Suicide Prevention for Kentucky Nurses Nursing CE Course

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This course reviews relevant terminology and statistics related to suicide, including the increasing prevalence of nurse and other healthcare worker suicide. This course will also examine the risk factors for suicide and the clinical manifestations of burnout, compassion fatigue (CF), and secondary traumatic stress (STS) in nurses. Finally, this course will review screening for suicide and prevention strategies that can reduce the incidence of suicide, specifically for nurses and other healthcare workers.  

Upon completion of this module, the learner will be able to: 

• review relevant terminology and statistics related to suicide in the general population and among healthcare workers 

• identify the risk and protective factors contributing to suicide, identify warning signs of those at risk for suicide, and the most common means of suicide 

• discuss the components of a suicide risk assessment, determine the level of risk, and identify evidence-based tools and interventions corresponding to each risk level 

• describe the clinical manifestations of burnout, compassion fatigue, and secondary traumatic stress among healthcare workers 

• discuss various strategies for the prevention of suicide in the general population and among healthcare workers 

Suicide is a complex, multifactorial phenomenon involving various risk factors and warning signs. It is a preventable public health problem with a devastating psychological impact on loved ones and the community. While statistical data regarding suicide and suicide attempts vary based on race, gender, age, and other characteristics, suicide can occur among all demographic groups. Nurses must understand the defining features, risk factors, warning signs for suicidal behaviors, and the critical components of suicide risk assessment. To combat this growing public health problem, timely, evidence-based interventions must become the standard of care across all healthcare settings (Centers for Disease Control and Prevention [CDC], 2022; Clayton, 2019). Nurses should be aware of the following terms related to suicide: 

• suicide: is death caused by self-directed injurious behavior and the intent to die due to the behavior 

• suicidal behavior: a term encompassing suicide attempts and suicidal ideation 

• suicide attempt: a non-fatal, self-directed, potentially injurious act intended to result in death that may or may not result in injury 

• suicidal ideation: thoughts about killing oneself that may include a specific plan 

• suicide threat: verbalizing intent of self-injurious behavior intended to lead others to believe that one wants to die, despite no intention of dying 

• suicide gesture: self-injurious behaviors intended to lead others to believe that one wants to die, despite no intention of dying 

• non-suicidal self-injury (NSSI): self-injurious behavior characterized by the deliberate destruction of body tissue in the absence of any intent to die and for reasons that are not socially sanctioned 

• suicide means: an instrument or object used to carry out a self-destructive act, such as weapons, chemicals, medications, or illicit drugs  

• suicide methods: actions or techniques that result in an individual inflicting self-directed harmful behavior, such as an overdose (CDC, 2022b; National Institute of Mental Health [NIMH], 2021a; Schreiber & Culpepper, 2022) 

Statistics 

Suicide is the 10th leading cause of death in the US and is the 2nd leading cause of death among those aged 10 to 24 years. More years of potential life are lost to suicide than to nearly any other cause, except for heart disease, cancer, or unintentional injury. Suicide rates have increased by 33% between 1999 and 2019. In 2019, more than 47,500 people in the US died from suicide. On average, 132 people die by suicide daily, and one person dies every 11.1 minutes (one male every 14.1 minutes and one female every 51.3 minutes). There are 3.6 male deaths by suicide for every female death. According to the American Association of Suicidology (AAS), white males have the highest suicide rates (26.1 per 100,000), followed by Native American/Alaska Native males (13.8 per 100,000), non-white males (12.2 per 100,000), and Black males (11.8 per 100,000). Among females, white females have the highest rate of suicide (7.0 per 100,000), followed by non-white females (3.4 per 100,000) and Black females (2.8 per 100,000). Suicide rates are highest amongst middle-aged adults (45 to 64 years, 19.5 per 100,000), followed by older adults (≥ 65 years, 17.0 per 100,000), and young adults (15 to 24 years, 13.9 per 100,000) in the US (AAS, 2020; CDC, 2022b; NIMH, 2021a). 

Among adolescents aged 15 to 19, suicide rates have increased by 32% since 2016, rising from 8.4 to 11.1 (per 100,000) deaths. Native Americans/Alaska Natives are the most prominently affected adolescent subgroup (31.6 per 100,000 deaths). Adolescent males are affected at a rate over three times higher than females (16.7 per 100,000 male deaths compared to 5.2 per 100,000 female deaths; United Health Foundation, 2021). The Substance Abuse and Mental Health Services Administration (SAMHSA, 2021) 2020 National Survey on Drug Use and Health revealed an increasing prevalence of major depressive episodes (MDEs) among adolescents that correspond to the rise in suicide deaths among this age group. The percentage of MDEs increased from 5.5% (1.4 million people) in 2006 to 17% (4.1 million people) in 2020 (SAMHSA, 2021).  

Several studies have demonstrated that suicide rates are higher in states with higher gun ownership and that these heightened rates are driven by increased firearm suicides (American Public Health Association, 2018). Given this finding, it is not surprising that western US states with the fewest firearm laws comprise the top 5 highest suicide rates: Wyoming (29.4 per 100,000), Alaska (28.7 per 100,000), Montana (27.0 per 100,000), New Mexico (24.5 per 100,000), and Colorado (22.8 per 100,000). Following firearms, the most common methods of suicide include suffocation (28.5%) and poisoning (12.9%). While men are more likely to attempt suicide with more lethal methods, such as firearms or suffocation, women are more likely to use poison. Those with substance use disorders (SUDs) are six times more likely to die by suicide than the general population. Suicide also inflicts a tremendous economic burden on society, costing more than $70 billion annually (AAS, 2020; CDC, 2022b). 

Self-injurious behavior accompanied by any intent to die is classified as a suicide attempt; Nurses and society must err deliberately on the side of caution by viewing debatable behaviors as suicidal. While males are more likely to die by suicide, females are 3 times more likely to attempt suicide. Still, it is challenging to determine the exact number of attempted suicides in the US since there is a lack of all-inclusive databases or tracking mechanisms. Data are primarily compiled through self-reported surveys and ICD-10-CM billing codes. Due to the stigma associated with suicide attempts, they are greatly underreported. According to SAMHSA (2021), 12.2 million Americans aged 18 or older reported having serious thoughts of suicide, 3.2 million made suicide plans, and 1.2 million attempted suicide. These numbers translate to a suicide attempt every 23 seconds and 25 attempts for every death by suicide across the nation (100-200:1 for young adults and 4:1 for older adults). People who survive a suicide attempt may experience serious injuries and long-term health consequences. Many survivors experience high levels of psychological distress for lengthy periods after the initial exposure (AAS, 2020; CDC, 2022b). 

