With this article, MedPage Today begins a series on suicides among nurses, investigating the reasons, reactions from colleagues, and what can be done to prevent them. Some individuals' names have been changed or withheld at the request of family members.

In late November 2018, a nurse in Southern California took her own life.

"Dana" arrived by ambulance, unresponsive, at the emergency department where she had worked for nearly 20 years, and was cared for by her own colleagues before a transfer to a nearby hospital's critical care unit.

Three days later, Dana was declared brain-dead. She was 47.

"She would walk by and give you a big smack on the ass, like 'Good morning. I'm here,'" said Naomi Kelley, RN, a nurse colleague.

Despite sometimes seeming frazzled when she arrived for work -- wet hair, coffee in hand -- Dana was able to make people smile, feel listened to, and feel validated, remembered Kelley.

"She had such a radiance that I kind of always looked forward to working when I saw her there, because she just, she was such a bright personality," said Rhonda Simpson, RN, another one of Dana's colleagues.

Dana had spent the week before her death with her family at the beach celebrating Thanksgiving.

It was "business as usual, family as usual," said her brother Luke. They had gone to town, shopped together, cooked together, and ate dinner together. Dana seemed happy, he said.

She had no known clinical depression, Luke said, and was not receiving treatment for any kind of substance use problems.

Quiet Decision

In the ICU, it was clear that Dana had suffered brain damage. Clinicians waited 3 days to determine the extent and whether recovery was at all possible.

Luke, an emergency room physician, told MedPage Today, "I've never seen anyone survive like that. ... I wanted to have some hope and my family wanted to have hope."

Within a few days, the means to her suicide and a suicide note were found. Her access and knowledge of healthcare were instrumental. (Suicide prevention experts recommend that media reports on individuals' suicides not get into specifics, to prevent copycat attempts; however, opioids were not a factor in Dana's death.)

Her note "was all just stuff that sounded like someone who is in such a state of hopelessness," her brother said.

She "was a brilliant nurse, a very, very smart girl," said Nikki Taylor, RN, a nurse who worked with Dana for 10 years before a recent move to Colorado. "If you had a critical patient, Dana would be one of the nurses that you would want for sure taking care of that patient."

She had recently been struggling with marital problems, but Dana and her family had visited Taylor and her family in Colorado last summer and things seemed to be improving.

"Dana was kind of a master at hiding a lot of what she was going through," Taylor said. "As emergency room nurses ... we're trained to see the signs of people who are having difficulty or contemplating suicide, and I definitely didn't see it in her."

It was not unusual for Dana, after a difficult day, to crawl into bed and read for hours, said Taylor. "That was kind of like her escape outlet, [to] kind of go into herself when she was having problems."

She was a "fierce friend" and cared deeply for her patients, Taylor said.

Simpson said other nurses would grow frustrated with just how much time Dana spent with her patients, but she recalled that Dana often discovered new problems that needed to be addressed.

"She wasn't just like that with patients, she was like that with me," said Simpson, who suffered from back pain. Dana was "adamant" about getting her patients the right care.

"If she didn't think that the doctor was ... going the right course with a patient or had missed something," she never let the doctors shrug off her concerns, Simpson said.

But Dana wasn't fully able to hide her internal struggles. Near the end, Simpson heard her say something bizarre.

"You know how nurses are, we kind of have a sixth sense, and I just felt like something wasn't okay," Simpson said, her voice starting to crack over the phone.

"She came out of the patient's room and it was an elderly man ... and she started to give me a report and then she went, 'It doesn't matter. It just doesn't matter,' and I looked at her because that ...wasn't her at all," Simpson said, unable to stop herself from sobbing.

Simpson said she was washing her hands at the sink and Dana walked over to her.

"She looked me straight in the face and she said, 'None of this matters ... nothing matters,'" Simpson continued. "She saw the quizzical look on my face, because I had one."

Dana then repeated herself: "It doesn't matter. Nothing matters."

"I think I said something to her like 'I understand,' because I did understand how she was feeling, but I had patients to take care of and I just went on," Simpson said.

Buried Grief

Before Dana's death, Simpson had thought about taking her own life.

In fact, when Dana made her out-of-character comment about the elderly patient, "I kind of turned it around and made it about myself thinking, I'm not alone in feeling like none of this matters," Simpson said. "I think if Dana wouldn't have killed herself, I think I would have."

When Dana took her life, Simpson said that forced her to stop and think about how her co-workers might be affected and also her family.

"I kind of know how people feel afterwards, but you do get to a point where you don't care ... because you're in so much inner pain, that you can't even think about their pain ... and I know that's where she was, because I was pretty much right along at that point with her," she said.

The department held a debriefing after Dana's death -- a meeting to allow hospital staff to discuss a critical event -- but it was only open to those who had directly cared for Dana as a patient.

Simpson broke down crying in the nurse's lounge when she was told she could not go.

