
for help or knowing people in the industry creates barriers to system confidentiality, as discussed
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by 1P, 5P, and 12P. The solution raised by 4P and 8P was telehealth services, allowing providers
to use services outside of the community where the provider lives and works.
Telehealth itself could solve confidentiality, but not the concern of in-network coverage
and payment, as participants 2P, 3P, and 9P discussed payment concerns. Interviewee 12P stated
these services should be free of charge and outside of the current healthcare benefits, “Helping
providers with a stipend to see, set up and schedule their own help would be meaningful and help
ensure anonymity and use.” Interviewee 1P added, “Spiritual care can often fill a gap for acute
needs when available,” but not the ongoing needs of routine counseling. Interviewee 11P agreed
with 12P and said, “Personally, if there were a stipend to do your own counseling it would be
helpful. It seems like every counselor I have had has left or moved, so I have felt abandonment
by the counselors” (12P). Creating safe, supportive, and 12P shares “consistent support is the
cornerstone of care for mental health.” Inclusive of emergency department providers’ challenges,
other provider shortages impede the basic availability of mental health support and resources
specific to one-on-one counseling. Continued confidentiality concerns can lead to delayed help,
“further eroding a provider’s confidence in receiving help” (8P). Ensuring confidentiality is
upheld and access for all providers is enabled is essential to supply full access to mental health
support.
Peer Support
A significant theme of the current state of mental health resources is the magnitude of
help and support providers get from formally and informally leaning on each other. Most support
is informal, staff meetings where providers share stories 1P, 2P peer-to-peer chart review for
challenging cases, 9P, 10P, and 11P the ability to call a mentor. Interviewee 12 said, “The most
valuable thing we have in terms of mental health is each other, peer support in case review,
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collective decision-making, and a sympathetic ear.” When speaking with interviewee 9P, there
was an agreement outside mental health support from a counselor is helpful, but nothing like
peer support from someone who might know what you are going through, “understanding the
dynamics and complexities of patient care” (9P). Although the support of a counselor might be
nice, “not the same level of connection, you have with a mentor when they likely understand
exactly what you are feeling” (5P). Interviewee 4P was very honest about the struggles in finding
help, “being comfortable with whom you are and talking is the largest roadblock to receiving
useful help.” Interviewee 9P said, “Unless you have told someone their child is dead, you do not
know what this is like.”Peer-to-peer support in the current state is often not structured or
provided by the health system, but all eleven interviewees discussed the importance of a mentor
or a peer. Both 8P and 10P stated providers could do hard things for an extended period if there
is a sense of meaning and peer support, ensuring understanding of the role and the professional
hardships.
The other informal feedback which providers felt was a part of their positive or negative
mental health outlook is patient feedback; 13P states, “One of his barriers to mental health is
knowing how a patient ends up, are they OK when they go home, were they happy with the
services provided?” The unknown of the patient question added unneeded stress for 13P.
Reducing stress could occur if there were provider follow-up calls; 13P does not make these calls
at their facility, but 1P and 9P do, and said contact could add to the satisfaction of the job
creating meaning to experiences. Phone calls develop a human connection to the fleeting work
and interactions of an emergency department, unlike other outpatient care where the patient
relationship has longevity. Interviewee 13P said,
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Providers can do an excellent job caring for patients to get a verbal thank you, but you
really feel it when you get a complaint or something does not go the right way, young
deaths or draining cases are the negative of the job and can outweigh the multiple
moments of positivity.
Interviewee 10P also supported the sentiment, “as the stress and pace of the job can make
it easy to forget all the good done in a day.” The relationship to a patient, their outcome, and the
effects of the care provided on both parties creates an untraditional bond.
System Barriers
Systems support mechanisms are only as effective as the providers who are able to use
them; improving access in times conducive to a provider’s schedule is an essential first step to
being available when needs are presented. A joint theme brought up by two providers, 4P and
12P, who have used the mental health resources, is that counselors have limited hours, often not
congruent with the providers’ schedules. The challenge with using mental health resources is
“not knowing when they will be needed and will they be available at that time” (4P). Time came
up not only in using resources; but also in training, peer support, and meetings as work
schedules; affect a provider’s ability to spend time on themselves, stated 10P and 13P. Not only
was the function of time a concern for resources vetted and needed, but it was also wonderment
if “time spent on mental health support would be worth it” (12P). For some providers, a shift is
“led by dread; it can be challenging to commit more time to work-related items, such as dealing
with mental health after the dreadful twelve hours” (11P). Testimonials, as discussed in the
interviews with 3P, 4P, 10P, and 12P, were listed as a helpful addition to understanding the
takeaway and advantage of using resources and discussing the amount of time needed for them
to be effective. “Hearing the effectiveness from someone you trust can help bridge the gap
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between understanding resources, knowing where to find them, reducing the stigma, and
optimizing time” (12P). The factor of time takes a different format when the schedule of an
emergency department provider, as 8P states, “can be days, nights, weekends, holidays, and a
mixture of everything in between, further challenging seeking resources outside of the healthcare
system”. In discussion with 4P, she has tried to access resources for a prolonged period without
avail to “match her schedule” 12P stated the same notion of timing being a barrier to receiving
help. Interviewee 9P supported this belief as he has used “four different therapists in the past 2
years trying to find one who could be available in the hours/days needed”. Time is a limiting
factor both “at work due to the pace” (8P) and “at home due to family needs and decreased
connection” (13P). Interviewee 10P was tearful when he said, “Missing holidays and school
events stack up and takes a toll in developing meaningful relationships outside of the hospital to