Suicide Statistics Among Healthcare Workers 

As suicide rates have continued to increase in the US over the last three decades, various disparities have been found based on race, gender, ethnicity, sexual orientation, age, and other factors. In addition, some occupations are known to have higher rates of suicide, including construction, transportation and warehousing, protective services, and healthcare workers. Occupational stressors can place healthcare workers at an increased risk of depression and suicide. In a 2019 systematic review that included over 60 studies, the researchers found physicians at significant risk for suicide, with female physicians at particularly high risk (Dutheil et al., 2019). The Covid-19 pandemic has significantly impacted the mental wellness of healthcare workers. Mental Health America (MHA) surveyed 1,119 healthcare workers (i.e., nurses, physicians, support staff, community-based healthcare workers, emergency medical technicians [EMTs]/paramedics, physician assistants, and nurse practitioners) to assess burnout and stress between June and September of 2020. The survey revealed that 93% of healthcare workers were experiencing stress, and 76% reported exhaustion and burnout. In addition, 86% of those surveyed were experiencing anxiety, 77% were experiencing frustration, and 75% reported being overwhelmed (MHA, 2020).  

Although there is significant research documenting burnout, compassion fatigue (CF), and stress among nurses, there is very little information regarding nurse suicide statistics. Davidson and colleagues (2020) published the results of a longitudinal analysis of nurse suicide in the US between 2005 and 2016. Their analysis utilized data from the CDC's National Violent Death Reporting System. These researchers found that nurses have a greater risk of suicide than the general population. Female nurse suicide rates (10 per 100,000) were higher than female suicide rates in the general population (7 per 100,000). Similarly, male nurse suicide rates (33 per 100,000) were higher than male suicide rates in the general public (27 per 100,000). Female nurses most frequently used pharmacologic poisoning (i.e., opioids and benzodiazepines), whereas male nurses used firearms. Davidson and colleagues found no change in nurse suicide over this time frame; instead, nurse suicide has remained unaddressed for decades (Davidson et al., 2020).  

Risk Factors 

Nurses must develop a keen awareness and understanding of the risk factors associated with suicide to identify individuals at risk. Assessing suicide risk should occur in all healthcare settings, including primary care offices, emergency departments, and outpatient clinics. Nurses must acquire the skills necessary to evaluate if an individual is in distress, depressed, in a crisis, or at imminent risk for suicide prompting timely intervention. Risk factors include behavioral signs and symptoms that are statistically related to an individual's amplified risk for suicide. These factors may also include issues related to a person's background, history, environment, and circumstances that increase their risk potential or likelihood of suicidal behavior. Individuals differ in the degree to which risk factors affect their propensity for engaging in suicidal behaviors, and the weight and impact of each risk factor will vary by person and throughout their lifespan (CDC, 2021; Schreiber & Culpepper, 2022; The Joint Commission [TJC], 2019).  

While a combination of situations and factors contribute to suicide risk, a prior suicide attempt is the strongest single factor that predicts future risk. The risk of dying by suicide is more than 100 times greater during the first year following an initial suicide attempt. Studies have demonstrated a strong correlation between people who re-attempt suicide, those who complete it, and the timing of the re-attempt. In a prospective study evaluating 371 adult patients with a suicide attempt, 19% (70 people) re-attempted, and 60% of re-attempts occurred within the first 6 months (Irigoyen et al., 2019; Schreiber & Culpepper, 2021).  

While risk factors increase the likelihood of suicide, predicting who will act on suicidal thoughts remains challenging. Even among those who have risk factors for suicide, most people do not attempt suicide. However, the risk for suicide increases as the quantity of contributing factors increases (CDC, 2021; Schreiber & Culpepper, 2022). Other than a prior suicide attempt, the most well-cited risk factors for suicide include the following: 

• General Risk Factors: 

  • social isolation or alienation 

  • recent or ongoing impulsive and aggressive tendencies and/or acts 

  • problems tied to sexual identity and relationships 

  • problems linked to other personal relationships 

• Environmental Influences: 

  • low socioeconomic status 

  • access to lethal means, including firearms and drugs 

  • barriers to accessing health care and treatment 

  • prolonged stress, such as harassment, bullying, relationship problems, or unemployment 

  • stressful life events like rejection, divorce, financial crisis, other life transitions, or loss 

  • exposure to another person's suicide or sensationalized accounts of suicide 

• Health Factors: 

  • mental health conditions, such as:  

    • SUD/substance abuse problems 

    • bipolar disorder 

    • schizophrenia 

    • hallucinations and delusions  

    • personality traits of aggression, mood changes, and poor relationships 

    • conduct disorder 

    • depression 

    • anxiety disorders 

  • persons aged 18 to 25 years prescribed an antidepressant  

  • persons institutionalized for a mental health condition 

  • serious physical health conditions, including pain 

  • traumatic brain injury (TBI) 

• Historical Risk Factors: 

  • previous self-destructive behavior 

  • history of mood disorder(s) 

  • history of alcohol and/or other forms of substance abuse 

  • family history of suicide and/or psychiatric disorder(s) 

  • loss of a parent or loved one through any means 

  • history of trauma, abuse, violence, or neglect 

  • certain cultural or religious beliefs tied to suicide (CDC, 2021; Schreiber & Culpepper, 2022) 

Special populations with an increased risk for suicide include those who identify as a member of the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community, military personnel, and incarcerated individuals. Modifiable risk factors, such as mental health conditions, should be managed appropriately to lower a patient's risk (CDC, 2021; Schreiber & Culpepper, 2022).  

Risk Factors for Nurses 

There are 3.4 million practicing nurses in the US, making them the largest group of healthcare workers. Nurses work in busy, fast-paced, and stressful environments. Caring for patients from birth to death and during times of wellness and illness can be one of the most rewarding jobs. Nurses often describe choosing to enter healthcare as a calling to serve others. However, the multiple demands on the nurse's time throughout the workday can sometimes lead to chronic toxic stress (i.e., chronic stress that results in prolonged activation of the stress response, with failure of the body to recover fully), leaving them frustrated, overwhelmed, and overextended. The nurse's inability to adequately meet all the competing demands on their time can result in burnout. When nurses experience burnout, there are negative consequences for the nurse, the healthcare organization, and patients. Nurses can experience physical and emotional manifestations of burnout that impact their work and home life. In addition, high rates of nurse and healthcare worker burnout can lead to staffing concerns and turnover. Healthcare organizations affected by healthcare worker burnout experience decreased quality of care and increased safety events (Davidson et al., 2018).  

