Troubling Findings on Nurse Suicide Rates Bring Health Care Providers Together to Find a Solution

Erratum: Since posting this blog, Dr Myers has learned of an important resource for nurses. He was contacted by Laurie Barkin, RN, MS, author of the 2011 book of the year award winner from the American Journal of Nursing. Her book, The Comfort Garden: Tales From the Trauma Unit, showcases the importance of caring for the caregivers as well as the patients.

Suicide in female nurses is twice as likely than women in the general population. Psych Congress Steering Committee member Andrew Penn, MS, PMHNP, is joined by Rosalind De Lisser, MS, PMHNP, and Michael Myers, MD, in this blog to discuss the alarming suicide rate among female nurses, and what steps their health care colleagues can take to offer support, especially in this post COVID environment.

Andrew Penn and Rosalind De Lisser will also be discussing this important topic at the Psych Congress Elevate virtual meeting on Saturday, June 12, 2021.

The opinions expressed by Psychiatry & Behavioral Health Learning Network bloggers and those providing comments are theirs alone and are not meant to reflect the opinions of the publication.

Andrew Penn, MS, PMHNP and Rosalind De Lisser, MS, PMHNP:

We were troubled to read a recent JAMA Psychiatry paper by Davis and colleagues at the University of Michigan, Ann Arbor School of Nursing revealed an unsettling finding: compared to the general population, female nurses were two times more likely to die by suicide than women in the general population. Female nurses were 70% more likely to die by suicide than their female physician counterparts. Among physicians, the rate of suicide was no higher than the general population, but those physicians who did die by suicide were more likely to be men.

Nurses and physicians who died by suicide were more likely to overdose on opiates, barbiturates, and benzodiazepines as a means of death. This is, not surprisingly, due to their knowledge about and access to lethal medications. A blood alcohol level of >0.08% was present in over a quarter of those deaths.

Perhaps most disquieting about these already troubling findings is that these statistics were gathered between 2007-2018, so these numbers predate the recent stressors of the COVID-19 pandemic and some of the high profile deaths by suicide of medical professionals such as ICU nurse William Coddington and ER physician Lorna Breen.

The paper did not speculate the reasons for this increased risk of suicide among our female nurse colleagues, leaving us, not unlike those left behind in the wake of suicide, with more questions than answers. As someone who has lost nurse colleagues and trainees to suicide, these questions are more than theoretical for us. How could a profession dedicated to caring for others lose so many of its own? Some reasons are obvious – as COVID has pointed out, health care is incredibly hard work. Nurses often work 12-hour days and care for some of the sickest patients, witnessing death and suffering, sometimes of multiple patients in the course of a workday.

Choflet et al (2021) report that of nurses who died by suicide, as reported in the CDC Death Reporting System from 2003-2017, job problems were more prevalent than in the general population. One could argue that job problems are linked to the work environment. There are now countless studies, including one by the National Academies of Medicine, and others led by the University of Pennsylvania Nursing Center for Health Outcomes and Policy Research, Philadelphia. These studies have found that the nurse work environment is associated with burnout, decreased patient safety, and increased patient mortality. Hospitals with positive nurse work environments have been found to have higher patient satisfaction scores and lower nurse burnout. A positive work environment is also associated with psychological safety, wherein one feels safe enough to report an error without fear of reprisal.

Witnessing the suffering of others in the context of helplessness is a recipe for moral injury. Moral injury is noted in veterans who suffered PTSD not from traumas they had endured but from being asked to engage in actions that are misaligned with their moral compass. Nurses who are asked to inflict trauma on others in the provision of care are often overlooked in health care providers and contributes to burnout.  This year it has been worse, where hospitals were overwhelmed by critically ill patients, having to engage in the anguishing decisions of triaging who can and cannot be saved and witnessing the despair of families separated from their loved ones. When nurses are intimidated into not reporting patient care safety errors, they are forced to choose between satisfying their employers (and possibly keeping their jobs) or protecting their patients.  When nurses are forced to make these monumental choices, the weight of the decision falls upon the nurse.

Other reasons may be more structural and therefore, invisible and insidious. A popular trope in the health care industry (and health care is an industry) is to encourage greater “self-care” among clinicians. Appealing while remaining anodyne, this seems like a reasonable suggestion, but underlying the notion that the antidote to burnout and moral injury is to meditate more or make time for yoga shifts the responsibility for burnout to the individual. It absolves the employer or the larger health care industry from culpability. In this model, if a nurse is exhausted and depressed, it is not because she works in a system that contributes to her ailments, it is because she is failing to take good care of herself. This is nothing short of victim-blaming and can no longer be considered to be a legitimate solution to the problem of burnout. (Please see the Erratum at the beginning of this post, Dr Myers has since learned of a resource available for caregivers).

A closer look at the data reveals that it is female nurses who are at greater risk than the general population for suicide. Male nurses (who comprise about 12% of the workforce) actually had a lower risk for suicide than the general population. Why women? In Choflet et al’s analysis of the nurse suicide data, female nurses who died by suicide were more likely to have a diagnosis of bipolar disorder, depression, and dysthymia than their male counterparts. Less than half of which were receiving treatment for their mental illness. This speaks to stigma and shame. As women, we are taught to be strong and push through, and that vulnerability and weakness cannot be seen by others.

If nurses do not feel safe, either in the eyes of their employers or in the eyes of their colleagues, in seeking care for their mental health struggles, they will try to manage these conditions on their own, sometimes to catastrophic ends.

