Case study
An experienced nurse, recently widowed, moved to a new state for a fresh start and changed specialties from community health to the cardiac catheterization lab. She only received 2 weeks of orientation in her new specialty because she had previous nursing experience. She subsequently experienced high anxiety and told her supervisor that she did not feel she was providing safe care because of the minimal preparation she received. However, her supervisor dismissed her concerns. The nurse's colleagues felt that she was not experienced enough to be a part of the team and exhibited exclusive and bullying behavior toward her. For example, no one helped the nurse with patient care and she was excluded from social events like staff lunch parties.
One day, the nurse disposed of a medication based on her experience in her previous specialty area, but the procedure turned out to be incorrect for her current specialty. The pharmacist berated and belittled the nurse in front of her colleagues. That night when the nurse went home, she took her own life by overdosing on medication.
Introduction
Suicide is the 10th leading cause of death in the US.1 Nurse suicide, in particular, is concerning as the suicide rate among nurses has been found to be higher than that of the general population.1 Suicide is typically impulsive and occurs when stressors exceed the coping mechanisms of someone experiencing mental health distress.2,3 The nursing profession-characterized by long hours, exposure to disease and death, and burdensome demands-puts nurses at increased risk of suicide.4 This article discusses the epidemiology of suicide, the suicide rates among the general population and nurses, suicide risk factors and barriers to reporting mental health issues among healthcare professionals, strategies to recognize nurses at risk for suicide, and interventions to prevent nurse suicide.
Epidemiology
Nurses are at an increased risk of developing serious mental health issues, such as depression and anxiety, which can lead to suicide.5 Research contrasting the nursing profession with nonmedical occupations such as teaching reveals an increased risk of dying by suicide for nurses compared with their peers working outside healthcare settings.1,6 While nurses often represent the front line of healthcare, providing direct care to patients in need, the nurses themselves are at risk for adverse mental health issues, such as depression and suicidal ideation.7
The underlying causes associated with higher risks for suicide among nurses involve stressful working environments in which nurses are exposed daily to high-pressure levels while caring for patients who require urgent medical attention.8
Patient safety incidents (PSIs) occur daily. Nurses who possess type-A personalities are self-critical when these events occur.9 A PSI involves at least two victims: one being the patient, the other being the healthcare worker.9 Healthcare workers may leave a job or change departments to avoid remembering a PSI. Following a PSI, nurses face a 20% increased risk of attempting suicide.9
Other factors that increase the risk of suicide among nurses include inadequate resources such as staff shortages leading to longer shifts, bullying or harassment from peers or supervisors, feelings of isolation due to a lack of social support networks in the workplace, loss of an important personal relationship, financial problems caused by low wages, and difficulty balancing demands between home and work responsibilities.10 Nurses face numerous mental health challenges, including compassion fatigue, anxiety, depression, ethical dilemmas, and second-victim syndrome.11 Together, these elements create a stressful environment in which individual coping mechanisms become overwhelmed, leading nurses to feel hopeless and contributing to suicidality.3
Nurse suicide is a major issue requiring immediate intervention.12 Understanding the epidemiology behind this phenomenon facilitates targeting specific areas when devising prevention strategies.