Burnout 

Burnout is "a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur in individuals who do' people work 'of some kind" (Maslach, 2003, p. 2). This phenomenon involves the emotional and physical exhaustion from a stressful work environment and the important responsibilities of caring for others. Maslach and Leiter (2017) expanded upon Dr. Maslach's earlier work on burnout and provided additional insights into burnout syndrome's three dimensions: emotional exhaustion, depersonalization, and the loss of personal accomplishment. The first dimension, emotional exhaustion, is described as the first sign of burnout or burnout syndrome. Individual workers are "overextended by work demands and are depleted of physical or emotional resources…drained without any source of recovery" (p. 160). This dimension is characterized by a lack of physical or emotional energy and an inability to deal with workplace demands or face another day on the job. The second dimension of burnout, depersonalization or cynicism, is "a negative, callous, or excessively detached response to various aspects of the job…in response to overload or exhaustion" (p. 160). Cynicism with the resulting detachment results in nurses doing just enough to get by rather than doing their best work. The third dimension of burnout, reduced personal accomplishment or inefficacy, includes "a feeling of incompetence and lack of achievement and productivity at work" (p. 160). Inefficacy can be exacerbated in a work environment that lacks adequate resources, such as supplies, equipment, and staff (Maslach & Leiter, 2017). 

Compassion Fatigue or Secondary Traumatic Stress 

Although burnout and compassion fatigue (CF) have some similarities, they are fundamentally different phenomena. Healthcare workers are impacted by burnout from a stressful work environment and working conditions. In contrast, CF or secondary traumatic stress (STS) affects healthcare workers due to caring for victims that have experienced trauma or critical illness and death. CF is the emotional, physical, and spiritual distress resulting from caring for others. The emotional strain from caring for those who experience suffering can culminate in detachment and a loss of empathy. In addition, CF can manifest quickly, whereas burnout has a more gradual onset. Healthcare workers suffering from CF can experience emotional and mental exhaustion, self-isolation, and lack of fulfillment in the professional setting. Burnout and CF can manifest similar signs and symptoms, making it hard to differentiate them. In addition, Healthcare workers can experience one or both phenomena simultaneously. Nurses experiencing burnout, CF, or STS can suffer from anxiety, depression, and suicidal ideation. Understanding that burnout, CF, and STS can increase the risk of nurse suicide is critical to preventing self-harm or death (Administration for Children and Families [ACF], n.d.).  

Protective Factors 

Protective factors are key behaviors, environments, and relationships that may enhance resilience and decrease the risk that an individual will attempt suicide. Protective factors have been shown to safeguard individuals from suicidal thoughts and behaviors. Individuals differ in the degree to which protective factors affect their propensity for engaging in suicidal behaviors. Like risk factors, each protective factor's impact on suicidality varies across the lifespan (CDC, 2021; Schreiber & Culpepper, 2022). Research demonstrates that some of the most well-established suicide protective factors include the following: 

• presence of adequate social support and family connections (connectedness) 

• supportive and effective clinical care from medical and mental health professionals  

• positive learned skills in coping, problem-solving, conflict resolution, and other nonviolent ways of handling disputes 

• cultural and religious beliefs that discourage suicide and support instincts for self-preservation (e.g., intentional participation in religious activities and spirituality) 

• restricted access to lethal means, also known as protective environments (CDC, 2021; Schreiber & Culpepper, 2022; TJC, 2019) 

Warning Signs 

Although statistical data demonstrate that most people who die by suicide received some form of healthcare services within the year preceding their death, suicidal ideation is rarely detected. Nurses must take all warning signs seriously and offer appropriate support quickly. Warning signs indicate an imminent threat (i.e., within hours or days) for the acute onset of suicidal behaviors. These are indicators that the individual may be in acute danger and urgently requires help. The more warning signs the individual displays, the greater their risk of suicide and the higher their need for timely assessment and intervention (CDC, 2021; Schreiber & Culpepper, 2022; TJC, 2019). The following warning signs are correlated with the highest likelihood of the short-term onset of suicidal behaviors: 

• threatening, talking, or thinking about hurting or killing oneself 

• searching for ways to kill oneself, including seeking access to drugs or other lethal means (e.g., stockpiling or obtaining weapons, strong prescription medications, or items associated with self-harm) 

• writing or posting on social media about death, dying, and suicide 

• engaging in self-destructive behaviors, such as substance misuse or self-harm (CDC, 2021; Schreiber & Culpepper, 2022; TJC, 2019) 

Individuals who display these warning signs are considered at high risk for suicide and warrant immediate intervention, evaluation, referral, and hospitalization. Additional warning signs and behaviors that require a prompt mental health evaluation and precautions to ensure the safety of the individual include the following: 

• expressing feelings of hopelessness and a lack of purpose or reason to live 

• talking about feeling trapped or in unbearable pain 

• increasing the use of drugs or alcohol 

• changing behavior regarding eating and sleeping (too little or too much) 

• fixating on death or violence 

• engaging in self-destructive or risky behaviors 

• withdrawing or expressing feelings of isolation 

• showing extreme or dramatic changes in mood and personality, such as acting anxious, agitated, restless, irritable, or enraged, or talking about seeking revenge 

• expressing overwhelming self-blame, remorse, guilt, or shame 

• feeling like a burden to others 

• giving away prized possessions 

• losing interest in things 

• experiencing bullying, sexual abuse, or violence (CDC, 2021; Schreiber & Culpepper, 2022) 

Nurses and healthcare organizational leaders must recognize the signs and symptoms of burnout, CF, or STS. In addition to the warning signs listed above, additional warning signs specific to healthcare workers include: 

• emotional and physical exhaustion 

• dreading going to work 

• constant dread or panic when at work 

• apathy towards others 

• frequent absenteeism or tardiness 

• negative attitude at work 

• lack of engagement with friends and family 

• resistance to change 

• poor work quality 

• safety concerns with patient care 

• a decreased sense of purpose 

• emotional disconnection 

• difficulty maintaining personal relationships 

• a decline in morale (Singh et al., 2021; Walters, 2022) 

