Suicide Prevention for Nurses

Suicide affects all countries, cultures, genders, and ages worldwide. The definition of suicide is the act of injuring oneself with the intent of causing death. A suicide attempt means an individual intentionally harmed themselves, but death did not occur (Centers for Disease Control and Prevention [CDC], 2023a). Other definitions pertinent to understanding suicide include suicidal behaviors and suicidal ideation. Suicidal behaviors encompass thoughts or ideations, preparations, attempts, and completions (Suicide Prevention Resource Center, n.d.). Suicidal ideations include thoughts about engaging in suicide-related behaviors and attempts (Harmer et al., 2023).

Unfortunately, suicide rates continue to rise. Within the last few years, there has been nearly an 8% increase in suicide rates in the United States (Mundell, 2023). Almost 50,000 people in the United States died last year by suicide, with an increase seen in both males and females. The most common age group affected by suicide is 25-44 years old, with 45-64 years old being affected nearly as much. Shockingly, over 12 million United States adults considered suicide last year (CDC, 2023b).

As joyful and rewarding as the nursing profession can be, it does expose nurses to risk factors that increase the occurrence of suicide. Common risk factors include the following (Davidson et al., 2020):

• Workplace violence
• Repeated trauma exposure
• Feeling unsupported or unprepared
• Long, consecutive shifts
• Loneliness and depression
• Access to highly abused and lethal substances
• Increased work environment stress
• Isolation
• Fear of hurting others
• Lack of self-care
• Inadequate work/life balance

Many nurses are exposed to some, if not all, of these risk factors throughout their nursing careers.

Other risk factors include previously diagnosed mental health conditions like depression, bipolar disorder, and anxiety disorders. Historical factors, such as a past history or family history of suicidal behaviors, and stressful life events, such as divorce or losing a loved one, are also considered risk factors (American Foundation for Suicide Prevention [AFSP], 2019).

There are protective factors that nurses can possess that may decrease the risk and incidence of suicide. They can be divided into individual, relationship, community, and societal protective factors.

An example of a strong individual protective factor includes reasons for living, such as family, pets, friends, etc.

A relationship protective factor would be a sense of connectedness to others.

An example of a community protective factor includes feeling connected to and utilizing community institutions.

A societal protective factor includes reduced access to lethal means, especially if at risk of suicide (CDC, 2022).

Other protective factors include the following (AFSP, 2019):

• Cultural and religious beliefs
• Good coping skills
• Strong familial connections
• Sense of belonging
• Access to and willingness to participate in mental health services

Signs and symptoms of suicidal individuals are also called warning signs.

The following are examples of warning signs, especially if they are talked about:

• Actively mentioning killing themselves
• Feeling burdensome, trapped, or hopeless
• Feeling as if there is no reason to live

The following behaviors may signal there is a risk of suicide:

• Isolating
• Withdrawing from others and previously enjoyed activities
• Excessive alcohol or drug use
• Giving away possessions
• Increased sleep or not sleeping much

Individuals experiencing suicidality often experience the following moods:

• Depression and anxiety
• Irritation
• Anger
• Relief or sudden improvement in mood (AFSP, 2019)

These are just some warning signs of suicide; many others may exist. It is also possible not to notice signs and symptoms until the person has already attempted or completed suicide.

Ethics are an important aspect of caring for a patient, especially one experiencing suicidality. Ethics has recently become a highly discussed topic when caring for a suicidal nurse.

There are ethical issues arising from the discrete decisions that are made, especially in acute care settings. Examples of this involve surrogate decision-makers and potential involuntary hospitalization.

There are ethical issues surrounding previous therapeutic relationships and the boundaries of those relationships. The approach to those therapeutic relationships may be different if the patient (nurse) and healthcare provider have a previous working relationship (Montreuil et al., 2021).

