Study Identification activity



Nurse suicide prevention starts with crisis intervention Make a plan to protect yourself and your colleagues. By Judy E. Davidson, DNR RN; Amanda Choflet, DNP, RN; M. Melissa Earley, BSN, RN; Paul Clark, PhD, RN; Sattaria Dilks, DNE RN; Linda Morrow, DNE MBA; Sharon Tucker, PhD, RN; and Trisha Mims, MSN, RN

leagues that it's okay not to be okay. Not every suicide can be prevented, but ac-

cepting the fact that suicide happens is a nec- essary precursor to prevention. In this article,

in the first article in this series on nurse mental ~ vve'll build on the resiliency strategies covered

healili ( The goal is to empower you with concrete steps that will help you protect yourself and identify col-

~ leagues in crisis and to provide evidence-based actions you can take to ensure they get the as-

" sistance they need , (See Resources for belp.)

Be aware, identify, and recognize Most people who are having suicid:11 thoughts are in too much distress to get help on their own. Their view of the world becomes my- opic and focused on the negative, They need a friend or colleague to encourage them to use resources to seek help or to even make the call for them. Nurses aren't immune to the effects of depression, and we're socialized to ''buck up

nize overwhelming feelings of sadness or de- and take it," making it difficult for us to recog-

pression in ourselves, Or that we've reaclied the point where we can't function. However,

WE KNOW that suicide rates are higher in nurses we can help each other if we know what to do than the general population. but we don't yet and how to take action to save a life. know the exact reasons why. However, the na- Use the acronym AIR (Awareness, Identify, ture of the work we do increases our risk of Recognize) to help you identify colleagues anxiety, stress disorders, and depression. The who are at risk. COVID-19 pandenlic makes us even more vul- nerable (as has been documented during previ- Awareness ous disease outbreaks, such as Ebola virus dis- Be aware of the warning signs frequently seen ease ). ( See Nitme suicide riskfactors.) in someone in crisis . Listen for them during

We haven't yer overcoine the stigma associ- conversations with colleagues ancl watch for ated with seeking niental health treatment , but behavior changes . (See Crisis warning signs.) given the increased incidence of suicide among Because someone can have suicidal nurses. we need to change our perspective and thoughts and not display any noticeable signs, normalize conversations about mental health regularly check in with colleagues, giving them and wellness. We ni,ist create :itmospheres of space to discuss their feelings. Open the door acceptance and empathy withjn healthcare or- by asking, "I've noticed you're more down ganizations :ind send the message to our col- than usual. Do you want to talk about it?"

14 American Nurse Journal Volume 16, Number 2

Identify V wl ~0 - r- i *,'T- - Your awareness of the warning signs and the , A -7.conversations you have with colleagues will help

>r li identify when someone is at risk of suicide. '4Have the conversation. The most impor- t:int thing you can do is start a conversation. Empathy makes a powerful connection to re- duce the risk of loneliness. Direct questions can lie lifes:lving. (See Ke)' com,e,Nation elements.)

Motivational interviewing can help, espe- cially if your colleague is ambivalent about making change. This noniudgmental conver sational style uses empathy and collaboration to strengthen a person's motivation for com-

The following factors place nurses at risk for suicide:mitment and change. The discussion becomes • chronic paina partnership and focuses on next steps. You • depressionassume the position of the learner, not the • evaluation for substance use disorder at work

teacher, where you ask about goals and what • fear for safety or safety of others could be done next, rather than telling your • fear of harming a patient colleague what to do. 'Ihis approach may en- • feeling out of place courage them to be more open to seeking • feeling unprepared forthe role help . ( See Concersation dos and do , 1 ts.) • feeling unsupported in the role

Learn evidence-based communication • financial stress skills. Training is available on peer suicide • inadequate self-care evaluation and self-screening tools. Here are • isolation from family and friends

• job lossthree examples: • loneliness• A series of eight videos prepated hy Sharon • long, consecutive shifts

Tucker, PhD, RN, is available to the public • management conflicts and provides examples of words to say tO • repeated requests for overtime someone you think is at risk of suicide. • repeated trauma exposure • risky substance use and substance misuse

• The American Foundation for Suicide Pre- • work/home role conflict vention (AFSP) developed "Have a #Real- • workplace stress Convo," which includes guidance and real • workplace violence, incivility, and bullying. stories using lay language to help anyone

A video ( M85tEa6JU) by Laurel Prince, learn how to talk to someone they think tiiay MSN, RN, a trauma nurse, depicts the stress and burnout experi- be at risk of suicide. https://afsp.c,rg/realconvo enced by many nurses.

