Nurses need saving, too | Division of Research

This article discusses suicide and substance abuse. If you are having thoughts of suicide, call or text 988 to reach the Suicide and Crisis Lifeline. You can reach the National Substance Abuse and Mental Health Services Helpline at 800-662-HELP.

She uncovered the problem by accident. In 2014, as a nurse and researcher at Johns Hopkins Hospital, Amanda Choflet began researching substance use disorders in cancer patients. Then, unexpectedly, her nursing colleagues started confiding in her about their own substance abuse battles. Choflet had been researching nurses’ patients, but she accidentally held a mirror to the nurses themselves.

One nurse told Choflet she received a DUI after celebrating a promotion at a bar with some colleagues. She entered a 12-step program, but a year later the board of nursing in her state, decided to discipline her. After a lengthy legal battle, she was left with thousands of dollars of legal fees, no job and no house. It was at this point that she considered taking her own life.

“Those are the kinds of stories we hear on an ongoing basis,” says Choflet, the dean of Northeastern’s School of Nursing and a clinical professor. “You just think about all of the barriers that these nurses are up against in relation to [substance abuse], and it can be really overwhelming for them.”

These conversations led her to switch from studying substance abuse disorder in cancer patients to studying it in nurses, physicians and pharmacists instead. Researchers have found that nurses have similar rates of substance abuse as the general public, but they often have precariously easy access to drugs. All the while, they struggle with higher rates of depression and PTSD and are 1.3 to 2 times more likely to take their own lives. Choflet and her team wanted to understand why this was and decided to use data about nurse suicides as a way to understand exactly what issues were at play.

In two studies published in 2021, one in the Journal of Clinical Nursing and another in the Journal of Nursing Regulation, Choflet’s team analyzed data from the thousands of nurse suicides reported to the CDC from 2003 to 2017 and extracted common themes from hundreds of death notes. (The studies do not confirm what causes suicide — that would require analyzing data from surviving nurses, too.)

The team found that nurses who died by suicide were almost twice as likely to be experiencing job-related problems compared to the general public — the largest discrepancy out of all the measured risk factors. Reviewing the death notes, they found that many took their own lives just hours after finding out they were losing their jobs: and the reason for the job loss was often substance abuse.

“We found rich stories in those notes … in a majority of the cases of nurses who died by suicide, substance use was named as a contributing factor,” says Choflet. “And there was a large cohort of nurses who died by suicide who specifically talked to someone about or wrote in their suicide note that they were under intense pressure from a regulatory process, from a disciplinary process or from a threat of a disciplinary process related to mental health or substance use issues.”

The moment substance abuse issues start seeping into a nurse’s work, they are immediately at risk of losing their job and their nursing license, which can lead to a whole host of compounding effects. In Choflet’s conversations with colleagues, one told her that her boss not only fired her and got her nursing license revoked but also called the police, who showed up to arrest her. She was charged with 27 felonies for allegedly diverting medicine from work.

“When a nurse is discovered to have a substance use issue, it often comes up through either a diversion investigation or a fit-for-duty investigation at work. So, they show up drunk or high and seem to be acting off. Then they get sent for drug testing or an evaluation — or something comes up on a criminal record that goes to the board of nursing,” says Choflet.

Losing a job is a major life disruptor — and losing it while already struggling with mental health challenges is even harder. Coflet’s team found that out of people who died by suicide, nurses were almost twice as likely to have been struggling with job problems. And out of those nurses, 60% had experienced depression and 65% had experienced substance abuse problems.

While alternative to discipline (ATD) programs — which focus on recovery as opposed to punishment — have gained traction, they aren’t so effective at preventing suicide. They were developed in the 1980s when boards of nursing realized nurses weren’t coming back to work after their substance abuse problems were discovered. This was a problem for a profession constantly in an employee shortage.

Right now, 39 out of 50 states have ATD programs, and the state with the highest number of nurses with job-related problems prior to death, Colorado, has had an ATD program in place for the past 35 years.

In the studies, Choflet’s team argues that substance abuse’s close relationship with suicide — and the critical time at which ATD programs take over — means these programs ought to include suicide prevention into their scopes. The focus can’t just be simple workforce retention.

To change this, the researchers say the programs need to allow nurses to retain employment and continue paying them to alleviate the financial and psychological strain of being out of work. And the programs should provide confidential, routine, intensive care for the nurses over an extended period of three to five years to be maximally effective.

Choflet argues this should be paired with more proactive monitoring of nurses and support for nurses at large, given the high-stress high-trauma environments in which nurses are asked to perform.

“Trauma from exposure in the workplace is a workplace injury,” says Choflet. “Just like if a sledgehammer dropped on your toe, and it broke your big toe. It happens at work. It wouldn’t happen if you didn’t go to work.”

Now, the research team wants to expand on the story of how the profession has failed nurses and provide the profession with a little bit of hope. “What we’re hoping to do in the next series of studies will be prospective qualitative interviews with suicide survivors in the nursing profession,” says Choflet. “We’ve done a lot of work trying to listen to people who have died, and now we really want to switch over and try to listen to people who are alive.”

Story from the Science Media Lab.

Last Updated on May 1, 2024