Nurse suicide
Suicide rates among nurses are higher compared with the general population and have been increasing, especially among female nurses.13,14 According to a study published in 2020, depression rates rose from 25% to 43% among nurses.13
The impact of job-related stress on mental health is compounded by the fact that nurses often lack adequate support and resources to cope with the demands of the job. The typically long hours, high workload, and exposure to emotional and physical trauma can all lead to burnout-a condition characterized by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment.6,7 Burnout has been linked to depression, a major risk factor for suicide.4
Risk factors
Risk factors for nurse suicide include relationship issues, difficulty on the job, professional burnout, working long hours, feelings of inadequacy due to incomplete orientation, bullying, medical errors or adverse events, and lawsuits (see Risk factors).4,7,9,10,11-14
The pressures of being a nurse can often strain relationships between nurses and their significant others.9 Such relationship strain can arise from varying work schedules, long hours, and their partners' inability to provide empathy for nurses' job stressors due to ethical issues that prevent nurses from sharing details, leading to feelings of loneliness and increasing depressive symptoms.10 In turn, depression increases the likelihood of suicidal ideation among those affected by relational distress.10
Nursing requires working long hours under stressful conditions, which affects mental health over time.13 One study found that nurses who work 12-hour or longer shifts experience poor physical and mental health compared with those who work 8- to 10-hour shifts.13 Many nurses, especially those in EDs and critical care, are exposed to difficult situations, such as death or illness, which can engender guilt or helplessness if not managed properly.4,7 Furthermore, nurses' work-related responsibilities involve making decisions that can have life-altering consequences for patients. This responsibility, coupled with fatigue from long shifts, increases the risk of anxiety and depression, leading to the potential for suicidal ideation.9,13 Gender is also a factor in that nurses who are women are more likely to experience job problems than nurses who are men.10
Nurses often have high stress levels while balancing their personal lives and work obligations. Inadequate support at home can increase the difficulty of coping with additional stressors encountered at work, leading to professional burnout.1 This lack of support has been directly linked to suicidal ideation.9
The nursing shortage introduced many young nurses to the profession. Those attracted to nursing typically have type A, perfectionistic personalities.9 Inadequate training can result in feelings of inadequacy, leading to depression and anxiety.9 Daily experiences with PSIs, even those that may not cause harm to the patient, can cause perfectionism- and trauma-related guilt that can increase the risk of suicide among nurses.9 Similarly, medical errors carry immense emotional weight for the nurses who commit such errors because nurses are responsible for any harm caused by their actions.9 In addition, fear of disciplinary action further compounds nurses' emotional burden, creating an environment ripe for suicidal ideation and self-harm if left unmanaged.9 Lastly, lawsuits arising from these incidents, such as in the RaDonda Vaught case, exacerbate these risks.15
Nurse vs. general population suicide
Nurses experience higher rates of suicide than the general population. For women, one study reports a rate of 11.9 per 100,000 compared with 7.5 per 100,000 women in the general population.16 The rate for men is also higher (39.8 per 100,000) compared with the general population (28.2 per 100,000).16 The odds of a nurse dying by suicide are 1.58 times higher compared with the general population.17
Nurse suicide means
Chosen methods of suicide differ by the nurse's gender: women are more likely to die by suicide by poisoning; men are more likely to use a firearm.10
Pharmaceutical poisoning is higher in healthcare professionals than in other professions.10 Nurses' extensive knowledge about medications can make them more inclined to use medications to die by suicide.4,12,16,17 Nurses most commonly utilize antidepressants, opiates, and amphetamines.4,10
Reporting barriers
Among the barriers that prevent nurses from seeking help is a persistent stigma toward mental health. Nurses often hold themselves to a higher standard and may be disinclined to report struggling.11 Many nurses are unlikely to report poor coping mechanisms, such as substance abuse or self-harm, out of fear of disciplinary action from the Board of Nursing or loss of employment.12
Stigma
Nurses should have access to affordable mental health screenings and treatment, and the use of these resources should not negatively impact licensure.18 The National Academies of Sciences, Engineering, and Medicine (formerly known as the Institute of Medicine) recommends evaluating and strengthening programs and policies within organizations and the Boards of Nursing to reduce the stigma of behavioral health.19 For example, the state Board of Nursing should encourage nurses to seek help versus stigmatizing them with questionnaires that violate the Americans with Disabilities Act.20
Similarly, punitive action for nurses seeking help for mental health and substance use disorders must be eliminated.21 By not punishing nurses who are struggling with mental health and substance use disorders, there would be less underreporting, and nurses would be able to get the help that they need.20
Recognizing nurses at risk
Signs of nurses at risk for suicide include excessive absences from work, loss of interest in activities that were once enjoyable, and difficulty concentrating, among others (see Warning Signs of Suicide22).1 The following interventions can help in recognizing at-risk nurses and preventing suicidal ideations.