Nurses have legal and ethical responsibilities when caring for a patient experiencing suicidality; those responsibilities become challenged when the patient is a coworker. Other potential ethical challenges include balancing the need for distance with the desire to further a therapeutic relationship, balancing the need to do the "right" thing with trying to remain the nurse's friend, and trying to support the nurse's autonomy while remaining in control of the situation (Fisher, 1995).

From a legal perspective, suicide can be a significant liability for healthcare professionals. Regardless of the working relationship or friendship, it is critical to provide the same standards of care to prevent negligence (Pinals, 2019). For example, a fellow nurse colleague is brought into the emergency room with thoughts of suicide. This means that just because you are familiar with the nurse you are caring for, you cannot give them extra or special rights that could increase their risk of harming themselves, such as giving them access to their purse or belongings.

Liability can also rest with the care provider assessing the nurse. A full risk assessment must be performed, and if a risk is identified, all steps should be appropriately taken to mitigate that risk (Pinals, 2019). Regardless of the nurse's profession or experience with suicidality, the same assessments and treatments should occur.

There are clinical pathways and evidence-based approaches for caring for nurses experiencing suicidal behaviors.

Any underlying comorbid psychiatric disorders, such as anxiety or depression, bipolar disorder, or substance abuse, should be addressed and treated appropriately. Assessment and management of non-psychiatric disorders that could increase suicide risk should also occur. These conditions include insomnia, pain, and distress. Insomnia, often experienced by nurses working multiple long shifts at odd hours, can alter brain function; this increases the importance of identifying and treating sleep disorders.

A failed suicide attempt requires suicide-specific interventions to prevent further attempts. Specific therapies can include cognitive behavioral therapy or dialectical behavior therapy (Brent et al., 2019).

Cognitive behavioral therapy for suicide prevention (CBT-SP) is a manualized treatment focusing on cognitive behavior that identifies and manages precipitants of suicidal behaviors and thoughts. This treatment focuses on developing behavioral, interactional, and cognitive skills that enable the nurse to use more positive and effective coping skills to navigate stressors and precipitants of stress and refrain from suicidal behavior. CBT-SP is a form of risk reduction strategy and treatment (Stanley et al., 2009).

Dialectical behavior therapy uses multicomponent treatment strategies that focus on enhancing tolerance for distress and emotional regulation. Unfortunately, this type of treatment has not had great success rates in adults (McCauley et al., 2018).

Other care pathways include utilizing the family to ensure that the environment is safe, secure, and supportive for the individual. Another contextual factor is the level of social support; if possible, providers should assess the level of support and offer resources to increase social interactions and engagement.

Care coordination is an important avenue in caring for nurses experiencing suicidal behaviors. Evidence-based care, access to mental health services, a 24-hour crisis line, and supportive provider collaboration are essential for effective care (Brent et al., 2019).

Urgent multi-faceted approaches are necessary to reduce the incidence of nurse suicide.

Education is an important aspect of reducing suicide rates. General practitioners and physicians see 45% of those who complete suicide within 30 days of their visit. Education should occur on screening and assessing for depression.

Education should also occur at a young age, focusing on effective coping mechanisms when stressors arise. Depression management education should be refreshed as often as possible.

One of the most significant approaches to decreasing nurse suicide involves system-level education. Continual training and awareness should be incorporated into education training for all nurses and healthcare providers, with increased education for nurses who work with and experience high stress and increased levels of trauma.

Screening is key to identifying at-risk individuals. If a problem is identified with screening, a referral is necessary for effective interventions and treatment (Mann et al., 2021).

There is a need for multi-level interventions. Societal-level actions include policy and practice changes. Self-care and wellness are absolute necessities (Lee & Friese, 2021).

It is important to recognize that we must move from crisis intervention to prevention. Preventing stress as much as possible can reduce the risk of suicide. Ways to decrease stress in the nursing environment include decreasing overtime worked, increasing staffing ratios, and increasing morale (Babapour et al., 2022).