Suicide Risk Assessment 

A suicide risk assessment is a process by which a nurse gathers clinical information to determine an individual's risk for suicide. A risk assessment identifies behavioral and psychological characteristics associated with an increased risk for suicide, allowing for the implementation of effective, evidence-based treatments and interventions to reduce this risk. A risk assessment for suicide is an ongoing process, as suicidal behaviors can fluctuate quickly and unpredictably. Screening responsibilities are no longer limited to medical providers, as current health policy and suicide prevention guidelines call for the support and participation of all healthcare workers (i.e., physicians, advanced practice providers, nurses, behavioral health specialists, social workers, and case managers), regardless of their work setting (acute or non-acute) or specialty (National Action Alliance for Suicide Prevention, 2019). A complete risk assessment must include the following vital aspects: 

• information about past and present suicidal ideation and behavior 

• information about the patient's context and history 

• prevention-oriented suicide risk formulation anchored in the patient's life context (National Action Alliance for Suicide Prevention, 2019)  

The National Action Alliance for Suicide Prevention (2018) published an updated guideline, Recommended Standard Care for People with Suicide Risk, which supports two critical goals cited by the National Strategy for Suicide Prevention (US Department of Health & Human Services [HHS], 2021): 

• goal 8: promote suicide prevention as a core component of healthcare services 

• goal 9: promote and implement effective clinical and professional practices for assessing and treating those identified as being at risk for suicidal behaviors 

Together, the Action Alliance (2019) and National Strategy put forth the Zero Suicide (ZS) Model, last updated in 2021, which provides a framework to coordinate a multilevel approach to implementing evidence-based practices. ZS encourages the screening of all patients for suicide risk on their first contact with an organization and at each subsequent encounter. The core elements of the ZS model include ongoing risk assessment, collaborative safety planning, evidence-based interventions specific to the identified risk level, lethal means reduction, and continuity of care. Structuring a suicide risk assessment is not a straightforward task and involves asking difficult questions about suicidal ideation, intent, plan, and prior attempts. Individuals may openly respond to queries and engage in discussion, or they may be limited in their replies and offer minimal information. At times the patient may bring up the topic on their own, but research demonstrates that this is rare (Brodsky et al., 2018; HHS, 2021; SAMSHA, 2017). The list below outlines the assessment of risk for suicide as compiled and adapted from the National Action Alliance for Suicide Prevention (2018) and HHS (2021) guidelines:  

• The suicide risk assessment should consider risk and protective factors that may increase or decrease the patient's risk of suicide. 

• Observation and the existence of warning signs and the evaluation of suicidal thoughts, intent, behaviors, and other risk and protective factors should be used to inform any decision about a referral to a higher level of care. 

• Mental state and suicidal ideation can fluctuate considerably over time. People at risk for suicide should be re-assessed regularly, especially if their circumstances have changed. 

• The clinician should observe the patient's behavior during the clinical interview. Disconnectedness or a lack of rapport may indicate an increased risk for suicide. 

• The nurse should remain both empathetic and objective. A direct, non-judgmental approach allows the nurse to gather the most reliable information collaboratively and encourages the patient to accept help. 

To assess a patient's suicidal thoughts, the nurse should inquire directly about thoughts of dying by suicide or feelings of engaging in suicide-related behavior. The distinction between NSSI and suicidal behavior is essential. Nurses should be direct when inquiring about any current or past thoughts of suicide and ask individuals to describe any such thoughts. According to the Action Alliance (2018) and HHS (2021), a comprehensive evaluation of suicidal thoughts should include the following: 

• onset (when did it begin) 

• duration (acute, chronic, recurrent) 

• intensity (fleeting, nagging, intense) 

• frequency (rare, intermittent, daily, unabating) 

• active or passive nature of the ideation ("wish I was dead" vs. "thinking of killing myself") 

• whether the individual wishes to kill themselves or is thinking about or engaging in potentially dangerous behavior such as cutting to relieve emotional distress 

• lethality of the plan (no plan, overdose, hanging, firearm) 

• triggering events or stressors (relationship, illness, loss) 

• what intensifies the thoughts 

• what distracts the thoughts 

• association with states of intoxication (if thoughts are triggered only when the individual is intoxicated) 

• understanding the consequences of future potential actions (HHS, 2021; National Action Alliance for Suicide Prevention; SAMSHA, 2017) 

Evidence-Based Risk Assessment Tools for Suicide 

A comprehensive suicide risk assessment requires a validated, evidence-based screening tool consisting of a set of directed questions. Evaluating the risk level and appropriate actions for each risk level is a critical aspect of suicide prevention. All nurses must understand how to perform a proper risk assessment, ascertain the risk level, and respond according to evidence-based guidelines. Several tools have been developed and are used throughout various clinical settings. Within the same facility or working environment, all staff members are encouraged to use the same tool and procedures to ensure that patients with suicide risk are identified and managed consistently. Similarly, nurses must become familiar with and comfortable using the assessment tool to elicit an open discussion with the patient. The standard of care in suicide risk assessment requires clinicians to conduct a thorough suicide risk assessment for all patients (Falcone & Timmons-Mitchell, 2018; National Action Alliance for Suicide Prevention, 2018). 

Columbia Suicide Severity Rating Scale (C-SSRS)  

The C-SSRS is one of the most widely used, validated, and evidence-based instruments in suicide risk assessment and is available in 114 languages. Several versions of the C-SSRS have been developed for clinical practice. The tool is supported by extensive evidence that reinforces its validity as a screening method for longitudinally predicting future suicidal behaviors. It screens for a wide range of suicide risk factors straightforwardly and concisely, using direct language to elicit honest responses. The C-SSRS provides a framework to assess suicide risk and NSSI, identify the risk level, and guide appropriate action according to the risk level. The C-SSRS is endorsed by several prominent organizations, including the National Action Alliance for Suicide Prevention, SAMHSA, CDC, World Health Organization (WHO), and the National Institutes of Health (NIH; Brodsky et al., 2018; Columbia Lighthouse Project, 2016; SAMHSA, n.d.). 

Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) 

SAFE-T is a tool that incorporates the American Psychiatric Association (APA) Practice Guidelines for suicide assessment and is used most commonly in emergency departments by clinicians and nurses. SAFE-T can identify risk and protective factors; inquire about suicidal thoughts, behavior, and intent; and determine the patient's risk level. It provides appropriate interventions directly to enhance safety. The five steps are outlined in Figure 1 (HHS, 2009). According to the SAFE-T screening tool, a person's risk of suicide can be any of three levels: low, moderate, or high. These risk levels, defining features, and interventions are summarized in Table 1. Suicide precautions should be implemented whenever a patient is deemed at-risk. For patients at low risk of suicide, the nurse should make personal and direct referrals to outpatient behavioral health and other providers for follow-up care within a week of the initial assessment, rather than leaving the patient to make the appointment (Columbia Lighthouse Project, 2016; HHS, 2009). 

