According to the Centers for Disease Control and Prevention, suicide was responsible for 49 449 deaths in the United States in 2022, an increase of 2.6% from 2021.1 Since 2000, the national suicide rate has increased 36%, becoming a major public health concern.1 Among healthcare workers, nurses are at an increased risk of suicide.1 Given this increase, nurses' risk for suicide has become a major concern for clinicians and nurse administrators.2 Nurse administrators can be faced with numerous practical and emotional challenges when a suicide occurs. Their attention to the welfare and safety of nurse employees becomes a major focus of their time and energy. Staff can become depressed and disillusioned with their roles, and attrition can increase. Problems associated with care provided, staffing shortages, and overall environmental difficulties can also result.3

Nurse suicide seems to be a growing problem. Clearly, nurses are vulnerable due to the psychological, emotional, and physical demands of their work; work hours that are long and irregular; low staffing level; and difficult work relationships.2 Another contributing factor identified by Davis et al4 is that nurses are continually exposed to patient pain, suffering, and helplessness that can increase the risk of depression and suicide. Davis et al4 suggest the need for increased support and the development of initiatives to promote nurse well-being and prevent suicide.

The Kentucky Board of Nursing (KBN) has reported that, from 2016 to 2022, 58 nurses have died by suicide within the state.5,6 As a result, the KBN revised its continuing education competency requirements to include a minimum of 2 contact hours related to suicide prevention before license renewal.5 Content requirements for the 2 contact hours included information related to the potential impact of stress, how to identify individuals at risk for suicide, appropriate referrals for individuals at risk, ethics regarding suicide, and legal implications when caring for patients and nurses who are suicidal.5 The purpose of this study was to evaluate an educational intervention, based on KBN requirements, on nurses' understanding of the act of suicide, accepted beliefs regarding suicide, and actions to be taken regarding nurse suicide.

Methods Study Design

An institutional review board–approved quasi-experimental study was conducted to examine the effect of an educational intervention on nurses' knowledge, beliefs, and actions to be taken, regarding suicide. Data were collected immediately pre and post intervention.

Setting/Sample

The study included 7 sites within a 9-hospital system located in the southeastern United States. One group of participants attended an in-person class at one of the sites, a Magnet®-redesignated, 434-bed inpatient facility. The other participants in the 6 remaining hospitals convened at each site synchronously to the program via a Zoom link with a program facilitator present on-site.

Educational Intervention

Swift and Twycross7 reported a positive association between providing nurses with knowledge and their willingness to respond effectively. In response to this relationship, a number of approaches to informing nurses about suicide have been developed.8 At this institution, an educational intervention was designed to enhance nurses' knowledge of 3 categories of concern related to suicide in general: level of understanding related to suicide, accepted beliefs regarding a suicide, and actions that nurses could take to prevent a suicide. Given the importance of this topic, an administrative decision was made to give nurses time during working hours to access this education intervention.

Two psychiatric nurse practitioner faculty with experience in suicide education from a local university and 3 hospital-based professional development specialists created a 2-hour class focusing on content required by KBN. Overall cost of the intervention was the cost of nursing time for attending or watching the program. That cost is estimated as $17 136. Among other related topics, responses to stress; risk for suicide; national, state, and hospital-based resources; and ethical/legal issues were addressed (SDC, https://links.lww.com/JONA/B149). During the development of the class, the content expanded beyond the state requirements to include the effects of trauma and compassion fatigue among nurses in response to anecdotal evidence of these problems within the system. To supplement class content, a trifold resource brochure was developed by one of the professional development specialists (SDC, https://links.lww.com/JONA/B150). The brochure was presented during the class, and a copy was given to each participant. Hospital-based and community-based resources are clearly described in the brochure.

Two faculty and 1 professional development specialist taught the class. The host facility had live presenters for nurses who could attend in person. The presentation was virtually facilitated at 6 hospitals simultaneously. In addition to information sharing, the presenters engaged participants in case scenarios, assessments, and self-reflection to apply and promote learning.

Measures

After a review of the literature and discussion among experienced educators (n = 3), an investigator-designed questionnaire was developed. Content validity was assessed individually, and agreement was reached. Given that all items are factual and there is not an expectation of change over time, reliability was not assessed. The Baptist Health Knowledge of Suicide Questionnaire (BHSQ) assessed knowledge (10 items), beliefs regarding suicide (4 items), and actions to be taken to prevent suicide (3 items) (SDC, https://links.lww.com/JONA/B151). A Likert scale1-3 was used to score the instrument. Range of scores for each of 3 subscales was as follows: understanding, 10 to 30; beliefs, 4 to 12; and actions to be taken, 3 to 9 points. A space for comments was placed at the end of the instrument. The instrument took 5 to 10 minutes to complete. Scores were calculated on each of the 3 subscales.

Data Analysis

Data were analyzed using SPSS version 25 (Armonk, New York). Descriptive statistics and paired sample t tests were calculated.

