Female nurses' suicide risk remained higher but didn't worsen through the COVID-19 pandemic compared with other women, according to a large retrospective cohort study.
Female nurses had 21% and 41% higher suicide rates than their general population counterparts in the pre-pandemic years of 2018 and 2019, respectively, found researchers led by Judy E. Davidson, DNP, RN, of the University of California San Diego.
During the pandemic, incidence rate ratios were in the same range, elevated 26% for female nurses versus female non-nurses in 2020 and 35% in 2021. All comparisons between the two groups were statistically significant.
In comparison, male nurses' suicide rates were comparable with those of male non-nurses across the period covered by the study published in the Journal of Nursing Administration.
Given the overwhelming stress of the pandemic, "we had anticipated a rise," Davidson said via email. The lack of a pandemic-related surge in female nurse suicides may be due to a host of factors, she said.
"You can imagine from the early pandemic that there was a lot of angel/hero praise ... that might have been temporarily protective," Davidson told MedPage Today. Additionally, "those that 'ran into the fire' might have been hardier, less burned out, and diluted the overall risk of others," she noted.
Another "troubling possibility" is a potential protective effect from courts being closed early in the pandemic, temporarily pausing nurse discipline, she said.
In her group's study of the CDC's National Violent Death Reporting System (NVDRS) data, nurses had a higher chance of mental health problems, job problems preceding suicide, and of poisoning themselves, with adjusted odds ratios of 1.28, 1.60, and 1.54, respectively (all P<0.001 compared with non-nurses). Nurses were also more likely to use opioids, cardiovascular or diabetic agents, and drugs not prescribed for home use.
Job-related problems, which have been linked with suicide among nurses in prior studies as well, often involve discipline by nursing boards or employers and premature separation from the workforce, Davidson pointed out.
She questioned whether more "holistic treatment-first" approaches, for example those involving a leave of absence for treatment, would decrease suicides associated with substance use disorder and the disciplinary process.
An important next step will be to study treatment-first policies versus termination, she said.
Davidson also urged reauthorization of the "Dr. Lorna Breen Health Care Provider Protection Act" to renew its funding of evidence-informed strategies to prevent suicide and address burnout, mental health conditions, and substance use disorders.
At a minimum, all drug diversion disciplinary policies need a "baked in" suicide prevention plan and psychological support for anyone involved in an investigation, she said.
In addition, she urged nursing boards to adopt licensing questions that are compliant with Americans With Disabilities Act (ADA) protections against discrimination around physical and mental disabilities. A 2019 study found that 22 of 30 nursing boards ask non-ADA-compliant questions, and a 2024 study found the situation hasn't improved.
K. Jane Muir, PhD, RN, FNP-BC, of the University of Pennsylvania School of Nursing in Philadelphia, stressed the need to strengthen safeguards for nurses given their higher rates of suicide than the general population.
"Employer support of nurses through safe patient-to-nurse staffing ratios and improving the reporting and prevention of workplace violence are actionable solutions," she noted, as are flexible schedules, generous family leave policies, and financial incentives for hard-to-staff shifts.
The retrospective cohort study relied on suicide data from the NVDRS from 2017 to 2021, which draws from death certificates, medical examiner, and law enforcement reports for an anonymous data set detailing demographics and substances used in suicide.
Altogether, 1,368 nurse and 104,576 general population suicides among individuals ages 21 years and older were identified by reported sex and state. Decedents whose sex data was missing were excluded.
A study limitation was that the analysis included limited jurisdictions that met the NVDRS reporting threshold -- 30 states -- and only limited information collected from death investigations, therefore it might not be nationally representative. Additionally, the normal sources of NVDRS data might have been overwhelmed during the pandemic, leading to coding errors or underreported suicides.
The authors suggested that further research on suicide attempt survivors could help clarify risk and protective factors.
Disclosures
The authors reported no conflicts of interest.
Primary Source
Journal of Nursing Administration
Source Reference: Davidson JE, et al "National incidence of nurse suicide and associated features" J Nurs Adm 2024; DOI: 10.1097/NNA.0000000000001508.
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