588286
research-article2015
JAPXXX10.1177/1078390315588286Journal of the American Psychiatric Nurses AssociationAdams
Board of Directors’ Column
APNA’s Suicide Competencies for Inpatient Psychiatric Nurses: “Saving Lives . . . One at a Time”
Journal of the American Psychiatric Nurses Association 2015, Vol. 21(3) 175–179 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078390315588286 jap.sagepub.com
Susie Adams1 Suicide is the 10th leading cause of death in the U.S. across all age categories (Centers for Disease Control and Prevention [CDC], 2015a, 2015b). This major U.S. public health problem is being addressed on multiple fronts across different health professions (American Psychiatric Association Work Group on Suicidal Behaviors, 2003; CRICO/RMF, 1996; Suicide Prevention Resource Center, 2006), including the development of suicide risk assessment and management competencies. Yet prior to 2015, none of the suicide competencies addressed the unique responsibilities of psychiatric mental health [PMH] inpatient nurses who provide 24-hour care for the most acutely distressed individuals including those hospitalized for suicidal and homicidal thoughts and behaviors. Providing emotional as well as physical care while creating a safe milieu or environment is the responsibility of the PMH nurse generalist for psychiatric inpatient facilities. Based on American Psychiatric Nurses Association (APNA) annual organizational surveys of member needs, PMH nurse generalists expressed the desire for educational content and best practices regarding management of individuals with suicidal thoughts and behaviors (APNA, 2015a). Additionally, literature reviews (Combs & Romm, 2007; Knesper, 2011; Large, Smith, Sharma, Nielssen, & Singh, 2011) and an analysis of Essentials of Baccalaureate Nursing (American Association of Colleges of Nursing, 2008) further supported gaps in nursing education regarding suicide risk assessment and management. In 2012, APNA •• Acknowledged that there are serious gaps in nursing education specifically in the area of suicide risk assessment, prevention, and intervention •• Recognized that despite the development of suicide prevention therapeutic frameworks, core competencies, guidelines, and standards of care for psychiatrists, psychologists, social workers, and advanced practice nurses, none have been developed specifically for inpatient PMH nurse generalists •• Identified that although generalist nurses represent the largest professional workforce in inpatient psychiatric units with 24-hour accountability for the
care and safety of the most vulnerable persons with mental illness, they have limited training in the assessment and management of persons at risk for suicide •• Recognized that there are no developed structures and processes for the education and training of generalist nurses who provide care and treatment to people at risk for suicide in psychiatric settings To address this knowledge gap among nurse generalists, the APNA Board of Directors convened a task force with the charge to develop suicide risk assessment and management competencies for inpatient PMH nurse generalists along with core course content in 2012 (Puntil et al., 2013). This column highlights the culmination of the work of this task force with the recent press release and online posting of APNA’s Suicide Risk Assessment and Competencies for PMH Nurse Generalists, APNA’s Position Statement for Dissemination, next steps in delivering the course content, providing certificate of course completion, and future plans for modifying the competencies and course content for application to general medical-surgical nurses, intensive care unit nurses, and other non-PMH nurse populations.
