Raising awareness, screening proactively, and delivering evidence-based care can make a difference

Suicide is a leading cause of death in the United States, and research shows that nurses are disproportionately represented in its toll. A study that examined data from 2007-2018 found that suicide incidence among nurses was 17.1 per 100,000 — twice the rate of that among women in the general public.

Efforts to raise awareness and increase understanding of mental health issues include National Mental Health Awareness Month each May and Suicide Awareness Month each September. These are important initiatives that increase national attention at annual intervals, but all clinicians know that interventions and action are needed daily. This article highlights one example of the many innovative programs and models used by nurses, nurse practitioners, and healthcare organizations to prevent suicide among nurses and other healthcare professionals. Read about other suicide prevention programs on the blog by our sister company, ATI. And for continuing education opportunities focused on suicide, visit our sister company, Nursing CE.

Are you experiencing suicidal thoughts?

Call the National Suicide Prevention Lifeline at 800-273-8255

OR text TALK to 741741 to text with a trained crisis counselor

Proactive Prevention

One of the most well-known suicide prevention interventions focused on healthcare professionals is the Healer Education Assessment and Referral (HEAR) program. HEAR takes a proactive approach to screening and follows up with education, support, and referrals. The program launched at the University of California San Diego (UCSD) School of Medicine in 2009 to identify physicians and medical students at risk of suicide and proved so effective that the American Medical Association now endorses it as a best practice for physician suicide prevention.

Inspired by this impact, an interprofessional UCSD team led by Judy E. Davidson, DNP, RN, MCCM, FAAN, adapted the HEAR program for nurses and implemented it throughout the university hospital system in 2016. Three years later, HEAR program therapist Rachael Accardi, LMFT, led a study that examined the sustainability and outcomes of the program. This research, published in Worldviews on Evidence-Based Nursing in 2020, determined that HEAR identifies nurses who are experiencing suicidality, that it provides necessary support and referral resources, and that it can be replicated at other institutions.

“The HEAR program is effective at identifying nurses at risk for several reasons,” Accardi said. “First, we are proactive rather than reactive — we screen nurses at least once each year. Second, the process is anonymous. Stigma still exists, even among healthcare professionals. Third, we’ve built trust within the hospital.”

HEAR incorporates a three-pronged approach:

1. Education to decrease the stigma associated with mental health, plus group debriefings after significant events
2. Proactive anonymous risk screening
3. Bridge counseling with referral to treatment.

The anonymous screening takes place using the Interactive Screening Program (ISP) developed by the American Foundation for Suicide Prevention (AFSP). More than 160 healthcare institutions in the United States currently use the AFSP ISP to screen nurses and other employees. The HEAR assessment administers the nine-item Patient Health Questionnaire (PHQ-9) and asks about 17 measures of intense emotional distress linked to depression with suicidal ideation. It also asks about alcohol and drug use; disordered eating behaviors; current suicidal thoughts, behaviors, and plans; past suicide attempts; and current mental health treatment. (As the HEAR program has grown, its creators have added questions about burnout and work stressors.)

Computer analysis by the ISP classifies responses into one of four tiers, each reflecting a level of distress. A designated HEAR program therapist reviews each participant questionnaire and posts a confidential response on the ISP website. In this response, the therapist offers an option to communicate anonymously via the website or to connect by phone or in person to initiate counseling. The HEAR therapist also provides referrals to community-based providers for continued treatment. Between 2016 and 2020, the HEAR program at UCSD identified and transferred almost 300 nurses into treatment.

“The program does not wait for people to seek help but instead strongly encourages screening and dialogue,” Accardi and coauthors wrote. “Over the course of these 3 years, we identified a significant number of high-risk, suicidal nurses and connected with them easily through the simple act of sending an email. These nurses were previously insured and had access to mental health treatment, but it took a proactive approach with the assurances of anonymity to make it happen.”

In an interview, Accardi noted that the scientific support for HEAR, coupled with the significant burnout cited by nurses over the past few years, underscores why now is an important time for hospitals to implement suicide prevention programs. “With increasing suicide rates among nurses, employee-centered care is just as crucial and important as patient-centered care,” Accardi said. “Programs like HEAR go a long way toward not only addressing the mental health concerns of healthcare staff, but also giving them a platform to feel heard, recognized, and valued.”

Tips for Healthcare Facilities

The following recommendations for healthcare institutions are from the HEAR program:

• Identify and address work-related stressors to increase staff morale, innovation, job performance, and positive patient outcomes.
• Get help with creating a suicide prevention program by contacting the American Foundation for Suicide Prevention at 212-363-3500 or emailing info@afsp.org.
• Address the root causes of stress in the workplace. Start with leadership so that leaders have the emotional capacity to help others.
• Create rituals or traditions that work toward integrating and socializing new employees to increase staff connectedness and decrease loneliness.
• Have an honest conversation with people who are struggling, and encourage them to seek treatment or contact their provider or therapist.
• Regularly debrief staff members after significant events, to create a safer, caring, destigmatized work environment.

Additional Resources

For more information on suicide prevention, see the following articles or websites:

Suicidality screening and treatment protocol for primary care settings

Ketel, C., Hedges, J. P., Smith, J. P., et al. (2021). Suicide detection and treatment in a nurse-led, interprofessional primary care practice: a 2-year report of quality data. The Nurse Practitioner. doi: 10.1097/01.NPR.0000737208. 68560.b8

Suicidality among nurses and physicians

Davis, M. A., Cher, B., Friese, C. R., et al. (2021). Association of U.S. nurse and physician occupation with risk of suicide. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2021.0154

Centers for Disease Control & Prevention Suicide Prevention website

https://www.cdc.gov/suicide/index.html

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