APNA Member Article / Opinion Piece: WHAT IF We Had a Nurse-Specific Crisis Line Option?
Elizabeth Kreuze, PhD, RN, ATC, Assistant Professor, College of Nursing and Health Innovation, University of Texas at Arlington
Jan York, PhD, PMHCS, FAAN, Affiliate Professor of Research, College of Nursing, Medical University of South Carolina
World Suicide Prevention Day is commemorated globally each year on September 10, a somber reminder of the devastating impact of suicide around the world. This day focuses on raising awareness, preventing suicide, and saving lives (World Health Organization [WHO], 2024). Historically, there has been a failure to identify, recognize, and respond to nurse suicide as a priority area. In the last few years, the COVID-19 pandemic underscored nurse wellness, including suicide, as one severe outcome associated with workforce stress, trauma and moral injury (Ulrich et al., 2020).
There are several epidemiological studies on nurse suicide mortality, including one study that included informant interviews by Keith Hawton and colleagues (2002) and U.S. studies by Judith Davidson and colleagues (2020, 2019). There are also three reviews on nurse suicide morbidity and mortality, most notably Lascelles Groves et al. (2023). Keith Hawton, and his colleagues at the Centre for Suicide Research in England, are the most notable historical and current international researchers in nurse suicide. In the U.S., Judith Davidson is the most consistent contributor to empirical and intervention work on nurse suicide, and has also been a significant policy leader in raising awareness regarding the critical nature of nurse suicide with corresponding calls for action.
Collective evidence (see Groves et al., 2023) suggests suicide rates among female nurses are consistently higher than suicide rates among females in other occupations and the female general population, and suicide rates among male nurses are generally higher than males in other occupations and the male general population. The primary suicide method among nurses is self-poisoning (commonly prescriptions, such as antidepressants, opiates, and benzodiazepines). Proportionally, male nurses are more likely to use firearms than female nurses, with rates similar to males in the general population, although evidence suggests firearm suicide among female nurses may be increasing. There are a complex range of direct and indirect risk and contributing factors for nurse suicide mortality, including being female, mental health history (depression, psychiatric admission, previous suicide attempts, alcohol abuse), stigma associated with seeking help, fear of regulatory consequences, knowledge of lethal means, physical health morbidity, cigarette use, and occupational and psychosocial problems. York, Ulrich and Deatrick (2020) are currently assessing research gaps and methodological issues in empirical evidence for U.S. nurse suicide as part of Ulrich’s research on nurse wellness, and Kreuze et al., (2024) have similarly reviewed the epidemiology of suicide mortality among nurses globally.
Because suicide rates among nurses are higher than most other workforce groups and the general population, suicide among nurses should be considered a public health priority. More recently, suicide prevention for nurses has been recommended by the American Nurses Association, National Academies of Sciences, National Academy of Medicine, and American Academy of Nursing. However, nurses were not targeted in the National Strategy for Suicide Prevention, other than generalized references to the health care workforce.
The 2024 World Suicide Prevention theme is Changing the Narrative on Suicide and it includes a call to Start the Conversation. Overriding goals include raising awareness on the importance of reducing silence and stigma and encouraging open dialogue and understanding to prevent suicide (WHO, 2024). Supportive resources that include caring conversations can provide persons experiencing suicidal crises with hope and prevent suicide. One such evidence-based resource for suicide prevention is the 988 Suicide and Crisis Lifeline, which is a network of more than 200 local and state crisis contact centers that is available in all states and five territories (Substance Abuse and Mental Health Services Administration [SAMHSA], 2023). Evidence suggests that individuals who contact 988 feel significantly less depressed, less overwhelmed, less suicidal, and significantly more hopeful after interacting with a trained counselor (SAMHSA, 2023).
Individuals experiencing suicidal, mental health, or substance use crises, or other emotional distress (e.g., anxiety, depressive symptoms, loneliness, concerns regarding sexual orientation) may call, text or chat with trained crisis counselors 24/7 via the 988 Suicide and Crisis Lifeline (SAMHSA, 2023). Similarly, individuals may call, text, or chat with trained counselors if they are concerned about a loved one who requires crisis support. Individuals who contact 988 are not required to provide personal information, and the counselor will not know who the caller is or where they are located, as numerous safeguards are included to maximize privacy. Trained counselors listen non-judgmentally, using clarifying dialogue to understand how problems are affecting individuals in crisis, and they then provide support and share resources. Trained counselors reduce the intensity of the crisis, and approximately 98% of individuals who contact 988 are helped without the involvement of 911 during the call, text, or chat (SAMHSA, 2023).
