Last spring, when my son was a college senior, I received a distressed phone call from him. He related in great nightmarish detail the gruesome tale of a fellow student who had just leaped to his death from the 20th floor of his high-rise dormitory- a college student's suicide completed.
Also during the past spring semester, a young nursing student asked to speak to me. Upon completion of our interaction the facts were evident: this student had clearly stated that she wanted to die. Her plan was intact; she intended to drive her car off the road. Arrangements were made for her to be transported immediately to a nearby hospital's emergency department for psychiatric evaluation and treatment as required- a college student's suicide prevented.
An Age Group at Risk
According to the most recently available data presented in the Statistical Abstracts of the United States 1994 (United States Bureau of the Census, 1994), 17,100 young Americans (15 to 44 years old) died in 1991 due to suicide. At no other time in the life span were suicide rates so high. The statistical age group of 15 to 44 is used as our college student population is getting older. Hodgkinson (Farrell, 1988) reported a decline in the number of 18- to 24-yearold people seeking college educations and predicted that by 1991 half of all college students would be over 25, and 20% would be over 35. The age group being used also includes males, as the Division of Research of the National League for Nursing stated, "the overall number of men entering the nation's nursing schools has increased steadily for the past decade, from 6.3% of the total in 1985 to 8.2% in 1989" (Nursing Datasource, 1991, p. 16).
College Students: A Population at Risk
Suicide among college and university students is estimated by some to be 50% higher than for other Americans of comparable age (Westefeld & Pattilo, 1987), and Mathiasen (1988) states that according to many authors suicide is considered to be the number one health problem on the nation's campuses. Hardin and Weast (1989) inform us that suicide rates among college-age students have tripled over the past 25 years, and while national attention has been drawn to the problem of teenage suicide, research now indicates that the suicide rate actually increases as young adults move into jobs and college.
Hersh reminds us that "a student's college experience has always been filled with tension. The drive to succeed academically and interpersonally is feverish, stemming from the internal demands of identity formation and the external demands of performance in an evaluative, competitive, and challenging environment" (1985, p. 286). This author further states that crises will occur because college students seek change, take risks, and explore new territory. Colleges and universities have long recognized that all students will be in crisis at one time or another and that about 10% will show quite serious emotional problems (Hersh, 1985).
Mathiasen comments that "college students are faced with problems quite different from their peers who are not in college. Striving for academic success, having unclear vocational goals, and being away from home, many college students become depressed severely enough to contemplate suicide" (Westefeld, Whitchard, & Range, 1990, p. 468).
Professional Nursing Students: A Population at Intensified Risk
"Nursing students are more doubtful than other college students about their academic performance, they encounter stress in adjusting to a rigorous program of theory and clinical practice. The reality is often far different from a prospective student's image of it" (Lampkin, Cannon, & Fairchild, 1985, p. 148). This reality shock was poignantly illustrated to me by two young men to whom I was talking at a Freshmen Nursing Student Welcoming Reception. Each young man had previously completed a baccalaureate degree in another field and had now selected to pursue a professional nursing career. They were halfway through the first required nursing course- they were truly stunned, stating that "never" at any point during their previous academic endeavors had they ever worked so hard or experienced so much stress.
Frequently, because our nursing students are somewhat older, they experience the difficulty of adding the stressful role of full-time student to a life that is already strained with many other roles, such as marriage partner, parent, home manager, and/or maintainer of economic stability. The complexity of managing this diversified role overload can easily create a personal milieu with a potential for crisis, which not infrequently manifests itself in the symptom of depression.
Depression is the most frequent precursor of suicide (Mathiasen, 1988). It is of interest to note that Haack and Harford's 1984 research (Floyd, 1991) found that 55% of the nursing students studied from three private schools of nursing reported high levels of depressive symptomatology.
The Value of a Caring, Supportive Faculty-Student Relationship
If we as nursing faculty want to be in the best possible position to assist a potentially suicidal student, hopefully, the foundation of a faculty-student relationship, rich with trust, support, and caring, has already been established.
