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Depression and Suicidal Ideation Risks Among Nurses

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Contact Hours: 2

This online independent study activity is credited for 2 contact hours at completion.

Course Purpose

The purpose of this course is to provide an overview of depression and signs and causes of suicidal ideation among nurses. 

Contact Hour Designation

This online independent study activity is credited for 2 contact hours.

Overview

There are many factors that contribute to depression and suicidal ideation among nurses, such as burnout, compassion fatigue, and physical exhaustion. This online learning activity provides an overview of depression, suicidal ideation, safety planning, and best practices in reducing risks for suicide among nurses.

Objectives

Upon completion of the independent study, the learner will be able to:

  • Define depression and suicidal ideation
  • Summarize factors that can contribute to depression in nurses
  • Attribute chronic depression to increased risks for suicidal ideation
  • Review signs of depression and suicidal ideation
  • Recognize the benefits of best practices to reduce suicidal rates

Policy Statement

This activity has been planned and implemented in accordance with the policies of FastCEForLess.com.

Disclosures

Fast CE For Less, Inc and its authors have no disclosures. There is no commercial support.

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Definitions
Suicide The act or an instance of taking one’s own life voluntarily and intentionally.
DepressionA mood disorder that causes a persistent feeling of sadness and loss of interest.
Suicidal ideationAlso known as suicidal thoughts, refers to thinking about or planning suicide.
BurnoutDescribed as an occupational phenomenon characterized by emotional exhaustion, cynicism related to work, and reduced personal efficacy.
Second victim syndromeIs identified in the healthcare personnel who commits an error and is traumatized by it, which leads to psychological and cognitive disorders and has a personal negative effect.
Suicide awareness programsMultifaceted programs that follow a universal approach and focus on identifying at-risk groups.
Introduction

Suicide is the tenth leading cause of death in the United States and is increasing in almost every state.1 According to the world health organization (WHO), globally, an estimated one in 20 individuals reported an episode of depression in the previous year.2 Generally, depression and its symptoms occur differently in everyone.2

Depression is characterized by sadness, anxiety, or empty feelings; feelings of hopelessness or pessimism, guilt, worthlessness, or helplessness; irritability; restlessness; and loss of interest in activities or hobbies once found pleasurable.2 If depression and its symptoms are not treated, these symptoms can become chronic, recurrent, and lead to functional impairment.2

Working healthcare professionals are also included in the general population and face depression. In fact, nurses suffer from depression at almost twice the rate of individuals in other professions.2 Moreover, according to a survey, nurses experiencing burnout were twice as likely to have thoughts of suicide, and those with symptoms of depression were 11 times as likely to experience suicidal thoughts.3

Depression affects the employee’s performance and organizational productivity.2 It is linked to increased work absenteeism, short-term disability, and decreased productivity.2 Depression is also a major cause of functional impairment and can cause lapses in judgment, which for a nurse means medication errors, patient falls, and an overall poorer quality of care that patients receive.2 Nurse reported productivity loss due to depression is estimated to be $22.7 billion per year.2 Depression experienced by nurses is not fully preventable, still, nurses must be aware of the issues and take considerable steps to try to prevent an exacerbation of symptoms from occuring.2 A vibrant, functional, and present nurse is critically important to ensure quality patient outcomes are achieved.2

Suicidal Ideation

Suicidal ideation, also known as suicidal thoughts, refers to thinking about or planning suicide. It does not include the final act of suicide itself and indicates an underlying problem.4

Warning signs and symptoms of depression and suicidal ideation include:

  • Changes in personality, sleep patterns, and routine4
  • Eating more or less5
  • Experiencing a lack of enjoyment in pleasurable activities4
  • Feeling and appearing trapped and hopeless4
  • Feeling extremely sad, agitated, anxious, or full of rage5
  • Feeling unimaginable and intolerable emotions of pain4
  • Fixated on dying, death, and violence4
  • Having constant and severe mood shifts4
  • Increase in risky behavior, such as carelessly driving and being reckless4
  • Increasing drug and alcohol use4
  • Talking about guilt, shame, and being a burden to others5
  • Withdrawing from friends and family, making a will, giving away important things5

