Questioning the Question: Reducing Stigma Toward People with Mental Health Conditions

By Kanaka Sathasivan, MPH

This article first appeared in Texas Nursing Magazine Issue 4, 2021.

Download the PDF here.

Several years ago, the Board of Nursing (BON) added a simple question to the licensure renewal form: “In the past five years, have you been diagnosed with or treated for schizophrenia or other psychotic disorder, bipolar disorder, paranoid personality disorder, antisocial personality disorder or borderline personality disorder, which impaired or does impair your behavior, judgment, or ability to function in school or work?”

While the question was intended to protect public welfare and was considered standard and used by other licensing entities at one time, it reinforced stigma and perpetuated discrimination against certain health conditions.

“It was unfair and frustrating,” recalls Andrea Knott, BSN, RN, CPN. Following the birth of her daughter, Knott experienced postpartum psychosis, which led to a diagnosis of bipolar disorder. She worked carefully with her doctor to find a treatment that worked for her and had been doing fine at work. She was applying for renewal a year after her diagnosis. “At first, I saw the question and thought ‘I get it. I get that they want a letter from my doctor.’”

After she applied to renew her license in July 2019, answering the question honestly, she was stunned to receive a letter from the BON requesting documentation and proof of compliance with the Nursing Practice Act.

THE LETTERS

“I felt like I had done something wrong,” Knott said. “But in reality, there was nothing I could do to control what I went through. The only thing I could control was seeking treatment.”

Knott immediately complied with the request, providing documentation and information including work history and year-end evaluations; a resume; a letter outlining the circumstances of her hospitalization; and a response to the allegations of violating the Nurse Practice act to the BON. She also consulted an attorney who shared stories of other nurses who face similar barriers. Some had to wait months for their license to be reinstated, during which time they could not work.

However, Knott was confident she had done nothing wrong and that legally, there would not be grounds to remove her license.

Then the second letter came. On Aug. 13, 2019, the BON requested even more information. Knott began to ask more questions. She hired an attorney, and with their help put together a response packet that included yearly evaluations from manager and coworkers, letters of reference from community members, family, and her pastor attesting to her character.

“With the help of my doctor, I felt safe and confident to not just be a mom but also a health care provider. The packet included great reviews from my peers— they would be the first people to speak up if they were concerned,” she said. Her peers also reinforced that she was doing the right thing by being honest.

However, the BON’s response was discouraging: “They wanted me to be seen by one of their doctors.”

THE EVALUATION

Confused and upset, Knott decided to call the BON and talk directly to her case manager to understand their rationale. She learned that refusal to comply with evaluation could lead to administrative hearing. So, she tried to use their list of doctors to set up an appointment.

“I called a number of the pre-approved providers in the Dallas–Fort Worth area,” she explained. “The evaluation would have been $800. But when I asked them who they normally evaluated, it was usually nurses with substance use disorder. I asked specifically if they had any experience with bipolar or postpartum psychosis and none of them did. I know it’s my right to see someone that specializes what I need.”

Since Knott was not comfortable seeing any of their providers, she went back to her attorney at beginning of October. In addition, she sought support from her colleagues and employer. “I’m so blessed to have an amazing support system, bosses, coworkers—able to talk about feelings and feel supported. Not everyone has that.”

Knott also served on the committee for mental health in the med-surg unit, where she worked alongside former Texas Nurses Association Board Director Shakyryn Napier, DHSc, RN, CPN, NEA-BC. She shared her situation and her frustration: “I did nothing wrong, and I felt like I was being interrogated like a criminal.”

Napier, also chair of the TNA Policy Council, immediately brought the issue to the attention of TNA, including the council members, Chief Executive Officer Cindy Zolnierek, PhD, RN, CAE, and lobbyist Kevin Stewart, JD. In a heartfelt letter in January 2020, Knott explained how problematic the question had become. Crucially, she wrote: “[The BON’s] actions serve only to encourage nurses to hide their mental health issues and not seek medical care for fear of losing their license.”

THE CHANGE

Zolnierek and Stewart agreed that the question created undue hardship for nurses and further perpetuated stigma against people with mental health conditions. Jumping into action, they alerted the BON regarding Andrea’s experience speaking directly with the BON general counsel and executive director asking them to remove or change the question. TNA’s efforts paid off.

First, in early 2020, Knott’s case was closed—the evaluation by Andrea’s treating provider should have been adequate. There had been a breakdown in the BON’s processes, and they clarified their investigation procedures to prevent further occurrences. The BON also acknowledged that the question on their application and renewal forms regarding mental health issues was not aligned with the Americans With Disabilities Act and agreed to research more appropriate language. At its July 2020 quarterly meeting, the BON approved replacing the question with “Are you currently suffering from any condition for which you are not being appropriately treated that impairs your judgment or that would otherwise adversely affect your ability to practice nursing in a competent, ethical, and professional manner?”

“I don’t want any nurse to go through what I’ve been through,” Knott said. “It was not just demeaning, but stressful to have to relive that traumatic event and worry that my livelihood and license could be on the line.”

When Knott learned through a coworker that the question had changed, she almost started crying. “I was so thankful no one else would have to go through that, and I knew that if I had a relapse or needed hospitalization, I wouldn’t have to go through it again. I have control over my medications, see my therapist regularly, and take care of my health, but something could happen later that meant seeking treatment or hospitalization again.”

The change in the question meant that Knott and others would now be able to seek treatment without fear of losing their license.

“I’m so glad it changed at that time,” she said. “With COVID, there has been an increase in nurses needing help and now they don’t have to fear getting it. I want to erase the stigma behind people with mental health conditions. You can still be a productive and giving member of society.”

For nurses who need help with a mental health condition or substance use disorder, visit tpapn.org to learn more about the Texas Peer Assistance Program for Nurses.