Overcoming the historic dearth of data on a critical issue, the authors of a new study reported that nurses are at higher risk of suicide than the general population.
Researchers reported1 that female nurse suicide rates in the United States were significantly higher than for women in general, with a rate of 11.9 per 100,000 nurses, compared to 7.5 suicides per 100,000 women in the population. Male nurse suicides are even higher, with a rate of 39.8 per 100,000, compared to 28.2 per 100,000 men in general, says lead author Judy E. Davidson, DNP, RN, FCCM, FAAN, nurse scientist at University of California, San Diego (UCSD).
“We had a series of [nurse] suicides here in San Diego that piqued my interest in the topic,” she explains. “I went to the literature and found out there was nothing. The data I could find about nurses in the U.S. were over 20 years old. But all of that old data were speaking to the point that nurses were probably at higher risk. For some reason, we had just let this research question go silent.”
The ongoing research is difficult due to the lack of a national database that links cause of death by occupation and gender. Davidson is working with the National Council of State Boards of Nursing to collect as much detail as possible to continue her research.
“If I had my druthers and a magic wand, I would ask each state to report gender with their licensure workforce data at the end of every year,” she says. “Every state reports how many actively licensed [nurses] they have every year. If we had the gender data to go with it, we could do a much better job.”
The findings already have resulted in significant national action, with the American Nurses Association (ANA) forming a task force to specifically look at nurse suicide. Davidson was in discussions with ANA leadership on preventing nurse suicide when nurse members brought up that issue for discussion at the group’s annual conference in April.
“They have asked us to collaborate with them on a task force that [started] in the fall to look at suicide prevention in nursing,” she says.
When asked for comment, the ANA sent the following statement: “Whether it’s due to demanding shift work or the stress associated with providing care on the frontlines of nearly every clinical setting, we know that depression and anxiety are common complaints among nurses,” the ANA stated. “UCSD researchers’ investigation of nurse suicide provides much needed and timely insights into this critical issue.”
Physician suicide has been studied closer, and it is estimated that as many as 400 doctors commit suicide annually, she reports. However, the current incidence of nurse suicide in the United States has been largely undocumented, a situation Davidson first addressed in a pilot study.2 In a recently published follow-up paper, the researchers drew data for 2014 nurse suicides from the CDC’s National Violent Death Reporting System (NVDRS). The data set included all suicides reported by medical examiners from 18 states for that year. There were 14,774 suicides in the 18 states, including 205 nurses, the researchers found.
Davidson and colleagues confirmed that their pilot study data suggested nurses are at risk for suicide and experience higher rates than the general public. A larger NVDRS data analysis that will include 40 states is underway.
“We are fairly confident that what we are seeing is real,” she says. “We are finishing up a longitudinal analysis. The data should be released soon — 12 years of CDC data from 2005 to 2016.”
HEAR Suicide Prevention
Originally formed to address physician suicide risk, the UCSD Healer Education Assessment and Referral (HEAR) program has been expanded to include nurses.3 The program should be considered nationally by other institutions, she says. The program includes proactive measures like contacting clinicians to offer voluntary mental health screening.
“They can remain completely anonymous through this encrypted system that is managed through the American Foundation for Suicide Prevention,” Davidson says. “We found that usually only people who are moderate to high risk answer the survey. They know they have a problem and have been waiting for someone to reach out.”
Counseling is available by phone without providing identification. Referrals can be made to counseling outside the geographic area to avoid recognition by colleagues or friends.
“We have had no physician suicides since that program was put in place, and we have had hundreds of clinicians accept referrals for the mental health that they needed,” she says. “Three years ago, we started this same program for nurses. We just extended the program and tested it, and lo and behold, we are having the same results.”
The chief of nursing sends a letter asking nurses to undergo the screening as a matter of self-care. The healthcare system employs two full-time counselors in the HEAR program.
“This year, we had 40 nurses accept referrals for mental health treatment that had expressed suicidality,” Davidson said. “In the meantime, the therapists don’t drop them in a hole — they don’t say, ‘Your appointment is in six weeks.’ They continue counseling them until they go to their appointment, which is the beauty of the program.”
It was the recognition and response to physician suicide risk that ultimately opened the door for nursing, she adds. “It’s because of physician suicide [awareness] that here at UCSD we were able to develop the first nurse suicide prevention program in the country,” Davidson said.