Burnout and compassion fatigue also need to be addressed and mitigated. Burnout, classified as a psychological syndrome, emerges after there is prolonged stress at the workplace. Three signs of burnout include overwhelming exhaustion, lacking accomplishment or feeling ineffective, and feeling cynicism or detachment from the job (Maslach & Leiter, 2016). Emotional exhaustion may be evident and is characterized by fatigue, weakness, and difficulty adapting. Feelings of ineffectiveness can reduce personal achievement with a negative self-evaluation (Edú-Valsania et al., 2022).

Compassion fatigue can be a combination of burnout and secondary traumatic stress. The stress results from exposure to trauma, often repeated trauma, and is characterized by mental and physical exhaustion with an inability to cope with the environment. Compassion fatigue can lead to providing lower standards of care and can affect relationships with colleagues (Cocker & Joss, 2016).

Burnout and compassion fatigue can increase the risk of nurse suicide, especially when experienced with other risk factors and symptoms.

Sherry is a 42-year-old registered nurse (RN) who has worked in a busy urban emergency room (ER) for the last five years but has been an RN for the past 17 years. Usually, Sherry is excited to start her day in the ER and very passionate about her work and the care she provides. She enjoys the fast-paced environment and can often be found working on difficult trauma cases such as car accidents and shootings. Recently, Sherry experienced a workplace violence incident that left her emotionally shaken. Colleagues have noticed that since then, Sherry has had a detached disposition and seems reluctant to care for others. Outside of work, she is going through a difficult divorce.

Another RN, Lisa, who frequently works alongside Sherry, has noted she is isolating, drinking more often, and is very agitated and short when interacting with others. She has also mentioned while drinking that she would be better off dead.

With the signs present, it is pertinent that Lisa reports the concerning behaviors to management as soon as possible. After reporting, management intervenes and meets with Sherry, who becomes visibly upset and admits to having suicidal behavior. Sherry is given leave from work, enrolled in therapy to discuss her negative experience with workplace violence, and starts participating in support groups.

Lisa was able to identify the risk factors and indicators that were present, and because of her awareness of the situation, interventions were able to be implemented. Had Lisa not reported these behaviors, it is possible that Sherry's suicidal behaviors and thoughts could have progressed to a suicide attempt or completion.

Suicide, though often considered a taboo subject, can be experienced by anyone. Nurses are predisposed to risk factors that increase the chances of suicidal behaviors. Risk factors include workplace violence, repeated trauma exposure, and an inadequate work/life balance. Protective factors include having a good supportive network, feeling connected, and accessing/utilizing mental health services. Nurses must identify and utilize protective factors.

Symptoms of suicidal behaviors can include agitation, depression and anxiety, isolation, and expression of thoughts of suicide. It is important to be aware of others experiencing these symptoms and report if you are experiencing any of these feelings. Identification and intervention are key for prevention.