She had worked through Dana's memorial service and regretted not being able to say her goodbyes.

There were people much closer to Dana, but "it was hard for me to lose her," Simpson said.

That day, she badly wanted to go home, but instead she was sent to triage.

"I had to straighten up. I had to get my act together ... I had to do what we do: Forget about my own problems and take on other people's problems," Simpson said.

When a colleague is upset, Kelley said, "The thing that you need to hear from your co-worker is, 'Go take a minute, I got you.'"

Instead, she said, the feeling from management was, "Wipe your eyes. Get to work."

Another emergency department sent flowers. The note read, "I can't imagine what you're going through ... and just know that we're thinking of you," Simpson said.

The department leadership invited the family to the hospital to hang a "memory box" containing Dana's scrub top, her name tag, and one of her aromatherapy bottles -- a favorite hobby -- on the wall of the break room.

But the message from leadership was still clear: do not talk about Dana's death at work.

Kelley said they threatened to "write up" anyone who spoke about Dana. Simpson said she and her colleagues were told they would be terminated.

"If you need to talk about Dana, here's the number to call" -- for the employee assistance program -- was essentially what nurses were told, according to Kelley.

Kelley reached out to the program. Simpson did not.

Through therapy, Kelley said, "I kind of came to the conclusion that the healthcare system really sucks at taking care of their own."

Because the department would not allow people space to grieve, Kelley invited everyone to her home a couple days after Dana was declared brain-dead.

Some 40 to 50 people stopped by her bungalow. They brought food and tequila and read poems.

It rained that evening, so Kelley set up a canopy in the yard, and still the gathering spilled into her bedroom because there were so many people -- technicians, doctors, phlebotomists, even some retired nurses.

"There were people crying. There were people yelling. There was lots of emotion ... but I don't think that people are completely healed yet ... because you know there's still patients to take care of, there's still a job to be done," she said.

Risk Factors for Suicide

Many of the suicide risk factors for nurses are the same as in the general population, said Sidney Zisook, MD, a psychiatry professor at the University of California San Diego whose research focuses on mood disorders. These include past history of a suicide attempt, suicidal ideation, and past or present history of a serious mental illness such as depression or bipolar disorder.

Nurses are no more immune to these factors than anyone, Zisook said.

Judy Davidson, RN, DNP, a nurse scientist for the UCSD School of Medicine in the Department of Psychiatry, added that feeling isolated at work also contributes to nurses' suicide risk.

"Feeling alone and disjointed from your team is one risk factor to suicide," she said.

Over-regulation is another.

"Any time you feel lack of autonomy, feel helpless or hopeless, [that] there's too much work to do, [that you] can't get it done in the time allotted, [that there's] too many rules ... that leads to despair," Davidson said.

And then, there's the plain fact that medicine is stressful.

"You're dealing with life-and-death issues, life-and-death decisions. Patients in great amounts of pain ... families who are in great amounts of pain," Zisook said.

Those stressors can trigger compassion fatigue -- growing indifference to others' suffering -- which can cascade from burnout to depression to suicidal thoughts, he said.

As to whether medical errors are a factor in nurse suicides, Davidson said the issue hasn't been studied.

"We don't know the answer to that yet, but we do know that the fear of making a mistake to a patient is one of the factors that pushes people over the edge," she said. "And we do have anecdotes of nurses who have killed themselves following medical errors."

Kimberly Hiatt, RN, a critical care nurse at Seattle Children's Hospital who accidentally overdosed an 8-month-old baby in 2010, was fired from her job, subjected to an investigation by the state nursing commission, and committed suicide within a span of less than 7 months.

Then there's "second victim syndrome," also known as secondary trauma, where individuals feel themselves traumatized by someone else's trauma.

For Jeremy Cabrera, RN, who worked as a a bedside nurse at UCSD's regional burn center for years and is now a nurse manager, his secondary trauma was exacerbated by becoming a father.

"If I'm taking care of a burned 3-year-old, but I've got a 3-year-old at home, how do I separate that?" he said. "I come home and I have a 3-year-old, but I see a patient in pain."

With each patient, Cabrera said he tries to put himself in the individual's shoes.

"And it's hard because you're trying not to become too attached, but how can you not?" he said. "If something negative happens to the patient or say if a patient does pass away, you built that connection so how are you supposed to separate [that] without help?"

"Our patients' deaths affect us," Simpson said. "Most of the time it's like a second self that's doing the job, and then you go home and replay everything in your mind and wonder if you could have done something different, and you are not easy on yourself about it. You berate yourself."

Stigma, Inertia, Barriers to Help

Depression, particularly when coupled with stigma, can be deadly, Zisook said.

"Almost all of the physicians I've known who have died by suicide have been depressed. Almost all of them were caught up in stigma -- weren't open about the way they felt," he said.

These were people who weren't open to treatment, who tried to be tough, and instead became disconnected from those around them, from supports, and from family, he said.