• A video from AFSP describes how to bring up the conversation ancl why. An opener like this can help start the conversation: "The ployed by any organization to proactively eval- way you've been talking lately really con- uate the suicide risk of faculty, employees, and cerns me [pause] can we talk? I'ni here for students. This anonymous, encrypted survey is you." sent via a simple email with a link. The org:iii- depressic,n-and-suicide-prevention ization must have therapists on hand to engage Implement proactive screening. A through enciypted email :ind a referral system

proactive approach to regular screening can toi those identified as at-risk. This process is help you identify colleagues with mental cost-effective, can be scaled to any size or type health conditions or risky substance use be- of organization, and has been successfully fore it becomes a matter of silicidal ideation transferring clinici:ins who are depressed and or legal action. The Healer Education, Assess- suicid:11 into treatment for over 10 years. ment mid Referral (HEAR) program Chased on AFSP's Interactive Screening Program Recognize pro- Recognize the urgency to intervene. Once vides a comprehensive tool that can be de- you've seen the warning signs, don't hesitate. February 2021 American Nurse Journal 15

person can stay safe (keep in mind :1 .,Lifety plan Resources for help doesn't guarantee safety), don't leave them alone.

Discuss your concern with them and give them If you oryourcolleagues are having thoughts of suicide, call on these the opportunity to choose to go to the hospital, resources for help. but be prepared to call 911. Although making Crisis: Thoughts of suicide or self-harm that call is difficult, especially when you have a • Call the National Suicide Prevention Lifeline: 1 800-273-TALK. relationship with the individual in crisis. it must

he part of your plan. Relationships can be re-• Call 911 immediately. paired. Life can't be restored. Make the call.

• Contact your healthcare provider now.

Clinician friendly hotlines Safety planning • Safe Call Now ( This crisis referral service sup- Every nurse should create a safety plan for

ports public safety employees, emergency services personnel, and themselves. Self-care and talking about your their families. 206-459-3020. problems with a trusted coworker, family mem-

• Disaster Distress Helpline ( her, or friend are excellent ways to help you -helpline). This 24/7, 365-day-a-year national hotline run by Sub- deal with stress and anxiety. Encourage your stance Abuse and Mental Health Services provides crisis counseling colleagues to do the same. for those in trauma-related emotional distress. Call 800-985-5990 or Being familiar with your resources makes it text TalkWithUs to 66746. more likely that you'll use them when a crisis

• Crisis Text Line ( Trained crisis responders provide occurs. Your safety plan should include know- 24/7 support to frontline healthcare workers. In the United States ing suicide risk warning signs and the coping and Canada text HOME to 741741.

strategies that work best for you. including tile people who can help olin or distract ycm. Your plan also should include maintaining in yourCrisis warning signs contacts the names and numbers of people to call for help as well as emergency phone num-

Watch for these crisis warning signs to help prevent suicide. hers. The Suicide Prevention Lifeline offers a • Acting anxious, agitated, or unusually angry Patient Safety Plan Template (, • Erratic or unusual behavior and Staying Safe from Suicidal Thoughts has a • Extreme mood swings quick online plan (httpS:// • Giving away belongings to help start the process. • Increasing use of alcohol/drugs After you've completed your own safety • Looking for a suicide method (for example, searching online) plan, you'll be better prepared to help col- • Rumination (can't get rid of negative thoughts) leagues develop theirs. Safety plan prompts • Self-injury (for example, cutting) about resources--such as "Who do you nor- • Sleeping too much or too little mally go to when things get rough?" "What :ic- • Talking about feeling hopeless, having no reason to live tivities normally calm yoli clown when you're • Talking about feeling trapped or being a burden to others stressed?"-also can help you during conver- • Talking about unbearable physical or psychological pain sations with colleagues who've become tiin- • Talking, writing, or creating art about wanting to die or kill themselves nel-visioned by stress or depression to remind • Withdrawal or isolation them of help they may not have accessed.