The 988 services have been adapted to specific populations and users are oriented to these options (SAMHSA, 2023). Veterans and LGBTQIA+ youth and emerging adults may connect with counselors with additional specialized training when they call, text or chat 988. Counselors also receive training in best practices for calls, texts and chats from Native North American and Alaska Native individuals. Further, Spanish speaking individuals may connect with Spanish-speaking counselors, and deaf and hard-of-hearing individuals may connect with counselors trained in American Sign Language. The 988 Lifeline uses Language Line Solutions to provide translation for more than 240 languages (SAMHSA, 2023).
Because 988 counselors receive specialized training to better communicate with and address the concerns of general and specific populations, it may be indicated and feasible to incorporate additional specialized training to further support callers who identify as a nurse. Specifically, nurses who call, text, or chat 988 could be provided with an option to select a dedicated line that connects nurses with counselors or nurse counselors with additional specialized training. The privacy afforded by 988 would help to address barriers associated with help seeking among nurses in crisis, and counselors with specialized training could provide problem-solving skills and coping strategies for specific psychosocial problems and occupational stressors experienced by nurses. These counselors could also partially address and/or provide resources for some of the direct risk and contributing factors for nurse suicide.
Because the existing 988 Suicide and Crisis Lifeline infrastructure is established, specialized counselor training would likely increase costs only modestly. There are very few sustained interventions for nurse suicide prevention in the U.S., and further tailoring the 988 Suicide and Crisis Lifeline may represent an important national level strategy to partially address nurse suicide morbidity and mortality. Potential next policy steps may include informed discussions among nursing and public health organizations and nurse policy leaders, development of a white paper, collaboration with the developers and managers of 988 services and partnering with the National Alliance which was tasked with implementing the 2024 National Strategy for Suicide Prevention. Further, potential next steps may also include nurse-specific focus groups regarding receptivity to tailoring training for 988 staff in nurse-specific, compassionate communication. It is important to explore new adaptations of proven innovations to prevent suffering, crises, suicidal behavior, and loss of our professional nurse colleagues.
Published September 2024
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References
- Davidson, J., Proudfoot, J., Lee, K., Terterian, G., & Zisook, S. (2020). A longitudinal analysis of nurse suicide in the United States (2005-2016) with recommendations for action. Worldviews on Evidence-based Nursing, 17(1), 6-15.
- Davidson, J.E., Proudfoot, J., Lee, K., & Zisook, S. (2019). Nurse suicide in the United States: Analysis of the center for disease control 2014 national violent death reporting system dataset. Archives of Psychiatric Nursing, 33(5), 16-21. https://dx.doi.org/10.1016/j.apnu.2019.04.006
- Groves, S., Lascelles, K., & Hawton, K. (2023). Suicide, self-harm, and suicide ideation in nurses and midwives: A systematic review of prevalence, contributory factors, and interventions. Journal of Affective Disorders, 331, 393-404.
- Hawton, K., Simkin, S., Rue, J., C., Barbor, F., Clements, C., Sakarovitch, C., & Deeks, J. (2002). Suicide in female nurses in England and Wales. Psychological Medicine, 32, 239–250. https://dx.doi.org/10.1017}S0033291701005165
- Kreuze, E., Merwin, E.I., & York, J. (2024). Epidemiology of suicide among nurses internationally. Manuscript under review.
- Substance Abuse and Mental Health Services Administration. (2023). 988 suicide & crisis lifeline. https://www.samhsa.gov/find-help/988/faqs
- Ulrich, CM, Rushton, CH, & Grady, C. (2020 November/December). Nurses confronting the coronavirus: Challenges met and lessons learned to date. Nursing Outlook, 68(6), 838-844 https://www.nursingoutlook.org/article/S0029-6554(20)30659-X/abstract
- World Health Organization. (2024). World suicide prevention day 2024. https://www.who.int/campaigns/world-suicide-prevention-day/world-suicide-prevention-day-2024
- York, J. Ulrich, C. & Deatrick, J. Suicide mortality among nurses: What is the evidence? Unpublished Manuscript.