Lessons Learned: The Shocking Truth Regarding Job-Related Problems Prior to Nurse Suicide

Quality Quarterly Article

It has often been referred to as the “silence of shame.” Mental health conditions, substance use, and workplace events have been documented as contributing antecedents to nurse suicides. When a nurse is at risk for losing or loses his/her license, the psychological impact can be devastating. The experience of isolation, feelings of failure, public humiliation, and the stigma of losing his or her career can result in cascading events, potentially leading to a lethal outcome.

In May, CHPSO and HQI had the opportunity to host a webinar with four thought leaders and trailblazers who have made it their mission to advocate, educate, and act as workplace change agents on behalf of at-risk nurses. The panelists included Marie Manthey, PhD, MNA, FAAN,FRCN, an international scholar and researcher who was bestowed the Living Legend designation by the American Academy of Nursing; Judy Davidson, DNP, RN, MCCM, FAAN, a nurse scientist and well-known researcher from University of California, San Diego; Amanda Choflet, DNP, RN, OCN, an assistant professor of nursing and the leadership concentration chair at San Diego State University; and Deborah Koivula, a registered nurse and eastern regional coordinator for the Statewide Peer Assistance for Nurses program in New York.

Choflet began the webinar on nurse suicide with some alarming findings:   

  • The nurse suicide rate far exceeds the general population: A University of Michigan study found that female nurses are two times more likely to die of suicide compared to the general population and 70% more likely than female physicians.[i]
  • Nurses (both male and female) were more likely to experience a mental health problem, with depression being a common historical diagnosis, compared to non-nurses.
  • Although the prevalence of nurse substance use has not been well established, nurses were far more likely to show the presence of substance at the time of death for almost all drug classifications.[ii] (See Table 6-antidepressants, antihistamines, benzodiazepines, alcohol, and opioids were statistically significantly higher than all other groups)
  • Employment issues were reportedly more widespread for both male and female nurses compared to the general population — 12.8% and 19.9% vs. 7.2% and 11.9%, respectively.[ii]
  • Other contributing factors include reports of physical injury/health problems among female nurses compared to any group.

Davidson’s recent publication of a study using the Centers for Disease Control and Prevention’s National Violent Death Reporting System (NVDRS) data, titled Job Related-Problems Prior to Nurse Suicide, 2003-2017: A Mixed Method Analysis Using Natural Language Processing and Thematic Analysis, found job related matters was the highest risk factor prior to nurse suicide, followed by physical problems and mental illness (see Table 7). Of the 203 narrative reports from NVDRS, 92% were unemployed or in the process of losing their job and/or their license, while 82% had known depression with bipolar being the second most common diagnosis.

The theoretical framework created by the American Foundation of Suicide Prevention (Moutier & Harkavy-Friedman, 2004) depicts the intersection of biological, psychological, social/environmental factors with current life events and how hopeless paralysis can lead to suicide (Table 8). Dr. Davidson and her team extrapolated on that framework illustrating what happens when biological/psychological/social/environmental variables are compounded by the chronic struggles of mental disorders, substance use and physical pain (see Table 9). As job loss or impending job loss occurs, this crisis reaches a tipping point. Davidson notes this interval around job loss called “peri-job loss” is an extremely vulnerable period. Because of the correlation with suicide, there is a need for structural change around the traditional disciplinary action policies that result in job loss. Many nurses seek help late in the process, if at all.  Without an intervention, the way out is often suicide.   

So, what resources and effective intervention programs currently exist to address this public health crisis that has mushroomed in recent years? 

The panelists highlighted four distinct programs. Koivula discussed the importance of creating a cultural shift from crisis intervention to prevention and early intervention. The Statewide Peer Assistance for Nurses program in New York is a confidential program that helps nurses navigate the legal consequences of addiction and provides support and assistance in nursing professional recovery. Through their strategic advocacy efforts, multidisciplinary approach, diversion prevention team, peer support including nurses with lived addiction experience, over 70% of their nurses have returned to work safely.  

Another program, Healer Education Assessment and Referral, has been in place for approximately five years at the University of California, San Diego. According to Davidson, the suicide prevention and referral program transitions approximately 40 nurses per year for both substance use and mental health issues. It is an anonymous and encrypted system that is easily replicated at the nominal cost of only $2,000/year. She explained that a survey is sent out by the institution’s high-ranking executives to their constituents. The survey is a self-screening tool and managed by the American Foundation for Suicide Prevention. If the individual is deemed moderate or high risk, a therapist will contact that individual through a computer interface. Upon contact, they will receive counseling using any mode that the recipient chooses — virtual, phone, or in person. Since it is 100% anonymous, management has no knowledge that a nurse may be receiving counseling for a substance abuse problem. Hence, mandatory reporting is sidestepped.  

Manthey concluded the webinar with a powerful assessment of the current system by affirming that we need to transition our collective consciousness of “moral failure to chronic disease” in reference to substance use. Her philosophical approach is that addiction requires long term treatment and should be managed no different than a chronic condition such as diabetes. As a recovering alcoholic herself, Manthey has years of lived experience grappling with the isolation, the conspiracy of silence, and the stigma of shame and pain.

In 2014 she established a non-profit organization in the Minneapolis area called Nurses Peer Support Network, which deals with substance use. She is also the creator of “In the Rooms”, a free program offering online meetings for recovery and mental well-being. She firmly believes that substance use is a complex and poorly understood issue and can be best managed by other nurses because “experts cannot deal with the stigma and the shame” that contribute to nurse suicide. Finally, her call to action to transform the conversation from “I see myself as a nurse” to “I see myself as a person who is a nurse” can be the catalyst building block toward a solid recovery.

If you are experiencing depression, having bouts with mental health challenges, or having suicidal ideation or know someone who may be at risk, seek immediate help. The National Suicide Prevention Lifeline can be reached at (800)273-TALK (8255) or text the Crisis Line at 741-741.

An on-demand recording and the presentation slides are available on the CHSPO website.

Table 6: Comparison of substances used in suicide

Table 7: Risk Factors that contribute to suicide: Female nurses vs. Female other

Table 8: The Interacting Risk and Protective Model for Understanding Suicide (American Foundation of Suicide Prevention, Moutier & Harkavy-Friedman, 2004)

Table 9: Job loss Spiral to Death
(Judy E. Davidson, DNP, RN,MCCM,FAAN; Gordon Ye; Melissa C Parra, BSN, RN; Amanda Choflet, DNP,RN,OCN; Kelly Lee, PharmD; Adrianna Barnes, MSN,RN,CCRN,SCRN,PHN; Will Harkavy-Friedman, PhD; Sidney Zisook, MD)

[i] Davis MA, Cher B, et al.  Association of US Nurse and Physician Occupation with Risk of Suicide. JAMA Psychiatry. 2021;78(6):651-658. Available here.

[ii] Choflet A, Davidson J, et al. A comparative analysis of the substance use and mental health characteristics of nurses who complete suicide. Journal of Clinical Nursing. 2021 Mar 25. Doi:10.1111/jocn.15749.

Abstract available here.

Davidson JE, Ye G, et al. Job Related-Problems to Nurse Suicide, 2003-1017: A Mixed Method Analysis Using Natural Language Processing and Thematic Analysis. ScienceDirect. Abstract available here.