Removing access to means: Firearm Assume you're the only one who has noticed and medication safety the colleague in distress and speak up. If Suicide frequently is impulsive. Removing im- something is making you feel that a col- niediate access to lethal methoils-Rich as league is in trouble, speaking up could save firearms ancl medications-reduces the likeli- their life. If you're wrong and they're okay, hood that an individual having suicidal you've opened the door to future converse- thoughts will act impulsively and increases the tions because they know you care. chance that theyll seek help instead.

Recognize when to treat the situation as an The use of firearms by nurses who die by emergency. When someone says they're thinking suicide is rising, so any screening should in- about suicide, always take thern seriously. If at clude a direct question to determine whether any point you have doubts about whether the tlie person has access to a firearm. Removing

16 American Nurse Journal Volume 16, Number 2

fire:irms from the home during treatment for depression is an evidence-based strategy to Key conversation elements reduce suicide incidence. The same is true of medications. If someone you know has talked Use this algorithm to guide your conversation with a colleague who might about a suicide plan that involves medications be at risk of suicide. found in the home, remove the medications.

When medications or firearms clint be re- Scan the environment for safety nic)ved from tile home, steps c:in be taken to and confidentiality. Use

situational them in a sate. Nurses who are gun owners are encout-

aged to follow firearm safety recommenda- tions. Store firearms locked and unloaded, and Safety

risk? (for Call emergencystore ammunition separately from firearms. Us- »example, Yes medical firearm safety precautions may save the life weapon) of a friend or family member. (See Firearms and niedication safety resources.) No

Risky substance use and substance use Engage in discussion.disorder

Risky substance use is best understood on a continuum, where one end represents little ~ use and little risk of harni ancl the other rep- resents acute addiction and extreme risk for

Ask if suicidal. h:irm. In tile middle Of the continuum, maily Signs of risk for »

suicide? Yes Ask abouta plan.people use xiii)st:inces in :i way thilt negative- ly impacts their well-being and increases the risk for addiction, ~No Yes

Substance use in the nursing profession is especially challenging because of the poten- Plan to reconnect Stay with the individual tial for harm not only to yourself but also to and check back. and get help. patients. The first step is to understand your own risks :ind hone.stly evaliiate yolir sub- stance use. Risky substance use and substance

IS use disorder can be detected ii.sing comnion this a assessment tools, which are available from mandatory

reporting Yes the National Institute on Drug Abuse at drug- state?

Report.screening-tools-resozirces/chart-screening-tools. After youve evaluated your own risk, think Nurse

impaired atabolit how to suppoit your colleagues with work with alcohol Yes ~ risky behaviors. Approaching a colleague early or other

drugs?in the substance use continuum makes it more likely that theyll get help before they're found impaired at work, divcrting 1'1'ic.Lic,lti„Ith, ui driving under the influence. A conversation be- tween friends-using motivational interviewing low the organization:s process. Ethically. we techniques and reflective listening-in which have a duty to support the nurse through you share your feedback and concerns can be treatment and welcome them back to the an effective way to open the door to help. workforce when treatment is completed.

If a nurse is found impaired at work. youl Nurses die by suicide during formal imes- options are limited and guided by your state's tigations for substance use disorder. Talking to reporting mandates. For patient Mafety, the sit- a colleague who's struggling with risky behav- imtion must be reported to a manager who ior before they're found impaired on the job will remove the nurse from duty and then fol- can save a life. February 2021 American Nurse Journal 17

Speak with empathyConversation dos and don'ts Suicide prevention requires that we overcome the stignia associated with mental health con-

When talking to a colleague you fear may be having suicidal thoughts, cerns and instead view the stress, anxiety, :ind use this list of dos and don'ts to ensure you're providing a nonjudg- depression we .soinetimes experience as part ofmental space forthem to express their feelings and experiences.

being human. We must lie open to discussing DO ()lit' emotions :nic| actively listening to someone • provide empathy who may be at risk for suicide. Save a life hy • listen authentically learning the skills to speak empathically with a • be a friend or colleague

colleague you've identified as being :it risk. AN • be curious ("Tell me more.") • use silenceto helpthem open up Judy E. Davidson is a nurse scientist at the University of California San • have the moral courage to ask the question, "Are you thinking about

suicide?" Diego Health and in the department of psychiatry at the University of California San Diego School of Medicine. Amanda Choflet is an assis-