Buchanan (1993) believes that the nature of teacher-student relationships can be understood within Peplau's interpersonal relatione framework, in which nursing education would be perceived as an interpersonal, investigative, nurturing process through which the teacher fosters the development of the student's personality and selfhood in the direction of maturity. There is evidence that support and encouragement are as important in adulthood as in early developmental periods of life (CReilly-Knapp, 1994).
As the concept of caring continues to escalate in importance as our dynamic definition of nursing evolves, so too is caring a crucial component of the teacherstudent relationship. Leininger and Watson agree, stating that "[c]are is the essence of nursing; it is a powerful and distinctive attribute of the discipline. Care is becoming a central focus of nursing education, and faculty members in schools of nursing are beginning to make care an imperative factor in teaching, research, and practice" (Beck, 1991, p. 18).
Faculty members might wonder just how expansive is this student caring. Does it extend to issues in their personal lives? The six nursing students who participated in Miller's 1990 phenomenological study related to the experience of caring in the teaching-learning process of nursing education felt that faculty caring about their personal concerns was important, as the research subjects described caring as a "[plrocess characterized by a pervasive atmosphere of support in a oneto-one or group context. An essential dimension of the caring interaction, as perceived by the students, was the faculty's 'holistic concern' [italics added] for them personally and academically" (Beck, 1991, p. 19).
It is important to point out that although faculty strives to provide a caring and supportive atmosphère that will enable students to easily approach them in times of need, their role is to listen and provide referrals as appropriate. One role they cannot assume is that of primary counselor. Speck points out, "[t]here is a great difference between taking someone on as a client for counseling and the appropriate use of counseling skills within our primary role as nurse, manager, chaplin, or nurse teacher, the difference lies in setting boundaries, being clear about the focus of the relationship and our role within it, and knowing the limitations of what time and skill we can offer" (1992, p. 22).
The following are faculty functions that will provide the most therapeutic outcome for a potentially suicidal nursing student. The acronym S.A. VE. is used to assist faculty in quickly recalling the essential components of the process:
* S: Suicidal behaviors.
* A: Assessment interview.
* V: Value student.
* E: Evaluation- referral.
S: Suicidal Behaviors
Identifying the potentially suicidal nursing student is the first step. Because of the longevity of contact hours spent with students in both lecture and clinical milieus, nursing faculty are in a uniquely favorable position to observe possible suicidal behaviors.
Ae previously mentioned, depression is the most frequent precursor to suicide (Mathiasen, 1988). Westefeld et al. support Mathiasen, stating, "[ depression, of course, has been found to be a predictor in many studies concerning suicide, and it has been identified as relevant for the college population as well" (1990, p. 467). Obviously, it would be most valuable if faculty planned an assessment interview with any student displaying depressive behaviors. In addition, any of the following behaviors would also warrant an immediate assessment:
1. Verbally threatened suicide (This is to be taken very seriously.).
2. Reports by others of depressive or suicidal behaviors by another individual.
3. Abrupt personality changes such as becoming moody or hypersensitive.
4. Dramatic drop in academic performance.
5. Themes of suicide, death, or depression in conversation, reading material, writing, or art work.
6. Making final arrangements, such as giving away prized personal possessions or making (or changing) a will.
7. Sudden unexplained recovery from depression.
8. Statements such as "1 just can't take it anymore."
Individuals who are considering suicide almost always give either a verbal or nonverbal clue of their intent to someone (Wilson & Kneisl, 1992). If a student has become socially isolated or estranged from their significant others, their lecturer or clinical instructor could be the only person to whom a clue has been given. It has been said that if a suicidal person is able to communicate and feel connected to just one person, the suicidal risk is greatly reduced. Nurse educators should be prepared and willing to immediately intervene therapeutically on behalf of a student who is sending them (and perhaps only to them) a cry for help.
