10 American Nurse Today Volume 13, Number 10 AmericanNurseToday.com

WHEN CELEBRITIES die by suicide,discussion of this stigmatized topicmakes its way into the headlines andconversations at work and home.That was true this year when KateSpade and Anthony Bourdain diedby suicide. These shocking deaths oftwo people who appeared to have itall once again brought our attentionto this serious public health issue.We must remember, though, that nogroup—occupation, race, gender,socioeconomic status—is immune tosuicide. (See Troubling numbers.)That includes nurses, who work ina profession that’s strenuous andstressful and requires a high level ofcompassion and empathy.

Unfortunately, nurse suicide hasbeen a hidden phenomenon andhasn’t been adequately studied inthe United States. The loss of anurse coworker to suicide is morecommon than we realize becauseit’s frequently concealed by thefamily and organization. However,when we talk about suicide—itscauses, who’s at risk, and how wecan help to prevent it—we cansave lives.

Research and epidemiologyA 1990 report on occupationalsuicide risk in the United Statesshowed that when adjusted for

gender, the odds ratio for a nursedying by suicide was 1.58 timesgreater than the general population.Although more recent data for thiscountry isn’t readily available, wecan turn to others who have beenstudying nurse suicide on an ongo-ing basis. In 2017, the United King-dom released a report from its Of-fice for National Statistics thatreviewed 18,998 suicides between2011 and 2015 in England and Walesamong people age 20 to 64. Thereport revealed that suicide amongfemale nurses was 23% higher thanthe average for women in generaland the highest among female pro-fessionals. The study also showedthat most suicides among nurseswere by poisoning, which may belinked to their knowledge of and ac-cess to drugs. It’s worth noting, how-ever, that identifying occupationalrisk for suicide is difficult, given thecomplexity of the relationship.

A general internet search pro-duced no public data identifying a

national nurse suicide rate in theUnited States, yet data on suiciderates are readily available for physi-cians, teachers, police officers, fire-fighters, and military personnel. TheCenters for Disease Control and Pre-vention (CDC) maintains a restrictedNational Violent Death ReportingSystem (NVDRS), which is the mostcomprehensive death registry bysuicide coded by occupation. It hasbeen growing yearly, with data avail-able for 40 states, the District ofColumbia, and Puerto Rico. Thedataset has not been queried fornurse suicide statistics.

To address nurse suicide, wemust do more, starting with increas-ing our knowledge and awarenessof suicide within the profession,including the cost to society, riskfactors, prevention, and barriers tocare. (See What’s the cost?) In addi-tion, we need to provide support atall levels with proactive educationand risk screening tools (other pro-fessions, including physicians, havedeveloped protocols and toolkitsspecific to their workforce). Individ-uals, policy makers, professional or-ganizations, and healthcare systemleaders (specifically nurse executivesand educators) are potential stake-holders for promoting awareness ofnurse suicide and implementing pro-grams designed to prevent it.

A better understanding of healthdeterminants and their interactionsand impact is key to improving andmaintaining mental health. Individualand institutional attention to nursingstressors (workload, long hours, lat-eral violence, bullying, staffing, lack

Suicide among nurses: What we don’t know might hurt us

Research, prevention programs, and open discussion arerequired to reduce nurse suicide.

By Leah Heather Rizzo, MSN, RN-BC, CENP

LEARNING OBJECTIVES

1. Discuss the risk of suicide in nurses.2. Identify protective factors for pre-

venting suicide.3. Describe suicide prevention strategies.

The author and planners of this CNE activity havedisclosed no relevant financial relationships withany commercial companies pertaining to this ac-tivity. See the last page of the article to learn howto earn CNE credit.

Expiration: 10/1/21

CNE1.6 contact

hours

Depression is a treatable illness.If you or someone you know

needs help, contact the NationalSuicide Prevention Lifeline at

1-800-273-TALK (8255).