These telltale warning signs clearly indicate that the individual suffers from depression or suicidal ideation. However, a significant number of people with suicidal ideation, including nurses, don’t share their thoughts or express their feelings of depression or suicidal ideation with others.4

Risk Factors

Burnout has always been a big topic in healthcare and has become more prevalent since the Covid pandemic.3 Burnout is one of the major risk factors for depression in nurses. In a study, researchers found that 38% of nurse respondents reported at least one symptom of burnout, and of those, 43% screened positive for depression.3

There is not much research on suicidal ideation in nurses because the lines between burnout and depression get crossed.3 Burnout is described as an occupational phenomenon characterized by emotional exhaustion, cynicism related to work, and reduced personal efficacy.3

A study found that recent suicidal ideation was nearly twice as common in nurses reporting burnout, even when other personal and professional characteristics were controlled for.3

The following are some of the risk factors that are specific to nurses working in healthcare:2,6

  • Compassion fatigue and growing indifference to others’ suffering can progress from burnout, to depression, to suicidal thoughts.
  • Depression was cited as more frequent in single and divorced nurses versus married nurses.
  • Nurses with positive evaluations and expectations of themselves and others reported lower depression levels.
  • Nurses working in intensive care and psychiatric units suffered from depression more frequently than nurses in other units.
  • Registered nurses reporting higher levels of workplace violence or traumatic events also reported higher levels of depression.
  • Second victim syndrome occurs when a healthcare professional commits an error and is traumatized by it, which leads to psychological and cognitive disorders and has a personal negative effect.
  • The highest rates of depression were found in young, female, registered nurses.

Moreover, many risk factors for nurses are the same as for the general population, and they include:4,6

  • Dealing with financial problems
  • Exposure to suicidal behavior in others
  • History of family violence, abuse, and neglect
  • History of mental illness, such as depression and bipolar disorder
  • History of suicide attempts
  • Isolated at work
  • Loss of friends, loved ones, or work
  • Not seeking help due to fear and stigma
  • Over-regulation, over-work, constantly under pressure
  • Unable to access care for mental health issues

Most of the risk factors of depression for nurses correlate with2:

  • Female gender
  • Length of employment
  • Marital status
  • Mood disorders like anxiety
  • Overcommitment and job strain
  • Role overload, role conflict, stress, burnout, absenteeism, intention to leave, and turnover
  • Shift work or alternating shifts
  • Somatic symptoms like fatigue, pain, and sleeping issues

As a result, higher job satisfaction, self-efficacy, optimism, learned resourcefulness, and positive ideation are considered significant buffers against depression.2

COVID-19 Effects on Nurses

Since the Covid-19 pandemic in March 2020, there have been almost 160 million confirmed cases of Covid-19 infections and over 3 million deaths associated with Covid-19 worldwide.8 The mental health crisis stemming from the COVID-19 pandemic increased suicidal behavior globally.7 Healthcare workers are the most vulnerable group to experience psychological burdens.8

As a result, the mental health needs of frontline healthcare workers have been highlighted as a priority.7 It has been researched that physicians who are female, United States-based, and in disciplines such as anesthesia, psychiatry, general practice, and general surgery may have a higher suicide risk than the general population.7 The reason for this is because healthcare professionals are directly exposed to patients that have COVID-19 and also due to heightened work conditions related to overtime hours and shortages of personal protective equipment.8

Recent studies on healthcare professionals’ mental health after the height of the COVID-19 pandemic revealed that most of the population reported stress, anxiety, depressive symptoms, and burnout.8 Despite these grave implications, published systematic research in terms of the pandemic’s effect specific to suicidal behavior (ideation, non-fatal and fatal attempt) in this high-risk population is limited.7

According to anecdotal reports, recent suicide deaths among healthcare professionals are because of the combination of the following factors:7