A: Assessment Interview
Mathiasen reminds us, "[tjhere is a dire need for prompt evaluation of suicidal risk* (1988, p. 259). If we have reason to believe a student is at risk, an assessment interview should be arranged immediately. Although all nurse educators have solidly learned the fundamentals of suicide assessment in their basic nursing programs, lack of use of these skills can easily send a faculty member on a swift trajectory toward their own panic level of anxiety.
The goals of the assessment interview are to:
1. Enable the student to feel valued as a person.
2. Enable the student to express thoughts and feelings.
3. Assess if the student is a danger to themselves or others.
4. Provide an appropriate and timely referral, as required.
Hersh (1985) provides nurse educators with valuable information related to carrying out the assessment interview:
1. Present yourself as calm and confident (reassuring to studente).
2. Approach the student in a manner that says, "I am here to help you."
3. Conduct the interview in a room that feels comfortable and safe and where there will be no unnecessary interruptions.
4. Be empathie. It is unlikely that a therapeutic contact is possible without empathy. You must be open to share the burden of feelings that the student is experiencing in a nonjudgmental, supportive, and understanding manner.
5. Be genuine. Although students in crisis present a disorganized picture, they are alert to the genuineness of what is being said. If, for example, you do not understand what the student is saying, do not try to cover up or pretend. Or if the student asks whether you are feeling uncomfortable, do not try to hide the fact if you are.
6. Conduct a mental status exam. A long and formal history taking is not appropriate for the crisis situation. Essentially you want to answer the following question: How dangerous is this student to himself or to others?
7. Specific attention should be paid to the student's appearance, behavior, speech, mood, thinking processes, perceptual and motor functions, and orientation to time, space, and people.
8. Facilitate appropriate release of feelings. This emotional release assist in facilitating equilibrium.
After allowing a student ample time to express thoughts and feelings, if potential suicidal indicators have been noted, it is important to ask the student directly: Are you thinking of taking your own life?, or Are you feeling so badly that you are thinking about harming yourself?
V: Value Student
By the mere fact of your presence at an assessment interview, you are not only communicating value for that specific student's life, but additionally value for the quality of that life.
E: Evaluation'- Referral
At the conclusion of the interview, the faculty member needs to make a decision regarding disposition. If the student is found to be not suicidal, an appropriate follow-up plan should be made depending on the nature and severity of the student's present status.
For the student who, in your judgment, is at risk for harming themselves or others, it is now essential to make an immediate referral for a complete psychiatric assessment by a qualified psychiatric clinical expert. At this point you must assume the responsibility for ensuring the student's safety (Hersh, 1985). This means that the student should not be left alone. Arrangements for the psychiatric assessment can usually be made by contacting the Mental Health Services Department or Medical Office of the college or university. If these services are not offered on campus, plans should be made for a responsible person to accompany the student to the Emergency Department of a local hospital.
It is important to comment on the normal heightened stress level that is engendered in faculty when attempting to deal with a suicidal student's referral for care. Perhaps the knowledge that a large proportion of students who completed a suicide were never referred for treatment (Dashef, 1984) will give us the added strength to initiate and complete this humanitarian task.
Regardless of the type of disposition that has been made for the student, it is most beneficial for the faculty member to keep the lines of communication open. If the student has been hospitalized, phone calls or cards will enable the student to feel connected and will be a thoughtful demonstration of your continued support and caring. If the student has not been hospitalized, seek them out at intervals, just to ask how things are going. Again, your continued caring will be deeply appreciated.
Professional nursing studente are significantly at risk for possible suicide attempts or suicide completions. Nurse educators can play a crucial role by identifying, assessing, and immediately referring for further psychiatric evaluation and intervention, those students who exhibit possible suicidal behaviors.
Concomitantly, nurse educators can play a valuable role in the prevention of needless death of all college students by: 1) enhancing the awareness of this devastating problem among all individuals who make up their academic community, 2) assisting in the implementation of campus suicide prevention programs, and 3) advocating for the availability of maximum mental health services for the student population.
Our future nurses are a most treasured resource. We cannot afford to look the other way while many of our most promising young citizens are playing Russian roulette with their lives, thus risking societal deprivation of their potential contributions (Wright et al., 1984).
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