Nurse Suicide Is Real. Don't Ignore It.

Nurse leaders should recognize and respond to factors that contribute to nurse suicide. Here are three actions you can take to prevent it. 

This article appears in the July/August 2018 edition of HealthLeaders magazine.

The recent deaths of Kate Spade and Anthony Bourdain have thrust the issue of suicide into the spotlight. And for good reason. New numbers from the Centers for Disease Control and Prevention indicate that suicide rates are rising in every state, and in 2016 nearly 45,000 Americans age 10 or older died by suicide.

Suicide is a challenging concern for healthcare workers as well. It's estimated that between 300 to 400 physicians die from suicide in the U.S. each year.

But, as Judy E. Davidson, DNP, RN, FCCM, FAAN, a nurse scientist at UC San Diego Health discovered, the same type of national data on nurse suicide rates is lacking.

"We had nurse suicides in our own workforce and when we started talking to people, we found that many knew someone who had a nurse suicide in their organization. So, it wasn’t just us," she says. "But then, when we went to the literature, there was no accounting for nurse suicide at a national level."

However, as Davidson explains, that lack of data doesn't mean it isn't an issue.

"My hunch is, if every organization only has one [suicide], you don’t think of it as a problem," she says.

To give context to the issue, she gives the example of pressure ulcers on a med-surg unit. If each med-surg unit only had one patient with a pressure ulcer, they might write it off as "only one."

"But if you add them all together, you’re over the national benchmark for your organization in pressure ulcers," she says. 

Looking at nurse suicide through that lens helps to put the issue in perspective.

"It really brings up the concrete message that we cannot hide this," she says. "The more we talk about it the more lives we can save."

Here are three actions nurse leaders can take to prevent nurse suicide.

Offer Screening
 

After more than one nurse suicide occurred at UCSD Health, the organization piloted an expansion of the Healer Education, Assessment and Referral program to nurses.

The HEAR program was already in use to identify physicians at risk for suicide and to facilitate referrals to mental healthcare.   

The HEAR program included 1-hour sessions on the risks of burnout, depression, and suicide; a personal account from a nurse who had experienced suicidal ideation; and a presentation on the purpose of the program from nursing leadership.

The chief nursing officer then sent an invitation for nurses to participate in the anonymous, encrypted, online screening.

Davidson says the screening program uses the PHQ-9 depression risk screening plus other questions that are known to be predictive of suicide risk.

Through the encrypted system, nurses can go online and take the screening. The results, which contain no personal identifiers, go to a counselor who evaluates the results.

If the nurse is high risk, the counselor contacts them through the encrypted system and invites them to come for counseling.

The results of the HEAR program pilot expansion were published in the February 2018 issue of the Journal of Nursing Administration. 

During the first six months of the program:

• 172 of the organization's 2,475 nurses completed questionnaires
   
• 43% ranked as high risk
   
• 55% were moderate risk
   
• 12 individuals reported current active thoughts or actions of self-harm
   
• 19 individuals reported previous suicide attempts
   
• 44 nurses received in-person or verbal counseling
   
• 17 individuals accepted referral for continued treatment

"The report that’s in the literature right now is just the piece on nursing," Davidson says. "But we did extend it to the whole hospital staff. After the success of that pilot, it's funded to go on in perpetuity, and they’re looking at spreading it throughout the UC system across the entire state."  

More information about replicating the HEAR program can be obtained through the American Foundation for Suicide Prevention by emailing mmortali@afsp.org.

Be Proactive
 

In addition to the HEAR program, UCSD Health has also implemented proactive emotional crisis counseling.

"A crisis response team, the same counselors that do the screening on the back end of the online encrypted screening, will go out to any work team that has gone through a difficult situation and do emotional debriefings," she says. "That has been a big hit with our staff. They want it and they like it."

Previously, when a challenging situation occurred, risk management conducted clinical incident debriefings to uncover what went wrong and how to prevent something similar from happening in the future.

But, those debriefings didn't normally include the emotional aspects tied to those kinds of events.

"Now, when they find out about these cases, risk management lets the crisis team know so that they can go out and do a separate, emotional debriefing of the staff that are affected to try to proactively deal with emotions up front," she says.

Cases can include anything from a medication error to an unexpected death to staff getting assaulted by a patient. 

After the crisis team holds a group debriefing, they offer individual counseling to the people who were affected.  

Know the Risk Factors
 

As part of the HEAR pilot study, nurses identified factors that were causing them stress in an open-ended comments section.

"It’s a combination of work and home stressors," Davidson says. "There is some evidence in the literature that when you combine work and home stressors you’re at higher risk of suicide than if you have just work or home stressors."

Work stressors included:

• Management issues
   
• Work volume
   
• Staffing
   
• Changing departments
   
• Feeling unappreciated at work
   
• Stress related to learning new skills or teaching others
   
• Lateral violence
   
• Fear of harming patients
   
• Feelings of incompetence
   
• Emotional burden of patient care

Home stressors included:

• Marital strain
   
• Financial issues
   
• Personal or family health issues
   
• Grief
   
• Lack of purpose in life
   
• Childcare
   
• Academic stress
   
• Loneliness after moving
   
• Personal or family drug or alcohol use

Many of the work stressors can, and should, be addressed by nurse leaders.

"As nurse leaders we can always work on issues of lateral violence and bullying. We can always work on the issues of staff feeling unheard or feeling like they don’t belong. That’s a very strong risk factor for suicide—feeling like you don’t belong within your work group," Davidson says. "It's the obligation of nurse leaders to identify when these things are occurring and actively work on them."

While many nurse leaders may feel that addressing home stressors is out of their realm, Davidson says simply acknowledging when a staff member is going through home issues can go a long way in decreasing suicide risk.

In fact, some of Davidson's prior research on feeling cared for in the workplace, supports the concept that nurses want to be treated as a "whole person" and to be appreciated personally and professionally.

Feeling cared for also drives health-promoting behaviors and can contribute to outcomes such as feeling valued and important, teamwork, and loyalty to an organization, she says.

"Sometimes nurse leaders feel it’s beyond their purview to recognize those home issues, or that it’s not appropriate in the workplace," she says. "But I think from what we’re finding out from these risk factors for suicide, nothing could be further from the truth. Nurses want to be recognized as whole people."

More of Davidson's insights on the issue of nurse suicide and details on prevention strategies can be found in the National Academy of Medicine discussion paper, "Nurse Suicide: Breaking the Silence."

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