  • A feeling of fear, hopelessness, helplessness, and moral injury in the line of duty
  • Perceived risk of infection and transmission of COVID-19
  • Social isolation from support networks
  • Traumatization when caring for dying patients

There are only three studies located that examine suicidality in healthcare professionals during the COVID-19 pandemic.8

  • In the first study by Mamun et al. (2020), 6% of all participants reported suicidal behavior, with no differences between the general population and healthcare professionals. Unfortunately, suicidal ideation was not examined.8
  • Young et al. (2021), with data from April 2020, and Murata et al. (2021,) with data from April to July 2020, investigated suicidal ideation in healthcare professionals.8
    • Murata et al. (2021) reported that 10% of healthcare professionals had suicidal ideation, and one person reported a suicide attempt.8
    • In the study by Young et al. (2021), only 5.4% of healthcare professionals reported suicidal ideation.8

All three studies reported symptoms of psychological burden in healthcare professionals. However, two of the studies did not report the specific healthcare professions included. The one study that identified the healthcare professionals did not categorize any as “nurses.” ‘Healthcare professionals’ is a very broad term, including, for example, nurses, physicians, and psychologists. However, it must be assumed that the burden on healthcare professionals differs depending on the job type.8

The COVID-19 pandemic directly impacts nurses because they are involved in first-hand patient care.8 Thus, it can be assumed that they suffer from the psychological burden the most.8

Nurse Suicide Prevention Model

From the many studies conducted, the most alarming finding was that nurses experiencing suicidal ideation were less likely to report help-seeking behaviors than others who experience such thoughts.3 The main reason behind this is that there is still a stigma around mental health and people seeking help, professionals having difficulty taking time off work for counsel or therapy, fears regarding maintaining confidentiality, and job security.3

Noting lack of research on the incidence of nurse suicide, Judy Davidson, a nurse scientist, and her team created a nurse suicide prevention model, namely the Aware, Identify, and Recognize (AIR) model.9 The goal of this model is to shift the focus of nursing culture from solely caring for patients, and include self-caring.9 The model focuses on decreasing stigma around mental health in nurses through educational outreach and providing ‘in the moment care’ through group emotional debriefing after critical incidents that put nurses at increased risk of psychological trauma.9

The main elements of the nurse suicide prevention model include9:

  • A proactive screening program to detect nurses with risk factors such as substance use disorder, depression, anxiety disorders, and suicidal ideations
  • Therapy that is confidential
  • Referral to mental health treatment while remaining anonymous when indicated
  • Group emotional process debriefings facilitated by specialized therapists and educational outreach after critical workplace events

The nurse prevention model is evidence-based, backed by investigator-initiated research, and quantifies incidences and characteristics of suicidal nurses. It also has concrete steps that help nurses protect themselves and identify colleagues in crisis.10
Aware, Identify, and Recognize model
The first step of the nurse suicide prevention model is to recognize nurses who are having suicidal thoughts and get them the help they deserve.10 This is done by following the Aware, Identify, and Recognize (AIR) model.

To follow the model, you must first practice awareness by looking out for crisis warning signs in nurses discussed above.10 When nurses are not open with their feelings and emotions, give them space to discuss when they are ready, regularly check up on them, and open the conversation by making statements such as, “I’ve noticed you’re more down than usual. Do you want to talk about it?”10

Once you are aware of the presence of signs of depression in a nurse, you should consider risks for suicide based on the responses to questions during conversations.10
Starting a conversation is the most effective way to reduce the risk of suicide.10,11 It shows empathy and reduces feelings of loneliness.10,11 You should have the courage to include the term “suicide” in your questions and ensure you never belittle the nurse’s feelings.10,11

The following are some of the key components of having the conversation:10,11

  • Before initiating, scan the environment and practice situational awareness.
  • Provide authentic presence and empathy.
  • Be curious by making statements such as, “Tell me more.”
  • Ask if a nurse is feeling suicidal; if the answer is yes, ask if they have a plan. If the answer is yes, stay with the nurse until help arrives.
  • Don’t be an expert, and don’t teach. Acknowledge their emotions.