Wendy Hansbrough, MSN, PhD, a faculty member at California State University San Marcos, said stigma played a role in her husband's death.

John Hansbrough, MD, a prominent surgeon and director of the Regional Burn Center at the University of California, completed suicide in March 2001.

Wendy Hansbrough recalled being at a dinner with the surgery department, not long after her husband died, where the conversation turned to another physician who had mental health problems.

"One of the older physicians was sitting there and he said, 'Well, he was obviously flawed,'" she said. "I will never forget sitting there listening to that, that he was 'flawed.' And I thought 'wow, that's a problem,'" she said.

John Hansbrough, unfortunately, bought into that stigma.

"He sought counseling a couple of times," Wendy Hansbrough said, but he didn't like the side effects of his antidepressants.

"I used to tell people ... my husband didn't die from suicide, my husband died from untreated chronic depression that the culture of the medical community refused to acknowledge exists."

Inertia can also be an impossible barrier.

For those who are depressed, "It's hard to pick up the phone. It weighs a hundred pounds," Wendy Hansbrough said.

"[P]eople can maybe get to work and get through their shift, but maybe that's all they're able to do everyday," she said.

Nurses in Despair

Zisook and Davidson's experience isn't purely academic. Not long ago, three UCSD nurses took their lives in a short period.

"It became clear to us that they were under just as much stress and just as vulnerable [as physicians] but had been largely ignored and forgotten," Zisook said.

As a nurse scientist, Davidson sees the world around in her in terms of "signals and noise."

"With the suicides, I think the reason no one's paid attention to it ... is that every hospital gets one, and then it's a long period of time before it happens again ... Nobody knows what [the] benchmark is," she said. "You just think it's part of life. This person was lost to suicide. That happens, right?"

But Davidson could not leave it alone.

She had questions: "How often does this happen? What do we know about it? How much is too much?" she asked.

So Davidson combed the literature for national suicide rates for nurses.

"And I came up with nothing," Davidson said. Along with Zisook and three other researchers, she sought data from health systems, nursing boards, and the American Nurses Association. Not one group collects or reports figures on nurse suicides, they wrote in a January 2018 discussion paper published by the National Academy of Medicine (NAM), titled Nurse Suicide: Breaking the Silence.

"There hadn't been anything written in the United States in over 20 years," she said.

Among the older publications, the group found a 2001 study of occupational suicide risk, published in Social Science Quarterly, that found the odds for completing suicide by nurses were 1.58 times higher than in the general population after adjusting for gender differences. The underlying data were from 1990.

However, an analysis from the long-running Nurses Health Study covering data from 1982 to 1996 put the annual rate at 6.8 per 100,000, "essentially no different than women in the general population at that time."

Studies conducted outside the U.S. have all found nurses had higher incidence of suicide than the general population or other groups, according to the NAM paper.

Davidson and colleagues conducted their own limited studies. One, published last year in the Journal of Nursing Administration, focused on nurses in San Diego County, using de-identified medical examiner data to look at suicide deaths. But the effort was fraught with limitations, including the lack of authoritative data on nurses' sex -- an important point since suicide rates are markedly higher for men than women.

Another study relied on 2014 data from the CDC's National Violent Death Reporting System (NVDRS) -- which, among other things, tracks suicides with codes for individuals' occupations.

That effort wasn't totally satisfactory either. NVDRS data collection is not mandatory, and only 18 states participated that year. For those that did, some failed to enter codes for each occupation. In some reports an entry will say "RN" and in others it's "nurse." In the end, the researchers combed the data "line by line" by hand to arrive at nurse totals.

Davidson said the results, which were recently accepted for publication, indicate a higher suicide risk for nurses than other groups, as did the San Diego study: "We're getting the same signal throughout each time we look at it." She's hoping to get funding to examine NVDRS data for 2015-2016, which now covers 40 states.

"Given the data that's available today, we highly suspect that nurses are at greater risk of suicide. To be confident in that data, we need to know the gender and we need to have the suicide data from all 50 states coded by occupation," she said.

But, said Davidson, it's not ultimately about differences between nurses and other groups.

"I don't really care whether the rates are higher or not," she told MedPage Today. Davidson is mainly concerned with stemming future suicides, and prevention efforts she's taken part in appear to be succeeding.

"In the course of 2 years we were able to move over 40 nurses in one organization into the treatment they needed for mental health issues," she said. "And over the past 10 years the [organization] has moved almost 400 people into treatment -- nurses, doctors, other healthcare clinicians ... who really needed it."

That organization is UCSD's Healer Education Assessment and Referral (HEAR) program.

Next: Tools and techniques the UCSD is using to help nurses and other clinicians facing burnout, untreated depression, or related challenges to access care and to prevent suicide.

If you or someone you know is considering suicide, call the National Suicide Prevention Hotline at 1-800-273-8255.