Suicide is the tenth leading cause of death for all age groups nationally, and the second leading cause of death for individuals aged 10 to 34 years in the United States (Heron, 2019). Suicide is preventable. The goal is to decrease suicide by focusing on protective factors and decreasing risk factors (Centers for Disease Control and Prevention [CDC], 2019).
Advanced practice RNs (APRNs) are a subset of the largest group of health care providers (Kroning & Kroning, 2016; Neville & Roan, 2013). In fact, the number of nurses nationally exceeds 3.8 million, with the number of working RNs estimated to be 2.9 million (American Association of Colleges of Nursing, 2020; Hadad et al., 2020). Nationally, there are 270,000 nurse practitioners from all specialties (American Association of Nurse Practitioners, 2020). APRNs can be instrumental in fostering prevention of suicide events by assessing patients at each encounter for suicide, decreasing the stigma of mental health issues, providing resources to get help for mental health issues and suicide, and having conversations related to their experiences with suicide.
The purpose of the current study was to assess attitudes of APRNs toward suicide in individuals aged 15 to 24 years. The author's previous doctoral studies examined two groups of APRNs (in psychiatric and pediatric specialties) and their attitudes toward suicide, as measured by the Suicide Opinion Questionnaire (SOQ) (Domino, 2005).
In 2017, the quantitative data were analyzed and the results demonstrated that, overall, there were no differences in attitudes between the two groups; however, when individual items were analyzed, pediatric APRNs had a more positive attitude on five items and psychiatric APRNs had a more positive attitude on three items (Glodstein et al., 2018).
The current article describes the results of analyzing the qualitative data, which were examined to find themes in the narrative comments APRNs made after completing the SOQ. These themes, which were shared anonymously, can help APRNs be more aware of the epidemic of suicide and foster prevention.
Suicide Prevention in Students
Assessing APRNs' attitudes toward suicide and examining their comments about suicide can promote awareness and opportunities for education in teens and young adults who may consider being involved as peer mentors in campaigns to prevent suicide.
Examining studies that were conducted in schools demonstrates prior suicide prevention efforts in these settings. Most teens and young adults were enrolled in high school or undergraduate studies. Four researchers focused on suicide prevention with schools. The first study comprised 700 adolescents in high school classrooms, in which adolescent peer leaders delivered a suicide prevention program. The study found peer modeling to be a healthy coping mechanism and students with a history of suicidal ideation benefitted from participation in this program (Petova et al., 2015).
Petova et al. (2015) focused on positive outcomes as opposed to negative consequences or outcomes that suicide prevention campaigns generally focus on. The authors reported that their study was the first to evaluate the impact of positive themed suicide prevention on high school aged students. APRNs who intervene to assess for suicide in their patients are encouraging discussion about mental health topics in their practice settings. These adolescents will be empowered to get help for themselves in the future and act as peer models in their own school communities (Petova et al., 2015).
The second research team investigated the extent to which non-suicidal self-injuries in young adults contributed to suicidal thoughts and behaviors. More than 1,400 students in a national sample participated from five colleges in a longitudinal study. The instrument used was called A Survey of Student Wellbeing, which participants accessed via the internet. The results demonstrated that self-injury contributed to suicidal thoughts and behavior in 61.6% of cases. Because suicidal self-injury can contribute to suicidal thoughts and behaviors, it is an important topic to address for practitioners treating teens and young adults (Whitlock et al., 2013).
The third research team examined whether belonging to a fraternity or sorority had an influence on suicidal behavior or depression. The hypothesis that membership in a fraternity or sorority would be associated with social support, increased self-esteem, lower depression, and decreased suicidal ideation was not supported by the study. Participants included approximately 300 students nationally who were primarily female. The Beck Depression Inventory, Rosenberg Self-Esteem Scale, and Multidimensional Scale of Perceived Social Support were used. The study comprised less than one third males (Ridgway et al., 2014).