Use Evidence-Based Methods
To identify fellow nurses experiencing suicidal behavior, it is recommended to learn evidence-based methods. For instance, one can use peer suicide evaluation and self-screening tools.10,11

The American Foundation for Suicide Prevention (AFSP) developed “Have a #RealConvo.” It focuses on using common language to guide an individual on how to start a conversation with someone who is at risk of suicide. Similarly, there are 8 public videos produced by Sharon Tucker, Ph.D., RN, that provide examples of statements to say to someone at risk of suicide.10,11

Implement Proactive Screening
Another way to identify at-risk individuals is through regular screening.10,11 The Healer Education, Assessment, and Referral (HEAR) program offers a comprehensive tool that any agency or organization can use to evaluate at-risk employees.10,11 It is a cost-effective process that can be scaled to any size and has been successfully used for the last 10 years in transferring individuals that are suicidal and in need of treatment.10,11

Finally, recognize the urgency to intervene.10,11 Suppose you are the only one that has seen the warning signs exhibited by a nurse. It is important that you discuss your observations with them. It is imperative to speak up.10,11 Even if the nurse is not at immediate risk, having the conversation opens the door to future discussions on the subject.

Safety Planning

Conversations with a trusted colleague or family member are a great start to self-care.10,11 It is also important to develop a safety plan and encourage others to do the same.10,11 When you are aware of the resources and help available in a crisis, you are more likely to use them.10,11

When developing a safety plan, ask yourself the following questions:10

  • Who do you normally go to when things get rough?
  • What activities normally calm you down when you’re stressed?

Your safety plan should include being aware of the suicide risk warning signs and the coping strategies that work best for you, the people who can help calm or distract you, and contacts of people to call for help as well as emergency phone numbers.10

Firearm And Medication Safety 

Did you know that among male nurses, the use of firearms is the most common method of suicide?11 It is important to remove access to lethal methods, such as firearms and medications, to reduce impulsive acts of individuals who are having suicidal thoughts.10,11 If they cannot be removed, they should be stored in a secure place10,11

Nurses who own guns are requested to follow the firearm safety guidelines and keep the firearms stored and locked.10,11

Substance Use and Substance Use Disorder

Nurses are also at risk of a substance use disorder, which can be best understood on a continuum.10,11 In this continuum, one end represents low substance use and a lower risk of addiction, while the other represents higher substance use and increased risk of addiction. 10,11 In the middle of the continuum are individuals who exploit substance use, negatively impacting their personal and professional life and increasing the risk of addiction.10,11

Nurses and fellow colleagues need to evaluate themselves on the substance use continuum using common assessment tools.10,11 After the evaluation, nurses should:10,11

  • Evaluate and notice colleagues with risky behaviors
  • Have a conversation using motivational interviewing techniques and reflective listening
  • Share feedback and concerns

The only way th stigma of mental illness can be overcome is by accepting our emotions and discussing the stress, anxiety, and depression that is experienced.10 By showing empathy, you can save a fellow nurse with depression and suicidal ideation.10

Best Practices to Reduce Suicidal Rates

Suicidal ideation is a rapidly growing problem, and no one strategy can be used to curb the issue.12 Instead, a systematic, multipronged, collaborative prevention strategy is needed to address population-level and individual-level factors.12 These strategies are similar for patients, nurses, and individuals working in the healthcare facility.