Results

This study included nurses (N = 225) employed at 7 hospitals within a community hospital system. Participants' mean age was 46 (11.5) years, with a range of 22 to 70 years (Table 1). Years of nursing experience ranged from 1 to 48, with a mean (SD) of 18.7 (12). Nurses from a variety of practice areas participated.

Table 1 - Nursing Demographics (N = 225) n % Gender  Male 15 6.7  Female 204 90.7 Area of practice  Critical care/ICU 23 10.2  Surgical services 20 8.9  Outpatient oncology and infusion 7 3.1  Emergency department 14 6.2  Med/surg/tele 34 15.1  Inpatient psych 2 0.9  Women's and children's 23 10.2  Cardiac services 5 2.2  Outpatient clinic or medical practice 13 5.8  Other 82 36.4 Nursing position  Staff nurse 119 52.9  Charge nurse 17 7.6  Nurse leader 77 34.2 Highest degree earned  LPN 5 2.2  ADN 53 23.6  BSN 121 53.8  MSN 39 17.3  DNP 4 1.8  PhD 1 0.4  Other 1 0.4 Lost someone to suicide  Yes 64 28.4  No 159 70.7  Total 225 100.0

Abbeviations: ADN, Associate Degree in Nursing; BSN, Bachelors of Science in Nursing; DNP, Doctor of Nursing Practice; ICU, Intensive Care Unit; Med/ Surg/ tele Medical surgical, telemetry Inpatient psych; Inpatient psychiatric LPN, Licensed Practical Nurse; MSN, Master of Science in Nursing; PhD, Doctor of Philosophy.

Dependent t test analysis (Table 2) revealed a significant and meaningful increase in the subscale nurses' understanding related to suicide pre (mean [SD], 21.3 [4]) and post (mean [SD], 28.3 [2.5]) class (t = −26.2, P < 0.001). Although a statistically significant change occurred in the subscale of belief, the mean difference (0.6) is too small to be meaningful (Table 3). Regarding actions related to recognizing and intervening for a colleague at risk, a meaningful and significant increase was noted from pre (mean [SD], 5.9 [1.2]) to post (mean [SD], 7.9 [1.3]) workshop (t = −20, P < 0.001) (Table 4). The greatest improvement in individual items was in the knowledge assessment: “hospital-based support resources available” and “community support resources available.” Before the class, 63.1% of participants indicated they knew “a little” regarding hospital-based support resources available. After the class, 91.1% of participants indicated they knew “a great deal” regarding this item. Knowledge regarding “community support resources available” changed from “a little” (64.4%) pre to “a great deal” (80.9%) post. Comments from 27 participants focused on the complexity of suicide, personal loss, and the difficulty identifying “suicidal behaviors.”

Table 2 - Individual Item Analysis: Understanding Scale Pre, n (%) Post, n (%) 1. The extent of the problem in the United States  Not at all 5 (2.2) 0  A little 109 (48.4) 15 (6.7)  A great deal 111 (49.3) 210 (93.3) 2. General risk factors  Not at all 3 (1.3) 0  A little 108 (48) 6 (2.7)  A great deal 114 (50.7) 219 (97.3) 3. Assessment strategies  Not at all 11 (4.9) 1 (0.4)  A little 160 (71.1) 28 (12.4)  A great deal 54 (24) 196 (87.1) 4. Tools available  Not at all 33 (14.7) 1 (0.4)  A little 153 (68) 32 (14.2)  A great deal 39 (17.3) 192 (85.3) 5. Prevention  Not at all 18 (8) 1 (0.4)  A little 163 (72.4) 34 (15.1)  A great deal 44 (19.6) 190 (84.4) 6. Risk factors for nurses  Not at all 20 (8.9) 0  A little 137 (60.9) 8 (3.6)  A great deal 68 (30.2) 217 (96.4) 7. Legal issues  Not at all 78 (34.7) 6 (2.7)  A little 125 (55.6) 84 (37.3)  A great deal 22 (9.8) 135 (60) 8. Ethical issues  Not at all 35 (15.6) 4 (1.8)  A little 148 (65.8) 72 (32)  A great deal 42 (18.7) 149 (66.2) 9. Hospital-based support resources available  Not at all 36 (16) 1 (0.4)  A little 142 (63.1) 19 (8.4)  A great deal 47 (20.9) 205 (91.1) 10. Community support resources available  Not at all 46 (20.4) 2 (0.9)  A little 145 (64.4) 41 (18.2)  A great deal 34 (15.1) 182 (80.9)
Table 3 - Individual Item Analysis: Belief Scale Pre, n (%) Post, n (%) 1. It is a reflection of mental illness.  Not at all 12 (5.3) 14 (6.2)  Some of the time 169 (75.1) 152 (67.6)  All of the time 44 (19.6) 59 (26.2) 2. It is an understandable act.  Not at all 84 (37.3) 50 (22.2)  Some of the time 127 (56.4) 136 (60.4)  All of the time 14 (6.2) 39 (17.3) 3. My self-care needs are important.  Not at all 5 (2.2) 1 (0.4)  Some of the time 69 (30.7) 23 (10.2)  All of the time 151 (67.1) 201 (89.3) 4. I am able to recognize and process my emotions.  Not at all 2 (0.9) 2 (0.9)  Some of the time 111 (49.3) 94 (41.8)  All of the time 112 (49.8) 129 (57.3)
Table 4 - Individual Item Analysis: Action Scale Pre, n (%) Post, n (%) 1. I can recognize a nurse at risk for suicide.  Not at all 39 (17.3) 2 (0.9)  Some of the time 177 (78.7) 99 (44)  All of the time 9 (4) 124 (55.1) 2. I can assess risk factors for suicide among my colleagues.  Not at all 43 (19.1) 2 (0.9)  Some of the time 172 (76.4) 77 (34.2)  All of the time 10 (4.4) 146 (64.9) 3. I can intervene when risk factors are present.  Not at all 23 (10.2) 1 (0.4)  Some of the time 144 (64) 64 (28.4)  All of the time 58 (25.8) 160 (71.1)
Discussion