AmericanNurseToday.com October 2018 American Nurse Today 11

of resources, and dissatisfied pa-tients) may enhance employee en-gagement and nurse well-being.

Risk factorsWith no data to determine the sui-cide rate for nurses in the UnitedStates, risk factors for nurse suicidehaven’t received the attention theydeserve. What we do know is thatthe contributing factors related tonurse suicide are numerous andalarming.• Key risk factors for nurse sui-

cide—mood disorders, past at-tempts, access to means, sub-stance abuse, and past or currentmental illness—are similar tothose for the general population.

• A review by Davidson and col-leagues found that collective riskfactors leading to nurse suicideinclude depression, knowledgeof how to use a lethal dose ofmedication and toxic substances,personal and work-related stress,smoking, substance abuse, andundertreatment of depression.

• A recent quality improvementprogram at the University of Cal-ifornia in San Diego found thatworkplace stressors present innurses at high risk for suicide in-clude feelings of inadequacy,lack of preparation for the role,lateral violence, and transferringto a new work environment. Understanding the determinants

of mental health, which includerace, ethnicity, gender, age, incomelevel, education level, sexual orien-tation, and geographic location, al-so is important. In addition, socialconditions—interpersonal issues,family and community dynamics,housing quality, social support, em-ployment opportunities, and workand school conditions—can posi-tively or negatively influence men-tal health risk and outcomes.

Preventing suicide must includetwo goals: reducing factors thatraise the risk of suicide and in-creasing the factors that protectpeople from it; often the two over-

lap. Organizations, nursing leaders,and staff all play a role in preven-tion, starting with fostering protec-tive factors.

Protective factorsIn general, protective factors includeaccess to effective behavioral health-care; connection to friends, family,

and community; good problem-solving and coping skills; and hav-ing a sense of purpose. Healthcareorganizations can provide addition-al protection within the workplaceby emphasizing teamwork, promot-ing a culture of safety and wellness(including mental health), provid-ing access to insurance and mental

In the United States, suicides andintentional self-inflicted injuries areofficially calculated through theWeb-based Injury Statistics Queryand Reporting System (WISQARS), which is maintained by the Centers for DiseaseControl and Prevention (CDC).

• 44,965 people died by suicide in the United States in 2016 (American Asso-ciation of Suicidology).

• Suicide was the 10th leading cause of death in 2016 with a national rate of13.9 per 100,000 (CDC).

• There were 395,000 intentional self-inflicted injuries in 2013 (CDC).

• In 2016, an estimated 2.7 million adults made a suicide plan and 1.3million made a suicide attempt (Substance Abuse and Mental HealthServices Administration [SAMHSA] National Survey on Drug Use and Health).

• 54% of those who died by suicide didn’t have a known mental health con-dition (CDC)

• Suicide rates increased in nearly every state from 1999 through 2016 (CDC)

Data from both the American Association of Suicidology and the CDC demon-strate that suicide is a serious public health issue. Many experts believe the officialsuicide statistics are understated and don’t illustrate the full scale of the problem.

Troubling numbers

The emotional cost of suicide for friends and family who are left behind is im-measurable, as is the loss of the potential contributions by those who die. Howev-er, we can identify the financial costs to society.

• Shepard and colleagues reported that the national cost of suicide and suicideattempts in the United States in 2013 was $58.4 billion.

• Lost productivity represented 97.1% of this cost. When adjusted for under-reporting (several studies have shown that coroners in the United States maymisclassify some suicides, particularly in teens and minorities, because of in-complete data or stigma), the total cost rose to $93.5 billion.

• Although we lack data about suicide among nurses, consider that the cost toreplace a frontline nurse ranges from $38,000 to $61,100, according toa conservative estimate from the 2018 National Health Care Retention & RNStaffing Report. That cost is likely higher for high-demand specialties.

What’s the cost? $$$

12 American Nurse Today Volume 13, Number 10 AmericanNurseToday.com

healthcare, establishing support sys-tems, and training nurse leadersand managers.

