After three nurses took their lives in one year at her institution, Judy Davidson, RN, DNP, and colleagues set out to learn more about the prevalence of nurse suicide.

“We went to the literature and found nothing recent from the United States,” says Davidson, a nurse scientist at University of California, San Diego (UCSD) Health. All they found were a few research articles from other countries and some decades-old data from the United States, all of which suggested nurses were, in fact, at higher risk for suicide.

Compelling anecdotal evidence drove Davidson and colleagues to investigate further. “There were no data to guide us,” Davidson recalls. “But everyone we talked to said that they had experienced a loss in their career or their organization.”

Davidson and colleagues embarked on two large projects. First, they started a nurse suicide prevention program. There was a suicide prevention program in place at UCSD Health for physicians. “They never thought we were at risk, so didn’t think to expand it to us,” says Davidson.

In 2018, the program expanded to include nurses.1 The chief nurse officer and chief executive officer send an email once a year to all clinicians with a request to undergo a screening. “No one will ever know if you took the screening or what your results were,” Davidson notes. “You may remain anonymous all the way through treatment and/or referral for mental health issues.”

Approximately 40 nurses are identified each year who are high risk for suicide. “They accept help and treatment,” Davidson says.

It is something the nurses, who all had health insurance, could have handled on their own but did not. “Reactive programs aren’t enough,” Davidson stresses. “We have found that a proactive approach like this one is essential.”

Attitudes about asking for help are changing. Therapists used to approach often-reluctant nurses to offer assistance after difficult cases. Now, nurses ask for the debriefings routinely. “This is a signal that we have hit a tipping point,” Davidson offers. “We have changed the culture to accept the fact that we need help to process our feelings about what we witness at work.”

After establishing the suicide prevention program, Davidson and colleagues researched nurse suicides further. The group conducted a longitudinal study, which indicated nurses were at higher risk. “It was surprising that no one had thought of asking the question before,” says Davidson, who co-chairs an American Nurses Association committee on nurse suicide prevention.

Next, investigators analyzed data from the CDC’s National Violent Death Reporting System.2 At the time, the data set included only 18 states. It also was difficult to figure out how many male vs. female nurses there were in each state. “There is a movement toward building a better nursing workforce data set,” Davidson says. “But that was a difficult hurdle.”

Suicide rates were higher in both male and female nurses. In female nurses, opioids and benzodiazepines were the most commonly used method of suicide. Notably, the medications used by nurses in suicide were ones commonly found in the home, not drugs diverted from work. “This may indicate that knowledge to use drugs in a lethal manner is more of an issue than access to medications at work,” Davidson suggests.

Nurses who died by suicide were more likely than the general population to have experienced a job problem before taking their lives. “Incivility in the workplace puts nurses at risk for burnout, turnover, depression, compassion fatigue, and even suicide,” Davidson notes.

There are many modifiable work-related stressors that contribute to “putting nurses over the edge,” according to Davidson. Moral distress over providing treatment viewed by nurses as inappropriate is one common example. So are conflicts with colleagues, problems with managers, and constant demands for nurses to work overtime due to understaffing.

“Nurses are subject to bullying and violence from patients, families, supervisors, physicians, and, unfortunately, even peers,” Davidson laments.

Feeling unprepared for new or expanded roles also is a major stressor. “This leaves the nurse constantly worried about making a mistake that could harm someone,” Davidson says. Loss of autonomy and completing too many tasks in one shift also contribute to anxiety and depression. “There are ethical implications to all of these workplace stressors,” Davidson notes.

Stigma makes some nurses reluctant to seek mental health treatment. For some, this results in self-medicating, leading to substance use disorder. “Then, when this becomes apparent, in many states the licensure board is more punitive than helpful,” Davidson reports.

Currently, there is no standardized national response to substance use in nursing. “The intent should be to preserve the nurse within the profession, rather than punish and remove nurses who have unresolved, yet treatable, mental health disorders,” Davidson says.

REFERENCES

  1. Davidson JE, Zisook S, Kirby B, et al. Suicide prevention: A healer education and referral program for nurses. J Nurs Adm 2018;48:85-92.
  2. Davidson JE, 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 Psychiatr Nurs 2019;33:16-21.