THE NOVEL CORONAVIRUS (COVID-19) pandemic has brought with it a renewed focus on mental health, especially among health care workers and particularly among nurses. Yet, the crises of burnout, untreated mental illness, substance use, and suicide among nurses were looming long before this most recent pandemic. The direct link between provider well-being and patient care led Bodenheimer and Sinsky to propose that the Triple Aim (improve population health, enhance the patient experience, and reduce costs) be expanded to include a Fourth Aim of “improving the work-life of health care clinicians and staff.”1,2 Even before the first COVID-19 patient was admitted to a US hospital, nurses were known to have higher suicide rates than those in the general population.3,4 Several risk factors have been linked with nurse suicide, such as mental health, substance use, job problems, and physical health problems.5 The purpose of this article is to review the current understanding of nurse suicide and evidence-based practices that can reduce the impact of its predisposing factors.
LOOMING CRISES WITHIN NURSING
Within the United States, the incidence of nurse suicide has been studied by 3 different research teams4,6,7 using data collected by the Centers for Disease Control and Prevention (CDC) in the National Violent Death Reporting System (NVDRS) restricted database.8 Each team used a different analytical approach but reported the same result: nurses are at a higher risk of suicide in the United States than in the general population, adjusting for age and gender (see Supplemental Digital Content, available at: https://links.lww.com/NAQ/A10). Although nurses are more likely to use pharmacologic poisoning as a method of suicide than their matched general population counterparts, nurses are increasingly using firearms as a method of suicide,9 signaling that nurses may benefit from firearm safety education in the same manner as the general public.10,11
Much remains unknown about nurse suicide. CDC data indicate only that the victim was a nurse but does not specify critical distinctions such as specialty, work context, or level of care. We also do not yet know the effect of the pandemic on nurse suicide because of a 2-year delay in publishing CDC NVDRS data, though it is known that pandemics generally increase suicide risks.12
Mental health and nurse suicide
Within the nursing profession, mental health is discussed as a nebulous concept that “the profession” faces, while individual nurses rarely self-identify as suffering from a specific mental health issue, such as depression, anxiety, substance use, or traumatic stress. Meanwhile, studies have indicated that nurses have high rates of anxiety and depression, often linked to occupational stress.13–15 A recent study of the mental health characteristics of nurses who died by suicide found nurses being more likely than non-nurses to report a mental health problem and more likely to have a specific diagnosis of depression prior to death.5
While not considered a mental illness per se, burnout has been reported within the nursing profession to range from 33%16 to 50%.17 Burnout is an emotional response to chronic job stress that involves emotional exhaustion, demoralization, cynicism, and feelings of inefficacy. While not the same as depression, it appears to be a risk factor for myriad psychiatric problems, such as depression, anxiety disorders, substance use, posttraumatic stress disorder (PTSD), suicidal ideation, and neurocognitive problems, as well as family and relationship problems.18,19 In recent years, several studies have linked burnout with the intent to completely leaving the nursing profession20,21 and before the pandemic, up to 21% of nurses reported intent to leave their job or the profession.22
Substance use and nurse suicide
Similar to depression, substance use has long been correlated with suicide. A recent study of nurse suicide found that nurses were significantly more likely to have positive blood toxicology results across nearly all substances than their counterparts in the general population.5 Interestingly, in this study, nurses were not more likely to have a documented substance use disorder reported prior to death by suicide, a finding complicated by the suspicion that nurse substance use is widely underreported.23 Factors related to this underreporting include stigma, regulatory and licensure issues, and limited access to treatment resources.23
Substance use leading to job loss/discipline prior to suicide
A recent qualitative analysis of nurse suicide indicated that nurses who die by suicide report more job-related problems known prior to death than others.24 When CDC death investigation notes were analyzed, researchers found that job-related problems centered on 3 issues: mental health issues out of control, uncontrolled chronic pain, and substance use disorder, all leading to job loss.24 More than 90% of the job-related problems were associated with investigations or job loss, with the majority due to substance use disorder. The process of disciplining a nurse for suspicion of substance use disorder creates a vulnerable moment for the nurse: the chronology of the deaths suggests that job loss or license suspension was pivotal in the spiral to death.24
Psychological effects of the COVID-19 pandemic
The pandemic made visible the precarious nature of nurses' work and the psychological suffering of nurses,25 though these issues did not begin with the pandemic and will not recede upon its resolution. Previous research has linked nurse fatigue with increased mental health problems, poor patient outcomes, decreased nursing performance, and increased sick leaves.26 Others have noted that direct exposure to witnessing patient safety incidents is linked with significantly higher levels of sleep disturbances, PTSD, and intent to resign among health workers.27 Several researchers have reported increased anxiety, depression, and PTSD symptoms among nurses and other frontline health care providers as a result of COVID-19.28–31 In a study of health care workers during the surge in New York City in the spring of 2020, 39% met the criteria for symptoms of PTSD, major depressive disorder, or generalized anxiety disorder.32 In this study, prepandemic burnout levels were closely associated with the development of COVID-19–related PTSD.32
HELP-SEEKING BEHAVIORS AMONG HEALTH PROFESSIONALS
Although the presence of co-occurring variables, such as mental health issues and substance use disorders, might offer several natural opportunities for intervention, help-seeking behaviors for these issues are typically poor in the general population33 and even more so among nurses. Nurses live in a culture of personal and institutional stigma against treatment of mental health conditions, fear of judgment by peers and supervisors, consequences of having mental health treatment or condition on their “record,” and potential action by licensing boards.23,34 The prevailing nursing culture is “patient over self” when prioritizing time.35 Addressing stigma, confidentiality, and reliance on self are deeply ingrained but critical barriers to help seeking within all health professionals.
