Suicide among nurses is inadequately studied in the United States, resulting in limited data with which to analyze the problem and develop prevention strategies, according to a discussion paper, Nurse Suicide: Breaking the Silence, from the National Academy of Medicine. In addition, many health care institutions lack standard procedures to address the suicide of a nurse. This contrasts sharply with the response of health care organizations to suicide among physicians. Many hospitals have for years offered physicians, residents, and medical students screening programs for depression or suicide risk, as well as education and support for treatment.

How prevalent is suicide among nurses? The disturbing answer, according to the discussion paper's authors, is that no one really knows. While they were able to collect numerous personal accounts from nurses who had had a colleague die by suicide, inquiries to human resources and risk management departments, boards of registered nursing, the American Nurses Association, and the California Board of Registered Nursing yielded little hard data. The authors also found no national data on the nurse suicide rate, though data were readily available for physicians, teachers, police officers, firefighters, and military personnel. A literature search was equally disappointing: it yielded only five dated descriptive studies.

"The silence around this issue is multifactorial," said Judy E. Davidson, a nurse scientist at the University of California San Diego (UCSD) and the paper's lead author. "First, suicide data are muddy. There is little consistency in the way that medical examiners and coroners in various counties report their findings. Furthermore, the Centers for Disease Control and Prevention mortality data are not coded by occupation." Another obscuring factor is inadequate sex-specific data on the nursing workforce. This is important, Davidson told AJN, because of a difference of four to one in the suicide completion rate between men and women. Since nursing is a female-dominated profession, any analysis of suicide incidence must be informed by data on gender. Finally, the fact that suicide overall is an infrequent occurrence in health care organizations exacerbates the problem. "Any administration would think, 'Well, we had one, that's sad, but it isn't a problem.' But if every department has one, the incidence is over the benchmark as a whole."

The paper cites research documenting stressors faced by nurses, including exposure to human suffering and death, ethical conflicts, perceived lack of respect, inadequate equipment, excessive workload, and consequences-including blame-of medical error. Adding to these on-the-job pressures may be home stress and difficulty balancing personal and professional issues.

While attention to suicide among nurses has greatly lagged prevention efforts among physicians, there are signs of progress. The Healer Education Assessment and Referral (HEAR) program, developed in 2009 at UCSD in collaboration with the American Foundation for Suicide Prevention (AFSP) to aid physicians, residents, and medical students, is now being piloted to identify high-risk nurses and move them into treatment. In the pilot's first 10 months, HEAR assessed 184 nurses, of whom 17% subsequently engaged in counseling and 11% accepted referrals to psychologists and psychiatrists. Of the nurses who responded to a screening questionnaire, 97% were found to be at moderate or high risk for depression or suicide.

Endorsed by the American Medical Association as a best practice in suicide prevention, HEAR for physicians has been replicated at more than 60 medical campuses nationwide. The nursing program is now also available for replication. Contact Maggi Mortali at AFSP: mailto:[email protected].-Dalia Sofer