The fourth research team examined emotion regulation difficulties in high school students and youth–adult relationships. This study had approximately 8,000 students participating from more than 30 high schools in upstate New York and North Dakota. There were several scales used to measure suicide attempts, emotion regulation, and adolescents' perceptions of a trusted adult in the family, at school, and/or in the community. The study found that having a trusted adult in the community was associated with fewer suicide attempts. APRNs screening youth and their family members can provide support and positive reinforcement for healthy interactions between youth and adults as a source of strength (Pisani et al., 2013).
Suicide Prevention in Rural Communities
Walker et al. (2009) examined the pre- and post-test measures of attitudes, knowledge, self-esteem, and self-acceptance related to suicide in a national sample of 63 high schools from rural communities that participated in a suicide prevention training program. Results indicated a significant increase in participants' self-esteem, positive attitudes, and knowledge of suicide prevention but not an increase in self-acceptance. The authors suggest future work be conducted on improving peer support efforts. APRNs who complete training programs will have exposure to suicide prevention strategies that can lead to increasing knowledge and self-acceptance in teens and young adult patients.
Depression and Suicide
Researchers recommend psychiatrists incorporate depression and suicide screening at each encounter (Horowitz et al., 2009; Mann et al., 2005). However, it is imperative that pediatric and psychiatric APRNs incorporate depression and suicide screening during each well visit as an assessment measure (Shain & the Committee on Adolescence, 2016). These measures should occur for all patients as a baseline assessment and APRNs should create opportunities to have discussions with patients about depression and suicide.
Two groups of researchers discussed depression, with relevance to suicide awareness and prevention. In the first study, secondary data analysis was conducted by nurse researchers using the Beck Depression Inventory-II in a sample of >400 U.S. naval recruits in basic training to determine whether a sense of belonging was a buffer against depression (Sargent et al., 2002). The results of the study showed that a sense of belonging was inversely related to depression among persons with depression.
The second group of researchers evaluated a school program designed to prevent depression in adolescents (Garmy et al., 2014). This quasi-experimental study took place in Sweden with 62 students who were 14 years old. These students completed a pre-test, post-test, and 1-year follow up. Most students scored lower on depression after they attended a school program on prevention of depression. APRNs can recommend school districts referring students for evaluations conduct school-based programs focused on prevention of depression and suicide in their school settings.
Medical Illness and Suicide
Research conducted by Donald et al. (2006) discussed medically serious suicide attempts, characterized by patients requiring treatment in the emergency department (ED) in hospitals versus a population-based sample of adults. The age range of the 100 participants was 18 to 24 years and a questionnaire was designed to assess suicide risk and protective factors. The researchers identified risk factors associated with medically serious suicide attempts and factors that were protective against suicide attempts. One of the protective factors was social connectedness. The researchers wished to explore an understanding of risk factors for suicide because prior suicide attempts were the greatest predictors of completed suicides. They recommended designing evidence-based practice suicide prevention activities for young adults as a preventive measure (Donald et al., 2006).
Suicide Prevention in Health Care Professionals
Studies With Nurses. Traditionally, APRNs do not receive formal training in their educational programs in assessing for suicide, preventing suicide, and counseling families about suicide. APRNs' experiences with suicide assessment and prevention may be learned on the job through various experiences in practice. APRNs may not have a consistent protocol to follow related to suicide assessment. The literature and research about suicide prevention and education is primarily conducted in the medical community with the purpose of training medical residents to be competent in assessing suicide risk. The nursing literature that exists on this topic is limited and focuses on prevention in community settings, such as schools and community centers.
Botega et al. (2005) assessed nursing personnel's attitude to suicide prevention in Brazil and found that few professionals felt prepared to handle the risk of suicide. Nebhinani et al. (2013) assessed nursing students' attitudes toward suicide prevention in India and found that only one half of participants had positive attitudes toward suicide prevention as measured by the Attitudes to Suicide Prevention (ATSP) Scale (Herron et al., 2001), showing the need for education and training programs.
Another study using simulated standardized patients was conducted with a national sample of baccalaureate nursing students for the purposes of improving suicide screening behaviors (Luebbert & Popkess, 2015). Results of the study showed that the experimental group, which received the simulation versus standard lecture, demonstrated a significant difference in all measures compared to the control group.
