New research on nurse suicide that included meticulous reviews of death records and other materials revealed nurses who leave the profession because of substance use, mental health issues, or chronic pain are at risk for suicide.1
The researchers selected nurse suicide cases for those who appeared to have a job-related problem prior to death, as coded on forms or described in investigation narratives. Narratives from 203 nurse deaths between 2003 and 2017 were included in the study.
“[This] paper reveals the shocking truth about the job issues nurses face prior to death by suicide,” says co-author Judy Davidson, DNP, RN, MCCM, FAAN, a nurse scientist at UC San Diego Health Sciences. “After reading through the death narratives, we learned that nurses are killing themselves after being [dismissed or quitting] their jobs due to substance use disorder, chronic pain, or mental health issues that are not controlled. Nearly all [are] preventable deaths.”
The suicide rate of nurses is higher than the gender-matched general population. Quantitative data from the CDC’s National Violent Death Reporting System (NVDRS) had previously shown nurses experience more known job-related issues prior to death by suicide. However, this seems to be the first study of the nature of those job-related problems before nurse suicide.
‘We Are Going to Lose More Nurses’
Hospital Employee Health sought further comment from Davidson on this important issue in the following interview, which has been edited for length and clarity.
HEH: What motivated you to review these narratives?
Davidson: We knew from our prior research that quantitively, nurses have more known job-related problems prior to death by suicide than others. That was just a coded piece of data in that data set that a medical examiner or a law enforcement agent would click “yes, they had a known job-related problem.” People have been asking what are those job-related problems that nurses experienced prior to suicide? Every one of those deaths has a couple of [investigation narrative] paragraphs that nobody has ever analyzed. It is difficult to analyze hundreds of paragraphs. We performed a qualitative study and we used “natural language processing,” which is a cousin or subset of artificial intelligence. We used some mathematical computational analysis and also performed traditional thematic content analysis of the paragraphs.
HEH: Were you surprised at what you found?
Davidson: What came up was quite startling. Of the 203 nurses in that data set who died of suicide with a known job problem, 98% of them were either out of work or losing their job due to three different reasons. It was a matter of losing their identity as a nurse.
The three reasons were chronic pain — and some of that was musculoskeletal pain due to job injuries. Some of it was chronic illness. The second was uncontrolled mental health issues. That is kind of surprising because many of them had treatment before their death, but it was either incomplete or inappropriate treatment because they still had mental issues that were treatable but were uncontrolled. The third one is the most important: There was job loss due to substance use disorders, either drugs or alcohol. Many of the nurses were being fired before treatment. They would lose their job, lose their insurance, lose their capacity to pay for treatment, lose their homes, their families, and end up destitute and kill themselves.
HEH: You also are a co-author on another paper,2 noting current methods of dealing with nurse substance abuse puts some at risk of suicide.
Davidson: Yes, the process and the way we terminate employees. Substance abuse disorder is a disease in nurses. In my opinion, we are killing our own.
What happens in nursing, but does not happen in other professions, is that someone comes to work inebriated and they end up losing their job, and often their [nursing] license. We need to somehow turn this on its head and get these people into treatment for a disease, and then hopefully get them back into the workplace. That is a key point at this juncture — and it is a perfect time because the National Council of State Boards of Nursing is starting to look at what might be good “alternative to discipline” programs. There is a team already working on this at a national level. We hope to inform them from our research about the issue of suicide prevention.
HEH: What is the most important point to emphasize?
Davidson: One of the biggest findings from this that I think everyone in the profession needs to know is that we need to add suicide prevention measures when nurses are being worked up for substance abuse disorder. There are all kinds of ways to prevent suicide. There are evidence-based approaches, but right now the alternative to discipline programs do not include the evidence-based approach for suicide prevention because that was not on their radar. They are [addressing] substance use disorder, but they are not thinking of suicide prevention when they are working with these nurses. For the most part, they feel it is an alternative to discipline because they are not turning them over to law enforcement. But the problem is nurses perceive the voluntary surrender of their license during the time they are being treated as discipline. It is psychologically harmful to them. Many of these [suicides] were a spiral down to death. They are asked to turn in their license to go into treatment, and that really doesn’t need to happen. That does not happen in medicine [to physicians].
HEH: Do any of your findings hold implications for nurses during the pandemic?
Davidson: We won’t have that  data for another two years. The NVDRS data set always is two years behind. We won’t get the 2019 data until this fall, and the 2020 data a year from that. But that does not mean these findings are not relevant today. During pandemics — SARS, Ebola — it is known that substance use disorder increases. People drink more than they did before, and use drugs as a coping mechanism (maladaptive coping). It is known that suicide rates increase during pandemics, so we need to take action now to prevent the numbers from going up. It is a key point right now that we increase efforts on suicide prevention and change the way we are treating nurses with substance use disorder. [We] need to be more disease-focused than criminal-focused. We are going to lose more nurses if we don’t make a change right now.
HEH: Does that call for changes in the way substance abuse is reported to nurse licensing boards?
Davidson: We have a problem in nursing because some states require mandatory reporting to the board of nursing when things happen, like substance abuse disorder. It is a mental health illness. As a profession, our scope, standards, and code of ethics say we must report nurses who have a problem. We need to not do that. We need to get them into treatment, but reporting them to the board of nursing so their license can be taken from them is not helpful during this time. I am not saying they should work when they are in treatment, but they could go on a leave of absence while they are being treated. Those who comply will get the treatment they need and become sober. Don’t yank their license for the first [offense]. I’ve heard from too many nurses who had one DUI and lost their [nursing] license. Even after becoming sober, the [nursing board] catches up with them and takes their license. Then, they can’t get a job — even menial labor — because when people find out what has happened to them as a nurse, they won’t hire them.”
- Davidson JE, Ye G, Parra MC, et al. Job-related problems prior to nurse suicide, 2003-2017: A mixed methods analysis using natural language processing and thematic analysis. J Nurs Regul 2021;12:28-39.
- Choflet A, Davidson J, Lee KC. A comparative analysis of the substance use and mental health characteristics of nurses who complete suicide. J Clin Nurs 2021 Mar 25. doi: 10.1111/jocn.15749. [Online ahead of print].