The American Nurses Associa-tion (ANA) and the American Or-ganization of Nurse Executives bothrecognize the stress in the profes-sion and have called for action tooptimize a healthy work environ-ment. And a study on workplacewellness by Baggett and colleaguesreported that nurses feel cared forwhen leaders see them as whole

people, recognizing problems theymight be having at home as well asat work.

Creating a positive workenvironment Individual nurses and organizationscan start creating a more positivework environment by tapping intoexisting resources.

The American Association of Crit-ical-Care Nurses has identified sixHealthy Work Environment (HWE)

standards—skilled communication,true collaboration, effective deci-sion-making, appropriate staffing,meaningful recognition, and au-thentic leadership. Nurses can com-plete the HWE Assessment Tool(bit.ly/2p64SGU) and work as ateam to address identified problems.

Nurses and organizations mayalso want to participate in ANA’sHealthy Nurse, Healthy NationChallenge™, which encouragesnurses to take action to improveboth mental and physical health(bit.ly/2x41BMH).

In addition, a healthy work envi-ronment does not tolerate bullying,which can harm a nurse’s mentalhealth.

Prevention strategiesSuicide prevention must includestrategies that promote mental healthand involve both individuals and in-stitutions (communities, workplaces,schools, healthcare organizations).

Conducting researchPrevention starts with research atthe state, regional, and national lev-els. The more we know about sui-cide among nurses, the better wecan advocate for funding to createand disseminate education and pre-vention programs to healthcare or-ganizations across the country. Thefirst step is developing a standardmethod for collecting data on sui-cide among nurses across all health-care settings.

Providing educationLack of research and awarenessabout nurse suicide stymies educa-tion. However, several resources of-fer suicide prevention informationthat can be used to educate nurseleaders and staff nurses about whatto look for, how to offer support,and where to get help. (See Spot-ting red flags, taking action.)

All healthcare organizationsshould publicly display contact in-formation for the National SuicidePrevention Lifeline (1-800-273-8255).

If you know the warning signs that indicate a coworker may be in immediate dangerof suicide, you can take steps to help. The National Suicide Prevention Lifeline pro-vides a list of suicide risk factors and warning signs (suicidepreventionlifeline.org/how-we-can-all-prevent-suicide). Here are a few of the red flags that shouldprompt you to act.

Red flags• Talking about wanting to die

• Expressing feelings of hopelessness (for example, statements such as “I justcan’t take it anymore” or “What’s the use”)

• Talking about being a burden

• Acting anxious or agitated

• Withdrawing or isolating themselves

• Talking about changes in sleep (sleeping too much or too little)

• Searching online for ways to kill themselves or mentioning a recent gun purchase

• Expressing rage or talking about seeking revenge

• Displaying mood swings.

Additional red flags are available at bit.ly/2MG04RR.

Taking actionWhen you spot these red flags, consider taking these actions:

• Call the National Suicide Prevention Lifeline at 1-800-273-8255.

• Suggest the employee contact the organization’s employee assistance program.

• The Mayo Clinic suggests asking direct questions while also being open andsensitive (mayocl.in/2MriUw5):• How are you coping with what’s been happening in your life?• Do you ever feel like just giving up?• Are you thinking about dying?• Are you thinking about hurting yourself?• Are you thinking about suicide?• Have you ever thought about suicide before or tried to harm yourself before?• Have you thought about how or when you’d do it?• Do you have access to weapons or things you can use to harm yourself?

Note: Asking about suicide intention will not prompt the person to take ac-tion, as some erroneously believe. Extensive research, including a 2014 literaturereview, shows that asking if someone if thinking about suicide doesn’t increasethe risk and may, in fact, decrease it.

Spotting red flags, taking action

AmericanNurseToday.com October 2018 American Nurse Today 13

The lifeline provides free 24/7 con-fidential support to anyone in sui-cide crisis or emotional distress.