Neville and Roan (2013) investigated nurses' attitudes toward suicide in hospitalized medical–surgical adult patients. A national convenience sample of 45 nurses, which included some APRNs, from five medical–surgical units and the ED, participated. The Attitudes Towards Attempted Suicide Questionnaire was used to gain an understanding of nurses' attitudes toward suicide and how to improve nursing care for vulnerable populations (Neville & Roan, 2013). Results demonstrated nurses with more education had higher mean scores on this scale.
Studies With Health Professionals. Four studies focused on health professionals' attitudes toward suicide. The first study was conducted in Australia and examined health professionals' attitudes toward suicide prevention initiatives. Participants were non-mental health professionals, with 26.9% being midwives. The researchers used the ATSP Scale in this study (Brunero et al., 2008). The second study was a multidisciplinary study of clinicians' views regarding assessing suicidal patients, with primarily physicians (88%) and a combination of physician's assistants and nurse practitioners (12%) with internal medicine practices. The study found that female primary care providers had lower confidence in assessing and treating suicide compared to male primary care providers; however, 88% of participants were physicians. The results are not specific to nurse practitioners (Graham et al., 2011).
The third study examined attitudes of health professionals toward suicide in the United Kingdom. There were 168 participants in the study, including general psychiatric nurses; however, there was no mention of advanced practice nurses being included. This study investigated adults, not specifically teens and young adults. The findings showed the most positive attitudes of suicide prevention were among community psychiatric nurses. The researchers also found more positive attitudes toward suicide prevention among staff with prior training (Herron et al., 2001).
The fourth study examined a suicide prevention program for mental health professionals. This study took place in Australia, with 242 public mental health staff members being trained in suicide prevention. There was a 3-day intensive workshop for 53 workers. The researchers stated evidence-based practices related to suicide were incorporated into the training, but those specific evidence-based practices were not reported. The study aimed to determine if the two groups of participants had differences in knowledge because of the training programs. Results demonstrated the group with more training had significantly higher knowledge when tested at Time 3. This study, which has the components of prevention inherent in the training program, could be replicated, but the training tools and instruments used need to be made available. This study does not specifically include adolescents (Donald et al., 2013).
Suicide Prevention in Primary Care
Many individuals who die by suicide visit their primary care provider within a short period before the end of their lives. APRNs would benefit from education about suicide prevention and detection, and incorporating assessment measures into each encounter would ultimately help detect this problem (Luoma et al., 2002; Mann et al., 2005).
Researchers reviewed suicide screening in the following settings: schools, primary care clinics, and EDs nationally. They highlighted the importance of the connection between depression and suicide and recommended a minimum standard of assessment for suicide at each encounter. The researchers stressed the importance of the development of instruments specific to measuring suicide that were age appropriate for youth, as opposed to using measurements only validated in adults. Another crucial factor was for youth to have a safe place to be discharged following a suicide attempt (Horowitz et al., 2009).
A national sample of individuals who ended their lives found that 45% contacted their primary care provider within 1 month prior to their death, and 77% had contact within 1 year of their death (Luoma et al., 2002). Universal screenings conducted in primary care while routine vital signs are taken (e.g., height, weight, blood pressure) would help detect at-risk patients who might otherwise not be assessed. Suicide risk and depression screenings for pediatric patients aged 11 to 21 years are endorsed by the American Academy of Pediatrics (2014, 2020).
After analyzing a national study, Wintersteen (2010) suggested screening adolescents from the ages of 12 to 17.9 to detect suicidal individuals in the pediatric population. Wintersteen (2010) trained staff at three clinics on suicide risk. By adding assessment of suicide risk to standard questions, the detection of suicidal ideation allowed quick referral to safe levels of care and prevented fatal outcomes.
Studies Examining Risk and Protective Factors
Raising awareness about risk and protective factors for suicidal patients will allow APRNs to identify suicidal clients or those at risk to receive counseling, an intervention, and/or potentially lifesaving treatment. As discussed earlier, Ridgway et al. (2014) investigated the relationship among belonging to a fraternity or sorority in college, depression, and suicidal ideation and found depression and suicidal ideation correlated negatively with self-esteem and social support. Whitlock et al. (2013) investigated the extent to which non-suicidal self-injury contributed to later suicidal thoughts and behaviors independent of shared risk factors.
