The following are key points to remember from an American Heart Association science advisory on fostering psychological safety and supporting mental health among cardiovascular (CV) health care workers:

1. The CV workforce is not invulnerable to burnout and mental health conditions.
   • Nearly 25% of cardiologists reported burnout prior to the COVID-19 pandemic, with rates increased post-pandemic. Factors contributing to burnout also include an aging patient population and shortages of cardiologists, nurses, and other health care workers.
   • About 25% of male and 33% of female cardiologists worldwide report having a mental health condition, but only about one third of those report seeking professional help; nearly 3% have considered suicide. Approximately 44% of cardiologists report practicing in a hostile work environment.
   • About 55% of cardiothoracic surgeons reported having symptoms of burnout or depression in the past year.
2. The well-being of physicians and members of the health care team can be markedly influenced by their work environment.
   • Psychological safety is an important component of workplace well-being and has a significant but often overlooked impact on burnout and workforce shortages.
   • Psychological safety means an individual or team feels included, safe to learn, safe to contribute, and safe to state their ideas and viewpoint without fear of embarrassment, condemnation, or retaliation.
   • Positive work environments in which workers trust management, receive support from supervisors, and have adequate time to perform their work, are associated with reduced burnout and improved mental health among health care workers.
3. To promote psychological safety in health care organizations, this AHA advisory endorses several steps.
   • Leaders should:
     • Assess the culture of psychological safety in the organization.
     • Evaluate policies and practices to ensure fairness, civility, respect, and freedom from bullying and violence.
     • Give positive feedback and show appreciation for good work.
     • Educate staff during onboarding and through annual training courses to create and maintain an environment of psychological safety.
     • Hold respectful debriefings following adverse events, creating learning opportunities from mistakes.
     • Offer psychological support and resources for staff after adverse events.
     • Model positive habits such as attentive listening, facilitative questioning, approachability, openness, and integrity.
   • Teams can work on developing rapport, team trust, briefing tools, good role models, and positive relationships between team leaders and members.
   • Individuals can contribute to psychological safety by showing kindness and helpfulness to other team members and by speaking up and addressing uncivil workplace behavior.
4. Benefits of a psychologically safe workplace include improved clinical outcomes, better teamwork, greater adherence to hospital policies, enhanced learning, lower rates of emotional exhaustion and burnout among staff, increased staff engagement, and reduced staff turnover.
5. Lack of psychological safety can lead to occupational distress and possibly suicidal thoughts or behaviors.
6. Efforts to mitigate the risks of occupational distress and suicide can be classified as prevention, intervention, or postvention (organizational response after suicide).
7. Efforts at prevention of occupational distress and suicide can include:
   • Anonymous online mental health screenings.
   • Reducing the stigma of seeking access to mental health care.
   • Regular debriefings to proactively deal with workers' emotional states.
   • Abolishing mental health-based questions which violate the Americans With Disabilities Act from credentialing and recredentialling processes.
   • Establishing methods to detect situations known to elicit ethical or moral distress.
   • Offering support and treatment for employees on leave or in transition due to illness, substance use, mental health, or disciplinary issues—as even the thought of losing one's job or license can be emotionally traumatic and associated with suicide.
8. When occupational distress or suicide risk occurs, interventions may occur on a system-wide basis, community- or policy-level basis, or at an individual level.
   • System-wide interventions could include considerations regarding workload, practice efficiency, flexibility, personal autonomy, work-life balance, alignment of personal and organizational values, community contributions, purposeful work, limiting administrative and electronic health record burdens, policies on parental and medical leave, bereavement, and career deceleration, Schwartz rounds or grand rounds addressing the emotional impact of working in health care, and effects of racial discrimination and prejudice.
   • Policy-level and community-based interventions can include actions by licensing and specialty boards, professional societies, and medical education accrediting bodies to reduce mental health stigma, eliminate policies which discourage health care workers from seeking mental health care, adopt policies which encourage organizations to promote health care worker well-being, and address health care disparities and social drivers of health.
   • Interventions aimed at the individual can include psychotherapy such as cognitive behavioral therapy, stress management classes, resilience training, peer support programs, and psychotropic medications. Such interventions are most effective when not mandatory but available and treated and perceived as socially acceptable and appropriate.
9. Postvention refers to the organizational response after a suicide. Aims of postvention efforts are to promote healthy grieving and lessen the possibility of suicide contagion. Expert guidance and use of a crisis response team are recommended.
10. In summary, psychological safety in the workplace is critical for patients and health care workers. Institutional policies should reflect zero tolerance for workplace hostility and should be designed to reduce stigma regarding mental health conditions, which will include improving insurance coverage for mental health conditions and substance use. Both physical and psychological safety should be evaluated, reassessed, and improved on an ongoing basis.

Clinical Topics: Cardiovascular Care Team, Prevention

Keywords: Mental Health, Workforce, Workplace

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