Significance of the Problem Since 2006 suicide has consistently ranked as the second leading cause of death for ages 15 to 24 and 25to 34, the third leading cause of death for ages 10 to 14, the fourth leading cause of death for ages 35 to 44, the fifth leading cause of death for ages 45 to 54, and the eighth leading cause of death for ages 55 to 64 (CDC, 2015c). Suicide rates in the United States have steadily climbed from a low of 10.4 per 100,000 in 2000 to the most recent rate of 12.6 per 100,000 in 2013, taking 41,149 lives that year 1
Susie Adams, PhD, RN, PMHNP/CNS-BC, FAANP, Vanderbilt University School of Nursing, Nashville, TN, USA Corresponding Author: Susie Adams, Vanderbilt University School of Nursing, 313 Godchaux Hall, 461 21st Avenue South, Nashville, TN 37240, USA. Email: [email protected]
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(CDC, 2015b). Suicide rates are highest among people 45 to 64 years at 19.1, followed by people 85 years and older (18.6; CDC, 2015b). Although suicide rates are high among the elderly, suicide is not among the top 10 leading causes of death for individuals 65 and older (CDC, 2015c). By contrast, suicide rates among youth and young adults (10.9) are lower than older age groups, yet suicide is the second leading cause of death for young adults ages 15 to 24 and adults ages 25 to 34 and the third leading cause of death for youth ages 10 to 14 (CDC, 2015c). In 2013, someone ended their life by suicide every 12.8 minutes (CDC, 2015b). In 2013, men had a suicide rate of 20.2, and women had a rate of 5.5 (CDC, 2015a). Of those who died by suicide in 2013, 77.9% were male and 22.1% were female (CDC, 2015a). In 2013, the highest U.S. suicide rate (14.2) was among Whites and the second highest rate (11.7) was among American Indians and Alaska Natives. Much lower and roughly similar rates were found among Asians and Pacific Islanders (5.8), Blacks (5.4), and Hispanics (5.7; American Foundation of Suicide Prevention, 2015). Nearly 70% of all suicides in 2013 were White men (CDC, 2015a). Increased suicide rates among veterans with both combat and noncombat duties have been the focus of public, Congressional, and Veterans Health Administration concern since 2003 with the engagement of Operation Enduring Freedom/ Operation Iraqi Freedom in the Middle East (Nicks, 2014). Among male veterans the suicide rate increased from 38.7 in 2009, 37.4 in 2010, to 40.0 in 2011 (Kemp, 2014). Among female veterans the suicide rate increased from 12.9 in 2009, 15.1 in 2010, and 14.4 in 2011 (Kemp, 2014). Among male veterans this reflects a suicide rate increase of 44% between 2009 and 2011. Among female veterans this reflects a suicide rate increase of 11% in the same time period. These statistics indicate that nearly two veterans take their lives by suicide each day (Nicks, 2014). In 2013, firearms were the most common method of death by suicide, accounting for half (51.4%) of all suicide deaths (CDC, 2015b). The next most common methods were suffocation (including hangings) at 24.5% and poisoning at 16.1% (CDC, 2015b). Among male veterans, 70% suicide deaths were by firearms, 12.2% by poisoning, and 12% by strangulation or suffocation (Kemp, 2014). Among women veterans, 39% of suicide deaths were by poisoning, 37% by firearms, and 19% by strangulations or suffocation (Kemp, 2014). The increased occurrence of suicides on inpatient psychiatric units correlate with the overall increase in U.S. suicide rates over the past decade (Knoll, 2012). As early as 2003, the American Psychiatric Association estimated that 1,500 suicides annually occurred on inpatient units (American Psychiatric Association Work Group on
Suicidal Behaviors, 2003). More recent estimates project 1,800 inpatient suicides each year (Jabbarpour & Jayaram, 2011). The most common methods of inpatient suicide or suicide attempts include hanging or jumping from a roof or window (McBroom, 2012). Root cause analysis of suicides on medical units identified problems with communication of suicidal risk, the need for staff education on suicide assessment and management, the need for improved systematic suicide assessment and management. Root cause analysis of suicides on inpatient psychiatric units include inadequate monitoring and 15-minute suicide checks, reduced supervision especially during night shifts, change of shift handoffs, and unsupervised areas (Bowers, Banda, & Nijman, 2010). Since it only requires 4 to 5 minutes of moderate pressure on the carotid arteries of the neck to result in death by lack of oxygen to the brain, 15-minute suicide observation checks allow ample time for a patient to asphyxiate by hanging and almost any item of clothing can be used to form a noose (Maris, Berman, & Maltsberger, 1992). It is estimated that a psychiatric nurse will experience a completed suicide by a patient every 2½ years on average (Nijman, Bowers, Oud, & Jansen, 2005). The emotional toll of a completed suicide or suicide attempt on family and friends is widely recognized (Cerel, Jordan, & Duberstein, 2008; Parrish & Tunkle, 2005), yet the impact on the inpatient nurses who care for patients who complete suicide is not well studied in the United States. Studies in Norway and Japan note the need for emotional support and the risk of posttraumatic stress disorder among inpatient psychiatric nurses coping with traumatic events surrounding the suicide of a patient in their care (Gilje, Talseth, & Norberg, 2005; Takahashi et al., 2011). These researchers note the limited availability of systematic post-suicide mental health care programs for these nurses and the lack of suicide-related education as problematic (Takahashi et al., 2011). This correlates with APNA’s recognition to develop suicide competencies and educational content to prepare inpatient psychiatric nurses to assess and manage patients with suicidal thoughts and behaviors.
