Nurse Suicide: Breaking the SilencePage 7 of 10

5 Occupational Risks

Safety Measures

In the United States, there are 3.4 million practicing nurses representing the largest group of health care professionals [27]. Workers’ compensation data are universally reported, including injuries by type, days of work lost to injury, and cost. Organizations may also track leave of absence due to stress. We have found no evidence that hospitals measure employee loss due to suicide.

Further, more than one of the nurse suicides in the anecdotes we uncovered occurred shortly following separation from the job. If a suicide metric existed, these cases would have likely been lost to capture because the nurses were no longer employees.

Occupational Pressures

Internationally, outdated studies point to factors that appear relevant today to nursing in the US: ethical conflicts, organizational deficits, role ambiguity, shift work, social disruption of families due to work hours, team conflict, and workload [28,29]. In two US studies performed using a secondary analysis of the longitudinal Nurses’ Health Study data, a combination of work and home stress, smoking, stress, and Valium use were identified as suicide risk factors [7,8].

A critical review [30] on risk factors of nurse suicide identified nine studies published globally since the previous review [11], of which there were two US papers [6,7]. This review found that collective risks factors leading to nurse suicide included access to means, depression, knowledge of how to use lethal doses of medications and toxic substances, personal and work-related stress, smoking, substance abuse, and under-treatment of depression [30].

Notes: [a] Katz, R. M., 1983, Causes of death among registered nurses, Journal of Occupational Medicine 25(10):760-762; [b] Doebbert, G., K. R. Riedmiller, and K. W. Kizer, 1988, Occupational mortality of California women, 1979-1981, Western Journal of Medicine 149(6):734; [c] Stack, S., 2001, Occupation and suicide, Social Science Quarterly 82(2):384-396; [d] Feskanich, D., J. L. Hastrup, J. R. Marshall, et al., Stress and Suicide in the Nurses’ Health Study, Journal of Epidemiology and Community Health 56(2):95–98.

Source: Davidson et al., “Nurse suicide: Breaking the silence,” National Academy of Medicine.
Table 2| U.S. Literature Associated with Nurse Suicide

First author/
Title and location of study population/
Year

Findings and limitations

Katz [a]

Causes of death among Registered Nurses

Wisconsin

1983

1963–77 data extraction: Wisconsin Bureau of Health Statistics

Nurses and two control groups (all female workers, female professional workers) identified and compared

41 registered nurse (RN) suicides, average 2.9 per year

No risk factors identified

Proportionate mortality ratio significantly higher (value not reported) than working females and professional females; expected 27.2, observed 41

Doebbert [b]

Occupational mortality of California women, 1979–1981

California

1988

California study (1979–81) evaluating the mortality of working women

Licensed vocational nurse (LVN) and health aides included; no mention of RN

504 deaths over 3 years; average 168 per year; no breakdown of LVN, nurse aide

Females were at the greatest risk of suicide

General female risk factors:

  • Poor equipment
  • Extreme temperatures
  • Work violence
  • Toxic chemicals
  • Microbial agents
  • Shift hours


Lifestyle behaviors:

  • Smoking, drinking patterns

Stack [c]

Occupation and suicide

21 states

2001

21 states contributed data to the U.S. Public Health Service regarding 32 occupation groups and suicide

Did not include nurse occupational stressors

Risk of suicide 1.58 times more likely in nurses than similar working-age population

Feskanich [d]

Stress and suicide in the Nurses’ Health Study

11 states

2002

14-year prospective study beginning 1976; nurses completed self-perception questionnaire

Examined association among self-perceived stress, diazepam (Valium) use, and suicide for nurses

73 RN suicides over 14 years; 5.21 per year

When work stress combined with high home stress, risk increased fivefold

No details about type of work stress

Suicide rate: 6.8% per 100,000 person-years; same as U.S. rate for white females, 40–64 years

Female nurses at higher risk of suicide (RR=1.58) than general population

The high-pressure nursing environment and its associated demands have been clearly addressed within the literature [31-34]. Burnout among nurses is common [35-38]. Caring and compassion come at a price [39,40]. The American Association of Critical-Care Nurses, American Nurses Association, and Association of Nurse Executives all recognize the stress in the profession and have called for action to optimize a healthy work environment [41-45].

The profession of nursing entails demanding and stressful work, with frequent exposure to human suffering and death. Many nurses point to daily ethical issues and ethics-related stress, perceive limited respect in their work, and are increasingly dissatisfied with their work situations [46].

Cumulative stress may be related to administration of potentially inappropriate treatment, blame, inadequate equipment, insufficient labor resources, lateral violence, medication or medical errors, and moral distress (the result of being prevented from doing what you feel is right) [47-51]. Review of medical errors, near misses, and omissions of care traditionally focus on the clinical situation.

The key question in a case review is, “What can we do to prevent this from happening again?” However, the emotional toll of being involved in a case with adverse outcomes is often neglected. The question “How did being involved in this make you feel?” is rarely addressed.