Destigmatizing suicide anddepressionMental health care still carries a stig-ma. This is particularly true amongnurses, many of whom feel that theyshould carry their burdens alone.Creating an information campaign,speaking openly about suicide anddepression, and providing access tomental health resources can help al-leviate some of this stigma and nor-malize requests for assistance.

In 2008, the American Founda-tion for Suicide Prevention (AFSP),in conjunction with the Universityof California San Diego MedicalSchool, established the Healer Ed-ucation Assessment and Referral(HEAR) program. Originally devel-oped for physicians, this preventionprogram can be adapted to otherhealthcare professionals, includingnurses. (See HEAR.)

Community activities also canhelp to reduce stigma. For exam-ple, Out of the Darkness Communi-ty Walks (bit.ly/2N4OkfZ) not onlyraise money for AFSP but also drawattention to the issue of suicide.

Raising money Before many suicide prevention ef-forts can be put into action, fundingmust be secured. Financial resourcesallocated to prevent suicide are dis-persed from various sources, suchas the Substance Abuse and MentalHealth Services Administration,which, as of September 2017, hasawarded $14.5 million in grant mon-ey for suicide prevention programs.

Current policyFederal and state laws play a bigrole in suicide prevention activities.For example, state laws can provideresources for prevention, open doorsto collaboration, encourage train-ing, and help increase awarenessand knowledge. They also regulatetraining, policies, data collection,

and suicide prevention programs.Federal laws typically target fund-ing initiatives. Currently, no poli-cies specific to preventing suicideamong nurses exist.

Data collection is particularly im-portant because it’s not always col-lected consistently. Currently, suicidedata are most commonly stratified

by gender and age. Suicide alsocan be stratified by means (how theperson died), geographic region(which can be stratified from a na-tional level down to the county lev-el), race, and certain occupations.

Call to actionA national standard for preventing

The American Foundation for Suicide Prevention and the University of California SanDiego School of Medicine created the Healer Education Assessment and Referral(HEAR) program. HEAR is endorsed by the American Medical Association as a bestpractice in suicide prevention and is available for replication in nursing programs.

HEAR takes a three-pronged approach: Education and outreach to decrease stigma,prevention through risk screening, and referral of high-risk individuals for treatment.• The program offers a series of didactic presentations on understanding and

recognizing burnout, depression, and suicide; destigmatizing depression; andacquainting attendees with the membership and function of HEAR.

• HEAR provides access to an encrypted, confidential, and anonymous web-based screening and assessment tool (Interactive Screen Program), which wasdeveloped to identify and refer individuals at risk of depression and suicide.

To implement the HEAR program at your organization, contact mmortali@afsp.org.

HEAR

Access these resources for help in identifying risk factors and warning signs ofsuicide and depression and to find out how you can implement suicide preven-tion programs and activities in your organization and community.

Risk factors and warning signsReview the lists at these two sites to learn how to identify a coworker who’s at riskfor suicide.

National Suicide Prevention Lifelinesuicidepreventionlifeline.org/how-we-can-all-prevent-suicide

American Foundation for Suicide Prevention (AFSP)afsp.org/about-suicide/risk-factors-and-warning-signs

Programs and activitiesThese sites offer ideas and suggestions for programs and activities you can get in-volved in to bring attention to suicide risk in your organization and community. (TheSuicide Prevention Resource Center [sprc.org] includes state-specific information.)

AFSP Interactive Screening Programafsp.org/our-work/interactive-screening-program

AFSP Take Actionafsp.org/take-action

National Action Alliance for Suicide Preventionactionallianceforsuicideprevention.org/comprehensive-blueprint-workplace-suicide-prevention-1

Suicide Prevention Resource Centersprc.org

Resources

14 American Nurse Today Volume 13, Number 10 AmericanNurseToday.com

suicide among nurses must com-mence with the same urgency de-ployed to address physician suicide.You can take action in your ownorganization.• Get involved on committees that

work to create a culture of well-ness.

• Find out if your organization dis-tributes mental health awarenessmaterials (brochures, posters, factsheets). If it doesn’t, ask how youcan help make this happen.

