Burnout a Risk Factor for Suicidal Thoughts in Nurses

Nurses experiencing burnout were twice as likely to have thoughts of suicide, and those with symptoms of depression were 11 times as likely to experience suicidal thoughts, a survey study found.

Among more than 7,000 nurses surveyed from November to December 2017, a total of 5.5% experienced suicidal ideation, which is higher than rates of suicidal thoughts in the general population (4.3%), reported Elizabeth Kelsey, DNP, APRN, CNP, of the Mayo Clinic in Rochester, Minnesota, and colleagues in the American Journal of Nursing.

The researchers also found that 38.2% of nurse respondents reported at least one symptom of burnout, and 43.3% screened positive for depression.

“Burnout has always been a big topic in healthcare, becoming more prevalent since the pandemic,” Kelsey told MedPage Today. “If anything, potentially these numbers could be even higher now.”

But there hasn’t been a lot of research on suicidal ideation among nurses, she noted. (MedPage Today published a series highlighting this issue in 2019: see Nurse Suicide: Under the Radar.)

Kelsey said that while the lines between depression and burnout can “get crossed a little bit,” she defines burnout as “an occupational phenomenon … characterized by emotional exhaustion, cynicism related to work, and reduced personal efficacy.”

One goal of the study was to examine both burnout and suicidal ideation to see if there was a relationship — and indeed the researchers found there was.

After controlling for “all other factors,” Kelsey and colleagues found that white nurses showed higher likelihood of suicidal ideation compared with nurses of other racial and ethnic backgrounds (odds ratio [OR] 1.73, 95% CI 1.16-2.60, P=0.01).

Recent suicidal ideation was nearly twice as common in nurses reporting burnout (OR 1.98, 95% CI 1.54-2.56, P<0.001), even when other personal and professional characteristics were controlled for, the study noted.

Nurses Considering Suicide Not Seeking Help

The investigators were also concerned to see that nurses experiencing suicidal ideation were less likely to report help-seeking behaviors compared with those not experiencing such thoughts, Kelsey said. “So, those in most need were less likely to seek help.”

While 84% of nurses said they either “probably” or “definitely” would look for professional help if they experienced “serious emotional problems,” only 72.6% of nurses who had suicidal ideation said they would “probably” or “definitely” seek help.

“I think there’s still stigma around mental health and people seeking help, difficulty getting [time off] work, and even worries about confidentiality,” Kelsey said, adding that some state nursing boards require nurses to disclose mental health problems.

Curiously, nurse respondents were more likely to seek help than those in the general population to ask for help “when a serious emotional concern arose,” Kelsey said.

The researchers used the 22-question Maslach Burnout Inventory Human Services Survey to measure different components of burnout such as emotional exhaustion and depersonalization, as well as the Primary Care Evaluation of Mental Disorders to screen nurses for depression.

Nurses screened positive for burnout if they scored 27 or higher on the emotional exhaustion subscale and 10 or higher on the depersonalization subscale. The results showed that 34.4% of nurses’s scores indicated a high degree of emotional exhaustion and 20.4% of nurse respondents showed a high level of depersonalization.

The survey looked for suicidal ideation by asking, “During the past 12 months, have you had thoughts of taking your own life?” While there are “no reliability data” for the survey questions around suicide, it has been used by researchers to gauge suicidal ideation in both physicians and medical students in the past, Kelsey and co-authors noted.

The first two model analyses looked at nurses’ suicidal ideation in the prior year and the third used an age-matched sample of nurse responders ages 29 to 65 to compare with other workers in the U.S. population.

In all, 7,378 nurses were surveyed. The median age of nurse respondents in the survey was 51, and most were female (92.7%) and white (87.4%). In all, 73.7% were married or had a partner, and 70.9% had children. Respondents also had a median of 20 years of experience working as nurses. The mean number of mandatory or unplanned overtime shifts worked in the prior month was three, the researchers noted.

Suicide Research in the Pandemic Era

Overall, the suicidal ideation rates before the pandemic are consistent with more recent studies, and the paper cites an unpublished survey, shared by an American Medical Association’s vice president, of 85 healthcare organizations conducted between April and December 2020, which found that 5% of 2,333 nurse respondents reported suicidal ideation.

Suicide itself is challenging to study but suicidal ideation is a well-recognized precursor to suicide, Kelsey and co-authors noted. Nearly one in three people who report suicidal thoughts later develop a plan for suicide, and close to three-fourths of those with a plan will attempt suicide, according to the National Comorbidity Survey.

Other relevant research included a 1-year impact assessment from the American Nurses Foundation, which found that 23% of the 22,316 nurse respondents said they felt depressed in the last 14 days and 1% felt suicidal. A follow-up survey from the foundation published in mid-October, saw nurse respondents’ rates of feeling depressed jump to 35% and rates of feeling suicidal jump to 4%. (Rates of feeling suicidal among critical care nurses jumped from 2% to 6% between the 1-year and 18-month surveys.)

In the current study, the team stressed that the link between burnout and suicide is not necessarily causal — however, “we did find that burnout was a risk factor for nurses experiencing suicidal ideation,” Kelsey said.

Looking Ahead

As health systems look to the future, systems-level interventions are necessary to help address burnout through changes in policy and practice and increased awareness, Kelsey said. The hope is to “build a positive work culture … balancing the job demands and the resources that can help promote this workplace culture of well being.”

At a policy level, health systems and hospitals can establish well being as a “core value” and enact a “zero-tolerance” policy for violence and bullying in the work place.

Other concrete strategies for creating a “healthy work environment” include providing safe working conditions, appropriate staffing levels, and confidential mental health supports. Health systems should also provide channels for team members to raise concerns with leadership and teach clinicians, including nursing students, how to flag signs of distress and suicide risk.

Kelsey also pointed to a recent consensus study from the National Academy of Medicine that highlights much of the research around changes to practice, education, and policy aimed at preventing burnout among clinicians more broadly.

Limitations to the Mayo study, she said, in addition to the timing of being conducted before the start of the pandemic, included possible response bias, since the response rate was only about 8.5%. It wasn’t clear whether nurses with suicidal ideation were more or less likely to complete the survey, Kelsey noted. Survey items used to assess suicidal ideation and help-seeking behavior also have “limited evidence” behind them, which could impact the validity of the results, and because the survey was cross-sectional, the researchers were unable to identify causal relationships. In addition, factors outside of burnout that weren’t measured by the surveys could contribute to suicidal ideation, the team noted.

If you or someone you know is having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 .