Suicide Among Nurses: We have to talk about it.

Two high-profile nurse deaths by suicide rocked the Bay Area nursing community in early 2022. I was an emergency nurse there at the time and, while both were tragic losses, I was sadly not surprised by their occurrence. While nurse suicide is a phenomenon we often don't talk about, the data cannot be ignored. A 2020 study completed by Judy E. Davidson, DNP, RN, MCCN, FAAN, and her team at the University of California San Diego reveals that nurses have a higher risk of suicide than the general population. Why? Research suggests that it's simply for being a nurse.

Why is being a nurse associated with a higher risk of suicide?

The nursing profession has many risks factors for suicide and attempted suicide:

• High occupational stress
• Ethical conflicts such as fear of harming patients
• Social disruption and lack of work-life balance
• Isolation from loved ones
• Feeling a lack of support in their role
• Concerns about lack of preparation for the role
• Exposure to trauma, often repeated trauma
• Depression
• Workplace violence, incivility or bullying
• Leadership issues
• Lack of healthy work environments (HWEs)
• Financial concerns
• Feeling unsafe or fearing for the safety of loved ones
• Poor sleep hygiene
• Long work hours, often consecutive workdays/nights
• Access to controlled substances and knowledge of how to use them

Further, the COVID-19 pandemic has exacerbated the challenges and stress of working in healthcare. From fear of becoming sick or exposing family members to illness, increased patient numbers and acuity, to the moral distress related to rationing care, healthcare workers everywhere have had to work through unprecedented conditions. Nurses reported experiencing stress, sleep disturbances, anxiety and depression throughout the pandemic. And now, we face a historic nurse staffing crisis. Work stress continues to rise.

We need a layered approach to address nurse suicide.

The American Academy of Nursing (AAN) issued the AAN Expert Panel Consensus Statement in spring 2023, sharing research that suggests the drivers of nurse suicide include:

• The stigma associated with asking for and receiving treatment to support mental health
• Job-related stressors
• Lack of access to mental health treatment

Schimmels and their team promote a bundled approach, such as the National Plan for Health Workforce Well-Being from the National Academy of Medicine, to mitigate psychological harm experienced by nurses. The plan suggests that healthcare should:

• Create and sustain positive work environments
• Have mechanisms to measure, assess and research how to improve well-being
• Support mental health and reduce stigma
• Invest in useful technology
• Make well-being a long-term focus of healthcare
• Recruit and retain a diverse and inclusive healthcare workforce

Breaking the silence and stigma about discussing nurse suicide

For decades, it was taboo to discuss having any mental health issues if you were a healthcare worker. We didn't want to look "weak" or cause concern that we couldn't do our jobs. Some healthcare workers still fear losing their jobs over sharing their mental health challenges. However, it is essential that we break the silence and stigma about discussing our mental health. One way is to talk about it. We have to become OK with discussing it when we're not OK.

A few recommendations on how to foster supportive conversations about mental health conversations with nurse colleagues:

• Ask how colleagues are feeling at work.
• Did that last patient make you anxious?
• Today has been hard for me. How has it been for you?
• That code was heavy. How are you feeling about it?
• Normalize the idea that mental health is just as important as physical health.
• Support colleagues in using time off for mental health issues, not just physical health problems.
• Avoid using stigmatizing words such as "crazy" when discussing patients with mental health issues.
• Don't say: "That patient was super crazy!" >> Instead try: "That patient seemed to be experiencing a lot of mental distress."
• Familiarize yourself with the mental health care benefits offered by your employer in case you or a colleague may need to use them.
• Employee assistance programs (EAPs) often cover a certain number of therapy sessions for qualifying staff.

Creating HWEs to better support nurse mental health

According to "National Nurse Work Environments - October 2021: A Status Report" in Critical Care Nurse, the health of nurse work environments has declined dramatically since a similar 2018 study. What makes an HWE? How do we check to see if our work environments are healthy? And how do we make them better?

