Judy Davidson, DNP, RN, FCCM, FAAN, EBP, is the lead author of a recent research paper titled “Nurse Suicide: Breaking the Silence” published in the National Academy of Medicine’s Perspectives: Expert Voices in Health & Health Care.
We interviewed Davidson at length about this incredibly important topic to help raise awareness during National Suicide Prevention Month. What follows is Part 2 of our interview. (Check out Part 1 here.)
It seems like nurses—when it comes to suicide—don’t matter as much in the eyes of the health care system as other health care workers do. Why?
I don’t agree with this statement. It is our own problem that we don’t track these issues or actively address them. Believe me, when the Chief Medical Officer and CEO read the results of our pilot extending the Healer Education Assessment and Referral Program (HEAR) to nurses and hospital staff, they were right on top of it, working out a strategy for how to fund the program moving forward. We, as a profession, have to frame it as a problem with data to back up our emotional plea to move this into the public light.
I am very grateful for nurses who are now coming forward to share their stories, putting a “face” to the problem and helping to destigmatize mental health issues. When our initial data was published in the Journal of Nursing Administration on the same day “Breaking the Silence” came out, the American Foundation for Suicide Prevention changed their website from “Physician” Suicide Prevention to “Healthcare Clinicians.” The content is heavily geared towards physicians, but that is only because we haven’t studied or tested enough strategies with nurses to have more prominence on the page. As soon as we do, they will gladly market best practices for others to learn from.
Since they take the most prominent role of caregiver, do you think this is why they are being ignored? Why hasn’t more research been done? Why haven’t more programs been developed to help nurses prevent suicide and deal with its aftermath?
We are not being ignored, we have ignored ourselves. No one is to blame. We didn’t know what we didn’t know. No one thought to ask. Now that the questions are being asked, we will find the answers. We learn a great deal at an organization level by participating in the HEAR program and offering our nurses the interactive encrypted anonymous risk screening. They tell us about actionable risks that can be reduced in the workplace. Top on the list is bullying and lateral violence. Every leader has an obligation to actively reduce bullying in the workplace. It’s not just an issue of employee satisfaction and retention, workplace wellness—when you come down to it—is about saving lives.
How can nurses recognize signs in coworkers that they may be severely depressed and possibly contemplating suicide?
Burnout and compassion fatigue can lead to or coexist with depression. Recognizing those issues when they occur, and preventing them with caregiver support strategies, can go a long way. We tested a strategy for caregiver support that was originally published by Susan Scott at the University of Missouri. Peers elect peers that are naturally good at helping colleagues through rough days. These peers receive special training to become emotional first aides. They keep on the watch for people who might need help and provide comfort as the need arises. When they sense that this collegial help is not enough, they go up an emotional aide type of chain of command to get their colleague the help they need. It is a wonderful program. We are now expanding the HEAR program to include this level of caregiver support.
In addition, our HEAR counselors who become experts at workplace crisis management also provide emotional debriefings for groups and individuals after a significant clinical event. We don’t wait for them to ask for help. Risk management informs the counselors that there has been a significant event and the counselors proactively offer their services.
If they do become aware of these indicators, what’s the best way for nurses to intervene to help other nurses?
Once the HEAR program is in place, after getting into the habit of recognizing each other when there is stress or crisis, the counselors that run the screening help to triage and find people the professional help they might need.
Is there anything else that you think is important for people to know?
If you or someone you know is suffering from depression or suicidal thoughts, contact the National Suicide Prevention Lifeline at 1-800-273-8255.
For more information about starting a suicide prevention program in your own organization, contact [email protected].
Do not try to create a screening program on your own. The program at AFSP has been tested and works.
Suicide, in and of itself, is a tragedy for all involved. One field in which it hasn’t often been discussed is nursing. Earlier this year, that began to change when Judy Davidson, DNP, RN, FCCM, FAAN, EBP, and her colleagues published an article in Perspectives: Expert Voices in Health & Health Care titled “Nurse Suicide: Breaking the Silence” to start a conversation about nurse suicide while raising awareness.
In honor of National Suicide Prevention Month, we interviewed Davidson, who is a nurse scientist at University of California, San Diego Health, about this incredibly important topic.
What was the impetus for conducting research about suicides in the nursing community?