help with resiliency and help with burnout.” Participants showed needing a greater number of
internal resources to make up for the lack of support provided by family, friends, and
acquaintances who work the standard 8 –5 p.m. hours and are not available when needed.
Schedule Expectations
A provider’s schedule prior to the pandemic was set by day or night shift, in three
consecutive days and rotating over the month; due to provider staffing at the time of this
research, shifts are interchangeable increasing days worked. As discussed in the access section of
the results, the provider schedule came up as a listed barrier to mental health resources said by
1P, 2P, 8P, 9P, and 10P. The long hours, unknown coverage, and staffing, “coupled with the
need to cover at the last minute or miss important life milestones due to night or weekend shifts,
creates fear around being able to use resources and utilize informal peer relationships as support”
(10P). Providers 2P, 3P, and 4P stated often they would interchange between schedules and
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locations, adding to the stress of juggling both personal and professional demands. The erratic
schedules can lead to anxiety and stress; 1P gave an example: “working for three locations and
covering sick calls for others when needed, working seven hours one day, 12 hours the next and
a string of five shifts one month and 16 the next month”. Long hours in conjunction with no
vacation pay, although providers can take any number of days off if there is coverage, creates a
“work=pay and mental health support=decreased pay mentality” (4P). Balance is a key to mental
health, and providers stated current schedule constraints do not promote balance in hours, days,
and consistency.
Interviewee 10P stated even work is a balance of “spending time with people every day
and feeling isolated, as well as the feeling of being trapped in a job where you would like to do
something else but do not know how to get there.” Interviewee 10P went on to state, even though
it is a profession “many people spend a long time to get to, being a doctor, it might not feel great
as they quickly realize the emotional and physical toll of the role” (10P). Interviewee 13P posits
providers spend many years becoming a doctor just to find out it is not sustainable with the
“hours needed to support personal and familial expectations.” The consensus from 3P,4P, 8P, 9P
and 10P is if you are working anywhere near or even close to full time hours, “it devastates your
life in ways full time does not in other roles” (10P). For example, when you work an overnight
shift in the emergency department, the “day before and the day after are unavailable to you as
normal days” (10P). It is a combination of factors between actual hours, “missing life and
ensuring there are meaningful relationships outside of work as well as inside of work based on
consistency” (8P). In discussion with 1P, there is a current initiative to increase recruitment,
create home bases for providers, and post schedules further out. The hope is to create an
environment where work is not dreaded, as mentioned by 12P, and enlightened for the positive
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aspects of the patient-to-provider relationship 13P. Although schedules are complex,
unpredictable, and erratic, the outcome of patient care is the oath providers take when becoming
doctors to remove harm at any cost.
Staffing Shortages
In conjunction with scheduling is staffing. The more challenging the provider staffing,
the more shifts need to be worked, and if coupled with the decreased support staff, the more risk
there is for error, 1P believes. The increased risk from staffing can harm patients, with providers
feeling rushed to complete patient care while aligning with system metrics. Interviewee 1P
stated:
We are woefully understaffed in all locations, even CT techs and nurses, and thin on
physicians. People have transitioned to part-time or other jobs, and they are not staying as
long due to the stressors. Often, they think the grass is greener elsewhere. I do not think it
is. They are making the transitions to have control. It is the lack of control that leads
physicians to increased stress.
After the first interview, the message of staffing was laced throughout the other
interviews as the increase in stress drives not only the challenge of having enough providers to
cover the needs of the communities served 13P; but also the lack of support staff for patient care
4P, 9P, 8P. Interviewee 3P said, “the administrative and structural problems with the network,
and system are showcased; when we try to provide care to a patient and the care you are able to
provide is not what you want due to structural problems.” The scheduling challenges and
support needs lead to an increased risk in mental health pressures of providers as well as
decreased ability to use formal or informal resources, as the shortage in staffing affects the
morale of providers, patient care, and the team’s ability to support both.
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Traumatic Events
When asking providers interview question number five, in your opinion, what do you feel
is the most significant impact on emergency department providers’ mental health? The toll death
takes was the first response all eleven interviewees stated. It is a known fact of the emergency
department; trauma- unexpected death, death where the provider feels ownership, death of the
young, death due to a tragedy, having to explain the death to a loved one, and enduring the rest
of the shift without time to process. Interview 11P stated death, coupled with the feeling society
dictates today, which ED docs are “going to fix everything if another provider cannot figure it
out; creates a feeling like ER physicians are at the bottom of resources.” Emergency department
jack of all trades reputation in medicine is an additional burden on providers when the healthcare
system, staffing and resources do not support this breadth of scope. The increased strain on
resources “leads to more risk with increased acuity and possibly more bad outcomes” (11P).
Interviewee 9P stated he needed counseling from a death on a shift a year ago, “he is unable to
let go of this event; he is aware he could not have done anything differently, but the fact of
feeling helpless has weighed on him.” These continued stressors compound over time and are in
addition to baseline personal and professional daily stressors.
The job itself, as told by 4P, 5P, and 9P, is incredibly stressful and includes a high
burnout rate; without grief training in school, “hindering the coping mechanisms of providers”
(3P) as every time someone passes on a worked shift there is grief associated. The grief of
emergency department providers is so frequent its effects are compounding. In interviews with
8P and 13P, both recounted the deaths seen in their years on the job and how the stress of these,
if able to overcome, often comes back when faced with the next stressful event. The place death
holds in an emergency department physician’s daily reality is high, and 8P and 9P agreed leads
55