INSTITUTIONAL AND REGULATORY RESPONSES TO SUBSTANCE USE DISORDER IN NURSING
There is little clarity from the Drug Enforcement Administration (DEA) or other regulatory bodies regarding required action around the topic of institutional and regulatory responses to drug diversion among nurses.36 As a result, many agencies behave defensively when initiating diversion programs, which ultimately affects the availability and accessibility of mental health and substance use resources for employees. Many health care facilities believe that a full investigation along with termination of the individual shows due diligence on their part. Many facilities contact professional licensing boards but receive minimal guidance for fear of regulatory liability.36 This leads to ineffective management of the situation and leaves the nurse with an active substance use disorder without resources.
Several states have developed tool kits and road maps to assist facilities with performing their own gap analyses; many are freely available online, including the Minnesota Hospital Association road map (https://www.mnhospitals.org/Portals/0/Documents/ptsafety/diversion/Road%20Map%20to%20Controlled%20Substance%20Diversion%20Prevention%202.0.pdf),37 the California Hospital Associ-ation road map (https://www.chpso.org/sites/main/files/file-attachments/controlled_substance_diversion.pdf?1368720872),38 and the Missouri Bureau of Narcotics and Dangerous Drugs Guide to Preventing and Inves-tigating Diversion Issues in Hospitals (https://health.mo.gov/safety/bndd/doc/drugdiversion.doc).36,39 Resources such as these provide helpful suggestions to create a more transparent, less stigmatizing culture within a facility around mental health and substance use.
AN APPROACH TO MOVING FORWARD
The key to meaningful change is the implementation of evidence-based interventions that target specific problems in a group, setting, or community. Using a strategic planning process,40 the Suicide Prevention Resource provides a 6-step public health model of prevention and to select interventions and track outcomes that address the specific needs of the target population (https://www.sprc.org/effective-prevention/strategic-planning) (Figure). After a thorough assessment of the problem and establishment of long-term goals, appropriate interventions to address the needs of the nurses should fill the gap between the current and desired situations. Stone et al41 developed focused strategies, approaches, and outcomes that can help focus on specific interventions to meet the needs of their employees and track progress summarized in the Table. When in the planning phase, it is important for leaders to consider the needs of the target group to ensure that appropriate interventions will meet and address their needs.
Potential Methods of Intervention to Prevent Nurse Suicide
and Promote Help-Seeking Among Nursesa
|Strengthen Economic Supports
|Strengthen Access and Delivery of Care
Coverage of mental health conditional in insurance policies
Reduce provider shortages
Safer suicide prevention care through system changes
Develop an institutional HEAR program
Ensure mental health and substance abuse provider availability through EAP programs
Develop a peer support program
Provide for free, ongoing mental health and substance use treatment for nurses
Increase mental health service use
Lower treatment attrition rates
Reduction in depressive symptoms
|Create Protective Environments
Reduce access to lethal means for those at risk of suicide
Organizational policies and culture41
Community-based policies to reduce excessive alcohol use
Intervene at suicide hot spots
Safe gun storage practices
Proactive training for students and staff
Increase safe storage of lethal means
Reduce rates of suicide and attempts
Increase help-seeking behaviors
Reduction in alcohol-related deaths
Develop a peer support program
Ongoing, free, inclusive educational activities focused on mental health, coping, substance use prevention, and suicide prevention
Management training to promote engaged leadership practices
Increase in health coping behaviors
Increase in positive perceptions of support
Increase help-seeking behaviors
|Teaching Coping and Problem-Solving Skills
|Identify and support people at risk
Applied Suicide Intervention Skills Training
Improving Mood-Promoting Access to Collaborative Treatment (IMPACT)
Emergency Department Brief Intervention with Follow-up Visits
|Lessen Harms and Prevent Future Risks
Abbreviations: EAP, employee assistance program; HEAR, Healer Education Assessment and Referral.
Several opportunities exist for nurse leadership advocacy and support to prevent suicide
and promote help-seeking behaviors among nurses. Adapted from Stone et al,41
with modifications for nursing-specific strategies.11,25,45,46
Fortunately, many health care institutions have already provided helpful initiatives, resources, and guidelines42 to prevent suicide and promote help-seeking behaviors, though the overall culture has been slow to change. Two such promising innovations are briefly described in the following section.
