Introduction

According to the Centers for Disease Control and Prevention, suicide is a leading cause of death in the United States and, therefore, a significant public health concern (1). As underscored by the CDC, “In 2018, suicide took more than 48,000 lives and was the 10th leading cause of death in the United States”. Fast forward to 2025, and the CDC’s latest updates now state that suicide remains a leading cause of death, with 49,000 people dying by suicide in 2022 (which translates to one death every 11 minutes). Yet, it has been noted that suicidal ideations and attempts occur more often than suicidal deaths (2). However, suicide is preventable, and from a collaborative approach, preventive strategies, including early detection and intervention, can help reduce an individual’s risk for a detrimental outcome.  

Some of the warning signs of suicide include, but are not limited to, the following (3):  

• Feeling hopeless or helpless 
• Feeling like a burden to others or unable to find a reason for living 
• Unbearable pain 
• Expressing thoughts of suicide 
• Exhibiting signs of depression or loss of interest in usual activities 
• Aggression, impulsivity, or humiliation 
• Displaying a sudden sense of peace. 

 From a public health standpoint, all ages are affected by suicide. Nevertheless, there are higher suicide rates in some groups (e.g., non-Hispanic American/Alaska Native; non-Hispanic White populations; veterans; persons residing in rural areas; individuals who identify as lesbian, gay, or bisexual; and individuals holding certain occupations often considered high stress such as healthcare providers) in comparison to the general population (4).  

As stated, individuals requiring intervention are often those with high stressors and/or have a history of other acts of violence. One of the most demanding professions is nursing, and nurses are deemed at a higher risk for suicide than the general population. Taking that into account, suicide awareness and prevention programs are fundamental in all areas of the nursing profession.  

The Significance of Suicide Prevention

As emphasized, suicide is a public health concern due to the nature of its adverse impact on not only the individual but also their loved ones and communities. Factors such as socioeconomic issues, interpersonal problems, mental or physical health problems, substance abuse, previous suicidal attempts, occupational demands/workplace stressors, and being able to access deadly means may contribute to individuals being at a higher risk for suicide (5).  

Anxiety, stress disorders, and depression are all increased by the demands of the responsibilities related to the nursing profession, and sadly, those factors are interrelated to higher suicide rates among nurses. In saying that, nurses who work on the frontlines are heavily burdened, which is why it is so critical that support is rendered to yield a reduction in the risks of suicide. Many strategies can be implemented to protect individuals from suicidal thoughts and behavior. Some of those protective factors include the following: coping and problem-solving skills; cultural and religious beliefs that dissuade suicide; support from friends, family, and communities; supportive affiliations with care providers; access to physical and mental health care; and restricted access to fatal means among persons at risk for suicide (6). 

Suicide Risk Factors Among the Nursing Population

With suicide prevention being a public health concern, it is essential to identify groups of persons considered at substantial risk for suicide. Nurses are often faced with high demands of responsibilities and easy access to fatal means. Primarily, workplace stressors and lack of personal care can lead to burnout, which consequently can lead to an increased risk of suicide incidents in the nursing population. 

Burnout has been noted as one of the most common reasons nurses contemplate suicide, and circumstances such as short-staffing and the most recent pandemic (COVID-19) have brought about a wave of burnout among nurses who work on the front line (7). Nurses are often responsible for caring for all others (professionally and personally) while unintentionally neglecting their own needs; therefore, providing support for nurses is imperative.  

For example, there have been fifty-eight suicides amongst the nursing population in the state of Kentucky since 2016; hence, nurses in the state of Kentucky are required to obtain recurring suicide prevention education and training (8). While nursing-related training on suicide identification typically focuses on our patient care assessments, the state of Kentucky took its initiatives further and created specific training on how nurses can identify signs of overwhelming stress and hopelessness in themselves and others that are known risk factors for possible thoughts of self-harm/ suicidal ideation.

Nurse Burnout and Compassion Fatigue

Nurse Burnout (9) 

During a typical work day, nurses are often exposed to patients suffering from pain, as well as physical and mental health conditions. Ongoing stressors, compounded by staffing shortages, organizational demand, and usually inadequate resources, have resulted in many nurses reporting burnout symptoms.  

Nurse burnout usually has a gradual onset, manifesting in physical and behavioral changes (feelings of hopelessness, helplessness, and physical exhaustion, which negatively impact workplace productivity). Similar feelings have been reported in those with suicidal tendencies. If recognized early and addressed effectively, addressing nurse burnout can significantly affect all healthcare professionals’ physical and mental well-being.  