• Does your organization offer sui-cide prevention skills trainingand workplace mental healthscreenings? Suggest partneringwith your Employee AssistanceProgram (EAP) to explore proac-tive prevention strategies.

• Advocate for the implementationof a suicide prevention program,such as HEAR.Suicide prevention is a team ef-

fort that should include nurse lead-ers, staff nurses, human resourcespersonnel, EAP members, and fi-

nancial officers. Preventing nursesuicide requires identifying, organ-izing, inspiring, and facilitating thesuccessful implementation of re-search, policies, and programs thathelp nurses at risk or in crisis.

Leah Heather Rizzo is associate vice president for nurs-ing services at Geisinger Northeast in Wilkes-Barre,Pennsylvania, and she’s a doctor of nursing practice stu-dent at Carlow University in Pittsburgh, Pennsylvania.

Visit americannursetoday.com/?p=52258 for alist of selected references.

About the cover This month’s cover art is by Lin-da Lobbestael, MSN, RN-BC. Hereshe describes her work:

“If someonelooks at the im-age closely, theywill see so manyelements of nurs-ing practice aswell as other life

stressors in the ‘mind’ of the wo -man who has been brought totears. These elements are clippedand pasted chaotically from vari-ous magazines to illustrate thechallenges of finding peace with -in ourselves.

Being unable to regulate emo-tions and manage competingdemands, nurses and other health-care providers can reach an in-ability to cope effectively. Thereis the constant burden of timeseen as the digital clock, complexemotions seen in the words, suchas, ‘there is no way out’ and ‘to-day I am grieving.’

On her forehead, a computerindicator shows her ‘reachingmaximum capacity.’ If only wehad such an indicator on ourforeheads that faced the world.Maybe then we would betterknow when to help one anotheror at least be more empathetic.

This is someone who is at thetipping point of a crisis and theblue butterfly that perches on hershoulder symbolizes divergentpaths for this woman, because ithas its two meanings. The bluebutterfly is a symbol used on thedoor of a patient who is ‘in tran-sition,’ and in the dying process.It reminds people not to come inand out of the room unnecessar-ily and without conscious aware-ness of what is happening.

A butterfly is also a symbol ofrebirth and therefore appropriateconsidering the success of ther-apy and programs that can helppeople turn their lives aroundfrom severe depression, burnout,and suicidal ideation.

The daisy, a symbol of newbeginnings is a flower that hasblossomed; for some people, aseed of hope can bloom into anew life with the right support.The gold is just that, the hopeand possibility casting its lightonto this image of darkness.”

Editor’s note: This is an excerpt from a story titled “Depression and substance

abuse: The danger of being strong for far too long.” To read the full story, visit

americannursetoday.com/blog/the-danger-of-being-strong-far-too-long.

I learned early on in my career that as a nurse, I would never be a “regular” patientagain. I have never felt comfortable revealing that I am a nurse who has depression. Iwant the medical team to have an unbiased view of my aliments, with no judgment.

The reason is that I have personal examples of the stigma that affects nurseswhen anything having to do with mental health arises. During my health screen-ing before working in the emergency department (ED), I was asked to list mymedications. This was my first position as a nurse, and since they asked, I washonest, and listed Prozac, an antidepressant that I had been on since I was 18. Thenurse practitioner reviewed my chart and said, “Maybe you should think aboutanother department. I see that you are taking Prozac. The ED can be very stressfuland demanding.”

This was a defining moment in my career. I was expected to educate patientsalong with their family members that it was acceptable to take medications formental health issues such as depression. Your life was not over. You are not de-fined by this disease. I had falsely assumed that because society was being edu-cated, and the stigma that comes along with seeking and adhering to treatmentfor depression was decreasing, that I was in a safe place to disclose this as a nurse.I never felt so insecure, ashamed, and idiotic for thinking that nurses would betreated with the same grace as how we treat the public.