to post-traumatic stress syndrome, both undiagnosed and diagnosed. 10P believes “mental health
resources need to deal directly with the risk, outcomes, and fear of death from emergency
department providers” 13P states, “These are not specifically addressed in the resources
available today.” It is unrealistic to remove the concern of death from the role of the emergency
department provider, but as 9P, 10P, 12P, and 13P state, awareness is the first step in creating
supportive systems understanding the actual needs of providers in resources and support.
Career Shortening Shifts
When speaking of mental health resource barriers, there was a new term presented to the
researcher used by interviewee 9P, “career shortening shift” He used the phrase to describe the
amount of stress in the role of an emergency department physician. Interviewee 9P states the
very tragic, mass casualty or pandemic related shifts take years away from a provider’s
career. These shifts “make you not want to work in the field, or you cannot sustain as
your career is going to be one month shorter because of an event, or your retirement date
has just moved up.
Interviewee 12P stated, “if you care about what you are doing and doing an excellent job you
want to continue; when you feel you are not doing a good job at work, it is stressful.”
Interviewee 3P stated at 2 years on the job he almost quit because of a bad case, “a case of which
cannot be erased; but haunts every decision I make.” The aftermath of one shift can be career-
altering for emergency department physicians without the proper support.
When interviewee 9P was asked to elaborate on the role of an emergency department
provider in collaboration with the phrase “career shorting shifts” he said, “You feel like a waiter
at a restaurant no one wants to be at, everyone’s meal is too cold and too slow” (9P) a really
challenging place to work. Many people come to us for answers, states 2P,4P,5P, 13P, and the
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job of the provider is not to give everybody answers, “it is to ensure everyone who walks through
our doors does not die” (12P), and those are two vastly different things. The career-shortening
shifts are where acute mental health resources are needed as providers, “we cannot really meet
anyone’s needs, and we go the whole shift feeling we have not, and it is deflating” (10P). These
shifts and events have a lasting effect on the provider’s resiliency, longevity, and outlook.
Summary
The interviews completed confirmed; the knowledge and motivation of emergency room
providers seeking resources was a significant hindrance to resource use. The study’s findings
were broken up into categories; each category highlights a foundational breakdown to
understanding and using the resources available and the future resources needed. The themes
from the provider interviews fell into eight categories: awareness of resources, access to
resources, the stigma of needing help, confidentiality concerns, barriers to time, peer support, the
toll of death, and career-shortening shifts. Program participants were aware of mental health
resources in the Formation Healthcare system but not the totality of the resources. Providers
were unsure how to access the resources but felt they could be found if they asked a peer but
would be fearful to ask a peer due to the stigma associated with mental health concerns. For
those willing to ask for help, concerns with confidentiality due to their location or simply the role
delayed acceptance. Providers said time was the most significant barrier to accessing resources
as resources available did not have options congruent with their schedule; in turn, they felt the
informal resource of peer support, specifically in collegiality and access, supported positive
mental health the most. Providers agreed the most significant factors in needing mental health
support are due to the weight of death and shift trauma which providers call “career-shortening
shifts.” Mental health resources are needed, but finding the exact support which will be
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meaningful to emergency department providers is crucial in conjunction with creating an easy
button for providers to receive this care in the future.