Suicide Risk Reassessment 

Reassessment of a patient's suicide risk should occur when there is a change in their condition (e.g., relapse of alcoholism) or psychosocial situation (e.g., the end of an intimate relationship) that suggests increased risk. Nurses should update information about a patient's risk factors when changes in their symptoms or circumstances indicate increased or decreased risk (National Action Alliance for Suicide Prevention, 2018). 

Suicide Prevention 

Preventing suicide is the primary objective of suicide risk assessment and management. The most effective strategies focus on strengthening suicide protective factors, such as improving access to mental health services, counseling, and other psychosocial resources. Managing mental health conditions (especially depression) is one of the most important interventions for suicide risk reduction and includes nonpharmacological and pharmaceutical treatments based on individual needs (NIMH, 2021b). Given the long-lasting effects that suicide can have on individuals, families, and communities, the CDC has identified suicide as a serious public health problem. Suicide prevention requires a comprehensive public health approach that addresses all levels of society. By learning the warning signs of suicide, promoting prevention and resilience, and committing to social change, suicide rates can be decreased. See Table 2 for strategies to prevent suicide (CDC, 2022b). 

The National Suicide Prevention Lifeline  

For those with suicidal ideation, each patient and their family members should be given information to access the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). Counselors are available via the national toll-free phone number, on a web-based live chat (suicidepreventionlifeline.org), by text, or through a mobile application. This service is available 24 hours a day and 7 days a week across the US. Furthermore, individuals should also be provided with contact information for local crisis and peer support organizations (NIMH, 2021b).  

The National Suicide Prevention Lifeline lists the following three "prompt questions" which address current suicidal desire, recent (past 2 months) suicidal desire, and prior suicide attempts (NIMH, 2021b): 

• Are you thinking of suicide? 

• Have you thought about suicide in the last 2 months? 

• Have you ever attempted to kill yourself? 

An affirmative answer to any or all of these questions requires the crisis telephone worker to conduct a full suicide risk assessment based on subcomponents that review suicidal desire, suicidal capability, suicide intent, and buffers or connectedness. Since isolation is an identified risk factor and a potential precipitant of suicide, engagement of supportive third parties is critical if endorsed by the individual at risk for suicide. Third parties should be aware of the safety plan and understand resources to ensure safety (National Action Alliance for Suicide Prevention, 2018; National Suicide Prevention Lifeline, n.d.; SAMHSA, 2017).  

Impulsivity and Access to Lethal Means 

As described earlier, firearms are the most lethal and most common method of suicide in the US, and suicide attempts with a firearm are overwhelmingly fatal. Firearm owners are not more suicidal than non-firearm owners; instead, their suicide attempts are more likely to be fatal. The connection between impulsivity and access to lethal means dramatically enhances the risk of death by suicide. Most suicide attempts involve little planning and occur during a short-term crisis by individuals with access to lethal means. Therefore, there is a direct correlation between death by suicide and access to lethal means, such as firearms. If lethal means are made less available to impulsive attempters, and patients substitute less lethal means or temporarily postpone their attempt, the odds that they will survive increase. Studies have demonstrated that when access to a highly lethal suicide method is restricted, the overall suicide rate drops (Allchin et al., 2019). The Department of Veterans Affairs (VA; 2019) states in its suicide prevention plan that a reduction in access to lethal means at the population level should be implemented as a measure of suicide prevention. This may include firearm restrictions, reducing access to poisons and medications commonly associated with overdose, and barriers to jumping from lethal heights. Such restrictions may be accomplished through lethal means safety counseling (LMSC). LMSC consists of a discussion between a nurse and a patient at risk for suicide. Firearm storage suggestions should be based on the patient's risk level. Recommendations may include storing guns and ammunition separately, using a gunlock or removing the firing pin, storing firearms in a locked cabinet or safe, disassembling firearms, or keeping them at the home of a trusted individual. The National Action Alliance for Suicide Prevention (2018) suggests that nurses arrange and confirm the removal or reduction of any lethal means when feasible before allowing an at-risk patient to be discharged or return home. Family members or caregivers should be involved to help suicide-proof the environment (SAMSHA, 2017). 

Community Education 

In addition to restricting access to lethal means, expanding options for nurse education and gatekeeper training has a positive impact on reducing suicide rates. Gatekeeper training is more commonly referred to as "recognition and referral training" (RRT), referring to the critical role that individuals without formalized psychosocial training have in suicide prevention. RRT helps educate individuals across the community (e.g., teachers, coaches, emergency responders, clergy), equipping them with the skills to identify people who may be at risk of suicide. It offers training on how to respond to these individuals and refer them to support services and treatment. Training these individuals on how to respond to mitigate a person's suicide risk is vital since most individuals at risk for suicide seek guidance and support from close contacts (i.e., "gatekeepers"). RRT strives to create an informed support network of people within communities equipped to connect suicidal persons with the right resources. Applied Suicide Intervention Skills Training (ASIST) is one of the most effective and well-cited RRT programs (Stone et al., 2017).   

Suicide Prevention for Nurses 

Physician suicide has long been recognized as a serious concern, with various research studies focusing on prevention strategies. Traditionally, less attention has been given to nurse suicide. Healthcare worker burnout has been a recognized problem for decades and is a risk factor for depression and suicide. The COVID-19 pandemic has brought healthcare worker burnout to the forefront of global and national priorities. In 2007, the Institute for Healthcare Improvement (IHI) presented the Triple Aim framework to optimize healthcare system performance. The three dimensions of the Triple Aim include: improving the patient care experience, improving the health of populations, and reducing the per capita cost of health care. Healthcare organizations and national leaders have recently highlighted that a critical component to achieving the Triple Aim is the healthcare worker's work environment. Therefore, many organizations have advocated expanding the Triple Aim to include a fourth dimension of attaining joy in work. The evolution of the Quadruple Aim addresses the importance of a healthy work-life balance for healthcare workers as a foundation for achieving the Triple Aim. Addressing burnout and promoting joy in the workplace can improve patient outcomes and safety and prevent suicide among healthcare workers (Davidson et al., 2018; Feeley, 2017; Fitzpatrick et al., 2019).  