Dissemination of Task Force Suicide Competencies On March 12, 2015, APNA issued a press release announcing the Psychiatric-Mental Health Nurse Essential Competencies for Assessment and Management of Individuals at Risk for Suicide, the first competencies specifically developed for registered nurses that provide a guide for evidence-based best practice in nurses’ assessment and management of hospitalized patients who may be at risk for suicide (APNA, 2015b). The overall aim of the competencies is to improve the standard of inpatient
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Adams nursing care for suicide prevention and to reduce suicide morbidity and mortality in persons who are hospitalized for inpatient psychiatric treatment. The nine competencies aim to increase nurses’ comfort, confidence, and competence in suicide assessment and management of suicide risk and cover the following areas: the phenomenon of suicide; managing personal reactions, attitudes, and beliefs; developing and maintaining a therapeutic relationship; collecting accurate assessment information; communicating suicide risk to appropriate persons; formulating a risk assessment; developing an ongoing nursing plan of care; assessing the safety of the patient environment; legal and ethical issues; and documenting suicide risk. They provide a foundation for training curricula and measuring the knowledge, skills, and attitudes necessary for expert care in this area. A task force of APNA members with expertise in suicide prevention, including one member with lived experience of suicide, adapted these competencies for psychiatric-mental health nurses from existing national competencies (see Acknowledgments section). In addition, an external panel of national experts in suicidology validated the competencies (see Acknowledgments section). The competencies align with broader national strategies to enhance behavioral health workforce competencies in suicide prevention. According to Janet York, PhD, PMHCNC-BC, FAAN, of Robert H. Johnson VAMC, who participated in the APNA task force, There has been a gap in training and education in suicide prevention for inpatient nurses, although they provide services to patients in acute psychiatric crises. . . . These competencies were adapted from the national Assessing and Managing Suicide Risk (AMSR) Competencies developed by the Suicide Prevention Resource Center and the American Association of Suicidology, and are consistent with the goals of the 2012 National Strategy for Suicide Prevention.
Implementation of Task Force Recommendations This same APNA task force has also developed an educational curriculum to support the adoption and implementation of the competencies. The curriculum has been piloted and refined to ensure that the suicide competencies can be met. In June of 2015, the first course on suicide competencies, Saving Lives . . . One at a Time, will be offered in Baltimore, MD, prior to APNA’s Clinical Psychopharmacology Institute. Participants who complete the 8-hour course will receive certificates in Suicide Risk Assessment and Management. Subsequent courses including “train the trainer” will be offered so that other nurses can use the APNA materials to teach this course, providing certification to all who complete the course requirements. The goal of the task force is that each nurse
trainer will reach 100 nurses and the ongoing certificate program can reach all inpatient psychiatric nurses. In conjunction with the release of these competencies, APNA issued a position statement that stresses that these competencies “address serious gaps in education for nurses who provide care to persons with mental health and substance use needs and that their dissemination will improve outcomes in suicide risk assessment, prevention, and intervention, ultimately increasing safety.” The position statement calls on “health care facilities and academic settings to adopt these nursing competencies in order to increase patient and nurse safety, and to enhance nurses’ confidence and competence in caring for patients at risk for suicide, ultimately improving patient outcomes.”