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Chapter Five: Recommendations
Chapter five addresses the emerging themes and presents evidence-based
recommendations with a plan for implementing mental health support for emergency department
providers. These recommendations will aid in promoting a healthy workforce, decrease attrition
and reduce suicide. The estimated long-term cost savings is $1 million (US) per physician who
leaves the workforce each year in addition to the lost revenue by decreased patient access (Patel
et al., 2018). All physicians interviewed indicated mental health programs are “not one size fits
all as we have diverse backgrounds, stressors and human needs. The only string that binds us is
the work we do” (13P). The research done by Schwartz et al. (2019) stresses the importance of
diverse resources by location and provider need.
Discussion of Findings
The problem of practice for the research is emergency department providers lack the
proper mental health resources and support. The research questions are what mental health
resources do emergency department providers use, if any? Furthermore, what services and
resources do emergency department providers need to support their mental health? Both
questions were answered with the literature review and the physician interviews. Participants in
the interviews said they are aware of wellness applications, counseling, peer support, wellness
retreats, and state resources (Table 2). Although providers interviewed indicated they did not
know how to access these resources, many providers found their own. The research by Baird et
al. (1995) states telehealth services, online training, medical school training, and peer support
groups are available. The disconnect for both was providers understanding how and having the
available time to access the resources.
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The second research question asked about the resources that would be helpful for
emergency department providers, leading to four recommendations stemming from the
interviews: paid time off, formal physician mentorship, telehealth resources, and personal
services support. These resources would be meaningful to fill a void currently experienced or
solve a problem the providers currently have. Time and schedules were reviewed in the literature
by Moll (2014) with concerns about the hour’s physicians worked, which was supported in the
research interviews for this study. Peer support, researched by Baird et al. (1995), was supported
by physician interviews to create formality using peers to support providers’ mental health.
When peer support is insufficient, the providers interviewed stated telehealth services would help
alleviate the need to see a peer in their community. Fish and Steinert (1995) agree the ease and
confidentiality of telehealth services is an added support mechanism. Both research questions
were answered through the support of the literature and the interviews completed for the study.
The findings from the physician interviews were in alignment with the information
presented in the literature review as the interviews and literature agreed changes need to take
place to improve the mental health support of emergency department physicians. Brook’s (2018)
research posits that providers surveyed are leaving the workforce or reducing hours due to
barriers or lacking mental health support. Eleven participants interviewed indicated changes
would be helpful in the current mental health support; as the current mental health resources are
not easily accessible within the provider schedule, there is a lack of understanding of resources
available and decreased use for fear of confidentiality. Through the interviews, a review of
currently available resources, resources used and accessed was discussed, as well solutions for
the barriers in time and concerns about confidentiality. These findings aligned with the literature
reviewed for chapter two, saying there is a current unwillingness and concerns surrounding
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seeking treatment due to ramifications of employment and the stigmatization of asking for help
(Rubin, 2014). Not only was stigma discussed as a barrier in the literature, but also the act of
asking for help and finding help by Fish and Steinert (1995) and supported by the interviews
with providers. Because of the inherent and taught skill of putting patients first, physicians have
a tenancy to deny their basic needs and lack the foresight of colleagues’ needs through times of
stress posit (Kuhn & Flanagan, 2017). The concerns about the stigma of asking for help are why
interviewees stated there needs to be formal peer mentorship programs and an understanding
from providers of available resources.
In alignment with the literature was the response to the final interview question, in your
opinion, what do you feel is the most significant impact to emergency department providers’
mental health? The interviews were highly aligned with the research from Moskop et al. (2008),
saying that daily stress and the inability to process traumatic events create repetitive stress on
providers and lasting effects on mental health. These stressors are what four providers
interviewed (5P,8P,9P, and 10P) stated made them recognize their career in the field would not
be sustainable for the longevity originally thought. The recognition of a career wall, as reviewed
in the literature by Deutsch et al. (2021), is leading providers to seek career growth. Many
providers interviewed were already chief medical officers (CMO) and medical directors (MD),
and others were heading down this path. Providers who are already in leadership said this
allowed for a better life balance without many night and weekend responsibilities (10P & 13P).
As Deutsch et al. (2021) research posits, career growth, and leadership transitions can help
balance, self-care, and time availability. These near-term changes to hours, days, shifts, and roles
can help the balance to ensure “career shortening shifts” with peer support and opportunity
change the long-term effects on provider attrition (Harder et al., 2020). According to Downs et
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al. (2013), increased work has been done to find providers who could be affected by mental
health support changes in the past decade. However, little has been done to create platforms and
interventional resources to solve environmental factors. The physician interviews from this
research will be a step towards resource creation and physician involvement to better mental
health.
Theoretical Framework
The social cognitive theory conceptual framework used for the research focused on
assessing behavior, person, and environment where motivation, knowledge, and organization are
applied to review the usage of mental health resources. This framework is segmented by the
personal aspects of the mental health needs of emergency room providers, the behaviors, the
willingness to seek mental health support, and the environmental factors with a need for
improved mental health resources. The recommendations include person informal peer
mentorship and how providers utilize their agency to reach out and help others in need, behaviors
in personal services support, and environmental in paid time off and telehealth support. The
reduction of the stigma of utilizing mental health resources is supported through the person and
their belief on mental health, their behavior in how providers treat other providers in need, and
the environment in support of systemic change. Through the literature review and interviews, the
environmental deficits to support mental health and the collective behaviors of providers not
seeking mental health support hinders a doctor’s personal outcomes leading to career attrition
and provider suicide. Changing how mental health support is viewed and utilized will take a
commitment from the system for changes in the environment, reduced stigma from the person to
seek help, and changes in behavior to encourage peers to do the same.

