EXECUTIVE SUMMARY

In the first such study in more than two decades, investigators reported that nurses are at significantly higher risk of suicide than the general population. The study involves an analysis of data from the CDC’s 2014 National Violent Death Reporting System (NVDRS) database as well as the National Council of State Boards of Nursing and Oklahoma Board of Nursing websites. Investigators from the University of California, San Diego (UCSD) found that the rate of suicide among women nurses was significantly higher than the suicide rate among women in the general population. Likewise, the rate of suicide among men nurses also was higher than rate of suicide among men in the general population.

Investigators noted that many issues common to nursing contribute to symptomatic stress, including conflict in the workplace, lateral violence, a hefty workload, blame for a negative outcome, and witnessing death repeatedly.

While investigators did not report on ED-specific data, the lead author notes that nurse stressors common in the emergency setting include patient recidivism that nurses may feel powerless to address, the lack of time to establish a rapport with patients, and frequent exposure to traumatic injuries.

To prevent suicide among nurses, UCSD Health developed the Healer Education Assessment and Referral (HEAR) program to proactively and anonymously identify nurses and other healthcare workers at risk of suicide and to provide access to effective care.

The HEAR program is successfully identifying approximately 30 nurses a year with serious issues. These nurses are referred into mental health treatment to receive the support they need.


With mass shootings now happening at a predictable clip, several healthcare organizations are beginning to pay closer attention to the emotional toll these types of events can take on frontline clinicians who are charged with caring for victims. It is not easy to witness such trauma, and it can hit some healthcare workers hard, particularly when these events are added to a long list of other burdens clinicians often face daily.

The authors of a new study found that nurses are at higher risk of suicide than the general population.1 This is the first national investigation of the issue in more than 20 years. While there is no one factor highlighted as the primary cause, the research sends a powerful message that healthcare leaders need to do more to ensure that clinicians can access help when needed. Analyzing data from the CDC’s 2014 National Violent Death Reporting System (NVDRS) database as well as the National Council of State Boards of Nursing and Oklahoma Board of Nursing websites, investigators found that the rate of suicide among women nurses (11.97 per 100,000) was significantly higher than the suicide rate among women in the general population (7.78 per 100,000). Similarly, the suicide rate among men nurses (39.8 per 100,000) was higher than the rate among men in the general population (28.2 per 100,000).

When studying the issue, researchers needed to separate the data by gender because men are three to four times more likely to commit suicide than women. Still, nursing is a woman-dominated profession, explains Judy Davidson, DNP, RN, the lead author of the study and a research scientist at University of California, San Diego (UCSD) School of Medicine. However, it is clear that nurses of both genders are affected adversely when it comes to suicide risk, and this was not a surprise to investigators.

“From our prevention work we know that when people have a new manager or a new team, recent relocation, loneliness on the job, or feelings of inadequacy due to a perceived incomplete orientation to the role ... all of those things can increase symptomatic stress,” Davidson says.

Similarly, conflict in the workplace, lateral violence, [a hefty] workload, and blame for a negative outcome all can contribute to stress. “Then, there is the obvious: witnessing death repeatedly or experiencing firsthand, up front an unanticipated death. [These are] some of the gruesome things that nurses are exposed to that [people in other professions] don’t witness in their lifetimes. All of those normal aspects of nursing can cause wear and tear and take a toll on the psyche,” Davidson shares. “For instance, if you are caring for a burned baby that is the same age as your child at home, that can creep in and get under your skin. You need to talk about that and get it out.”

In fact, UCSD Health is ahead of the curve on this issue. They developed a program to prevent suicide among nurses and ancillary staff. The program was put into place three years ago after multiple nurses in the health system took their own lives within a short period.

The Healer Education Assessment and Referral (HEAR) program is an extension of a program that had been in place for seven years for physicians, Davidson explains. “We just extended it to nurses and the rest of the hospital staff,” she says. “We are successfully identifying approximately 30 nurses a year out of one organization that have serious issues and are being referred into mental health treatment to get the support they need.”

Davidson notes that similar programs typically are in place for police officers and firefighters, so a program for nurses was long overdue. “We feel very strongly that nurses need this type of support to be able to cope with the stressors they have on the job and at home,” she adds.

There are several key elements to the HEAR approach. For instance, Davidson notes that a facility needs a therapist who can counsel and respond at a moment’s notice to any issue of concern. “We have two paid therapists and then approximately 40 volunteers who can help in the case of a mass shooting [or an incident of that nature] where the need would exceed the capacity of those two people,” she says. “We also have the palliative care team members who are all willing to volunteer to help in the case of a need that exceeds capacity.”

The HEAR therapists also are charged with keeping a referral list of professionals who are willing to accept healthcare professionals who require counseling or mental healthcare support. “We all know there are not enough mental health providers in the community. [The HEAR program] works very hard to get a list of people who will take patients even if their patient panels are technically closed,” Davidson observes.