Compassion Fatigue (10) 

The term “compassion fatigue” describes the overall impact that helping others can sometimes have. Often mistaken for “burnout,” compassion fatigue encompasses the physical demands of an exhaustive schedule and the emotional and usually psychological impact accompanying physical exhaustion.   

Causative factors that can compound the actual physical demands of a career in nursing may include all too familiar issues: lack of available resources at a worksite (staffing patterns or reduced supplies), excessive workloads, and ongoing stressful work environments. While an isolated “bad day at work” can often be minimized, ongoing exposure to such factors usually results in physical and psychological exhaustion. Heavy workloads, long work assignments (mandatory overtime/ double shifts), and providing care in dangerous environments, as well as poorly regulated staffing assignments and patient ratios, all affect a nurse’s mental health.  

Reflect on the following scenarios: 

• Bed assignment gridlock (the hospital is at capacity/ we are holding ICU patients in the ER) 
• Diversion or bypass status (and the waiting room is full) 
• Chronic staffing shortages and a hiring freeze are in effect 

Additional signs of compassion fatigue may include any of the following. While everyone responds differently to workplace stressors, these noted behaviors are considered some “red flag” indicators that should be further explored.   

• Severe mood swings (often extreme pessimism or cynicism) 
• Increases in risky behaviors such as gambling, alcohol abuse, and illicit drug use 
• Difficulty concentrating, heightened feelings of anxiety or depression, sadness 
• Headaches, GI issues, unintentional weight loss, fragmented sleep patterns 

The effects of the COVID pandemic (11) 

Reflect for a minute on the early phases of the COVID-19 pandemic. The daily world news reports broadcast grim statistics on the number of critically ill and dying patients, as well as the ongoing lack of available resources (beds and ventilators, and even essential personal protective equipment), often showcasing a mentally and physically exhausted frontline healthcare team.  

Nursing research continues to report/research/study the impact of this healthcare crisis on the nursing profession, much less the entire healthcare landscape. While nursing shortages were already occurring before the pandemic, COVID accelerated the rates of burnout, staffing turnover, and early retirement. Some studies suggested that “22-32% are considering retiring, leaving the profession, or leaving their current position”. In the nursing specialty hit hardest at that time (Critical Care), the numbers were much worse: “An estimated 67% of nurses were planning on leaving their position within the next 3 years”. When questioned directly, many nurses responded that they were short-staffed, chronically stressed to the point of being burnt out, underappreciated, and overworked.  

Self-care is not selfish: Back to the basics (12) 

Suppose the risk of compassion fatigue and nurse burnout stems from physical and emotional fatigue (often to the point of exhaustion). In that case, it seems appropriate that self-care may positively affect overall health. Simple activities aimed at improving self-care include the following: Any of these activities positively impact emotional and physical health.  

• Meal planning- taking time to preplan/prepare healthy and nutrient-rich meals to prevent a poor dietary intake of heavily processed and refined foods.  
• Proper hydration. To stay hydrated, aim for water and unsweetened teas. Lower your intake of energy drinks and heavily caffeinated products. They give a false sense of energy and often wreak havoc on overall health. 
• Sleep hygiene: It is highly encouraged to assess your current sleep patterns. Fragmented sleep? Insomnia? Nightmares? Consider overhauling your bedroom, minimizing distractions (TV, handheld media devices), and using blackout curtains. Avoid OTC sleep medications and limit caffeine products for several hours before sleep time. 
• Meditation and related practices include yoga, white-out noise machines, dimming sensor lighting, massages, and aromatherapies. 

While these activities may seem incidental in the overall scheme of things, taking time to care for ourselves, especially after exhaustive workplace days, may improve overall health (both physical and mental well-being).  

As previously emphasized, in comparison to the general population, there is a notably higher risk of suicide amongst nurses (both females and males). There are many suicide risk factors among nurses, but the following are some of the most evident:  

• Exposure to frequent trauma and death 
• Working long, consecutive shifts 
• Workplace bullying 
• Neglecting self-care 
• Social isolation or seclusion 
• Access to, as well as knowledge of, lethal substances, such as opioids. 

