Deaths by Suicide among Registered Nurses: A Rapid Response Call

Abstract

We can no longer ignore the troubling data: registered nurses are at an alarmingly high risk for serious mental health threats and deaths by suicide. Without urgent, multi-faceted actions, nurses will continue to suffer, threatening overall population health. Below we review the recent data, the knowledge gaps, and the opportunities to understand and improve the well-being of the largest healthcare workforce.

The Alarming Evidence

Using the latest available data from the Centers for Disease Control and Prevention National Violent Death Reporting System, Davis and colleagues (2021) found that between 2007 and 2018, nurses were 18 percent more likely to die from suicide than the general population. Among female nurses, the risk of death by suicide was nearly twice the risk observed in the general population, and 70 percent more likely than female physicians. Rates of death by suicide among physicians did not differ significantly from the general population.

Davis et al. (2021) also reported that from 2017 to 2018, an estimated 729 American nurses committed suicide, the highest reported number on record. But we fear the worst is yet to come. The repetitive and traumatic stress experienced during the COVID-19 pandemic has placed nurses at substantially higher risks for poorer mental health, relative to other health professions (Kunz et al., 2021) A case review of international press reports described six nurses whose deaths during the COVID-19 pandemic were under investigation for suicide (Rahman & Plummer, 2020). We know from studies of past catastrophic events that thoughts and attempts at suicide may occur long after stressful events are over (L. A. Brown et al., 2018). It takes roughly two years to compile national estimates of suicides, due to the complex and sensitive nature of the data. We cannot wait another two years for those data to tell us what we know right now: nurses are in trouble (T. Brown, 2021).

The Need for Multi-Level Intervention

The socio-ecological framework provides an actionable path to recognize and protect nurses at risk for death by suicide (Wasserman et al., 2020). Actions must begin at the societal level. Prevention at this level aims to minimize suicidal risks by improving the surrounding environment, which includes policy and practice changes.

The American Rescue Plan Act of 2021, signed by President Biden on March 11, includes over $3 billion to support improved mental health care (American Rescue Plan Act of 2021, 2021). The bill includes $60 million to support and promote the mental health of health care professionals. This is an important and urgent step, but without a basic understanding of the factors that contribute to the mental health of nurses, these efforts may fail to protect America’s nurses.

The National Academy of Sciences, Engineering and Medicine (2019) report identifies clinician burnout as a threat to quality of patient care that requires urgent action. Health system leaders must recognize and address the fundamental threats to nurses’ work environments as they correlate to patient safety. Challenges in equitable workloads, adequate physical and human resources, assignment of non-nursing work to nurses, and fundamentally broken documentation and administrative processes can no longer be ignored. Akin to the patient safety movement, health systems and organizations must hold senior leaders accountable for nurses’ safety, through compensatory triggers and regular reporting to boards or formal governance structures. Leaders must partner with nurses to co-create working conditions that are conducive to care delivery and service provision, while minimizing workplace stressors. In addition, employers must provide confidential, high-quality mental health resources to nurses that include screening, referral, and connection to supportive resources.

At the individual level, we acknowledge the importance of self-care and personal wellness interventions. Yet given the sparse evidence to date, individual strategies are insufficient to protect nurses, especially those already in crisis (Zhang et al., 2020). A larger, looming problem is the number of nurses who suffer in silence. Prevention, detection, and care need to occur far before a suicide attempt occurs. Further, reliance on individual-level strategies excuses the societal and structural threats to nurses’ well-being that are pervasive and pernicious.

An All-Hands Page

As rising suicide rates reflect population-level struggles, society is left to speculate why nurses are at a much greater risk for death by suicide given the scarcity of data. We need to develop and expand prevention, treatment, and intervention strategies to meet the specific needs of nurses. We also need rapid dissemination channels to share basic data on patterns and correlates of nurse deaths by suicide, and promising interventions that are ready for implementation.

Namely, nationally-representative longitudinal surveys of nurses should monitor behavioral health concerns over time and identify contributing factors and protective mechanisms. Yet the National Institutes of Health has not funded such studies. Emerging intervention programs could be expanded. For example, the University of California San Diego’s Healer Education Assessment and Referral (HEAR) suicide prevention program, originally developed for physicians, has been successfully adapted for nurses (Davidson et al., 2020). Such programs include education to lower the stigma of seeking help, proactive anonymous screening to identify nurses at risk, debriefings after stressful incidents, and counseling and connections to treatment.

There is no time to waste. Approaches that embrace multiple disciplines – mental health, epidemiology, health services, organizational studies, and implementation – may narrow important knowledge gaps in incidence and intervention effectiveness. The absence of just-in-time data on nurses at risk, coupled with a fragmented system of assessment and referral, hinder the ability to identify and intervene. Collaborations which include cross-functional teams and novel data sharing across formal health care systems, regulatory bodies, and public health and social sectors, offer a promising strategy to curb the crisis.

In conclusion, there is an urgent need for robust research and evidence-based interventions to understand and improve the mental health of nurses. However, interventions will be ineffective unless leaders undertake fundamental transformation of nurses’ work environments to mitigate stressors and restore the joy in nursing work. A nursing workforce that is supported, safe, and healthy portends countless benefits to society. We have the opportunity and obligation to advance scientific and structural changes to reverse the disturbing trend of tragic deaths by suicide among nurses.