The suicide data reveal that nurses are more likely than the general public to have sought mental health treatment.
“They are seeking treatment, but it may be inadequate if their depression was so bad that it led to suicide,” she says. “It may be undertreatment, intermittent treatment, or not the right treatment. In any case, they have had more mental health access than the general population and they still completed suicide. That is a problem that needs investigation before more nurses die.”
The key difference in the HEAR program may be that someone is reaching out to the nurses and offering counseling, she adds. “We nurses are stoic as people. ‘Buck up and take it; the work is hard,’ is the way we have always been trained,” she says. “[We are] getting past that, changing the culture and getting nurses to reach out and get the treatment that they need when they really need it. This proactive approach is working, and our culture here is shifting.”
The hospital also offers “crisis debriefings” that may include group therapy with a clinical team that has been emotionally affected by a disturbing event. “It helps them process their feelings and emotions on what it was like to have a patient die, hit us, or throw things at us,” she says.
Such interventions are common in some other professions, but nurses traditionally have been expected to weather a crisis in the name of patient safety. “Why haven’t we done this all along? We are exposed to negativity all the time,” Davidson says. “The horrific things you witness, the connections to people who die.”
Even with a system designed to ensure anonymity, it is difficult for some nurses feeling suicidal to come forward. To self-medicate, they may develop substance abuse disorders with alcohol or drugs.
“They felt the stigma against mental health treatment was too great, and they didn’t get the help they needed psychologically,” Davidson says. “They turned to drugs or alcohol for their existential pain and suffering. It may be work issues or home issues, and it gets out of hand. They never get the help they need. They try to hide it, but eventually it creeps into their work and they are found out, or they get a DUI.”
Once these work or legal consequences arise, a nurse’s license to practice may be in jeopardy. “My personal recommendation is that we need to do more about making the nursing response to nurse substance-use disorder nonpunitive,” she says. “We need to develop systems like the physicians have in place to caringly refer affected nurses into treatment, without losing their license, so that they can come back into the workforce once they are rehabilitated. Substance use disorder is a disease, and needs to be treated like one.”
In the 2014 CDC data, pharmacologic poisoning was the most common method of suicide among nurses. However, nurses were more likely to use drugs at home than divert them from work to commit suicide.
“That signals to me — and we won’t know until we analyze the data from the longitudinal study — that the reason is usually not about access to drugs at work,” she says. “Instead, it may be because of an understanding of how to kill yourself with drugs. It’s the knowledge of how to use drugs in a lethal manner.”
The suicide prevention project reveals that nurse-reported stressors are roughly equal between work and home. “But the stressors from work are all modifiable,” she says. “Things like orienting your staff completely and thoroughly, making sure they feel welcome in the environment, and not alone when they move from another state or another organization. Loneliness and feeling separated are big risks.”
Nurse bullying, which has almost been viewed as a rite of passage in a culture that “eats its young,” can inflict psychological harm. “That can lead to depression, and depression can lead to suicide,” she says. “We need to actively address the bullying in our environment. Some of the bullying is from work compression. If people feel like rats in a cage, spinning the wheel and getting nowhere, they will act like rats in a cage.”
Other modifiable factors in healthcare include reactionary rules and policies that were enacted in haste but become entrenched. Some practices that began with a single physician preference, warning from the health department, or a warning from an accreditation agency are never revisited, becoming sacred cows that add layers of unnecessary work.
“On any given day, we are overregulated as a profession, with policies and rules that don’t have evidence behind them,” she said. “Doing that hard work of stripping out these [unneeded] policies is a suicide prevention technique.”
- Davidson JE, Proudfoot J, Zisook S, et al. Nurse suicide in the United States: Analysis of the Center for Disease Control 2014 National Violent Death Reporting System dataset. Arch Psych Nurs 2019. doi: https://doi.org/10.1016/j.apnu.2019.04.006.
- Davidson J, Mendis J, Stuck AR. Nurse Suicide: Breaking the Silence. National Academy of Medicine. Discussion Paper. Jan. 8, 2018. Available at: https://bit.ly/2FyMCvX.
- UC San Diego Health Sciences. Healer Education Assessment and Referral (HEAR) Program. Available at: https://bit.ly/2U8GEu7.