• American Foundation for Suicide Prevention. (2019). Risk factors, protective factors, and warning signs. American Foundation for Suicide Prevention. Visit Source.
• Babapour, A. R., Gahassab-Mozaffari, N., & Fathnezhad-Kazemi, A. (2022). Nurses' job stress and its impact on quality of life and caring behaviors: a cross-sectional study. BMC nursing, 21(1), 75. Visit Source.
• Brent, D. A., Oquendo, M. A., & Reynolds, C. F. (2019). Caring for Suicidal Patients. JAMA Psychiatry, 76(8), 862. Visit Source.
• Centers for Disease Control and Prevention (CDC). (2022). Risk and Protective Factors. Centers for Disease Control and Prevention. Visit Source.
• Centers for Disease Control and Prevention (CDC). (2023a). Facts About Suicide. Centers for Disease Control and Prevention. Visit Source.
• Centers for Disease Control and Prevention (CDC). (2023b). Suicide Data and Statistics. Centers for Disease Control and Prevention. Visit Source.
• Cocker, F., & Joss, N. (2016). Compassion Fatigue among Healthcare, Emergency and Community Service Workers: A Systematic Review. International journal of environmental research and public health, 13(6), 618. Visit Source.
• Davidson, J. E., Accardi, R., Sanchez, C., Zisook, S., & Hoffman, L. A. (2020). Sustainability and Outcomes of a Suicide Prevention Program for Nurses. Worldviews on evidence-based nursing, 17(1), 24–31. Visit Source.
• Davis, M. A., Cher, B. A. Y., Friese, C. R., & Bynum, J. P. W. (2021). Association of US Nurse and Physician Occupation With Risk of Suicide. JAMA psychiatry, 78(6), 1–8. Advance online publication. Visit Source.
• Edú-Valsania, S., Laguía, A., & Moriano, J. A. (2022). Burnout: A Review of Theory and Measurement. International journal of environmental research and public health, 19(3), 1780. Visit Source.
• Fisher, A. (1995). The ethical problems encountered in psychiatric nursing practice with dangerous mentally ill persons. Scholarly inquiry for nursing practice, 9(2), 193–208.
• Franke, H. A. (2014). Toxic Stress: Effects, Prevention and Treatment. Children (Basel, Switzerland), 1(3), 390–402. Visit Source.
• Harmer, B., Lee, S., Duong, T. V. H., & Saadabadi, A. (2023). Suicidal Ideation. In StatPearls. StatPearls Publishing.
• Lee, K. A., & Friese, C. R. (2021). Deaths by Suicide Among Nurses: A Rapid Response Call. Journal of psychosocial nursing and mental health services, 59(8), 3–4. Visit Source.
• Mann, J. J., Michel, C. A., & Auerbach, R. P. (2021). Improving Suicide Prevention Through Evidence-Based Strategies: A Systematic Review. The American journal of psychiatry, 178(7), 611–624. Visit Source.
• Maslach, C., & Leiter, M. P. (2016). Understanding the burnout experience: recent research and its implications for psychiatry. World psychiatry : official journal of the World Psychiatric Association (WPA), 15(2), 103–111. Visit Source.
• McCauley, E., Berk, M. S., Asarnow, J. R., Adrian, M., Cohen, J., Korslund, K., Avina, C., Hughes, J., Harned, M., Gallop, R., & Linehan, M. M. (2018). Efficacy of Dialectical Behavior Therapy for Adolescents at High Risk for Suicide: A Randomized Clinical Trial. JAMA psychiatry, 75(8), 777–785. Visit Source.
• Montreuil, M., Séguin, M., P Gros, C., & Racine, E. (2021). Everyday ethics of suicide care: Survey of mental health care providers' perspectives and support needs. PloS one, 16(4), e0249048. Visit Source.
• Mundell, E. (2023). Suicide Rates Continue to Rise Among Americans. U.S. News & World Report. Visit Source.
• Ogińska-Bulik, N., Gurowiec, P. J., Michalska, P., & Kędra, E. (2021). Prevalence and predictors of secondary traumatic stress symptoms in health care professionals working with trauma victims: A cross-sectional study. PloS one, 16(2), e0247596. Visit Source.
• Pinals, D. A. (2019). Liability and Patient Suicide. Focus (American Psychiatric Publishing), 17(4), 349–354. Visit Source.
• Stanley, B., Brown, G., Brent, D. A., Wells, K., Poling, K., Curry, J., Kennard, B. D., Wagner, A., Cwik, M. F., Klomek, A. B., Goldstein, T., Vitiello, B., Barnett, S., Daniel, S., & Hughes, J. (2009). Cognitive-behavioral therapy for suicide prevention (CBT-SP): treatment model, feasibility, and acceptability. Journal of the American Academy of Child and Adolescent Psychiatry, 48(10), 1005–1013. Visit Source.
• Suicide Prevention Resource Center. (n.d.). Topics and Terms. Suicide Prevention Resource Center. Visit Source.