Nurses form the backbone of Hong Kong’s health care system, making up some 70% of all health personnel in the city. And as health care professionals, they are expected to know how to take care of patients and nurse them back to health. But a pioneering study has found that Hong Kong nurses themselves may need care and attention for their own health, with twice as many nurses thinking about and attempting suicide as do other people of working age in the general population percentage-wise.

Owing to staff shortages in Hong Kong’s public hospitals, working long hours — mostly on their feet — amid similarly stretched colleagues and demanding patients’ relatives are the norm for nurses. Previous studies have examined depression, anxiety, and stress in Hong Kong nurses. Although depression is a risk factor for suicide, there are hardly any studies on Hong Kong nurses and “suicidality,” or suicidal thoughts, suicide plans and suicide attempts. Thus, a Hong Kong-based research team, comprising Clinical Associate Dr Teris Cheung Cheuk-chi and Assistant Professor Dr Paul Lee Hong of PolyU’s School of Nursing and Prof Paul Yip Siu-fai of the University of Hong Kong, who was Dr Cheung’s PhD supervisor, set out to fill in this gap in knowledge. Owing to time constraints, they used a cross-sectional study to find statistical correlations between risk factors and suicidality, since several years would be needed to conduct a longitudinal study to infer possible causality.

Through the assistance of the Association of Hong Kong Nursing Staff, 850 qualified nurses of different grades and specialties aged between 21 and 59 years old and who could read Chinese consented to take part in the study over a 4-week period from October to November 2013. To protect their identities, each participant was required to fill in the study’s anonymous survey online. The survey consisted of 9 sections of questions that examined different aspects of the respondents’ lives and suicidality over the past year and was designed to be completed in about 20 minutes.

The nurses’ self-reported answers were then analysed using different statistical methods. Out of the 850 respondents, 745 were female (87.6%). Some 70% of all respondents had an undergraduate degree or higher qualification. On average, the respondents were between 25 and 35 years old and had 11-15 years of clinical experience as nurses. Just over 55% were married or cohabiting, 42.5% were single, and 2.5% were separated, divorced or widowed.

Using the results of a 2006 study on suicidality among people of a similar working-age range in Hong Kong’s general population for comparison, the research team found that 14.9% of the nurses in the current study had considered suicide in the past year (defined as October-November 2012 to the same months in 2013) compared with 6% of the working-age participants in the previous study (whose data were collected in 2003-2004). The team also found that 2.9% of the nurses had attempted suicide at least once in the same past year compared with 1.4% of the working-age participants in the other study.

In the current study, female respondents reported more suicidality than male participants, which implied that female nurses had a higher risk of suicide than did their male counterparts. This was in line with conclusions from previous studies in other countries.

Dr Cheung and her co-authors also found that gender, having a religion, ill health, deliberate self-harm, depression, self-perceived poor physical and mental health, and poor help-seeking behaviour had significant correlations with suicidality. They did not find correlations between suicidality and age, marital status, monthly household income, academic qualifications or other work-related factors.

The research team also found significant differences in risk factors between the nurses who were non-suicidal, those who had suicidal thoughts, and those who had attempted suicide. Compared with the respondents who were non-suicidal, the nurses who had suicidal thoughts or attempted suicide tended to be female, had a chronic illness, perceived their physical health or mental health as being poor, were not teetotal, had undergone a family or relationship crisis, had been bereaved, and self-harmed. They also tended to be religious, contrary to the more positive correlations between religion and mental health outlined in previous studies.

Interestingly, some risk factors were associated with those who had suicidal thoughts or those who had attempted suicide but not both. Those who had suicidal thoughts tended to be female, a ward manager or an Advanced Practice Nurse, were married or cohabiting, had experienced disturbance in their marriage or partnership, had experienced self-harm in patients, were not teetotal, had symptoms of depression, and rated themselves as having poor physical health or mental health. Meanwhile, those who had attempted suicide tended to have a religion, a chronic illness, symptoms of anxiety and stress, self-harmed, were in debt, and worked shifts.

The research team also found that paracetamol was the most common drug used in overdoses by the respondents, the first such finding about Hong Kong nurses. The study’s results also lent support to previous studies that pointed to the common occurrence of negative life events, especially those related to health or interpersonal relationships, sometime before suicidal behaviour or suicide.

The team also discovered that deliberate self-harm was the biggest risk factor for suicidality: more than 50% of the 79 participants who reported they had self-harmed in the past year also reported they had considered suicide, but only 2.1% of them reported they had sought help for their situation.

The severity of depressive symptoms in the nurses showed a strong correlation with their suicidality, and the prevalence of depression and anxiety in the nurses was significantly higher than that found in the general population by a previous study.

Given these disturbing findings, Dr Cheung and her co-authors urged further research of suicidality in nurses and the development of suicide prevention strategies for the nursing profession.