However, even with such a list of willing providers, the HEAR therapists must often provide counseling to healthcare professionals in need of counseling or support until their first appointment with an outside professional. “The [HEAR] therapists provide the bridge to treatment and don’t drop anybody through the cracks,” Davidson says.

Another key pillar of the HEAR program is proactive risk screening. This occurs in collaboration with the American Foundation for Suicide Prevention (AFSP). “The reason why that works is because it is totally encrypted. We don’t know who the people are when they do a screening and come in at high risk for suicide,” Davidson says. “They may even make statements of suicidal intent, but we don’t know who they are because the screening is completely encrypted and goes through the AFSP back to our therapists. Then, a therapist will contact the person through encryption.”

The encryption is essential because it gives people the confidence to report their feelings, knowing that “Big Brother” is not listening in, Davidson shares. “All of our nurses that we have gotten into treatment and all of our doctors that we have gotten into treatment were all insured. They could have gone to treatment without [HEAR],” she says.

However, it took organizational leaders reaching out to them proactively with a memo stating that they care about their employees’ mental health, and that they know stressors on the job cannot be avoided, Davidson reports. Usually, the chief nursing officer sends this memo to nurses, and the dean or the chancellor of the school of medicine sends the memo to physicians. The document asks clinicians to take the screening. If they require help, the organization is there to provide it. “It is a push. It is not like an EAP [employee assistance program] where they just wait to hear from somebody,” Davidson adds.

Davidson does not have any data to show that emergency nurses are at higher risk for suicide than nurses working in other settings, but she points to several factors that typically add to the stress level in emergency settings. For instance, emergency nurses often do not have time to establish a strong rapport with patients. Some things these nurses witness in the ED can be particularly traumatic, she says.

“Then, there is the recidivism and the people you can’t help but you want to help,” Davidson observes. “If people can’t get the help they need on the outside, they keep coming back to the ED. There may not be enough mental health professionals to send these patients to, or they may not have the right insurance to get the care they need.”

These patients may keep returning to the ED, each time exhibiting deteriorating circumstances. “You can see why that would be stressful on a [nurse’s] psyche,” Davidson says. “There is this distress that is caused by knowing the right thing to do, but being prevented by society or the organization from being able to do it. That moral distress can lead to depression, and depression is a precursor — untreated — to suicide.”

Another factor that can adversely affect mental health in the ED is workplace violence. In fact, the ED at UCSD is studying whether holding clinical debriefing after any such incident can make a positive difference in these cases, explains Karen Elizabeth Mitchell-Keels, EdD (c), MSN, RN, CMCN, clinical educator and outreach manager in the department of emergency medicine at UCSD Health. “Usually, if you have a violent event, it affects more than one person,” she says. “What we are trying to do is have the nurse reach out and then pull in a group [to talk about it]. Facilitators will be coming down to facilitate those conversations.”

This is part of a referral project from the HEAR program, but it is addressing some of the same issues, according to Mitchell-Keels. “When you start talking about the emotional piece of working ... most healthcare providers are not that good at it,” she observes. “The HEAR project helps us do that.”

One aspect of the project will involve encouraging nurses to make use of the HEAR resource. “I know our nurses suffer from burnout and compassion fatigue,” Mitchell-Keels shares. “Watching them deal with patients on a day-to-day basis who are homeless, have a lot of socioeconomic needs, and often are not the most compassionate people themselves, that puts a burden on our nurses to really maintain their compassion and empathetic care.” Learning how to recognize burnout and how it may be affecting workplace engagement is something that nurses do not discuss nearly enough, Mitchell-Keels notes.

“[Nurses] have a mindset of resilience. It is part of the job ... and when you have that, you are reluctant to admit [there is a problem] until it is really getting to you that things don’t feel comfortable,” she says. “How is everybody feeling at the end of the day? Sometimes, that is the last thing we think about discussing in the ED. We just go on to the next emergency and the next crisis.”

However, healthcare organizations are obligated to create a healthy environment, which means it is important to facilitate access to programs like HEAR, Mitchell-Keels adds.

For hospitals or EDs interested in taking steps to better address suicide prevention, Davidson suggests there is no need to start from scratch. “Just replicate what is known to work,” she advises, citing the HEAR program as one example. “The AFSP can help with the encryption process.”

Further, the AFSP offers many resources that can help healthcare organizations and clinicians respond to suicide risk more effectively.2

(Editor’s Note: Any discussion or even mention of suicide can be a trigger to those at risk. Consequently, Davidson encourages colleagues who may be in need of help to contact the National Suicide Prevention Hotline: 1 [800] 273-8255.)

REFERENCES

  1. Davidson J, Proudfoot J, Lee K, Zisook S. Nurse suicide in the United States: Analysis of the Center for Disease Control 2014 National Violent Death Reporting System Dataset. Arch Psych Nurs 2019. Available at: http://bit.ly/2lFkh2d. Accessed Sept. 5, 2019.
  2. American Foundation for Suicide Prevention. Healthcare professional burnout, depression, and suicide prevention. Resources for healthcare professionals and medical educators. Available at: http://bit.ly/2kd67W1. Accessed Sept. 3, 2019.