Case in point, it has been proven that female nurses often opt for pharmacological poisoning (e.g., opioids and benzodiazepines) as a method to complete suicide. In contrast, their male counterparts utilize firearms in the same manner as the general population. Nurses are unlikely to seek mental health assistance in comparison to the general population due to some of the following reasons (13): 

• Concerns about how their careers could potentially be impacted 
• Uncertainties regarding confidentiality 
• Conflicts with taking time off to attend appointments, as well as the inability to obtain appointments 
• Fear of potential consequences associated with their professional licenses in the form of reprisals. 

 For optimal outcomes, strategies to address suicide risks must aim to correctly identify and address those exhibiting signs of burnout and depression, as well as to reduce stigma and other barriers to seeking treatment.  

Strategies to Address Suicide Risks

Mental health promotion is one of the most critical strategies to help decrease incidences of suicide in the nursing population (14). Upon identifying individuals and/or groups at risk for suicide, it is essential to derive pathways for proper intervention. The negative stigma associated with the treatment of mental illnesses is a well-known barrier for those in need of help, especially professionals such as nurses who are obliged to take care of others, and this stigma prevents individuals from seeking treatment when they lack any support system.  

Organizations can better support individuals who are at risk for suicide by ensuring that suicide training and screening tools for suicide risk are available to all employees, making every member of the organization part of their support network. The following initiatives/strategies are recommended for early identification and intervention of workplace situations that may increase the threat of self-harm behaviors:  

• Establishing a respectful, inclusive work environment, including mentoring and peer support initiatives 
• Identifying employees at risk for suicide 
• Formulating a responsive plan, including risk identification education, appropriate employee assistance services, and counseling services.  

Equally vital, identifying and reporting methods should be available for nurses to be screened anonymously. For example, individuals enduring a crisis should be able to contact and communicate with a crisis counselor quickly. Another example of an anonymous suicide prevention resource is the HEAR (Healer Education Assessment and Referral) screening program (15). The HEAR program is designed for screening, assessing, and referring nurses at risk for suicide as well as providing education about mental health. Likewise, it aims to remove the stigma associated with the reluctance to seek mental health assistance.  

In addition, managers and leaders should be equipped with the knowledge necessary for supporting their staff, which leads to healthier ways of alleviating stress and avoiding burnout. Organizations must convey to their employees that seeking assistance for mental health concerns is okay, as their well-being is a top priority. This can also be achieved by offering resources such as Employee Assistance Programs or displaying information for crisis hotlines for individuals who are experiencing depression and/or those afflicted by suicidal thoughts/ideations. Training and in-services (during initial orientation/ onboarding and annually) are also necessities.  

Oftentimes, an individual may require the assistance of a peer (whether a colleague or a friend) when faced with a crisis. Nurses should be educated and aware of suicide prevention strategies, which include assessing for risk factors, inquiring about plans (ask direct questions) as well as means, monitoring behavior, and collaboratively creating a safety plan.  

Specifically, some of the strategies recommended to prevent suicide include the following: reinforce economic supports; strengthen access and delivery of suicide care; generate protective environments; encourage connectedness; teach coping and critical thinking skills; identify and support people at risk; and reduce harms and prevent future risk (16).  

Though suicide prevention strategies may not be 100 percent effective in stopping an individual from executing a plan, peers need to know how to identify signs of suicide risk to properly support their colleagues in obtaining appropriate mental health assistance. Additionally, the American Foundation for Suicide (https://afsp.org/) provides an abundance of suicide prevention resources. In essence, suicide awareness and prevention are vital.  

Additional Interventions and Protective Factors to Reduce Suicide Rates

Though assessing and safety planning are crucial in caring for nurses at risk for suicide, it is also essential that appropriate referrals and follow-up interventions are implemented. As previously indicated, the HEAR program is an anonymous program that was designed to assess and refer individuals at risk for suicide. The program interactively screens the individual and categorizes the responses into tiers. Proactively provides options for counseling either online, via telephone, or in-person, and/or referrals are submitted to community providers for continuity in treatment.  

This method is remarkable for nurses who are reluctant to seek help because of the fear of jeopardizing their career and reputation, as their organizational safety net does what it is supposed to do – recognize and report. What is also more noteworthy is that the HEAR team can be contacted for assistance by employees who have identified colleagues at risk. Organizations can replicate the HEAR program at their facilities by modifying their Employee Assistance Programs to incorporate the HEAR service, establishing contracts with local or virtual mental health agencies, or imitating the program through staffing provisions.  