• paraphrase back what you've heard ("It sounds like your workload is tant professor at the San Diego State University School of Nursing in causing you a lot of stress at home.") San Diego, California. M. Melissa Earley is a mental health profession-

• name emotions ("I hear that you're sad.") al and nurse consultant in Richmond, Virginia. Paul Clark is an assis- • make an appointment to talk again if they don't need crisis inter- tant professor in the school of nursing at the University of Louisville in

vention. Louisville, Kentucky. Sattaria Dilks is president of the Amerkan Psy- Don't chiatric Nurses Association in Falls Church, Virginia. Linda Morrow • try to fix the problem is a clinical associate professor at Sacred Heart University College of • be a teacher or therapist Nursing in Fairfield, Connecticut. Sharon Tucker is the Grayce Sills • minimize ("lt's not that bad.") Endowed Professor of Psychiatric Mental Health Nursing at The Ohio • assume you know how they're feeling State University College of Nursing in Columbus. Trisha Mims is direc- • try to find a silver lining ("At least you have a job.") tor of program and education at the National Student Nurses Associa- • make it about you tion in New York City, New York. • try to change what thpy'rp fppling

ib learn abc'iut Suie'lute prevelition 111 ilie i'dilutic)lial bellilig• leave the person alone if they've admitted an intent to self-harm. and access additional resources, as well as creative expressioiis To better understand empathy, view the video at Evwgu369Jw. related to this issue, visit my, Learn more about motivational interviewing at 7'he painting on tlic first page ofthis article is "Dread"by medicine-and-dentistry/motivational-interviewing. Sarah Pai, MSN,APRN, PMHNP-BC.

Referencec Firearms and medication safety Burke TA, Jacobucci R, Ammerman BA, et :11. Wentifying

ilie relative importance of non-suicidal self-injury featilresresources iii classifying suicidal ideation, plans. and behavic):· ll.sing expl<Jialuty Jaw litittilig. Ps):btato, Rex. 2018,262.175 83.

Reducing access to lethal methods is key to suicide prevention. Tliese Coleman I), Black N, Ng.1, illumenthal E. Kognito's resources offer information, toolkits, and training. .ivatar-based suicide prevention training toi- college • American Foundation for Suicide Prevention (AFSP): Firearms and students: Results of a randomized controlled trial and

suicide prevention ( afsp . org /firearms -and - suicide - prevention ). a naturalistic evaluation . 9// icide Li/2 Tbreal Reba ,. 2()19;49(6):1735-45.Answers frequently asked questions and provides access to resources. I):ividson JE. Proudfoot J. Lee K. Terterian G, Zisook S. A• National Shooting Sports Foundation (NSSF): Suicide prevention Ic ingitudinal analysis of nuise suicide iii the United Statesprogram ( nssf. org/safety/suicide - prevention /suicide - prevention - ( 2005-2016 ) with reiommendations for action . \)2( 31 -lduiews

toolkit/). A toolkit developed through a partnership between NSSF Evid Based Nms. 2020:17(1 ):6-15. and AFSP to promote suicide prevention through firearms safety.

1).ividson JE, Accardi R, Sanchez C, Zisook S, Hofintin • Suicide Prevention Resource Center: CALM (Counseling on access LA. Sustainability and outcomes of a suicide preventic)n

to lethal means ) ( sprc . org /resources - programs/calm - counseling - program for nurses . Wbrlaviell 'x Erid Based Num 2 () 20 ; access-lethal-means). A training course that includes how to 17(1):24-31. identify people who might benefit from lethal means counseling, Dickens C. Guy S. 'Three minutes to save a life': Ad- ask about access to lethal methods, and work with them to re- dressing emotional distress in students to nliti,gate the duce access. risk of silicide. Aic,//a/ Hea//l) Practice. March 11. 2019.

• U.S. Department of Health and Human Resources: How to safely Goetz CA. Are you prepared to S.A.V.E. your nwsing dispose of drugs ( hhs . gov/opioids/prevention /safely - dispose - student from suicide?/ Nurs Educ . 1998 ; 37( 2 ): 92-95 . drugs/index.html). Provides information about safe medication Leal SC, santos JC. Suicidal behaviors, social slipport .ind storage and disposal . reasons for living among nursing students . Nuise Eclitc

Tht/ar. 2016:36: 434-8.

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