Future Steps The original task force for suicide competencies has been “sunsetted” and the APNA Board of Directors has appointed a new task force to develop universal competencies for nurses to use when assessing and managing individuals at risk for suicide across a variety of health care settings, including medical/surgical and critical care hospital settings. In addition to developing universal suicide competencies and refining “train the trainer” courses, the task group will publish findings once pilot and follow-up data collection is completed and analyzed. The dissemination of suicide competencies for nurses across academic and health care settings is intended to ultimately improve patient care and save lives. We are indebted to this team of APNA nurses who have developed the suicide competencies and course content that will serve as a foundation and catalyst to support psychiatric nurses across the country make a difference in saving lives. We look forward to the next iteration of task force suicide competencies and content for nurse generalists applicable to other practice settings. Who better than psychiatric mental health nurses to lead this initiative? Acknowledgment of Task Force Members Core Leaders:
Barbara J. Limandri, PhD, PMHNP, BC Cheryl Puntil, MN, APRN, PMHCNS-BC Janet York, PhD, PMHCS, BC, FAAN Pamela K. Greene, PhD, RN Deborah Hobbs, PhD, RN Content Contributors:
Eric Arauz, MLER Barbara Bonney, APRN
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Benjamin M. Evans, DD, DNP, RN APN, PMHCNS-BC Cynthia Kane-Hyman, MS, RN, CNS Dorothy Kassahn, MS, MEd, RN, PMHCNS-BC Pamela E. Marcus, RN, APRN/PMH-BC Joanne M. Matthews, DNP, APRN, PMHCNS-BC Esther Meerwijk, PhD Charmaine Platon, BSN, RN Amanda L. Schuh, MS, RN, PMHNP-BC Acknowledgment of External Validation Reviewers Jane Pearson, PhD Chair, Suicide Research Consortium National Institute of Mental Health (NIMH) Laurie Davidson, MA Project Manager, Provider Initiative Suicide Prevention Resource Center & American Association of Suicidality Caitlin Thompson, PhD Deputy Director of Suicide Prevention US Department of Veterans Affairs Peter Mills, PhD, MS Department of Veterans Affairs National Center for Patient Safety Field Office Psychologist, VAMC White River Junction Jane Englebright, PhD, RN At-Large Nursing Representative Joint Commission Board of Commissioners Richard McKeon, PhD Chief, Suicide Prevention Branch Center for Mental Health Services Substance Abuse and Mental Health Services Administration (SAMHSA) Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. American Foundation of Suicide Prevention. (2015). Understanding suicide facts and figures. Retrieved from https://www.afsp.org/understanding-suicide/facts-andfigures
American Psychiatric Association Work Group on Suicidal Behaviors. (D. Jacobs, Chair). (2003). Practice guidelines for the assessment and treatment of patients with suicidal behaviors. American Journal of Psychiatry Supplement, 11, 160. American Psychiatric Nurses Association. (2015a). APNA position statement: Competencies for nurse-assessment and management of inpatient suicide risk. Retrieved from http://www.apna.org/i4a/pages/index.cfm?pageID=5688 American Psychiatric Nurses Association. (2015b). Psychiatricmental health nurse essential competencies for assessment and management of individuals at risk for suicide. Retrieved from http://www.apna.org/i4a/pages/index. cfm?pageID=5684 Bowers, L., Banda, T., & Nijman, H. (2010). Suicide inside: A systematic review of inpatient suicides. Journal of Nervous and Mental Disorders, 198, 315-328. Centers for Disease Control and Prevention. (2015a). National suicide statistics at a glance. Retrieved from http://www. cdc.gov/violenceprevention/suicide/statistics/aag.html Centers for Disease Control and Prevention. (2015b). Suicide and