One innovative program at UC San Diego Health, the Healer Education Assessment and Referral (HEAR) program, has been in place since 2009. Originally developed as a physician suicide prevention program, a series of nurse suicides at UC San Diego led to expanding HEAR's target group to nurses in 2016, soon followed by the inclusion of all health care providers and compounding its outcome aspirations to enhancing wellness and engagement.43 HEAR's approach is multifaceted, including a comprehensive educational program, proactive screening for high distress and suicide risk coupled with “warm” referrals, crisis intervention and critical incident debriefing for clinical units and their individual providers under duress, a peer support program as a first-line intervention, and Schwartz Center Rounds, which provide opportunities for health care staff to come together on a regular basis to share and discuss personal thoughts and feelings on emotional aspects of patient care in a safe space.43,44
HEAR's signature suicide prevention component is its online, anonymous Interactive Screening Program (ISP),45 which is provided through a partnership with the American Foundation for Suicide Prevention. To date, the HEAR program has screened thousands of UC San Diego Health trainees, staff, and faculty. HEAR program counselors have reviewed each of these completed questionnaires, have made recommendations for further evaluation or treatment as indicated, and have made themselves available for further confidential dialogue to each respondent.
Peer support programs can be structured within a health care system, offered as an extension of alternative to discipline programs, be a freestanding program, or be available individually with the utilization of telehealth and nurse coaching.46,47 Nursing leadership plays an important role in increasing access to services, raising awareness through education, integrating peer support language to relevant policies (ie, reasonable suspicion of impairment), and encouraging earlier compassionate intervention without fear of immediate termination for mental health or substance use disorder.46 Implementing internal programs or referring to external peer support resources benefits individual nurses and systems by promoting a culture of awareness, compassion, and help-seeking behaviors.
Peer support can be useful on its own but, ideally, is an important adjunct to the employee assistance program, mental health counseling, alternative to discipline program participation, diversion prevention, treatment of substance use disorder, and recovery practices. A key component of the success of peer support is confidentiality and the ability to connect with others who have similar or lived experiences. Nurses “get” each other. This connection provides hope during an otherwise desperate and potentially isolating time when risk for suicide is high. Legal and licensure complexities stoke an already burning fire of shame and guilt for nurses who seek help due to a catastrophic or public event such as diversion or driving under influence. Those who engage in peer support either individually or in a group setting express feelings of connectedness and “being understood” in ways other forms of help leave void when addressing shame, fear, and guilt.48 When utilized, the connections formed with those who understand through lived experience provide an outlet for healthy coping.
INSTITUTIONAL EFFORTS TO PROMOTE COPING AND REDUCE SUICIDE
Evidence-based coping strategies should be taught and reemphasized during training programs of health professionals and continue to be offered throughout professional life. A focus on improving effective management skills for hospital leadership is essential.18 Active, rather than passive, coping strategies are associated with decreased burnout.49 Evidence-based stress management techniques include progressive muscle relaxation,50 biofeedback,51 guided imagery,52 diaphragmatic breathing,53 and transcendental meditation.54 These strategies have been shown to be effective in reducing stress and anxiety associated with work and chronic illness and can improve health care providers' interaction with their patients.55 The emotional toll of the COVID-19 pandemic has put a spotlight on the need for improving mental health and well-being for health care workers. Organizations such as the CDC (https://www.cdc.gov/coronavirus/2019-ncov/hcp/mental-health-healthcare.html), Ameri-can Medical Association (https://www.ama-assn.org/delivering-care/public-health/managing-mental-health-during-covid-19), Substa-nce Abuse and Mental Health Services Administration (SAMHSA) (https://mailchi.mp/jbsinternational.com/self-care-for-healthcare-professionals-and-responders-to-covid-19?e=1162024328), and the American Nurses Association (ANA) (https://www.nursingworld.org/practice-policy/nurse-suicide-prevention/) have compiled resources to help health care professionals cope with stress and improve resilience. Ideally, these strategies and resources should be integrated into workplaces, with equal emphasis on other mandatory training such as Basic Life Support. While national efforts have resulted in the implementation of well-being programs in some health systems, more work is needed to identify and remove barriers to help seeking among health professionals. Education is needed to remove the stigma associated with mental health and substance use treatment, and material resources are needed to improve access to care for clinicians.
In the last year, we have witnessed unprecedented pain and suffering both within and surrounding health care institutions around the world. It is daunting to make sense of the events of the last year and a half to move toward recovery. Nurses are already in a vulnerable position and negotiating mental health issues, burnout, substance use, and suicide. Many are recognizing the heroic labor of the nursing profession along with the oncoming period of emotional reckoning, as nurses and other health care workers exit the stage of acute crisis and begin to contextualize their pandemic experiences. Nurse leaders must embrace this moment of renewed commitment to the nursing profession by acting on evidence-based strategies to prevent harm and reduce the suffering of nurses battling mental health issues, substance use, and suicide.
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