The American Association of Critical-Care Nurses (AACN) has six standards to establish and sustain an HWE:

• Skilled Communication
• True Collaboration
• Effective Decision-Making
• Appropriate Staffing
• Meaningful Recognition
• Authentic Leadership

To assess the health of your work environment, consider using the AACN Healthy Work Environment Assessment Tool (HWEAT). In her AACN blog, Kristine Strohbin, MSN, RN, CNS, ACCNS-P, CCRN, shares great tips on how to use the HWEAT and how to optimize your responses from colleagues.

Once you assess the health of your work environment using the HWEAT, now you have results to evaluate and interventions to decide on. Work to gain support from leaders and colleagues. To be most effective, use the following strategies to set yourself up for success:

• Introduce HWE standards to your unit and leadership
• Make a case for implementing the HWE framework
• Perform a return on investment calculation
• Become an HWE advocate

Creating HWEs is impactful in many ways. Nurses who work in HWEs experience lower rates of burnout and compassion fatigue. Units that have HWEs have lower rates of workplace violence. These outcomes are data validated and support nurse wellness, including their mental health.

Increasing access to mental health care

Access to mental health care is difficult to get in the United States. There are not enough mental health providers for the number of patients in need. However, new organizations and initiatives are expanding access to mental health care, specifically for healthcare workers:

• 988 Suicide & Crisis Lifeline (or 988 Lifeline) - Call, text or chat with the 988 Lifeline to be connected to trained counselors from over 200 local crisis centers 24 hours a day, seven days a week.
• American Foundation for Suicide Prevention - A list of crisis resources for immediate support for healthcare professionals
• Debriefing the Front Lines - Nurse-led mental health organization helping nurses navigate the physical, emotional and spiritual effects of Cumulative Care Taking Trauma (CCT)
• National Alliance on Mental Illness (NAMI) Frontline Wellness - Resources and tools developed specifically for public safety, and healthcare professionals and their family members
• Therapy Aid Coalition - Free and low-cost short-term therapy for U.S. healthcare professionals and first responders
• The Well-Being Initiative - Resources to help support the mental health and resilience of nurses

Strategies for Action

Suicide, the 4th leading cause of death for Americans ages 10-54, is a national public health crisis. Nurses do not have to plan to intervene alone. The Centers for Disease Control and Prevention created "Suicide Prevention Resource for Action," which details strategies supported by the best available evidence. Important actions include:

• Strengthening economic support
• Creating protective environments
• Improving access and delivery of suicide care
• Promoting healthy connections
• Teaching coping and problem-solving skills
• Identifying and supporting people at risk
• Reducing harms and preventing future risk

Why I care: My mental health story

When I was a new nurse in the emergency department, I was told it would be hard, but I really struggled. I often struggled in ways that no one told me were normal. I couldn't sleep, sometimes for days. I would cry at almost anything. I was super anxious. I drank too much alcohol on my days off. I was reliving a lot of patient experiences when I wasn't at work. I was isolating myself from friends and family.

However, most people didn't know. I was really bubbly and energetic at work. They didn't see the days when I couldn't get out of bed. They didn't know about my thoughts of self-harm. No one else seemed to be feeling like I was, so I just kept it to myself. I felt so different. I felt so alone.

Through time, therapy and medication, all of this got better. Loved ones reached out. I got help. I was lucky and privileged. Systemic barriers to appropriate mental health care and resources exist for many communities. We must work to mitigate them to ensure that every person can access the support they need.

Mental health is a journey and, like my physical health, I am sometimes better and sometimes worse. I know now that I need a therapist and antidepressant medication. I know how to ask for help. I know when to connect with the people I need. I am also a lot better about saying "no" to things when I can't do any more, when my mental health bandwidth is maxed out.

I am passionate about helping others, specifically helping others learn to help themselves. You are not alone. Nurses must take care of themselves and continually assess their own mental health. If you don't take care of yourself, you cannot take care of others. If I hadn't had the support I needed when I needed it, I might have been another nurse suicide statistic. It really can be just someone checking in with you that changes your course of decisions and actions. A simple action can truly save a life.

You can make a difference.

While nurses have a unique occupational risk for suicide, we are also positioned to help break the silence and stigma on the topic of nurse suicide. We can use data and compassion to drive change on a personal, systems and community level.

Remember - You have the opportunity to impact every nurse you work with just by checking in - "Hey, how are you doing?" Sometimes that's all it takes.

What are your favorite mental health support resources?