Organizations can also elicit protection for at-risk employees by promoting safety and wellness, encouraging teamwork, and providing support. Similarly, other preventive and/or protective factors must be explored to achieve a reduction in suicide rates.  

It is believed that there are certain “protective factors” that reduce the risk of self-harming practices in vulnerable individuals. While these factors do not guarantee the prevention of suicidal behaviors, there are often factors or situations that provide an individual the ability to refocus efforts on more supportive environments and behaviors. 

Protective factors may include any of the following and are uniquely specific to each person (17,18): 

• Appropriate access to mental health counselors and resources 
• Family and community support 
• Appropriate coping skills 
• Appropriate problem-solving skills 
• Restricted or limited access to firearms and potentially life-threatening materials, including medications 
• Religious faith and associated belief systems in the avoidance of self-harm practices 
• Active engagement in spirituality  

Similarly, following up with an individual at risk is another intervention that can assist in prevention and protection. In this regard, one significant advantage of the HEAR program is its unique outreach approach, which entails counselors following up with the individual to assist him/her in seeking emergent care or to help the affected individual obtain an appointment for mental health treatment/counseling promptly. 

Ethical and Legal Considerations Regarding Care for Suicidal Individuals

As previously stated, no intervention is 100% certain to prevent an individual from executing a suicidal plan, but with training and resources to help recognize and support, the resulting interventions have proven to be positively impactful in many cases. However, when providing care for suicidal individuals, ethical and legal considerations should be prioritized. 

For one’s protection as well as the protection of the individual and the organization, the following legal considerations are notable when caring for persons who are at risk for suicide: become familiar with suicide policies and procedures for your organization; gain awareness regarding state laws associated with advanced directives, involuntary commitment, seclusion, and restraint; familiarize yourself with HIPAA regulations and exceptions regarding confidentiality; and if dealing with a patient, document all action in his/her health record.  

Additionally, the current organizational protocol should be followed if one is assisting a colleague in such a vulnerable situation. As a nurse professional, one must follow policies, procedures, and protocols to avoid breaching patient confidentiality and potentially being sued for negligence or malpractice. It is equally important to consider ethical responsibilities when dealing with individuals at risk of suicide. A nurse can reference the professional code of ethics as a guide for dealing with ethical concerns, or he/she can consult with an ethics committee. Regarding ethical responsibilities, one should display these key attributes: be respectful and compassionate, serve as an advocate, promote health and safety, encourage autonomy, maintain confidentiality, refrain from conflict of interests, participate in collaborative care, engage in research to remain cognizant of evidence-based practices, and address ethical issues.  

Case Study 

A 24-year-old novice nurse has been noted to have discrepancies in the narcotic counts of her medication cart on a few occasions. Moreover, other colleagues have observed that the nurse is often truant, and her mood is unpredictable. She has episodes of extreme euphoria, and she has become overly generous (i.e., offering a necklace that she inherited from her late mother to a colleague). Even more so, an incident report was recently completed regarding her miscalculation of a critical medication dosage. Although the nurse’s error reflected in the incident report was a “Near Miss,” the nurse’s recent behavioral changes warrant immediate intervention.  

Regrettably, this error has caused the nurse to feel even more overwhelmed and emotionally detached. All the above occurrences have resulted in her feeling emotionally unstable to the point of her expressing suicidal thoughts and ideations. A colleague who has established rapport with the nurse makes herself available to listen, asks the nurse direct questions, and encourages the nurse as well as supportive resources (i.e., phone numbers for the Employee Assistance Program, the National Suicide Prevention Lifeline, and the Crisis Text Line).  

Conclusion

All nurses and healthcare professionals in the same respect should engage in continuing education that addresses suicide prevention. Principally, it takes a collaborative approach to provide individualized and organizational support to a nurse/colleague in crisis. For best results, there should be programs in place and resources available that promote suicide awareness, highlight protocol, and offer ongoing support. Ultimately, the goal of promoting mental health and wellness for nurses is to reduce the likelihood of suicide. 

As with many areas in healthcare, prevention is key. Early recognition and treatment interventions offer our patients (in many cases, ourselves and our colleagues) the best outcomes while lowering the risk of long-term complications. Do we, as nurses, not deserve the same treatment for ourselves? Let’s be proactive instead of reactive and stop the cycle of nurse burnout that could one day worsen and result in potentially life-threatening consequences.