Nurses struggling with addiction may be reluctant to seek help. Go online toamericannursetoday.com/blog/my-journey-to-addiction-and-back/ to accessone nurse’s story.

Learning to hide

AmericanNurseToday.com October 2018 American Nurse Today 15

Please mark the correct answer online.

1. Where does suicide rank in causes ofdeath in the United States?

a. 5b. 10c. 15d. 20

2. The number of people in the UnitedStates who died by suicide in 2016 was

a. nearly 15,000.b. nearly 25,000.c. nearly 45,000.d. nearly 65,000.

3. Which statement about the nationalcost of suicide and suicide attempts in theUnited States is correct?

a. Most of the cost has been determinedto come from lost productivity.

b. The cost may be as high as $15 millionannually.

c. Suicides may be overreported, whichmay affect cost calculations.

d. The cost may be as high as $20 millionannually.

4. Although not adequately tracked, thesuicide rate for nurses in the UnitedStates appears to be

a. comparable with other occupations.b. lower compared with physicians. c. lower than the general population.d. higher than the general population.

5. Which statement about nurse suicidein the United Kingdom is correct?

a. Suicide among nurses is higher thanfor women in general.

b. Suicide among nurses is lower than forwomen in general.

c. In general, men have a higher rate ofsuicide than nurses.

d. In general, men have a rate of suicidethat is comparable to nurses’.

6. Which of the following is the leastlikely to be a risk factor for nurse suicide?

a. Untreated substance abuseb. Anxiety disorderc. Mood disorder d. Depression controlled with

medication

7. The American Association of Critical-Care Nurses identifies six Healthy WorkEnvironment Standards, including

a. effective decision making.b. support systems. c. coping skills.d. physical activity.

8. Red flags that indicate someonemight be in danger of suicide include allof the following except

a. sleeping more than usual.b. displaying mood swings.c. talking about being a burden.d. expressing hopefulness.

9. An appropriate step to take if youthink someone is considering suicide is

a. Not asking questions, to avoidupsetting the person.

b. Asking, “Are you thinking aboutsuicide?”

c. Joining several friends to approachthe person.

d. Asking, “Do you want to be alone?”

10. Which statement about the HealerEducation Assessment and Referral(HEAR) suicide prevention program iscorrect?

a. It was created by the AmericanFoundation for Suicide Prevention andthe University of California San DiegoSchool of Social Work.

b. It was created by the AmericanFoundation for Suicide Prevention andthe University of California San DiegoSchool of Medicine.

c. It takes a two-pronged approach:education and prevention.

d. It takes a two-pronged approach:medication and prevention.

11. A correct statement about researchand suicide is:

a. Funding for suicide research issufficient at the national level.

b. Data on suicide rates for physicians arenot readily available.

c. A standard method for collectingsuicide data on nurses is needed.

d. Data on suicide rates for teachers arenot readily available.

POST-TEST • Suicide among nurses: What we don’t know might hurt us Earn contact hour credit online at americannursetoday.com/article-type/continuing-education/

Provider accreditationThe American Nurses Association’s Center for Continuing Edu-cation and Professional Development is accredited as aprovider of continuing nursing education by the AmericanNurses Credentialing Center’s Commission on Accreditation.ANCC Provider Number 0023.

Contact hours: 1.6

ANA’s Center for Continuing Education and Professional Devel-opment is approved by the California Board of Registered Nurs-ing, Provider Number CEP6178 for 1.92 contact hours.

Post-test passing score is 80%. Expiration: 10/1/21

ANA Center for Continuing Education and Professional Devel-opment’s accredited provider status refers only to CNE activitiesand does not imply that there is real or implied endorsement ofany product, service, or company referred to in this activity norof any company subsidizing costs related to the activity. Theauthor and planners of this CNE activity have disclosed no rele-vant financial relationships with any commercial companiespertaining to this CNE. See the banner at the top of this pageto learn how to earn CNE credit.

CNE: 1.6 contact hours

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