Below are best practices used to reduce suicidal rates:12,13.14

Suicide Awareness Programs

Suicide awareness programs are multifaceted programs that follow a universal approach and focus on identifying at-risk groups.12 For nursing professionals, these programs are designed to help healthcare workers recognize and respond to psychological stress and suicidal thoughts and improve the detection and treatment of depression.12

Suicide awareness programs also highlight post-suicide attempt, counseling, and restriction of means to increase the individual’s knowledge, comfort, and counseling skills on suicide.12

Access to Care

One of the most effective ways to prevent suicide is to provide access to high-quality care.13 At-risk individuals should have timely access to evidence-based treatments, suicide prevention interventions, and coordinated systems of care.13 This is important because it can immediately identify the problem and develop significant improvement and recovery methods.13 The following are some of the ways to improve access to care:13,14

  • Adapt zero suicide framework
  • Reduce financial, cultural, and logistical barriers to care  
  • Health insurance policies should cover mental health
  • Reduce provider shortages in underserved areas

Gatekeeper Training

To understand gatekeeper training, you first must understand what the term “gatekeeper” means. A gatekeeper refers to an individual who regularly interacts with potentially suicidal persons and is available to recognize the key behavioral clues indicating an elevated suicide risk.12

Gatekeepers can include counsellors, teachers, school support staff, etc.12 This type of training involves recognizing those exhibiting suicidal behaviors, risk factors, warning signs, availability of support systems available, signs of depression, communication, and counselling skills to address at-risk populations.12

However, there are many concerns regarding gatekeeper training, such as the effectiveness of long-term training received from such programs.12 Thus, for these reasons, it is important to include multiple individuals such as the clergy, legal functionaries, and health and law enforcement personnel.12

Organizational Linkages

Suicide risks in nurses and other individuals can also be reduced by ensuring they have an uninterrupted transition of care.13 This can be achieved through appropriate exchange of information among organizations, facilities, and individuals that are involved in the patient’s care.13 It is important that the family is also involved in such discussions and should be a part of the communication process.13

Examples of organizational linkages include13,14:

  • Community engagement activities
  • Cross training
  • Follow-up contracts
  • Formal referral protocols
  • Patient and family education
  • Peer norm programs

Restrictive Techniques

Restriction to harmful substances is another effective way to reduce suicide in individuals. For instance, restricting access to potentially harmful and lethal substances, drugs, firearms, pesticides, etc., can all greatly prevent suicide attempts.12

Follow-Up Care

Did you know that the risk of suicide increases post-discharge?12The suicide re-attempt rates are the highest in the first week, followed by the first three months post discharge, and may last up to 1–3 years from the present attempt.12 To prevent suicidal re-attempts, it is important that organizations, facilities, and caregivers primarily involved in the care of the at-risk individuals practice follow-up care techniques.12 These follow-up practices can include caring letters, postcards, frequent phone calls, text messaging, brief and regular supportive counseling sessions, follow-up by mental health workers, and outreach programs.12

Ethical And Legal Considerations

Many ethical issues are raised when considering day-to-day clinical practice in providing care to the person at risk for suicide, such as:15

  • Ethical issues arising from discrete decisions and acute care settings
  • Ethical issues arising from therapeutic relationships and chronic care
  • Organizational factors and their effect on care

Across the above-mentioned categories, several everyday issues were identified, such as training and preparation of healthcare professionals, involuntary hospitalization, different clinical responses in an acutely and chronically affected individual, and the impact of suicidality on the well-being of healthcare professionals.15

A survey suggests that psychologists and psychoeducation reporters are less prepared than nurses to address everyday ethics in relation to suicide care.15 It also suggests that nurses encounter more ethical issues than other healthcare workers as they have the most interactions with patients.15

A nurse’s absence of ethical sensitivity can lead to inaction and incongruent care. It can also lead to greater moral distress, perhaps because of a lack of insight into the nature of moral problems or the lack of ability to deal with them.15

Conclusion

Suicidal ideation occurs in people of all ages and backgrounds, which negatively affects families, communities, and the healthcare professionals who care for them.15 There are many factors that contribute to depression and suicidal ideation among nurses, such as burnout, compassion fatigue, and physical exhaustion.11

