Nurses who lose their jobs or are forced to leave the profession because of a substance use disorder, mental health problem, or chronic pain are at risk for suicide, according to a study published last week in the Journal of Nursing Regulation.
“What really breaks your heart is the ones that lost their jobs last night,” said Judy Davidson, DNP, RN, a nurse scientist at the University of California San Diego and lead author of the study, underscoring the impulsive nature of suicide.
“They may have been feeling chronically depressed, but from the moment that they think about suicide till they do it, is usually a very short interval.”
Previous research by Davidson and her colleagues, including a 2020 study in Worldviews on Evidence-based Nursing, found nurses in the U.S. had higher rates of suicide than the gender-matched population. Female nurses in that study were 1.4 times more likely than females in the general population to complete suicide.
Separately, a study published in JAMA Psychiatry on Wednesday by University of Michigan researchers confirmed nurses’ heightened risk of suicide, while also questioning previous research on trends in physician suicide.
Nurses in Crisis
The JAMA Psychiatry study found suicide rates for female nurses in 2017-2018 were twice that among women in the general population (RR 1.99, 95% CI 1.82-2.18). Data for the analysis came from the CDC’s National Violent Death Reporting System (NVDRS).
“The reason for higher suicide rates among nurses could be due to several factors: long and stressful shifts, lower autonomy in the workforce, avoidance of mental health services for fear of stigma, greater access to means to complete suicide,” lead author Matthew Davis, MPH, PhD, at the University of Michigan, told MedPage Today.
Because of the high demands of the job, their known reluctance to engage with mental health services due to stigma, and their greater access to means of completing suicide, those working in healthcare are believed to be at higher risk of suicide than the general public, wrote Davis and colleagues.
However, the study noted that suicide rates among physicians did not differ from the general population with the exception of female physicians in 2011-2012. The researchers also found that suicide rates for male nurses fell below that of the general population in 2017-2018.
In an accompanying editorial, Constance Guille, MD, a reproductive psychiatrist at the Medical University of South Carolina in Charleston, said the study stands out from prior research in finding that, for the most part, physicians do not have a greater risk of suicide than the general population.
Davis and colleagues make a “convincing argument,” Guille wrote, that much of the literature comparing physician suicides to that of the general population came from outside of the U.S. and that studies conducted in the U.S. are outdated or have limited generalizability.
But Guille also pointed out that, by excluding physicians under 30, the Michigan group left out most physicians in training, including residents and interns. Suicide is “the first and second leading causes of death for male and female physicians in training, respectively,” she noted.
Davis and his colleagues noted other limitations of the study including that NVDRS coders may misclassify decedents’ occupations. Additionally, while the study was restricted to those 30 and older, no maximum age was defined; therefore, some of the clinicians included in the study may have been retired. Also, while suicides among nurses younger than 30 were excluded from the analysis, that demographic was still counted in workforce estimates. Finally, the NVDRS database does not include all states.
Guille said she was most concerned that the study period predated the pandemic, which has increased work-related stressors and mental health problems among healthcare professionals, both of which are “well-known risk factors” for suicide.
While there is no clear “road map” for reducing the risk of suicide in healthcare professionals, Guille argued the need for “a tiered public health prevention and treatment approach” that includes promoting health and wellness, implementing confidential mental health screening and examining workplace stressors — including staffing ratios, shift-lengths, and “untenable schedules.”
In addition to supporting the individual, such interventions also help institutions by reducing absenteeism and turnover and improving job performance, she said.
“Given that nurses alone make up the largest number of health care workers in the United States and are the backbone of patient care and the health care industry, we cannot afford to ignore the mental health and workplace stressors health care professionals endure,” she wrote.
Nurses and Job Loss
Davidson said the idea for her group’s study emerged from previous observations that nurses had more known job-related problems before their deaths than the general population.
So, she and her colleagues decided to study the context of those job problems.
A job problem in the NVDRS is defined as “any problem with employment known by friends, family, or co-workers or found in suicide notes,” the Journal of Nursing Regulation paper explained. As well, the NVDRS is the only data source on U.S. suicide deaths that tracks occupations, and it includes toxicology results, as well as certified medical examiner and law enforcement narratives.
From 2003 through 2017, the NVDRS data set contained 203 suicides among nurses that included notations of job problems, out of 2,302 nurse deaths in total.
In all, 415 cases mentioned “job” or “work,” however more than half of those were “false positives” — they included phrases such as “came home from work” — and were removed, leaving behind 203 cases.
Davidson and colleagues then used both natural language processing via computer and “manual thematic content analysis” by clinicians to tease out key themes or topics among the narratives.
The thematic analysis involved an initial review of investigation narratives separately by Davidson and a co-author, who then worked together to identify key themes.