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Recommendations for Practice
To combat the current mental health concerns for providers, there are four opportunities
that came out of the interviews: the creation of paid time-off programs, formal peer mentorship,
telehealth virtual support resources, and creative personal services support. These
recommendations are intertwined and focus on actionable items in the current healthcare
environment, considering finances, staffing, overall need, and challenges in patient care.
Allespach et al. (2019) research states to decrease physician stress, there need to be mental health
resources to promote self-care in four ways: relaxation exercises, breathing exercises,
mindfulness, and cognitive structure changes, of which three of the recommendations will
support. In addition to Allespach et al. (2019), Lemaire et al. (2018) research agrees with the four
needs of mental health resources and adds an additional metric of time spent for a healthy work-
life balance to ensure providers are well to improve patient experience and outcomes, which
supports the fourth recommendation. Brooks et al. (2018) itemized the four Ps as a critical aspect
of successful physician wellness, including policy, practice, preparation, and programs to include
their planning. To effectively implement the recommendations, there need to be new policies,
expected practices, preparation, and implementation understanding healthcare organizations are
complex systems and systemic change takes time.
The grave cost associated with doing nothing is patient and provider lives; but it also
costs healthcare every year; Han et al. (2019) research conservatively estimates the cost of career
attrition of physicians to be annually 4.6 billion dollars. The cost estimation in broader terms is
approximately 5% or greater than the total operating budget of healthcare organizations
(Waldman et al., 2010). These statistics support the importance of addressing the problem of
career attrition and suicide or, at a minimum, making a change. As shown in the Figure 3,
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Jennings et al. (2022) recommend implementing protected hours, staffing support, and improved
workflow. aligns with the interview participants’ themes: peer discussion groups, protected time
for balance, creation of a wellness team, and work to reduce the stigma will change the landscape
of emergency department providers’ mental health. The pyramid is sectioned into institutional
change, professional assistance, and individual practices, which align with the research and
recommendations. The institutional change is paid time off with changes in scheduling,
telehealth services to reduce the stigma and formalized peer mentorship. The changes in
individual practice and professional assistance are recommended personal support services. The
SCT aligns with Figure 3 as institutional in the environment, professional in a person’s beliefs,
and individual practice as in their behavior of seeking mental health services.