We began this exploration of nurse suicide after experiencing suicides in our own workforce and then finding nothing in the recent literature about nurse suicide in the U.S. International data and historic U.S. data suggested nurses were at higher risk than the general population, but before our recent work it hadn’t been studied in over 20 years. A lot has changed in the profession since then and suicide is on the rise worldwide.
What was the most surprising fact about nurse-related suicide that you discovered in your research?
What I couldn’t believe is that we do not collect gender as part of our yearly workforce data. We are struggling to do the research that is needed on suicide because of it. While the world has increased a focus on gender issues, we do not really know how many men vs. women are licensed nurses—and that is just the binary code. We should be further along on understanding this very basic demographic of our own workforce.
Why is it important with suicide? Well about four men complete suicide to every one woman in the general population. Nursing is a female-dominated profession, so you can’t just compare nurses to the general population. To do this work correctly, we need the denominators of males and females to figure out comparative proportions and relative risks. It can’t be just our work that would be enhanced by accurate gender data. There must be hundreds of research questions about nurses that would benefit from this information. And it wouldn’t be hard to do. Every year on December 31, every state reports the number of licensed nurses to the National Council of State Boards of Nursing. If gender were collected with the license renewals, within three years we would have accurate data on a national level.
Another surprise is that in the literature it often points to “access to means” as a risk for nurse suicide. This assumption is made because wherever it has been studied in the world nurses are more likely to use medications as the method of suicide. However, in our pilot looking at 10 years of nurse suicide in San Diego, we did find that nurses completed suicide more commonly with medications than other methods, but the mess were things like Benadryl and Tylenol; not drugs of diversion. We are just beginning to sift through the longitudinal NVDRS [National Violent Death Reporting System] dataset from the CDC and the 2014 Data is suggesting the same thing. It is beginning to look like knowledge about how to use medications in a lethal manner may be a more prominent factor than means.
Your research yielded so much information about how nurse suicides haven’t been recorded, dealt with, and that there is no standard best practice across the board for how to prevent them or how to help the coworkers deal with it. Why are nurses, in this way, not being taken care of? Are they expected to keep the proverbial stiff upper lip and keep going no matter how they feel? Do you think that nurses are concerned about losing their jobs by admitting that they may have mental health problems?
Since we have published “Breaking the Silence,” I have heard from many nurses who have personally had suicidal intent. They tell me that stigma plays a large part, not wanting to be treated for mental health problems, especially by the very people you work with. Untreated depression can lead to overuse of alcohol and drugs. Sadly, we often move nurses out of the profession if they are found to have this problem.
Then there is the travesty of DUIs. When untreated depression leads to problem drinking, eventually a DUI is bound to occur which is reported to the Board of Registered Nursing. When that happens, at least in the state of California, it is almost impossible to keep a position as a nurse. So, out of work and untreated, some lose hope.
I’m not saying we should excuse people who drive under the influence, but instead let’s focus on the root causes and seek and find those who need help and welcome them back to the workforce after they get the help they need.
Partnering with physicians on this research, I’ve learned a lot about how they deal with these issues. It is very different. Faculty or house staff can leave for months without penalty, license intact, and come back when they are on the mend.
The Healer Education Assessment and Referral Program (HEAR) seems like a good one. But why do you think it wasn’t extended to include nurses until seven years after its inception? It is very strange. The founders of that program shake their heads and wonder too. The most remarkable thing is that the program was “jump started” by a nurse after losing her husband, a physician, to suicide. It might have something to do with the fact that physicians have known for a long time that they are at risk. We, as nurses, are just coming to that awakening.
Another odd coincidence is that I was conducting a study on Caregiver Support at the time our local nurse suicides occurred in a luster. I mentioned it to my research partner, who’s a founding member of the HEAR program. He told me about the physician prevention program, and I was stunned. Right there, under our noses was the answer I was looking for. I’d been searching in the literature without success to find prevention measures when, in our own house, a program had been developed that the American Medical Association has recognized as a best practice in suicide prevention—but none of us nurses even knew it existed.
They gladly shared their resources, and instead of recreating a parallel program for nurses, we expanded theirs to include us. The reason we were in this cone of silence to begin with was because we operate in parallel universes. Coming together, we are really learning a lot about each other, our mutual stressors in the workplace, and creating stronger action plans for change.