Suicide prevention is complex, requiring individual and organizational efforts. Therefore, it is more effective for nurses and healthcare organizations to implement strategies to prevent risk factors such as burnout, CF, and STS. Nurse burnout and CF can occur due to factors within the healthcare organization, individual factors within the nurse, or both. Healthcare leaders must identify and address the organizational factors that can cause burnout and CF in nurses. To improve their work-life balance, individual nurses also need to recognize modifiable risk factors. Various organizations, including the CDC and TJC, have put forth recommendations for improving healthcare workers' well-being to reduce burnout and manage fatigue and stress during times of crisis. Healthcare workers continue to provide care despite challenging work demands, increased stress, and more complex care needs in times of crisis. Healthcare organizations are faced with the challenge of caring for patients while also considering the needs of their staff. Managing stress and exhaustion is a shared responsibility between the individual healthcare worker and the healthcare organization. By working together, effective prevention and treatment strategies can be instituted (Hittle et al., 2020; TJC, 2021). 

Individual Strategies 

Nurses must be proactive about their physical and mental health, given the risk for burnout, CF, and STS. However, real and perceived barriers often prevent nurses from engaging in physical and mental health wellness strategies. Suicide prevention for nurses starts with developing healthy coping and resilience, modifying self-perpetuated stigma, and providing self-care. First, the individual nurse must recognize the signs of burnout, CF, STS, or suicidal ideation. Nurses should identify the changes in their minds and body when they feel burnt out, depressed, or suicidal to better care for themselves. Next, nurses need to embrace the concept of work-life balance. Nurses are caregivers who often put the needs of their patients ahead of their own. However, a nurse who prioritizes self-care and embraces work-life balance will be more content and able to function effectively in the workplace for a longer career (ACF, n.d.; American Nurses Association [ANA], n.d.). Additional strategies that nurses can use to prevent burnout, CF, or STS include (ACF, n.d.; ANA, n.d.): 

• Improve schedules: nurses should minimize rotating between shifts throughout the week. Also, nurses should avoid working overtime or extended shifts.  

• Take breaks: nurses should utilize their vacation time to get away from the workplace. During the workday, nurses should not skip breaks or their scheduled mealtime. Getting away from the unit for brief periods throughout the day is crucial.  

• Learn to say "no": nurses naturally want to help others, which can sometimes be problematic when the nurse overextends themselves. Learning to say no and setting boundaries can prevent burnout.  

• Ask for help: nurses who are feeling signs and symptoms of burnout, CF, STS, or suicidal ideation should be empowered to speak up. Making their needs known can help healthcare leaders make appropriate changes to ensure the nurse's or healthcare workers' well-being.  

• Reignite the passion for nursing: when nurses experience signs and symptoms of burnout, CF, or STS, reflecting on why they chose nursing can be helpful. Sometimes getting involved in a new initiative they are passionate about can change those feelings of burnout into personal accomplishment. Nurses may also consider going back to school to advance their careers.  

• Seek support: nurses should seek out support groups, buddies, or mentors that can serve as an outlet to vent frustrations or discuss challenges. Creating peer mentors encourages teamwork and collaboration, decreasing the risk of burnout, CF, or STS.  

• Learn coping methods: resilient nurses are less likely to become burned out. Therefore, effective coping is critical to healthcare workers' well-being. Potential approaches include breathing techniques, mindfulness, meditation, restorative exercise, journaling, and a post-work relaxation routine. 

• Changing specialties or focus: one of the unique features of nursing is that there are numerous different specialty areas. If the current work environment is causing significant stress, a change of pace or setting may be necessary. Strategies could include changing units or facilities, moving from inpatient to outpatient, or changing roles.  

• Prioritize physical wellness: basic strategies could include healthy eating, regular exercise, sleeping at least seven hours per night, smoking cessation, and limiting alcohol intake. For more information, see the NursingCE course, Avoiding Nurse Burnout. 

Organizational Strategies 

Various organizations have put together evidence-based resources for communities and organizations to foster the development of suicide prevention strategies. In 2017, the CDC released Preventing Suicide: A Technical Package of Policy, Programs, and Practices to target suicide prevention, see Table 2 above. Healthcare organizations must create evidence-based strategies to address screening, assessing, safety planning, and referrals for nurses at risk for suicide. An essential component of these strategies is confidentiality for nurses who report burnout, CF, STS, or suicidal ideation and creating a culture that destigmatizes suicide. Organizational strategies should focus on system-wide changes that promote healthcare worker wellness, self-care, and resilience. Reducing the risk of burnout, CF, and STS will decrease the risk of suicidal ideation and suicide. The Health Policy Institute of Ohio (HPIO) released an evidence-based policy brief stating that a multistakeholder approach is required to improve nurse well-being, including state lawmakers, health professional colleges and universities, health professional licensing boards, and healthcare leaders (ANA, n.d.; Davidson et al., 2018; HPIO, 2020).  

Reducing the Stigma 

Organizational leaders must create a culture within the workplace that reduces the stigma associated with healthcare worker burnout, CF, STS, or suicidal ideation. Ethically, nurses and other healthcare workers are taught to promote autonomy and beneficence, or doing right by others. These ethical principles apply when caring for patients and when working with colleagues. Creating a culture that promotes knowledge and positive attitudes about physical and mental wellness can be critical in addressing healthcare worker distress and suicide risk. Healthcare organizations should educate their staff about the signs and symptoms of CF, burnout, and STS and how to assess for and recognize them in patients and their colleagues. Signs of distress can be subtle at first, but colleagues who work closely together are well poised to notice and act on these changes. Creating a culture that promotes an open dialogue about health worker distress can normalize engagement in mental health treatment. With stigma reduction being a core component of successful wellness and suicide prevention programs, organizations must provide education, policies, and procedures to make it safe for staff to seek treatment (ANA, n.d.; Davidson et al., 2018; Moutier, 2018).  

Creating a Positive Organizational Culture 

It is well documented that the organizational culture directly impacts healthcare workers' well-being. Therefore, healthcare organizations must create a positive organizational culture that prioritizes wellness and safety and recognizes that healthcare workers' well-being is the responsibility of everyone (ANA, n.d.; Davidson et al., 2018; HPIO, 2020). Some evidence-based strategies to promote a positive organizational culture include (ANA, n.d.; Davidson et al., 2018; HPIO, 2020): 

• Leadership must prioritize wellness: Healthcare organization executive leadership plays a critical role in creating a positive organizational culture. Healthcare leaders can deploy various strategies to prioritize wellness.  

  • Appointing a Chief Wellness Officer (CWO) demonstrates a commitment to wellness and support for healthcare workers. The CWO should be a member of senior leadership and be equipped with resources to support wellness initiatives. 