Programs
The University of California San Diego addresses the risk to nurses through the Healer Education Assessment and Referral (HEAR) program (see Resources).11
The program begins by emailing a questionnaire to all nurses. The nurses' responses are assigned random numbers to ensure anonymity.23 If any risk factors are mentioned, the email address is flagged.23 Certified counselors reach out through the anonymous database asking if the nurse would like to follow up or receive resources. Nurses who wish to follow up have access to counselors and a psychiatrist at no cost for a specified number of visits or the entire episode that leads the nurse to seek assistance. Nurses who choose not to use the resources provided by the hospital are provided with other external resources. According to research findings, the program increases access to care and decreases feelings of helplessness and hopelessness.23
Another resource for nurses is an employee assistance program (EAP), available through the nurse's employer. This program assists in finding a counselor within a certain mile radius of the nurse's home or place of employment. An EAP covers the cost of three to five sessions with a counselor. Under these programs, the nurse is responsible for requesting help and covering the costs after the free visits end.
Another program for nurses is the Peer2Peer program, where nurses work with other nurses as a support system. Instead of providing professional counseling, this approach uses a buddy system to support those experiencing job struggles.
Lastly, MINDBODYSTRONG is a cognitive behavioral therapy-based approach aimed at helping new nurses develop coping skills to decrease depressive symptoms and anxiety.13 The MINDBODYSTRONG program is a novel adaptation of an evidence-based cognitive behavioral skills-building intervention that provides a theory-based approach to improve nurses' mental health, health choices and behaviors, and job satisfaction.24
Education
Education is an important aspect of preventing nurse suicide. The American Psychiatric Nurses Association (APNA) offers continuing education on suicide prevention for nurses.25 Such education can help managers and staff recognize at-risk nurses.
Other interventions
Employers can implement other interventions, including decreasing shift work from between 12 and 16 hours to between 8 and 10 hours,13 and providing education and resources to decrease or prevent workplace bullying or lateral violence. The National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience recommends hiring a chief wellness officer (CWO) to implement such programs and to create a healthy culture that provides resources for healthcare workers in need.13 The CWO must be part of the organizational leadership to educate upper management, access resources, and implement their plans. The CWO would track outcomes of best evidence-based practices to help struggling nurses.
Conclusion
Nurse suicide is a serious issue that should garner more attention. Nurses are more likely than the general population to die by suicide. More attention and support for nurses are needed to decrease the rate of suicide.
Preventing nurse suicide entails creating an environment that makes nurses feel supported, along with access to mental health services, if needed.
Risk factors
* Personal relationship stress10
* Difficulty on the job10
* Professional burnout10
* Long hours10
* Feelings of inadequacy due to incomplete orientation10
* Bullying10
* Medical errors or adverse events9,12
* Lawsuits4,7,9
* Depression7
Warning signs of suicide22
* Talking about wanting to die, great guilt or shame, or being a burden to others
* Feeling empty, hopeless, trapped, or having, no reason to live; extremely sad, more anxious, agitated, or full of rage; unbearable emotional or physical pain
* Changing behavior, such as:
* Making a plan or researching ways to die
* Withdrawing from friends, saying goodbye, giving away important items, or making a will
* Taking dangerous risks such as driving extremely fast
* Displaying extreme mood swings
* Eating or sleeping more or less
* Using drugs or alcohol more often
Resources
* Healer Education Assessment & Referral (HEAR) program23
* Employee Assistance Program (EAP)
* Peer2Peer program
* Local Community Service Board (CSB)
* Suicide Hotline-98826
* Crisis Text Line-74174127
* National Alliance on Mental Illness (NAMI)-Nami.org28
* Psychology Today-Psychologytoday.com29
* MINDBODYSTRONG app13
* Substance Abuse and Mental Health Services Association (SAMHSA)-SAMHSA.gov30
REFERENCES