In a seminal study, Resnick et al. (1997) conducted a cross-sectional analysis of data from the National Longitudinal Study of Adolescent Health, in which >12,000 adolescents from grades 7 through 12 participated to identify risk and protective factors in multiple domains. The importance of the authors' study over time and the identification of risk factors created relevance for the current author. Using data from a longitudinal analysis provides information about risk factors to educate teens and young adults so that they may pursue healthy lifestyles.
Mann et al. (2005) examined global plans for suicide prevention by performing a MEDLINE search and identified >5,000 articles related to suicide. One of the identified interventions was prevention programs in terms of primary and secondary outcomes. The important issues identified were that most clients who experienced completed suicide had contact with their primary care physician within 1 month of death and more than 90% of suicides in depressed youths were untreated pharmacologically at the time of death (Mann et al., 2005). Therefore, the importance of conducting suicide assessments at each encounter is underscored. The need to provide pharmacological intervention for teens and young adults with depression is paramount to treat and prevent suicide.
In a research study published in the American Journal of Psychiatry, children (aged 5 to 14 years) prescribed selective serotonin reuptake inhibitor antidepressant medications had lower suicide rates, and therefore being on a medication for depression was seen as a protective factor (Gibbons et al., 2006). Waldvogel et al. (2008) examined suicide risk factors and suicide prevention. Whitlock et al. (2014) examined the concept of connectedness and suicide prevention in adolescents aged 11 to 20 years.
Two studies investigated contagion peer suicidal behavior after exposure to suicide. The first study used a cluster method sampling design to obtain a national sample of >12,000 school-aged adolescents. The group exposed to a peer's suicide had a higher rate of suicide attempts in both waves or years examined. Some limitations of this study include: information was gathered from self-report interviews, which could lead to possible biases; information may have been misclassified; and data were collected more than 20 years before the study (Randall et al., 2015). The second study was taken from data in a Canadian sample of >16,000 teenagers aged 12 to 17 years. Results indicated the prevalence of exposure to a school-mate's suicide and personally knowing an individual who died by suicide increased with age. Exposure to suicide predicted suicidality in all age groups. Limitations of the study included self-report (Swanson & Colman, 2013).
Dr. Edwin Shneidman (1981) developed the psychological autopsy as a blueprint to recreate the events prior to and leading up to a suicide and focuses on the psychological aspects of the death. The process has been refined and now is a best practice postmortem procedure. The purpose of this blueprint is to make sense for survivors and foster preventive measures to reduce suicides in the population at large (American Association of Suicidology, 2016).
There are numerous studies using psychological autopsy. Two relevant studies include research by Portzky et al. (2009) and Houston et al. (2001). Using psychological autopsy, Portzky et al. (2009) investigated psychosocial and psychiatric risk factors of individuals aged 15 to 19 years living in Belgium who completed suicide. Relationship difficulties, adverse living conditions, and lack of treatment influenced the risk of suicide. Houston et al. (2001) investigated individuals aged 15 to 24 years who completed suicide in the United Kingdom and conducted psychological autopsy, examining coroner and medical records and conducting interviews with the living, close friends, or providers of the decedents. In this study, suicidal acts were not impulsive, but were attributed to a long history of problems starting in childhood and adolescence.
Assessing Attitudes of Health Professionals Toward Suicide
The Suicide Opinion Questionnaire. The SOQ measures individuals' attitudes to suicide as opposed to being an instrument assessing or predicting suicide in a person (Domino, 2005). This instrument comprises 100 items that measure attitudes to suicide using a Likert scale (Domino, 1980). The questionnaire has been used nationally, as well as internationally, and examines staff attitudes, as opposed to measuring an individual's level of suicide or suicidal behavior. The SOQ has been used in various studies, including a cross-cultural study of physicians in the United States and Italy, among college students in Canada and the United States, to compare Jews and Christians, and many other cross-cultural comparisons of groups (Domino, 2005). The study conducted using the SOQ with physicians compared attitudes and found that Italian physicians scored higher on seven of eight subscales. Researchers hypothesized that Italian physicians scored higher due to religious influences of Catholicism and the stigma associated with suicide in Italian culture (Domino & Perrone, 1993).