  • Ensure that all leaders in the organization improve wellness in the work environment within the scope of their role. Leaders must actively engage with their staff, listen to their wellness needs, and provide needed resources. The leaders must also role-model healthy physical and mental health behaviors.  

  • Open discussion and acknowledgment of the importance of healthcare worker well-being. When healthcare workers feel that their values align with the values of the organization, they are more likely to engage in healthy workplace behaviors. Healthcare workers will also be more likely to seek help when they feel that the organization is committed to their wellness.  

• Psychological safety and confidential assessment and referrals: When healthcare workers are experiencing burnout, CF, STS, or suicidal ideation, they need to feel safe to ask for help. When healthcare workers perceive the work environment as punitive or not supportive of wellness, they are more likely to experience distress. Healthcare organizations must ensure access to confidential mental health and addiction screening, assessment, and referral programs that support access to appropriate treatment.  

  • The Healer Education, Assessment, and Referral (HEAR) program is an evidence-based, confidential assessment and referral program for healthcare workers. The American Medical Association (AMA) and the ANA recognize the HEAR program as a best practice in suicide prevention. The HEAR program educates healthcare workers about burnout, depression, and suicide. In addition, the HEAR program provides a confidential, online assessment of stress, depression, and other mental health conditions. After the assessment, the HEAR program offers personalized referrals to local mental health clinics and community resources.  

  • A just culture focuses on the accountability of individuals and the organization for patient care and safety. Healthcare workers should be supported when they bring up safety concerns and not fear retribution. Healthcare workers should also be held accountable for their decisions when assessing safety concerns. Healthcare organizations must create a culture that promotes honest disclosure of errors and ensures support for healthcare workers following an adverse event.  

  • Healthcare organizations should measure wellness as a quality indicator. Utilizing valid and reliable tools to measure burnout and well-being can help establish healthcare worker wellness as a priority. This strategy allows leadership to implement effective strategies to reduce burnout and suicidal ideation, improve mental health, and evaluate these measures continuously or consistently.  

• Diverse and inclusive environment: A positive work culture is one where healthcare workers of all backgrounds feel safe and valued. Implicit or explicit bias, when unaddressed, contributes to burnout and distress. Healthcare organizations often have policies on responding to discrimination but limited resources for those who experience it.  

  • Leadership must be committed to changing cultural norms. Leaders must be aware of bias and how to respond effectively.  

  • Using the Implicit Association Test (IAT) to assess individual bias can increase the understanding of healthcare workers on ways that bias influences their decisions.  

  • Increasing diversity among healthcare workers can create a positive diversity climate. For more information, see the NursingCE courses, Civility in the Workplace and Implicit Bias. 

Interventions to Promote Mental Health and Well-being 

In addition to creating a positive work culture, organizations should focus on interventions to promote mental health and well-being and thereby reduce healthcare worker burnout, CF, STS, and suicidal ideation. For example, mindfulness-based stress reduction (MBSR) programs mitigate the signs and symptoms of burnout in nurses and other healthcare workers. In addition, healthcare organizations should create workplace environments that foster resilience and self-care for their staff. Some strategies that leadership can use to create a nurturing environment to manage burnout include (HPIO, 2020; Wolotira, 2022): 

• encourage staff participation in self-care activities at work (e.g., walking, mindfulness, meditation, journaling) 

• invite staff to go on a walk and listen to their stories 

• have crucial conversations with staff about signs and symptoms of burnout 

• diversify or decrease staff workload 

• support staff in having time off, including vacations 

• encourage participation in debriefing after traumatic events 

• provide positive recognition of staff 

• acknowledge and recognize the loyalty of staff members 

• promote peer support, teamwork, and collaboration 

• empower staff in professional development 

• support employee autonomy 

References 

Administration for Children and Families. (n.d.). Secondary traumatic stress. US Department of Health and Services. https://www.acf.hhs.gov/trauma-toolkit/secondary-traumatic-stress 

Allchin, A., Chaplin, V., & Horwitz, J. (2019). Limited access to lethal means: Applying the social-ecological model for firearm suicide prevention. Injury Prevention, 25, 44-48. https://doi.org/10.1136/injuryprev-2018-042809 

American Association of Suicidology. (2020). USA suicide: 2019 official final data. https://suicidology.org/wp-content/uploads/2021/01/2019datapgsv2b.pdf 

American Nurses Association (n.d.). Nurse suicide prevention/resilience. https://www.nursingworld.org/practice-policy/nurse-suicide-prevention/ 

Brodsky, B. S., Spruch-Feiner, A., & Stanley, B. (2018). The zero suicide model: Applying evidence-based suicide prevention practices to clinical care. Frontiers in Psychiatry, 9(33). https://doi.org/10.3389/fpsyt.2018.00033 

Centers for Disease Control and Prevention. (2021). Suicide prevention: Risk and protective factors. https://www.cdc.gov/suicide/factors/index.html 

Centers for Disease Control and Prevention. (2022a). Disparities in suicide. https://www.cdc.gov/suicide/facts/disparities-in-suicide.html 

Centers for Disease Control and Prevention. (2022b). Suicide prevention. https://www.cdc.gov/suicide/index.html 

Clayton, P. J. (2019). Suicidal behavior and self-injury. In R. S. Porter & J. L. Kaplan (Eds.), Merck Manual Professional Version. Merck Sharp & Dohme Corp. https://www.merckmanuals.com/professional/psychiatric-disorders/suicidal-behavior-and-self-injury/suicidal-behavior?query=suicide 

Columbia Lighthouse Project. (2016). SAFE-T with C-SSRS. http://cssrs.columbia.edu/documents/safe-t-c-ssrs/ 

Davidson, J., Mendis, J., Stuck, A. R., DeMichele, G., & Zisook, S. (2018). Nurse suicide: Breaking the silence. National Academy of Medicine. https://nam.edu/nurse-suicide-breaking-the-silence/ 

Davidson, J. E., 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 of Evidence-Based Nursing, 17(1), 6-15. https://doi.org/10.1111/wvn.12419 

Dutheil, F., Aubert, C., Pereira, B., Dambrun, M., Moustafa, F., Mermillod, M., Baker, J. S., Trousselard, M., Lesage, F. X., & Navel, V. (2019). Suicide among physicians and healthcare workers: A systematic review and meta-analysis. PLoS One, 14(12), e0226361. https://doi.org/10.1371/journal.pone.0226361 

Falcone, T., & Timmons-Mitchell, J. (2018). Suicide prevention: A practical guide for the practitioner. Springer Publishing. 

