Kentucky Suicide Prevention

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Suicide risks among nurses is a public health concern. The first and most profound way to address the troubling rates of suicide among nurses is to employ suicide prevention. For that matter, mandatory training, resources, and the establishment of policies and procedures are crucial within the operation of organizations. All healthcare providers are responsible for identifying and addressing situations which warrant intervention.  

This Kentucky Suicide Prevention course meets the “Suicide Prevention” requirement needed for Kentucky nursing license renewal.

Introduction   

According to the Centers for Disease Control and Prevention, suicide is a leading cause of death in the United States, which is subsequently a public health concern (6). As underscored by the CDC (6), “In 2018, suicide took more than 48,000 lives and was the 10th leading cause of death in the United States”. Yet, it has been noted that suicidal ideations and attempts occur more often than suicidal deaths (17). However, suicide is preventable and from a collaborative approach, preventive strategies can help reduce an individual’s risk for a detrimental outcome (6). Some of the warning signs of suicide include, but are not limited to, the following: 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 normal activities; aggression, impulsivity, or humiliation; or displaying a sudden sense of peace (4). From a public health standpoint, all ages are affected by suicide (6). 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 others (6). As stated, individuals requiring intervention are often those with high stressors and/or have a history of other acts of violence (6). 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.  This Kentucky Suicide Prevention course will increase your awareness among nurses at risk for suicide and provide tools for screening and preventative measures.

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 their loved ones and communities correspondingly (6). Factors such as socioeconomical 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 (6). 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 (7). In saying that, nurses who work on the frontlines are heavily burdened, which is why it is so critical that support is rendered with the goal of yielding a reduction in the risks of suicide. There are many strategies that 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 believes 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 Amongst the Nursing Population

With suicide prevention being a public health concern, it is important to identify groups of persons considered at substantial risk for suicide. Nurses are often faced with high demands of responsibilities as well as 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 for suicide incidences 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 (11). Nurses are often responsible for the care of 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; however, nurses in the state of Kentucky are required to obtain recurring suicide prevention education and training (15). Hence why the Kentucky Board of Nursing has added a continuing education requirement to address suicide prevention in nursing. Furthermore, Kentucky nurses can obtain additional education on identifying signs of burnout and ways to reduce stress by viewing a suicide prevention video and engaging in a program developed by the Kentucky Nurses Action Coalition in collaboration via the support of the Kentucky Nurses Association (15).  

As previously emphasized in this Kentucky Suicide Prevention course, in comparison to the general population, there is notably a higher risk of suicide amongst nurses (both females and males) (8). 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; and access to as well as knowledge of, lethal substances, such as opioids (5). 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, whereas their male counterparts utilize firearms in the same nature as the general population (8). Nurses are unlikely to seek mental health assistance in comparison to the general population due to some of the following reasons: concerns with how their careers could potentially be impacted; uncertainties regarding confidentiality; conflicts with taking time off to attend appointments as well as inability to obtain appointments; and fear of potential consequences associated with their professional licenses in the form of reprisals (11). For optimal outcomes, strategies to address suicide risks must aim to properly identify and address those exhibiting signs of burnout and depression as well as to reduce stigma and other barriers to seeking treatment (11). Next we will explore strategies to address suicide risk factors as required by the Kentucky Board of Nursing in this Kentucky Suicide Prevention course. 

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 (2). Upon identifying individuals and/or groups at risk for suicide, it is important 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 taking care of others, and this stigma prevents individuals from seeking treatment when they lack any type of support system. Organizations can better support individuals who are at risk for suicide by assuring that suicide training and screening tools for suicide risk are available to all employees, making every other member in one’s organization part of their support network. In fact, there are three primary initiative-taking strategies recommended by the Suicide Prevention Resource Center (SPRC) for organizations to implement and those strategies include establishing a respectful, inclusive work environment; identifying employees at risk for suicide; and formulating a responsive plan to enforce (12). Vitally, there should be identifying and reporting methods available for nurses to be screened anonymously (2). For example, individuals enduring a crisis can text “HOME” to 741741 to communicate with a crisis counselor (15). Another example of an anonymous suicide prevention resource is the HEAR (Healer Education Assessment and Referral) screening program (2). The HEAR program is purposed for screening, assessing, and referring nurses at risk for suicide as well as providing education pertaining to mental health, and likewise, it is aimed at removing the stigma associated with the reluctancy in seeking mental health assistance (16). In addition, managers and leaders are equipped with the knowledge necessary for providing support to their staff which, in turn, leads to healthier ways for alleviating stress and avoiding burnout (16). Essentially, organizations must convey the message to their employees that it is okay to seek assistance for mental health concerns as their well-being is priority. This can also be achieved by offering resources such as Employee Assistance Programs or displaying information for crisis hotlines (e.g., National Suicide Prevention Lifeline, Safe Call Now, Disaster Distress Helpline, or the Crisis Text Line) for individuals who are experiencing depression and/or those afflicted by suicidal thoughts/ideations (2). Trainings and in-services are also necessities.  

Oftentimes, an individual may require the assistance of a peer (whether a colleague or a friend) when faced with a crisis (2). 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 (13). 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 (6). 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 (2). Besides, the American Foundation for Suicide provides an abundance of suicide prevention resources (3). 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 important that appropriate referrals and follow-up interventions are implemented. As previously indicated in this Kentucky Suicide Prevention course, 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, categorizes the responses into tiers, then proactively provides options for counseling either online, via telephone, or in-person, and/or referrals are submitted to community providers for continuity in treatment (1). This method is remarkable for nurses who are reluctant to seek help because of the fear of having one’s career and reputation jeopardized, as their organizational safety net does what 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 who are at risk (1). Correspondingly, organizations can replicate the HEAR program at their facilities by either modifying their Employee Assistance Programs to incorporate the HEAR service, establishing contracts with local or virtual mental health agencies, or by imitating the program by means of staffing provisions (1). Still, organizations can elicit protection to employees at risk by promoting safety and wellness as well as encouraging teamwork and providing support (18). Similarly, it is important that other preventive and/or protective factors are explored to achieve a reduction in suicide rates. For that matter, Hutton (2015) listed the following as preventive or protective factors for individuals at risk for suicide: “Reasons for living, perceived meaning in life, adaptive beliefs; Social support and feeling connected that may include religious affiliation; Being married, and for women, being pregnant, having children; Restricted access to firearms; Moral objection to suicide; Engaged in treatment or having access to mental or physical health care; Resilience, coping skills; Fear of social disapproval; and Cognitive flexibility”. In the same aspect, following up with an individual at risk is another intervention that can assist in prevention and protection. In this regard, one major 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 in a timely manner (10). 

Ethical and Legal Considerations Regarding Care for Suicidal Individuals

As formerly 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 (13).

Also, if one is assisting a colleague, organizational protocol should be followed. As a nurse professional, it is crucial that one follows policies, procedures, and protocol to avoid breaching patient confidentiality as well as potentially being sued for negligence or malpractice. It is equally important to consider ethical responsibilities when dealing with individuals at risk or 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 (9).  

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, it has also been observed by other colleagues that the nurse is often truant, and her mood is very 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 the need for 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, she asks the nurse direct questions, and she provides encouragement to 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). What are other strategies that might be valuable to the nurse’s prognosis?

Recommendations

All nurses and healthcare professionals in the same respect should engage in continuing education which 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 which 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. 

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