Suicide Opinion Questionnaire in Studies With Nurses. Alston and Robinson (1992) surveyed 184 nurses, who were members of the North Carolina State Board of Nursing, about their attitudes toward suicide using the SOQ. The nurses had various levels of education, including diploma, associate, baccalaureate, and master's degrees. Although the entire survey was administered, only 16 items were analyzed. Results indicated that older nurses and those with more experience agreed with the patient's right to die under certain circumstances. Participants were permitted to add free text comments after the survey.
Another group of nurse researchers assessed attitudes toward suicide in nurses and physicians working with the self-harm pediatric population in England. This study had 179 participants, of which 134 were nurses. Both groups had agreement on six of the clinical scales that were analyzed; however, physicians scored higher (which suggests a more positive attitude) on the subscale for mental illness (Anderson & Standen, 2007). The two studies with nurses are the only such studies the current author was aware of that focused primarily on nurses' attitudes toward suicide, being assessed with the SOQ. These studies, Alston and Robinson (1992) and Anderson and Standen (2007), guided the current author in formulating the research of APRNs attitudes toward suicide in the 15- to 24-year-old population (Glodstein et al., 2018).
The SOQ was the survey administered to two groups of APRNs (i.e., nurses in psychiatric settings and nurses in pediatric settings). More than 300 people from one group took the survey and 100 took the survey from the other group. There were 95 surveys that were complete and usable from one group, therefore 95 surveys from each group were analyzed. Of the total 190 surveys that were analyzed, 107 individuals made comments after completing the survey. Forty-two comments were made by psychiatric APRNs and 65 comments were made by pediatric APRNs.
The comments made by participants contained personal, powerful messages. The statements made by individuals were done voluntarily and by more than one half of participants. Seven statements represented what many of the individuals who commented were expressing (Table 1).
Representative Qualitative Statements
Participants could make comments after taking the survey, providing narrative about their experiences. Narrative inquiry is a method that allows stories to be used as data (Duffy, 2012). Narrative comments allow participants to give their personal experiences and add richness to the quantitative information obtained. Without the narrative we would not know about the personal and professional experiences of participants, about their thoughts related to and attitudes toward suicide, and we would not be able to raise awareness by allowing APRNs to process their feelings related to suicide.
Representative Full Text of Statements
Every suicide attempt has a story. So generalizations are not useful. Culture, unreasonable expectations, loss, feelings of worthlessness or undeserved success may be the motivating factor. Concerned caring listening can help.
In my career, I have had several patients, a former student and two coworkers who have committed suicide. Each one takes something out of the provider. The current epidemic among servicemen and women is disturbing on many levels and we must do something about it. Two years ago a former PMHNP [psychiatric–mental health nurse practitioner] student took her own life after graduation. This time I did something by establishing a scholarship in her name for future PMHNP graduates. It is an epidemic.
My nephew committed suicide when he was 18 years old. He had thoughts of suicide most of his life. He finally told his parents approximately 6 months before he committed suicide. He did get intensive treatment that included several hospitalizations, therapy, ECT [electroconvulsive therapy]. He had attempts that usually took place during the time of an activity that he did well in the past but due to body changes, competition, he was no longer coming in first place. Something that he took pride in became an event where he committed suicide.
My younger brother committed suicide at age 19 after two previous unsuccessful attempts. My father may have also committed suicide, but we are not sure. Loneliness, broken family, etc., had nothing to do with it. In my opinion, depression is usually the cause of suicide, but not always.
I have had three patients [commit] suicide while active patients in my practice. It is a difficult tragedy to overcome. There is too much concern now placed on “risk management” and not enough attention on the grieving process for a therapist when a patient dies by suicide.
I interrupted the suicide attempt of a friend when we were 18, in the long run she was grateful, as was I. She was depressed, lonesome, and upset at family members.
...I am a survivor, just lucky and recovered. And I try to prevent suicide in my patients and learn as much about this as I can, but the more I study, the more I realize this is often not preventable.