Feeley, D. (2017). The Triple Aim or Quadruple Aim: Four points to help set your strategy. Institute for Healthcare Improvement. http://www.ihi.org/communities/blogs/the-triple-aim-or-the-quadruple-aim-four-points-to-help-set-your-strategy 

Fitzpatrick, B., Bloore, K., & Blake, N. (2019). Joy in work and reducing nurse burnout: From triple aim to quadruple aim. Advance Critical Care, 30(2), 185-188. https://doi.org/10.4037/aacnacc2019833 

Health Policy Institute of Ohio. (2020). A call to action: Improving clinical well-being and patient care and safety. https://www.healthpolicyohio.org/wp-content/uploads/2020/02/CallToAction_Brief.pdf 

Hittle, B. M., Wong, I. S., & Caruso, C. C. (2020). Managing fatigue during times of crisis: Guidance for nurses, managers, and other healthcare workers. Centers for Disease Control and Prevention. https://blogs.cdc.gov/niosh-science-blog/2020/04/02/fatigue-crisis-hcw/?deliveryName=USCDC_170-DM24834 

Irigoyen, M., Porras-Segovia, A., Galvan, L., Puigdevall, M., Giner, L., De Leon, S., & Baca-Garcia, E. (2019). Predictors of re-attempt in a cohort of suicide attempters: A survival analysis. Journal of Affective Disorders, 247, 20-28. https://doi.org/10.1016/j.jad.2018.12.050 

Joint Commission. (2019). Suicide prevention. https://www.jointcommission.org/resources/patient-safety-topics/suicide-prevention/ 

Joint Commission. (2021). Improving clinician well-being to reduce burnout. https://www.jointcommission.org/resources/news-and-multimedia/blogs/improvement-insights/2021/09/improving-clinician-well-being-to-reduce-burnout/ 

Maslach, C. (2003). Burnout: The cost of caring. Malor Books. 

Maslach, C., & Leiter, M. P. (2017). New insights into burnout and health care: Strategies for improving civility and alleviating burnout. Medical Teacher, 39(2), 160–163. https://doi.org/10.1080/0142159X.2016.1248918 

Mental Health America. (2020). The mental health of healthcare workers in COVID-19. https://mhanational.org/mental-health-healthcare-workers-covid-19 

Moutier, C. (2018). Physician mental health: An evidence-based approach to change. Journal of Medical Regulation, 104(2), 7-13. https://doi.org/10.30770/2572-1852-104.2.7 

National Action Alliance for Suicide Prevention. (2018). Recommended standard care for people with suicide risk. https://theactionalliance.org/resource/recommended-standard-care 

National Action Alliance for Suicide Prevention. (2019). Best practices in care transitions for individuals with suicide risk: Inpatient care to outpatient care. https://www.samhsa.gov/sites/default/files/suicide-risk-practices-in-care-transitions-11192019.pdf 

National Institute of Mental Health. (2021a). Suicide. https://www.nimh.nih.gov/health/statistics/suicide.shtml 

National Institute of Mental Health. (2021b). Suicide prevention. https://www.nimh.nih.gov/health/topics/suicide-prevention/index.shtml#part_153179 

National Suicide Prevention Lifeline. (n.d.). About the lifeline. Retrieved June 26, 2022, from https://suicidepreventionlifeline.org 

Ryan, E. P., & Oquendo, M. A. (2020). Suicide risk assessment and prevention: Challenges and opportunities. Focus: The Journal of Lifelong Learning in Psychiatry, 18(2), 88-99. https://doi.org/10.1176/appi.focus.20200011     

Schreiber, J., & Culpepper, L. (2022). Suicidal ideation and behavior in adults. UpToDate. Retrieved June 23, 2022, from https://www.uptodate.com/contents/suicidal-ideation-and-behavior-in-adults 

Singh, R., Volner, K., & Marlowe, D. (2021). Provider burnout. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK538330/#_NBK538330_pubdet_ 

Stone, D., Holland, K., Bartholow, B., Crosby, A., Davis, S., & Wilkins, N. (2017). Preventing suicide: A technical package of policy, programs, and practices. Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/pdf/suicidetechnicalpackage.pdf 

Substance Abuse and Mental Health Services Administration. (n.d.). Columbia suicide severity rating scale (C-SSRS). US Department of Health and Human Services. https://www.samhsa.gov/resource/dbhis/columbia-suicide-severity-rating-scale-c-ssrs 

Substance Abuse and Mental Health Services Administration. (2017). National strategy for suicide prevention implementation assessment report. https://store.samhsa.gov/product/National-Strategy-for-Suicide-Prevention-Implementation-Assessment-Report/sma17-5051 

Substance Abuse and Mental Health Services Administration. (2021). Key substance use and mental health indicators in the United States: Results from the 2020 national survey on drug use and health. https://www.samhsa.gov/data/sites/default/files/reports/rpt35319/2020NSDUHFFR1PDFW102121.pdf 

Tiesman, H., Weissman, D., Stone, D., Quinlan, K., & Chosewood, C. (2021). Suicide prevention for healthcare workers. Centers for Disease Control and Prevention. https://blogs.cdc.gov/niosh-science-blog/2021/09/17/suicide-prevention-hcw/ 

United Health Foundation. (2021). Teen suicide in the United States. https://www.americashealthrankings.org/explore/health-of-women-and-children/measure/teen_suicide/state/ALL 

US Department of Health & Human Services. (2009). SAFE-T pocket card: Suicide assessment five-step evaluation and triage for clinicians. https://store.samhsa.gov/product/SAFE-T-Pocket-Card-Suicide-Assessment-Five-Step-Evaluation-and-Triage-for-Clinicians/sma09-4432 

US Department of Health & Human Services. (2021). The surgeon general's call to action to implement the national strategy for suicide prevention. https://www.hhs.gov/sites/default/files/sprc-call-to-action.pdf 

US Department of Veterans Affairs. (2019). 2019 national veteran suicide prevention annual report. https://www.mentalhealth.va.gov/docs/data-sheets/2019/2019_National_Veteran_Suicide_Prevention_Annual_Report_508.pdf 

Walters, S. (2022). How nurses can combat compassion fatigue. NurseJournal. https://nursejournal.org/articles/combating-compassion-fatigue-in-nursing/ 

Wolotira, E. A. (2022). Trauma, compassion fatigue, and burnout in nurses: The nurse leader's response. Nurse Leader https://doi.org/10.1016/j.mnl.2022.04.009