Michael Myers, MD:

As a specialist in physician health, including suicide, I was eager to read this paper as soon as I saw “nurse” in the title. When I’m asked to give grand rounds on physician suicide at medical centers, there are often nurses (and other health team members) in the audience. My default position (and disclaimer) is that my research is limited to doctors and that we don’t have current and scientifically sound empirical data on nurses taking their lives. This has always bothered me, that such a vast group of fellow professionals, indeed our closest allies in health care, has been ignored. This is why the paper by Davis and colleagues and an earlier paper by Davidson et al (aptly titled “Nurse suicide: breaking the silence”) are so important.  Knowing that nurses are at higher risk of dying by suicide than their counterparts in the general population is a starting point. Next comes the “why”? Then, “what can we do”?

I agree unreservedly with Andrew and Roz that simply focusing on nurses themselves shifts blame from the systemic causal conditions of the workplace to the individual. But there is one overarching factor that in my mind spans both the environment or culture of nursing and the specific person. And that is stigma.

Below are a few sentences from Davidson et al’s paper:

One nurse leader speaks of her experience following a suicide.

“I found out through a whisper in the wind. Not a memo. Not an announcement. Just chatter. Then later, another whisper; another event. Again, there was no formal announcement. I thought more about the memos we received about key events with the physicians and how that seemed to be handled so differently. Each of their losses is sent out as a mass email so that anyone touched by that person could know, reach out to the family or friends, and grieve together. …”

This is heartbreaking to read. Whispering suggests institutional (or external) stigma. Sadly, suicide remains so shameful that we cannot speak openly about it. It is also disrespectful and unfair to those we’ve lost. We don’t whisper when a nurse colleague dies of cancer or heart disease or in a car crash. The authors write that it is very different when “key events” (read suicide) happen with physicians.

Internal stigma is ubiquitous and dangerous in health professionals. It leads you to deny and minimize your symptoms that you know suggest anxiety, depression, or substance use disorder. You just hope they’ll go away. You’re too embarrassed to confide in a colleague, let alone reach out to a mental health professional, so you clam up, isolate. Time passes, you’re no better, perhaps a bit worse. Say, you do go to see someone – a nurse practitioner, psychologist, psychiatrist – but stigma doesn’t end there. You still don’t tell anyone. You’re prescribed medication that seems to help, but again you’re tight-lipped. Each pill and each session with your caregiver are reminders that you’ve got an unacceptable disorder.

What about job security? What about my nursing license? What about my insurance? What about credentialing? Endless questions that complicate an already lonely and unshared private journey. You look around at your nursing colleagues, who may talk openly about being stressed or burned out, but no one blurts out, “and I’ve been diagnosed with depression. I’m on medication and getting psychotherapy. I think it’s working.” You search online for narratives of nurses writing about their vulnerabilities, coming out, self-disclosing. You find nothing. You feel even more alone.

My main takeaway from this research is the pressing need for allyship. Physicians are speaking up and joining hands with nurses. The National Academy of Medicine is doing this. Physicians with addictions and now in recovery have been meeting with nurse colleagues for decades in Caduceus groups. Physicians are not the experts in preventing suicide, but we have been studying it longer. Most physicians have been touched by the suicide death of a doctor colleague, often more than once. What they’ve learned as survivors of suicide loss can be offered to the nurses in their midst. Those with “lived experience” of psychiatric illness can share their insights, especially about stigma busting, with nurses. Support groups have been established for nurses and physicians since the Covid-19 pandemic, highlighting the message of interprofessional regard and caring.

Andrew and Roz contacting me and inviting me to pen this blog with them is a start. We welcome your joining us.

Rosalind De Lisser, MS, PMHNP:

As I consider the points made about suicide and the system level drivers of mental health decline, burnout, and the isolation and stigma that ensues, I am drawn to the quadruple aim.

In 2014, Bodenheimer and Sinsky suggested that the triple aim could not fully achieve population health and that as a system, we must adopt a fourth aim; to improve the work-life of health care clinicians.  Several institutions across the country have adopted the “quadruple aim,” creating centers for clinician well-being, these are to be applauded. In 2016, the Accreditation Council for Graduate Medical Education (ACGME), the National Academy of Medicine, and the American Association of Medical Colleges created an action collaborative on clinician well-being and resilience. Then in 2017, the ACGME adopted requirements for resident medical education to include psychological, emotional, and physical well-being as core competencies in the development of resilient physicians. There are 3 significant issues as I see it: 1) the quadruple aim has not been adopted nationally by entities such as IHI, HHS, AHRQ, 2) clinician well-being initiatives are not required, and 3) nursing education is not federally funded. Let me explain.

Adopt the 4^th AIM Nationally: If clinician well-being is to be made a priority, then we as a country must adopt the quadruple aim, and the fourth aim should be supported by the NIH with vigor and reflected in the goals of the National Institute for Nursing Research, National Institute of Mental Health, and National Institute of Drug Abuse. Another possibility is to create a NIOSH research grant program focused on Health Care Workforce Safety and Well-being (modeled after minor safety and health).

Well-being is a MUST: System-level clinician well-being must be a requirement for all clinics and hospitals supported by federal dollars. Moffatt-Bruce and colleagues at Ohio State Wexner Medical Center have shown such system-wide, large-scale interventions improve burnout, work engagement, increase resilience, improve patient outcomes, and result in large-scale return on investment.

Nursing Education MUST be federally funded: If we are to make well-being a core competency for the development of resilient nurses, then clinical nursing education must be federally funded (as CMS funds medical education). Support for nurse well-being will require financial support and infrastructure, starting at the beginning of a nurse’s career and reflected throughout their training, both in the classroom and in the clinical setting. A nurse educator can teach resilience skills all day, but without clinical training environments which support this, it cannot be actualized. Change starts at the beginning.