For the computational analysis part of the study, an algorithm sorted topics within the narratives into separate piles.
“All the computer tells us is that these things are similar,” said study co-author Gordon Ye, but it can’t put names to the piles. It takes a “human reviewer,” looking at a cluster of suicides that frequently mention for example the word “depression” to give meaning to a particular cluster or pile of cases in which that word appears with more frequency than in other cases.
Through this process, Davidson and her colleagues identified three main reasons for nurses’ job loss: drug use, uncontrolled mental illness, and inability to work because of chronic pain.
“They get trapped in this crisis, one of those three types, and they don’t see a way out, and then it’s the end,” Davidson said.
Nurses who die by suicide are older than the general population and have more “known mental health problems” and more job-related problems, Davidson said.
“And now we’re finding the job-related problems are not what we once thought they were,” she added.
Of the 203 suicides related to job problems, a full 92% involved nurses who were out of work or in the process of losing their role as nurses. And 82% of the 203 also had known depression, and 7% had bipolar disorder.
In about 17% of cases, it appeared the nurses had been fired.
With regard to the mental health and substance use codes represented in the analysis, researchers found rates for particular issues as follows:
- Alcohol: 38%
- Chronic pain: 26%
- Substance use disorder or misuse: 65%
- Prescription medications: 66%
- Medication abuse or theft: 37%
- Diversion of medication from workplace: 6%
The researchers’ inductive analysis also identified common events which they translated into themes that they mapped into a timeline that preceded suicides: “chronic struggle,” “peri- job loss” referring to the period just before and after job loss occurs, “trapped in crisis,” “tipping point,” “no way out,” and “finding a way out.”
“Chronic struggle” encompassed many of the mental and behavioral problems identified in the analysis, including battling with substance use, chronic pain, thoughts of suicide, or mental illness.
The computational analysis helped researchers to recognize another recurring code: previous suicide attempts. In 44% of cases, the nurse had at least one past attempt. That code was also nested under the theme of chronic struggle.
Davidson said the most important takeaway from the study is that suicide prevention measures should be taken when nurses are laid off or terminated.
“We need to change the way we dismiss people from the workplace and even consider should they be dismissed or,” in cases of a health issue, “should they be treated before dismissal,” she said.
Suicide prevention should also be incorporated into treatment for substance use disorders, including through alternative-to-discipline programs, she said.
Tragedies can be prevented, for example, by implementing “safety plans” — that include identifying a person to reach out to, when a person feels suicidal — so that it sets up a “patterned” quick reaction should a dangerous impulse strike.
Davidson also pointed out that nurses whose job problems relate to substance use may experience financial strains with serious downstream effects.
“They don’t have the money for ‘rehab,’ they don’t have the money for food, clothes, and rent. They lose their jobs. They lose their homes. They lose their ability to get well again,” she said. “The system is set up for failure.”
Better screening to identify nurses in need of support sooner, whether for a mental or behavioral health issue, and provide more complete treatment could help to prevent suicides, she said.
Root Causes Unknown
More research is needed to better understand why nurses leave the profession, Davidson said.
While her group’s research identified common themes in the nurse suicides, it did not get at “the root cause” of nurses’ challenges — the reasons behind their mental health issues, their chronic pain, or their substance use problems.
In most cases, for example, nurses coded as having mental health problems were receiving “some treatment,” but it wasn’t clear if it was psychotherapy or the appropriate treatment for their condition, Davidson said.
She pointed out that depression and bipolar disorder accounted for most of the mental illness cases in the narratives and these are “treatable conditions” — yet their issues were “spiraling out of control.”
Nurses may not have been adhering to a treatment plan, or didn’t see a psychiatrist at all, because of stigma, she said; what’s clear is that these nurses were “undertreated or treated inappropriately.”
As for those with substance use disorders, Davidson wonders why they started taking these drugs in the first place. That’s another unknown, she said.
“It may be because they were witnessing too much death and couldn’t take it psychologically, didn’t want to go for mental health treatment and turned to drugs and alcohol,” she speculated.
“We need further qualitative research with those nurses while they’re still alive,” Davidson said, including interviewing nurses in treatment programs.
With regard to chronic pain, she and her colleagues saw a couple cases that noted musculoskeletal injury, or mentioned fibromyalgia or cancer, but many cases simply referred to “chronic pain,” without “any clues” as to the cause.
Davidson reiterated the vulnerability of nurses forced out of work. “We need to have transition plans for them to deal with the psychological aftermath of that, and we don’t at this point,” she said. “You’re kind of left out there on your own.”
If you or someone you know is considering suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255.
Cheryl Clark, MedPage Today contributor, contributed reporting for this story.