Although minimal attention has been paid to preventing suicide among nurses compared with what has been done regarding physicians [15,63], it is clear that there are similar considerations with burnout, depression, and suicide risk [36,38,64-68]. Suicide prevention is a complex undertaking that involves both institutional and individual efforts. In this section, we highlight one institutional and one individual approach.
As health care professional burnout and suicide risk become more recognized and discussed, institutions and hospitals are beginning to respond and provide programs aimed at enhancing physician and nurse wellness [41,43,69,70]. One academic center, University of California San Diego, School of Medicine, developed a mental health program, the Healer Education Assessment and Referral (HEAR) Program, initially for physicians, residents, and medical students [15,71,72].
Following a physician suicide in 2009, a committee led by two psychiatry faculty working in collaboration with the American Foundation for Suicide Prevention (AFSP) developed a two-pronged program for the prevention of depression and suicide. One element of the program provides a voluntary, anonymous, web-based screening and referral program using a validated assessment tool developed by the AFSP. The second element includes system-wide grand rounds education, including topics such as physician burnout, depression, and suicide .
During the initial year of the program, 27 percent (101) of the individuals screened met criteria for significant risk for depression or suicide, and nearly half of those identified (48) accepted referrals for mental health evaluation and treatment. From the beginning, the program was supported by senior leadership from the medical school, who stated that no stigma should be attached to mental illness and encouraged everyone to participate in the program because physician wellbeing was and is a high priority .
The following year, the University of California, Skagg’s School of Pharmacy was added to the program’s agenda. Since its inception, this program for physicians has been adopted by over 60 medical campuses. Finally, in its seventh year, after experiencing nurse suicides, the HEAR Program was extended to the nursing community.
The HEAR Program is now being piloted as a quality improvement project at the University of California, San Diego Health, to test whether the program will identify high-risk nurses and successfully move them into treatment. In the first 10 months since the expansion of the program to nurses, HEAR has assessed 184 nurses, of which 16 (9 percent) dialogued with the counselor online through the encrypted website, 15 (8 percent) engaged with counseling in person or by phone, and 20 (11 percent) received and accepted personalized referrals to psychologists and psychiatrists.
Per the results of the AFSP Interactive Screening Program —which includes the Patient Health Questionnaire-9 depression screening tool [74,75] and validated questions on suicide risk—an astounding 97 percent of the 184 nurses who answered the survey were found to be at moderate or high risk. The results demonstrate an obviously biased sample of at-risk nurses. However, more important, the bias demonstrates that proactive anonymous screening will identify nurses who are at risk.
As was found previously with physicians , nurses commented that without this proactive screening, they would not otherwise have initiated mental health care. The HEAR Program, including this proactive depression-and suicide-risk screening for physicians, has been endorsed by the American Medical Association as a best practice in suicide prevention .
As a society, we need to better understand the factors that influence depression. Through analysis of the data received through the HEAR interactive screening, we can begin to understand the specifics behind risk factors of stress. In the HEAR program extension pilot , we found the following workplace stressors in nurses at high risk for suicide: feelings of inadequacy, lack of preparation for the role, lateral violence, and transferring to a new work environment.
It is not enough for institutions to take on the burden of reducing nurse suicide. There is much individuals can do for themselves to develop healthy coping and resilience, modify self-perpetuated stigma, and provide better self-care, including mental health care .
For our last personal account with suicide, we present this vignette written by a nurse who was experiencing depression and thought about taking her life. Her experience with depression was shared to encourage an open dialogue among nurses and to encourage nurses to take action and seek professional help when depressed.
Case: Nurse/Mother Experiencing Depression
I am a creature of habit; and so I begin each day in the same manner as I have done for the past 21 years: I stumble out to the kitchen in my pajamas to turn on the coffee maker; empty the dishwasher while I wait for the coffee to brew, then proceed to the master bath—coffee in hand, to take my antidepressants. As my sister, brother, mother, aunts, uncles, great aunts, and grandmother before me, I have been diagnosed with major depression. Too many of these tortured souls lost their battles with depression; forever traumatizing the loved ones who found them.
Besides being a creature of habit, I am a wife, a mother, a grandmother, and a registered nurse with a long and successful career. In my 30’s, my genetic disposition to depression began to creep into my life. Once delighted by my children’s antics, I now simply observed. I smiled and clapped at their words and accomplishments because I knew that was what a loving mother should do, yet inside, I felt nothing. After putting each child to bed at night with a kiss on their foreheads, I could immerse myself in self-loathing: How could anyone stand to be around me? I was fat, I was ugly, I was empty, and I was ignorant. But mostly, I was fearful that someone would someday see me for the fraud that I was. I tossed and turned—so tired, yet unable to sleep. The next day I would get up and resume the act; and the same the next day and the next.
At work, I was the person in charge, the person to go to with questions, the person who could turn chaos into order, and the person who could make even the most complex physiology make sense. Leaving the unit at the end of the shift, I often stood on the top deck of the parking garage staring at the road below thinking ‘It wouldn’t be so bad. Just one quick painful thud and then peace. If I jumped right, I’d hit head first, and wouldn’t feel anything at all. No one I loved would have to be traumatized by the blood and the displaced bones and organs.’ And then I’d realize that I couldn’t leave that legacy to my children, couldn’t abandon them, couldn’t leave them without a mother; couldn’t teach them that suicide was the way to take care of pain, and I’d turn and go home. After nearly a year, I finally realized that I was no longer who I once was. I was not the mother that I wanted to be, and was not feeling all the complex emotions of life. I called my doctor, asked for help, and started on the road back to myself. A few months after beginning medication, I heard an unfamiliar sound—laughter. It took me a minute to realize—it was coming from me! I was experiencing joy!
Although I still need the occasional medication adjustment, I am so very grateful that science has created effective antidepressants. If the treatments that are available today were available in past decades, I am certain that my family’s history would have been very different. I feel lucky that I and my children are genetically predisposed to a condition that is easily treatable. I have not dwelt on it, but have been open with them about depression, so that they may recognize the signs of depression if those signs ever emerge in themselves or others, and will know how to get help. I’ve also been open in the workplace about being treated for depression. A co-worker once pulled me aside and thanked me for my openness. She told me that she had come to work on a particular evening intent upon taking an overdose of sleeping pills and narcotics upon her return home. While at work, however, she heard me tell the story of my decision to ask for help for my depression. ‘So I went home,’ she said, ‘threw away the meds, and called my doctor.’ “I’ve been told that the piano and I each have 88 keys. It takes both the low and the high notes and chords to compose a concerto; so I experience the lows, but I know that the highs are waiting for me in the next line. It’s wonderful to hear and live it all.