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Figure 3
Physician Wellness Individual to Institutional Practices

Note. From “Orthopaedic surgeons have a high prevalence of burnout, depression, and suicide:
Review factors which contribute or reduce further harm,” by J. Jennings, P. Gold, K. Neillans,
and S. Boraiah, 2022, Journal of the American Academy of Orthopaedic Surgeons, 30(5):528–
534. Copyright 2021 by the American Academy of Orthopaedic Surgeons.
65

The healthcare burden costs not only patients’ and providers’ lives but also significant
money; the recommendations provided considers the sophistication, financial landscape, and
support of healthcare institutions at the time of this research. Patel et al. (2018) surveys found
physicians who experience burnout are susceptible to medical errors, and 9% of physicians who
claim burnout have had a minimum of one major medical error in the past three months. These
errors increase stress, and increased stress leads to errors; medical errors can have a cost impact
up to and including ending a provider’s career. As previously mentioned, burnout and physician
loss increase costs for healthcare organizations from $50,000 to $1 million in recruitment and
training (Patel et al., 2018). Although already high, the cost is not inclusive of the revenue not
generated and the downstream effects of patients not being able to be seen due to physician
coverage. Formation Healthcare cannot sustain increased costs due to physician error, attrition,
and suicide in turn; four recommended strategies are suggested based on the interview findings
in combination with the research.
Recommendation 1: Create Paid Time-Off Programs
The standard paid time-off programs do not exist for the emergency department subset of
providers in Formation Healthcare. Allespach et al. (2019) and Lemaire et al. (2018) agree that
time must be spent on a healthy work-life balance to ensure providers are well to care for the
patients and communities they serve. The suggested change in time off will be a change in the
healthcare environment where a balance of work and personal time creates space for mental
health growth, support, and awareness. The notion physicians are not human and do not get
emotional or sick is inaccurate and allowing a group of providers to relax is vital to improving
their mental health; Lemaire et al. (2018). As discussed in the interviews, taking time away can
help with the “career-shortening shifts.” Currently, at Formation Healthcare, emergency
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department providers are allotted as much time off as requested; but these are unpaid hours, and
the use of these hours has been scarce due to staffing constraints at the time of this research.
The recommendation is to formalize paid time off and ensure providers decrease unneeded shift
coverage to return to the three days a week, twelve-hour shifts to improve work balance.
The paid time-off would include two weeks, which aligns with the Formation Healthcare
employed providers’ benefits. To ensure physicians establish importance in their mental health
and wellness, formal time should be carved out for vacations and physical or mental wellness.
These hours could be used at a time the provider chooses, either by the day or weeks at one time.
Bao (2020) states wellness time helps in three ways: increasing productivity, creating happier
employees, and improving recruitment efforts. Depending on states labor laws time off should
not be able to be accrued year over year to encourage paid time-off usage. To implement the
proposed change, there would need to be the creation of a new paid time off policy in
conjunction with human resources leadership, approval from the finance team, and leadership
support for communication and execution. A change in compensation in Formation Healthcare
would need to take place at the beginning of the fiscal year.
Another aspect of time off is extended leave outside of medical or family leave called a
sabbatical. In the case of providers, extended periods off can be dangerous with the continual
changes in medicine (Fish & Steinert, 1995). Davidson et al. (2010) research state sabbaticals
increased self-efficacy and resource gain, with a balance of time off. The suggested sabbatical
from 13P is what Formation Healthcare had in place as a benefit from 2015 –2019. To qualify for
the sabbatical, you must have worked for the company for 3 years, and every 3 years after, you
would be allowed to have a 90-day sabbatical. To reinstate a sabbatical benefit, the current
staffing levels at Formation Healthcare would need to be stabilized (Formation Healthcare,
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2023). Secondarily, the announcement about this reinstated benefit would need to be circulated
in advance so providers could cross-train at facilities for coverage; this shared coverage is
congruent with peer support. The person in SCT framework requires support of person,
understanding of self, personal agency, and the human need for connection requires seeking this
support in others.
The structure of the time-off policy is essential, although, as said in the interviews not as
crucial as providers having the ability to take time off or feel comfortable taking time off.
Policies and procedures can help reduce the burden by setting parameters for the extent of time
off, the timing of requests, and how support will be given to peers during their absence. Time-off
usage can be achieved by developing holiday schedules in advance and known high-volume days
(ex. day after Thanksgiving, the last week of the year, etc.). To ensure providers take advantage
of the time off given, it needs to be supported by leaders, peers, and staff to ensure undue stress
is not placed on the providers in their absence or providers covering.
Recommendation 2: Develop Formal Physician Mentorship Programs
The need for formal mentorship was brought up by every provider interviewed. The ask
was to create a support mechanism from like-minded individuals who understand the stressors in
decision-making and outcomes and the aspects of the emergency department role. Najjar’s
(2020) research says a physician’s death by self-harm is 2% more likely without formalized peer
support. Formation Healthcare (2023) currently has peer reviews and peer recaps but does not
have a formal mentorship program. The recommendation is to develop a formal mentorship
program with resources, compensation, and expectations available to all emergency room. Peer
support, as said in the research by Brooks et al. (2018), can help with balance, modeling
productive and healthy behaviors, resiliency, and reducing the stigma. As stated in the
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interviews, reaching out to peer support is a way to re-check the thought process and heal after a
provider’s most challenging cases. The ability to be able to call someone at any time of day or
night and not need to make an appointment can help with real-time mental health improvement.
Formal mentorship can also create friendships; Lemaire et al. (2018) state camaraderie is
a crucial factor within complex health systems where peer mentorship time could be used to
vent, relax, and be vulnerable. If mentorship allows providers to share how a particular patient
affected them, how a particular case changed their thinking, or how personal or professional
woes are weighing on them, it opens the door to camaraderie. The ability to safely share
confidentially spreads the notion that it is okay not to be okay, in turn “reducing the sigma” of
seeking mental health support. The National Alliance on Mental Illness (NAMI) is working to
reduce systemic barriers, but as researched by McKinsey Company (2020) reducing the stigma is
not a high priority for many companies. Figure 4 notes employers’ emphasis on reducing the
sigma currently, which ranks in last place of priorities; the hope is reducing the stigma is an
unintended consequence of peer mentorship.

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Figure 4
Top Mental Health Priorities

Note. From McKinsey, McKinsey Health, www.mckinsey.com, In the public domain.

Although reducing the stigma surrounding mental health needs is a breakdown in the
global healthcare system, it is not a change that will happen without the support of the people
working in healthcare, the people seeking healthcare, and the systems providing healthcare. The
continued commitment to physician wellness, mental health support, and improved resources at
work will save wasted dollars on physician turnover and patient outcomes due to delayed care
and fear of seeking help.
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Recommendation 3: Institute Telehealth Resources
To support a providers mental health having confidential and flexible access to a
counselor can be extremely helpful and can aid in reducing the stigma by bypassing the need to
tell peers what you are going through. Unfortunately, in many communities, there are access
challenges, and the only providers are peers of those seeking help which can deter providers
from receiving help. Koninis et al. (2015) research stresses the importance of access and not
bypassing physicians’ mental health needs. The recommendation is to supply telehealth services
to all emergency department providers 24 hours a day, 365 days a year. As identified in the
interviews, flexibility in supplied resources would aid in an increased cadence of usage. These
resources would be accessed by a scheduled appointment or a virtual waiting room for the next
available slot; these changes to the environment will have financial implications balanced by
accessibility. Due to the confidentiality concerns of providers seeking mental health and the
barriers to identifying these concerns in peers, the policies should support speaking up and out
about mental health (Brooks et al., 2018) to a confidential provider.
Many Formation Healthcare (2023) emergency departments have on-call behavioral
health support for patients, and the recommendation would be to add telehealth provider-based
support with the current resources. These services are recommended to help provide emotional
support, reduce self-destructive behaviors, and develop healthy coping strategies. Telehealth
platforms currently exist in the organization, but a new platform would need to be developed to
support this need. The steps for implementation would be:
1. Development approval from the telehealth director, data security team, and chief
technology officer. Secondary, approval from the finance team for physician salaries,
technology equipment, implementation, and building expenses.
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2. The production would be put in to build, equipment ordered, and providers
completing these services identified.
3. Training would be completed for providers on how to utilize the new technology.
4. Information packets would be distributed to providers accessing the telehealth
services.
The total implementation time per the Telehealth team would be 90 –120 days (Formation
Healthcare, 2023). Telehealth services would allow for more convenient options for mental
health support based on the inflexibility of providers’ schedules.
Recommendation 4: Generate Personal Services Support Options
In the interviews with 10P and 13P, both providers spoke about the support that
colleagues across the United States shared with them and how they thought it could be helpful at
Formation Healthcare. The addition of support services would help with the time constraints of
the emergency department physicians (Downs et al., 2013), as well as help decrease the need for
paid time off to assist in life balance and more time outside of the constraints of work and
personal obligations. The recommendation from this research is not to ask for funding but
instead to partner with local businesses for these support services. As said in Brooks et al. (2018)
research, these programs can be improved upon to reduce burnout while increasing personal and
professional productivity where time is limited.
The partnership with local businesses would allow for their growth and name recognition,
supplying providers with convenience. The initial support services would be dry-cleaning (pick-
up and drop-off), car maintenance, car washing, and ready-made meals. All these services could
change based on the location and needs of the providers. Allespach et al. (2019) research states
to decrease physician stress; there need to be mental health resources to promote self-care in four
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ways: exercises, breathing, mindfulness, and structure changes. These changes in behavior
ensure a provider places their needs ahead of the needs of their patients realizing the armor of the
title doctor only goes so far. The resources offered could extend to phone applications, on-site
massages, and other services provided by the community and needed by the providers. To be
effective, each service offered must be listed via dates, times, and cost, as outlined in Table 3.
These services would aid in reducing stress for providers working to balance their personal and
professional lives.