Changes in understanding, beliefs, and actions to be taken post intervention suggest that conducting a specifically designed educational experience addressing problems associated with suicide among nurses is informative and can result in positive change. Responses to individual items revealed a number of important concerns. Results suggest that psychological, legal, and observational strategies need to be included when designing educational interventions regarding suicide for nurses.

Analysis of individual items revealed that knowledge regarding legal issues, ethical issues, and resources, both hospital based and community based, was largely unknown before the intervention. Positive change, however, occurred in each of these areas. In terms of action, knowledge regarding assessing “risk factors for suicide among my colleagues” and “intervening” when risk factors are present was apparent. In relation to the belief subscale, it seems that a considerable number of nurses did not believe suicide can be an understandable act. Responses retrieved from the “comments” section of the instrument reflected nurses' concerns regarding assessing behaviors that might lead to suicide. Collegial relationships at work were not thought to provide sufficient information to assess their coworkers' desire to end their lives. From this section of the instrument, it was clear that nurses who have experienced a suicide within their families or friends are seriously impacted by the loss.

The change in response to items addressing the availability of resources may, in part, be the result of the brochure. The brochure that was disseminated to all participants clearly identifies hospital-based and community-based resources. The small pre-post mean differences in beliefs after the intervention may be due to strong cultural biases regarding suicide. For example, 1 study examining trends in religious and social beliefs regarding suicide found that individuals who could be categorized as social liberals were more likely to convey their suicidal thoughts to another individual, thereby leading to an intervention, than Christian conservatives.9 Nurse administrators might want to consider religious and social beliefs of specific geographic regions when designing an educational intervention aimed toward enhancing nurses' knowledge regarding suicide. Items related to beliefs could be based on such an assessment.

Implications for Nurse Leaders

This study demonstrates the impact an education program can have in equipping nurses to recognize, assess, and intervene if they suspect that colleagues may be contemplating suicide. In an effort to promote practice environments that support the mental health of nurses, nurse leaders may want to consider implementing an educational program on the topics identified in this study and develop and disseminate a brochure clearly detailing hospital- and community-based resources. The development of the program described in this study was the result of a state Board of Nursing mandate. On the basis of an assessment of nurse suicide in specific states, nurse leaders may want to advocate for statewide education on this topic.

Limitations

Given that nurses' understanding, beliefs, and actions regarding suicide may depend on the culture of their geographical region, a limitation of this study is that it was conducted in 7 hospitals in 1 hospital system in 1 southeastern state. Because individual items may need to be modified based on geographical region, findings of this study may not be generalizable to other institutions. Another limitation is the inability to analyze gender differences in relation to nurse knowledge regarding suicide due to the sample size.

Conclusions

The findings demonstrate that pre-post an investigator-designed educational intervention related to nurse suicide, nurses' knowledge increased in the areas of understanding, actions to be taken, and beliefs about taking one's own life. Specific recommendations that flow from results include developing and disseminating a document containing information regarding hospital- and community-based resources, assessing cultural beliefs before designing the intervention, and modifying both questionnaire and intervention to consider those beliefs.

Acknowledgments

The authors would like to acknowledge the following: Aimee Wentz, MSN, RN, CNOR, Director of Education and Development, BH Hardin; Kim Scarborough, BSN, RNC-MNN, RRT, Educator, BH Hardin; Karon Curtis, MSN, APRN, ACNS-BC, Education Instructor, BH Paducah; Sherry Hopper, MSN, RN, APRN, Director of Education and Staff Development, BH Corbin; and Angela Mueller, MSN, RN, BH Floyd Clinical Education Manager. They thank the Chief Nursing Officers at Baptist Health System, namely, Dee Beckman, DNP, MBA, MSN, RN, NE-BC; Sharon Freyer, MSN, RN; Christy Littrell, BSN, RN-BC; Sharon Wright, MSN, RN, NE-BC; Mendy Blair, MSN, RN-BC, NE-BC; Sherri Mays, MSN, RN; and Kelly McMinoway, MHA, BSN, RN, as well as Librarian Lonnie Wright, MSLS.

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