  • Burnout is characterized by overwhelming emotional exhaustion, depersonalization, job detachment, and a sense of ineffectiveness.11
  • Compassion fatigue is used to describe a set of negative pervasive feelings that are unique to caregivers. These feelings arise from the inability to cope with exposure to patient suffering in addition to institutional barriers to providing quality care and result in losing the ability to nurture.11

Moreover, workplace incivility, bullying, and lateral violence in nursing have become a culture within the profession. Patterns of these unreasonable and inappropriate behaviors can result in anger, fear, low self-esteem, disengagement, psychological trauma, depression, suicidal ideation, physical illness, turnover, compassion fatigue, burnout, and personal and organizational financial costs.11 To overcome these challenges, interventions, evidence-based techniques, assessment of current culture, culture change, and team-building programs are necessary to curb the issues before they become severe.11

References
  1. Goldstein Grumet J, Goldstein J, Hogan M, Chu A, Covington D, Johnson K. Compliance Standards Pave the Way for Reducing Suicide in Health Care Systems.; 2019. Accessed September 13, 2022. https://vtspc.org/wp-content/uploads/2019/02/Compliance-Standards-in-Health-Care-2019.pdf
  2. Brandford AA, Reed DB. Depression in Registered Nurses. Workplace Health & Safety. 2016;64(10):488-511. doi:10.1177/2165079916653415
  3. Burnout a Risk Factor for Suicidal Thoughts in Nurses. www.medpagetoday.com. Published October 22, 2021. Accessed September 13, 2022. https://www.medpagetoday.com/nursing/nursing/95217
  4. Suicidal ideation: Symptoms, causes, prevention, and resources. www.medicalnewstoday.com. https://www.medicalnewstoday.com/articles/193026#causes
  5. NIMH» Warning Signs of Suicide. www.nimh.nih.gov. Published 2022. https://www.nimh.nih.gov/health/publications/warning-signs-of-suicide
  6. Nurse Suicide: Under the Radar. www.medpagetoday.com. Published May 9, 2019. https://www.medpagetoday.com/nursing/nursing/79730
  7. Sahimi, H. M., Mohd Daud, T. I., Chan, L. F., Shah, S. A., Rahman, F. H., & Nik Jaafar, N. R. (2021). Depression and Suicidal Ideation in a Sample of Malaysian Healthcare Workers: A Preliminary Study During the COVID-19 Pandemic. Frontiers in Psychiatry. https://doi.org/10.3389/fpsyt.2021.658174
  8. Höller I, Forkmann T. Ambivalent heroism? – Psychological burden and suicidal ideation among nurses during the Covid‐19 pandemic. Nursing Open. Published online November 18, 2021. doi:10.1002/nop2.1130
  9. Suicide Prevention in Nursing: Breaking the Silence – American Academy of Nursing Main Site. www.aannet.org. Accessed September 13, 2022. https://www.aannet.org/initiatives/edge-runners/profiles/suicide-prevention-in-nursing#:~:text=The%20goals%20of%20the%20Nurse
  10. Gartley CE. Nurse suicide prevention starts with crisis intervention. American Nurse. Published January 29, 2021. Accessed September 13, 2022. https://www.myamericannurse.com/nurse-suicide-prevention-starts-with-crisis-intervention/
  11. Nurse Suicide Prevention. ANA. https://www.nursingworld.org/practice-policy/nurse-suicide-prevention/
  12. Vikas M, Karthick S, Nivedhitha S, Shivanand K. Suicide prevention strategies: An overview of current evidence and best practice elements.
  13. A Comprehensive Approach to Suicide Prevention | Suicide Prevention Resource Center. www.sprc.org. https://www.sprc.org/effective-prevention/comprehensive-approach
  14. Prevention Strategies. www.cdc.gov. Published February 25, 2022. https://www.cdc.gov/suicide/prevention/
  15. Montreuil M, Séguin M, P. Gros C, Racine E. Everyday ethics of suicide care: Survey of mental health care providers’ perspectives and support needs. Menezes RG, ed. PLOS ONE. 2021;16(4):e0249048. doi:10.1371/journal.pone.0249048
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