Table 3
Opportunities for Support Scheduling
Resources Company Days available Time available Cost
Dry-cleaning TBD Monday thru Sat Noon/noon $5/item
Oil change TBD Tuesday, Thursday, Friday 8am/2pm $35
Meal delivery TBD Monday, Wednesday Friday 10am/ 8pm $9/Meal

Note. To be determined by interested business partners.

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Limitations and Delimitations
A research study has parameters for its collections and outcomes. In the research study,
the limitations are considered what the researcher cannot do, what is outside of their control, and
the delimitations are what the research did not do outside their boundaries. For the limitations of
the study, many of the questions were sensitive, which meant there was a risk interviewees might
not have been honest due to fear of confidentiality. The group of providers was set in one
healthcare organization Formation Healthcare, which limited the interviewees’ population
possible. In addition to the boundary of one healthcare organization, PI’s facility exclusion, time
with the organization, and time as a provider further limited the interviewee group. There was
also little control of the environment in the providers who completed the interview, which could
have affected their attention to the interview.
There were delimitations to the research questions based on the social cognitive theory
framework of person, environment, and their behavior regarding mental health resources and
their comfort in using mental health services. Further delimitation was created by the types of
questions asked as questions about a provider’s personal mental health state or mental healthcare
usage were removed. Inclusion could have created increased issues with the validity of the study
and providers willing to participate. Overall, there was significant importance placed on
understanding the challenges and barriers from a provider perspective while discussing future
possibilities for mental healthcare support via interviews in a confidential environment inclusive
of all willing participants.
Recommendations for Future Research
Future research is needed on the topic of emergency departments’ mental health as the
landscape of mental health is continually changing with the challenges, opportunities, and
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developments of the healthcare environment. In future research, the opportunity to ask specific
questions about the stressors a provider faces at home could help add more robust physician
support. All providers interviewed talked about the personal and professional stressors that
affected their mental health, but it was unclear if the personal issues were due to marital
concerns, children, finances, or something else. Understanding these specific needs would help
identify the proper resources.
Furthermore, asking about a provider’s “why” to becoming a physician could be helpful.
The question would be, why did you initially decide to become an emergency department
provider? Allowing dialogue in the interview outside of the negative experiences affects the
providers’ mental health and instead highlights the role’s positive: the babies born, the lives
saved, and the teamwork. The understanding of the initial “why” could set expectations and
create clarity on the resources which would aid in reminding providers about their past to
hopefully develop strategies to support career longevity.
Conclusion
This dissertation applied the social cognitive theory (SCT) from Bandura’s research on
the person, behavior, and environment in relation to accessing mental health resources for
emergency department providers as a foundation for these providers’ cries for mental health
support. With a specific emphasis on the cost of emergency department providers’ career
attrition and suicide to healthcare organizations and the avoidable loss of life. The literature in
chapter two supported the need for more resources beginning with medical school and followed
throughout a physician’s career. Through interviews with emergency department providers in the
Formation Healthcare system, themes appeared consistent from the literature around the
resource, which would help support career growth and sustainment. The recommendations for
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mental health support of emergency room providers are formal time-off programs, formal peer
mentorship, telehealth virtual support resources, and creative personal services support. No
recommendation alone will solve this workforce pandemic, as systemic change is needed.
The study’s findings reiterated that emergency department providers are at a crossroads with
emotional responses to the traumas seen, the stressors experienced, and the barriers to accessing
support. These traumas lead to irreversible and lifelong challenges in the emergency room
provider population. A provider’s ability to gain control of the resources including balance and
convenience of care will reinstate their power over the role and mental health and aid in
supporting their peers. The research from this dissertation will be shared with the Formation
Healthcare team to support meaningful changes ensuring the communities the healthcare system
serves will have healthy and staffed emergency departments for years to come. The research will
be impactful for families who have experienced the loss of an emergency department provider to
aid in their healing and display a commitment to change to ensure the provider workforce
reduction does not impact future patient care. A continued commitment to emergency
department providers’ well-being with continual future research will be imperative to align with
the recurrent changes in healthcare and the ever-changing provider population.
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Appendix A: Interview Protocol
Respondent type: 10 –15 emergency department providers who have been working in
their field for more than 3 years and with the interviewed healthcare institution for more than 2
years.
Introduction to the Interview
Thank you again for your time today. It is nice to meet you in person, I am Angie
Simonson, and I serve as an executive for a hospital in our system, and my dissertation is
studying emergency department providers to understand the mental health resources or lack of,
leading to career attrition and suicide. The purpose of the study is to access the current mental
health resources available, the understanding of these resources by providers, and utilization
based on system support. The key relationship between patient, provider, and system have
significance as I work to identify why providers are leaving a “calling” profession due to their
mental health, leading to career attrition and suicide. I would like to gain your consent to move
forward with the interview; it is entirely voluntary and should be less than 45 minutes. I will be
recording this interview for research purposes and will save it under the date and number given.
Do you have any questions about the interview, the topic, or the dissertation? If not, thank you
again. Before we start, please tell me your title, location, rural or urban, years employed by this
healthcare system, and years practicing medicine.
RQ1. What mental health resources are emergency department providers aware of and
use, if any?
RQ2. What services and resources do emergency department providers need to support
their mental health?
● How long have you been working at your facility?
88