The qualitative data were presented to a group of approximately 25 participants at an international conference. Conference participants were forthcoming and said many providers do not want to ask about suicide because they do not know what they will do if someone responds that they are feeling suicidal. Some participants reported that police were not working collaboratively with other mental health professionals. Others reported a great degree of collaboration with law enforcement, primary care, and community partners. One area that was discussed was the need to fully assess individuals for lethality and intent, as opposed to trying to talk someone out of it.
APRNs in any specialty will most likely have contact with a suicidal patient. The feelings patients elicit may cause anxiety, transference, counter-transference, and fear, which may affect the quality of care a patient receives. APRNs who encounter the loss of a patient from suicide, or the anxiety related to a patient who has made a suicide attempt, experience many feelings and may not have supervision and support to adequately process these emotions. Alston and Robinson (1992, p. 206) wrote that “it is imperative that nurses gain insight into their attitudes toward suicide and attempt to resolve those feelings.”
The language of the SOQ, which was created in the 1980s, uses terms such as “committed suicide.” This language is seen as outdated and is no longer in use because it is damaging and similar to accusing a person of committing a sin or committing a crime (Hocknell, 2017; Mental Health Coordinating Council [MHCC], 2018). Language related to suicide and mental health issues should not carry stigma. It is also important to note that individual free text responses included words and/or terms such as “committed suicide” or “successful suicide.” The verbatim comments of participants in this study were used to create authenticity; however, individuals are encouraged to use phrases such as, “one ends their life by suicide” in place of “committed suicide,” and “a person attempted to end their life,” instead of “unsuccessful suicide” (MHCC, 2018).
Implications for Practice
APRNs need education about using helpful language to promote patients and practitioners to get help for feelings of suicide and processing suicide events. To promote wellness, nurses from all specialties and educational levels need to provide care with language that is free of stigma. The work-force consists of advanced practice and novel practice nurses. Many may not receive education about the updated language to promote mental wellness and decrease stigma in mental health. Suicide, which is a national crisis, requires nurses to receive training during their basic education.
Graduate school nurse practitioner students have varying experiences, and some may have personal, professional, and/or no exposure to suicide prevention training and/or care of suicidal patients. This topic is infused in the graduate program, where the current author teaches. Students have various reactions to this topic. For example, a novice student expressed panic when she was requested to watch a documentary about suicide during one of her first on-site experiences, reporting she recently lost a friend to suicide. Students participate in a simulation about breaking “the bad news” to parents after the suicide attempt and eventual death of their son. Students display high anxiety, however, later report the simulation is invaluable as they have the chance to get in touch with their emotions around this exercise and process this in supervision with students and faculty. A suicide training conducted by the American Foundation of Suicide Prevention was met with mixed reviews by students as some believe this takes up “too much time,” whereas others are grateful for the topic and training. Students have awareness that this is a part of every psychiatric diagnosis, and no patient population is immune from the risk of suicide.
Groups exist to allow families and survivors of suicide to have support. Based on comments in this survey, the author is aware that APRNs have experienced the loss of patients but do not have a safe space to discuss these issues. The creation of a suicide support group for health care workers and APRNs to discuss and grieve the loss of patients would be beneficial and therapeutic.
Suicide should be a mandatory education piece for license renewal, just as infection control and child abuse are required in certain states. Certainly a phenomenon that is a leading cause of death in all age groups should require mandatory education for all health care specialties, and nursing should take the lead in initiating this standard of care.
Future studies should include the use of the SOQ with updated language, which uses phrases such as, “a person made a suicide attempt,” as opposed to “committed suicide.” This language is outdated and seen as judgmental. Updated language will be more inclusive, sensitive, and allow groups and individuals of all races, genders, and religions, who have mental health and physical needs to receive treatment, as opposed to individuals and groups feeling stigmatized or that they are not able to get care. Future studies using an updated tool, which measures attitudes toward suicide, could include more subspecial-ties of APRNs, a cross-cultural group of APRNs, and could administer the entire SOQ as opposed to only a few subscales, which may yield more data to raise awareness about attitudes toward suicide. There is a great need for all APRNs, RNs, and health care workers to have information that raises awareness about suicide, ultimately leading to prevention.