Researchers at the University of California San Diego School of Medicine and UC San Diego Health, Department of Nursing found that nurses had significantly higher suicide rates than the general population.
Specifically, the study, published in the journal Worldviews on Evidence‐Based Nursing, revealed that female nurses’ suicide rates were 10 per 100,000 compared to seven per 100,000 in the general female population. The rate in male nurses was 33 per 100,000, compared to 27 per 100,000 in men overall.
“I feel like I should be surprised but I’m actually not, because we underestimate what nurses go through on a daily basis” and “maybe that’s the scariest part of all that it’s not surprising,” said Rachael Accardi, LMFT, a therapist at the University of California San Diego School of Medicine (UCSD).
Accardi administers a suicide prevention program called Healer Education Assessment and Referral (HEAR), which was launched four years ago for nurses.
The study used the 2005-2016 National Violent Death Reporting System dataset from the Centers for Disease Control. Judy Davidson, DNP, RN, a research scientist at UCSD and lead author on the study, noted that these results don’t reflect an increase in suicide. Rather, “the data has been silently waiting. [Nurses] have been at a higher risk all along but we haven’t asked the research question.”
Davidson believes that this is “only going to get worse,” because the generation “coming into the workforce already has higher rates of anxiety and depression at baseline before they start this stressful work.”
According to Davidson, the most important finding from their research is that this isn’t an individual issue. It’s systemic. “Something about the work of nursing is stressful and unhealthy.”
One culprit is non-evidence-based rules, she said. For example, “about three years ago, The Joint Commission decreased nurse autonomy by disallowing nurses from using judgment to titrate medication infusions. Now physicians must write orders in advance for the increment and frequency of change.”
The problem? Because every patient is different, no one can predict in advance how the combination of medications being infused will affect them.
“With unstable patients, nurses have to delay care until they get a new order, or do what they used to do against the standards: titrate the medication independently and backtrack what they’ve done, which could jeopardize their license and the organization’s accreditation status,” Davidson said.
According to a new survey she’s piloted, 90 percent of nurses say they cannot consistently adhere to these standards and that they impose moral distress: “symptomatic stress from being prevented from doing what you know is right.”
Longitudinal data also shows that nurses have higher rates of physical problems prior to suicide than the general population, Davidson said.
Another psychological burden is the electronic medical records system. “There isn’t enough time for nurses to both chart and care for their patients,” Davidson said. “People laugh when you bring up computer charting, but it’s real. Every extra click imposes psychological burden.”
In fact, current research is using physician charting on nights and weekends to predict mental health issues, Davidson said.
“Nurses are like first responders,” Accardi said. “Because nursing is a fast-paced career, nurses become good at compartmentalizing. They don’t have time to process what they’re witnessing and how that might be impacting their psyche.”
Shame and stigma can make it harder to seek help. Nurses may think “if I’m suffering, I must be weak or incapable of doing my job, and I must keep quiet,” Accardi said. This isolates nurses even more, she said, and can lead to depression.
In 2009, Dr. Sidney Zisook and Dr. Christine Moutier developed HEAR after the UCSD burn unit lost their director to suicide and was averaging one physician or student to suicide a year, said Accardi.
Currently, HEAR has been replicated on more than 60 campuses, Davidson said.
How it works: Once a year, an email is sent out encouraging nurses to take a depression and suicide risk assessment created by physicians at UCSD in partnership with the American Foundation for Suicide Prevention.
According to Davidson, “that little email and the promise of anonymity” throughout the process has been powerful. “We’ve been finding 40 nurses a year expressing suicidality,” and helping to get them into treatment, she said.
If local resources have waiting lists, Accardi said, individuals can receive bridge care within the program. “We want to promise that we’ll stay connected and people feel supported.”
HEAR also includes an emotional processing debriefing. According to Accardi, after a difficult case or patient death, she and another therapist meet with staff to help them process their feelings.
Currently, Davidson is collaborating with Bernadette Melnyk, Ph.D, APRN-CNP, a professor and dean of the College of Nursing at The Ohio State University, on combining HEAR with Melnyk’s MINDBODYSTRONG program for nurses.
MINDBODYSTRONG is an eight-week cognitive behavioral therapy program that focuses on three areas: caring for the mind (e.g., managing emotions and stressful situations); caring for the body (e.g., physical activity); and skills building (e.g., positive self-talk).
Davidson is also collaborating with USD cognitive science student Gordon Ye to use Latent Dirichlet Analysis (LDA) and Latent Semantic Indexing (LSI) topic modeling techniques to analyze medical examiner and law enforcement investigation notes.
They’re hoping to gain “greater insight into the nature of these deaths,” which might be used to inform suicide prevention strategies, Davidson said.