● How long have you been working as an emergency department provider?
● What are your general thoughts on the resources and services that are currently
available to you (provider, not patient), through your current organization or through
other organizations, to support your mental health?
● What resources not currently offered in your organization would be helpful to have
(for provider, not patient)?
● What are the barriers that you or others have experienced in utilizing these available
resources?
● In your opinion, how could the barriers be best addressed?
● In your opinion, what do you feel is the largest impact to emergency department
providers’ mental health?
● Added: there was anything that should have been asked in the interview or would be
helpful for the research?
Conclusion to the Interview
Thank you again for your time and insight today, I appreciate you being so transparent
and honest, as it is crucial as I continue this important research. Your stories solidify why this
topic is so important and the barriers existing today. As I interview others there might be a need
to re-discuss some of these topics and receive your perspective. If this is needed, would you be
amenable to me reaching back out to you? Please take care of you both personally and
professionally as your patients and your systems need you.
89

Appendix B: Information Sheet for Exempt Research
STUDY TITLE: EVALUATION OF MENTAL HEALTH SUPPORT AND NEEDS FOR
EMERGENCY DEPARTMENT PROVIDERS
PRINCIPAL INVESTIGATOR: Angie Simonson
FACULTY ADVISOR: Kimberly Hirabayashi, Ph.D.

You are invited to participate in a research study. Your participation is voluntary. This document
explains information about this study. You should ask questions about anything unclear to you.
PURPOSE
This study analyzes the challenges with Emergency department providers’ mental health
resources and support. We hope to learn where resources could be bolstered and barriers
removed from utilizing resources. You are invited as a possible participant because you work in
the Centura system and are an emergency department provider.
PARTICIPANT INVOLVEMENT
If you decide to participate, you will be asked to complete a 30-minute interview.
PAYMENT/COMPENSATION FOR PARTICIPATION
You will not be compensated for the completion of the interview; however, for completion of the
interview, you will receive a token to support mental health.
CONFIDENTIALITY
The members of the research team at the University of Southern California Institutional Review
Board (IRB) may access the data. The IRB reviews and monitors research studies to protect the
rights and welfare of research subjects.

90

Information will be kept confidential on the PI’s computer and in the Qualtrics database. No
personal identifying information will be utilized in the transcribed Zoom interviews they will be
identified by a number. Any identifying information will not be saved with the transcripts.

Research themes will be shared with the employing institutions upon request subsequent of
dissertation submission and completion.
INVESTIGATOR CONTACT INFORMATION
If you have any questions about this study, please contact Angie Simonson at
asimonso@usc.edu.
IRB CONTACT INFORMATION
If you have any questions about your rights as a research participant, please contact the
University of Southern California Institutional Review Board at (323) 442 –0114 or email
irb@usc.edu.

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Asset Metadata

Creator Simonson, Angie Crystal Palmer (author)

Core Title Evaluation of mental health support and needs for emergency department providers

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2023-05

Publication Date 05/15/2023

Defense Date 04/07/2023

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag attrition,emergency department,Mental Health,mental health resources,OAI-PMH Harvest,physician wellness,provider,Suicide

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Hirabayashi, Kimberly (committee chair), Canny, Eric (committee member), Malloy, Courtney (committee member)

Creator Email acpsimonson@gmail.com,asimonso@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113127167

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