In today’s complex health care environment, nurses have more responsibility and accountability. The care nurses deliver is highly regulated. Nurses are under constant pressure to perform the required care within strict time limits. Spending less time with patients is linked to patient readmissions due to complications [52]. Thus, while burnout is common and painful in its own right, it also leads to suboptimal performance and patient safety issues, and is intimately associated with depression [38,53], a known precursor to suicide [54,55].

It is not known why some people experience despair and hopelessness as a result of negative workplace situations and others can use those environments for stress-induced growth [56]. Depression is a common mental disorder, with a prevalence of 14.6 percent among adults in high-income countries and 11.1 percent in developing countries [57,58].

While there are no reliable published data on the true prevalence of major depressive disorder among nurses, in the United States, one study showed that the prevalence of depressive symptoms among nurses was 41 percent, while another reported it to be 18 percent [59,60].

Nurses as Whole People

It has been suggested that, although work stressors alone are important, when they are combined with stress from home, suicide risk may increase in nurses [7]. The balance of personal and professional values often is neglected in clinical practice. Nurses may “wall off” personal issues to remain in a professional mode with their patients.

In a study on workplace wellness, it was reported that nurses feel cared for when leaders recognize them as whole people, acknowledging the troubles they might be having at home as well as at work [61]. A small 1996 study of 30 nurses and 60 nursing students documented that nurses who had less emotional expression were at an increased risk of depression, which may lead to suicidal ideation [62].

Nurses are also a community within their particular units and, perhaps, need to begin to speak more directly to one another on issues that matter personally as well as professionally. Nurses need to take time to ask themselves and their colleagues, “Are you okay today?” The nursing profession also needs to move beyond the stigma of mental illness and psychological concerns.

Nurses may too often hold themselves to a higher standard, and they might feel shameful or disinclined to confront their own issues with mental health because they are trained to help others, not themselves. In the following quote, we hear a hint that nursing culture might further drive suicide risk by discouraging nurses from seeking help.

Case: Hearing About Penny

I remember when I was hired in the intensive care unit [ICU] on the night shift after having moved to a new town where my husband had taken a new job. I had about 7 years of ICU experience by that time and chose to work nights to maximize family time and reduce daycare for my toddlers.

The culture was quite different from my previous hospital. The night nurses were noticeably less collaborative, with more of a ‘get your own work done so you can sit and read’ attitude. I was much more used to a culture of ‘no one sits down until everyone can sit down.’ The day shift culture and nurses seemed different, but maybe that was because of the day-shift supervisor.

Penny [not her real name] was a bright ray of light. I remember Penny very well. She looked like a perfect West Coast girl, tan, beautiful white teeth sparkling in her warm smile; energetic and always warm and friendly with a hint of mischief. A consummate professional, Penny was a fierce patient advocate and was loved by the staff, physicians, and families. I really looked up to her and knew that as I matured as a nurse I wanted to be like Penny. Her leadership on the day shift was reflected in the culture I observed at change of shift and missed in my night shift colleagues.

I’d been at my new job for about 6 months when I received a call from a day shift nurse in the late afternoon asking if I could come in early to start my night shift. There had been a tragedy amongst the staff and there were day shift nurses who were unable emotionally to finish their shifts. When I asked what had happened, the charge nurse told me Penny had died. They were looking for relief to allow the grieving nurses to go home. Without a second thought, I said I’d be there as soon as I could.

When I arrived, it was clear something terrible had happened. Everyone in the ICU was red-eyed from crying and looking shell-shocked. When I asked, what happened to Penny, I was told she was found dead at her home by her husband, from whom she had recently separated. I also was shocked and saddened by the news but, since I only knew Penny from our brief encounters at staff meetings and change of shift, I was able to contain my own emotions enough to relieve one of her closest colleagues so she could go home.

Many weeks later, after the funeral and many mournful days, we were told Penny’s death was due to an intentional injection of a neuromuscular blocking agent. She had removed the drugs from the unit’s secure drug storage locker the day before, at the end of her shift just before leaving. Only those very close to her knew of her marital problems. No one at work would ever suspect Penny was suffering so much in her personal life. She never let her pain show. Interactions with Penny were always upbeat and positive. She really did find time to laugh and have fun while expertly running a busy unit.

We all missed Penny terribly in those months after her suicide. We asked ourselves how we could have missed, or misjudged, her degree of despair over her failing marriage. We all hugged our families a little longer and treated each other more gently after we lost Penny.

Unfortunately, the culture on nights in ICU did not improve and I requested a transfer to the surgical trauma unit on the opposite side of the hospital. The ICU just wasn’t the same without Penny and the staff was still struggling emotionally. I’ll never forget Penny—her wonderful personality and her gifts as a nurse and leader.

I still struggle with the idea that someone with so many caring colleagues and access to support could have seen no hope in her situation. I can’t even begin to imagine how her family must have felt (and still feel). I’ve since learned that suicide is a complex and dynamic emotional condition.

There are stigmas that need to be overcome so nurses (and all people) suffering from depression, hopelessness, and despair know they can seek help without judgment. Maybe Penny thought that because she was a nurse she should be able to handle her life situation and depression on her own.