Several years ago, I was struck with the emotional news that three nurses in my own workplace died of suicide, one right after another. Even though I wasn’t close to these nurses, I felt their loss, and it troubled me to my core.
All the literature I could find was from outside of the United States—yet it suggested that all nurses were at risk (Kõlves & De Leo, 2013; Milner, Spittal, Pirkis, & LaMontagne, 2013; Silva et al., 2015). So, I decided to gather a team to take action. We needed to conduct research to identify the incidence of nurse suicide in the United States and, with that in hand, begin a nurse suicide prevention program.
Conducting suicide research
First, with funding provided in part by Sigma's Gamma Gamma Chapter at San Diego State University, we conducted a longitudinal analysis of suicides in San Diego (2005-2014), finding that nurses were at greater risk than the general population. In 2014, the only year that gender data for nursing was available, female nurses were indeed at greater risk than females in the general population. But we needed a larger sample to detect significance (Davidson, Stuck, Zisook, & Proudfoot, 2018). So we applied for and received the national dataset of suicides from the Centers for Disease Control and Prevention.
The 2014 analysis produced similar results to our previous pilot, and the sample size was large enough to detect significance. The national longitudinal analysis (2005-2016) confirmed what we had suspected—nurse suicide had been a risk all of these years but undetected because no one had asked the question. The data had been silently sitting there waiting.
A key finding from this study was that nurses who died by suicide were more frequently known to have job problems than suicides in the general population. Our work has something to do with these deaths (Davidson, Proudfoot, Lee, Terterian, & Zisook, in press).
Leading the charge to help nurses
The physicians within my own organization had partnered with the American Foundation of Suicide Prevention (AFSP.org) to develop the first physician suicide prevention program in 2009 following similar circumstances. The Healer Education Assessment and Referral (HEAR) program educated clinicians about mental health issues and professional risks, and assessed colleagues to detect those in need of help (Moutier et al., 2012; Norcross et al., 2018). We partnered to extend the program to nurses. Now, four years later, we are identifying approximately 40 nurses a year who are high risk, actively expressing suicidality, and referring them into treatment. This program also has the potential to identify nurses with substance use disorder and refer them anonymously into treatment while maintaining their license, job, and professional identity.
How HEAR works
HEAR uses an anonymous encrypted screening that is quite elegant in its simplicity. The chief nursing officer sends an email once a year to nurses asking them to perform a self-assessment online as a matter of self-care, though anyone can take the screening at any time. No one knows who completes the survey or the individual results. The assessment goes through encryption to the AFSP, and those who score moderate to high risk are anonymously forwarded to a therapist who communicates back to the person to engage in conversation. The nurse can remain anonymous throughout the whole process, whether they seek referral for treatment, treatment, or over the phone counseling. Those that choose to break anonymity may elect to come in for face-to-face counseling.
Additionally, these same therapists conduct interprofessional emotional debriefings following difficult workplace events—or nurses can request an emotional debriefing at any time. Last year, they performed 40 of these.
If the therapists learn of a significant event through risk management, they proactively contact the manager to offer debriefing, too. Further, we developed a bereavement procedure to support the workforce in the event of an employee death (Davidson, Accardi, Sanchez, & Zisook, 2019), and the special actions to take with a death by suicide (Davidson, Accardi, Sanchez, & Zisook, 2020).
What we’ve learned and HEAR today
The key to prevention is to use proactive approaches. Nurses have access to treatment through their benefits, but passive availability was insufficient. Proactively reaching out to nurses and asking them to screen is interpreted as an act of caring in leadership. It took the prompt of an email from someone who cared to spur apathy into action. At the inception of the program, the therapists had to reach out to managers to schedule debriefings. Now, four years into the program, most debriefings are requested, signaling that we are overcoming the stigma of seeking help to maintain mental health.
From this program, we’ve learned from nurses that there are modifiable workplace issues that can be addressed to reduce suicide risk:
- Feelings of loneliness and isolation after starting a new job or transferring
- Feeling unprepared to care for a new patient population
- Fear of making mistakes that could cause harm while feeling unprepared
- Discord between colleagues
- Issues with managers
- The burden of over-regulation
And then there’s the issue of burnout. Being asked repeatedly to work overtime, even if it is not mandated, causes those with loyalty to the profession to have role conflict that disturbs home/life balance (Accardi, Sanchez, Zisook, Hoffman, & Davidson, in press; Davidson, Zisook, Kirby, DeMichele, & Norcross, 2018).
The HEAR program not only provides individuals with the impetus to take action for mental health, but also provides leaders with information to make meaningful change for the health of the workforce. And it’s ready for replication by others. If you are interested in using HEAR in your workplace, please reach out to me at email@example.com
. But most importantly, if you or someone you know is in crisis or needs help immediately, contact the National Suicide Prevention Lifeline: 1-800-273-TALK (8255) or suicidepreventionlifeline.org
Judy E. Davidson, DNP, RN, FCCM, FAAN, is a nurse scientist at the University of California, San Diego (UCSD) in the Division of Nursing and is a member of Sigma’s Gamma Gamma Chapter at San Diego State University in San Diego, California, USA.
Accardi, R., Sanchez, C., Zisook, S., Hoffman, L., & Davidson, J. (in press). Sustainability and outcomes of a suicide prevention program for nurses. Worldviews on Evidence-Based Nursing
Davidson, J. E., Accardi, R., Sanchez, C., & Zisook, S. (2019). Grief management after a nurse’s death. American Nurse Today, 14
Davidson, J. E., Accardi, R., Sanchez, C., & Zisook, S. (2020). Nurse suicide: Grief management and prevention. American Nurse Today, 15
Davidson, J. E., Proudfoot, J., Lee, K. E., Terterian, G., & Zisook, S. (in press). A longitudinal analysis of nurse suicide in the United States (2005-2016). Worldviews on Evidence-Based Nursing
Davidson, J. E., Stuck, A. R., Zisook, S., & Proudfoot, J. (2018). Testing a strategy to identify incidence of nurse suicide in the United States. Journal of Nursing Administration, 48
Davidson, J. E., Zisook, S., Kirby, B., DeMichele, G., & Norcross, W. (2018). Suicide prevention: A healer education and referral program for nurses. Journal of Nursing Administration, 48
Kõlves, K., & De Leo, D. (2013). Suicide in medical doctors and nurses: An analysis of the Queensland suicide register. Journal of Nervous and Mental Disease, 201
Milner, A., Spittal, M. J., Pirkis, J., & LaMontagne, A. D. (2013). Suicide by occupation: Systematic review and meta-analysis. British Journal of Psychiatry, 203
Moutier, C., Norcross, W., Jong, P., Norman, M., Kirby, B., McGuire, T., & Zisook, S. (2012). The suicide prevention and depression awareness program at the University of California, San Diego School of Medicine. Academic Medicine, 87
Norcross, W. A., Moutier, C., Tiamson-Kassab, M., Jong, P., Davidson, J. E., Lee, K., … Zisook, S. (2018). Update on the UC San Diego Healer Education Assessment and Referral (HEAR) Program. Journal of Medical Regulation, 104
Silva, D. D., Tavares, N. V., Alexandre, A. R., Freitas, D. A., Brêda, M. Z., Albuquerque, M. C., & Melo, V. L. (2015). Depression and suicide risk among nursing professionals: An integrative review. Revista da Escola de Enfermagem da U S P, 49