self-inflicted injury: Fast stats. Retrieved from http:// www.cdc.gov/nchs/fastats/suicide.htm Centers for Disease Control and Prevention. (2015c). Ten leading causes of death and injury in U.S. Retrieved from http:// www.cdc.gov/injury/wisqars/leadingcauses.html Cerel, J., Jordan, J. R., & Duberstein, P. R. (2008). The impact of suicide on the family. Journal of Crisis Intervention and Suicide Prevention, 19, 38-44. Combs, H., & Romm, S. (2007). Psychiatric inpatient suicide: A literature review. Primary Psychiatry, 14, 67-74. CRICO/RMF. (1996). Guidelines for identification, assessment, and treatment planning for suicidality. Retrieved from http://www.rmf.harvard.edu/files/documents/suicideAs.pdf Gilje, F., Talseth, A. G., & Norberg, A. (2005). Psychiatric nurses’ response to suicidal psychiatric inpatients: Struggling with self and sufferer. Journal of Psychiatric and Mental Health Nursing, 12, 519-526. doi:10.111/ j.1365-2850.2005.00855.x Jabbarpour, Y. M., & Jayaram, G. (2011). Suicide risk: Navigating the failure modes. Focus, 9, 186-193. Retrieved from http://www.ap.psychiatryonline.org/article. aspx?articleid=114953 Kemp, J. E. (2014). Suicide rates in VHA patients through 2011 with comparisons with other Americans and other veterans through 2010. Retrieved from http://www.mentalhealth. va.gov/docs/Suicide_Data_Report_Update_January_2014. pdf. Knesper, D. J. (2011). Continuity of care for suicide prevention and research: Suicide attempts and suicide deaths subsequent to discharge from the emergency department or psychiatry inpatient unit. Newton, MA: Education Development Center. Knoll, J. L. (2012). Inpatient suicide: Identifying vulnerability in the hospital setting. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/suicide/inpatientsuicide-identifying-vulnerability-hospital-setting
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Adams Large, M. M., Smith, G. G., Sharma, S. S., Nielssen, O. O., & Singh, S. P. (2011). Systematic review and meta-analysis of the clinical factors associated with the suicide of psychiatric in-patients. Acta Psychiatrica Scandinavica, 124, 18-19. Maris, R. W., Berman, A. L., & Maltsberger, J. T. (1992). Summary and conclusions: What have we learned about suicide assessment and prediction? In R. W. Maris, A. L. Berman, J. T. Maltsberger, & R. I. Yufit (Eds.), Assessment and prediction of suicide (pp. 640-672). New York, NY: Guilford Press. McBroom, S. (2012). Reducing suicide risk in the hospital setting. Compass Newsletter, 12(3), 1-4. Nicks, D. (2014, January 10). U.S. veterans report: Suicide rate soars among young vets. TIME. Retrieved from http://time. com/304/report-suicide-rate-soars-among-young-vets/ Nijman, H., Bowers, L., Oud, N., & Jansen, G. (2005). Psychiatric nurses’ experiences with inpatient aggression. Aggressive Behavior, 31, 217-227.
Parrish, M., & Tunkle, J. (2005). Clinical challenges following an adolescent’s death by suicide: Bereavement issues faced by family, friends, schools, and clinicians. Clinical Social Work Journal, 33, 81-102. Puntil, C., York, J., Limandri, B., Greene, P., Arauz, E., & Hobbs, D. (2013). Competency-based training for PMH nurse generalists: Inpatient intervention and prevention of suicide. Journal of the American Psychiatric Nurses Association, 19, 205-210. doi:10.1177/1078390313496275 Suicide Prevention Resource Center. (2006). Core competencies in the assessment and management of suicidality. Newton, MA: Author. Takahashi, C., Chida, F., Nakamura, H., Akasada, H., Yagi, J., Koeda, A., . . . Sakai, A. (2011). The impact of inpatient suicide on psychiatric nurses and their need for support. BMC Psychiatry, 11, 38. doi:10.1186/1471-244X-11-38. Retrieved from http://www.biomedcentral.com/content/ pdf/1471-244X-11-38.pdf
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research-article2015
JAPXXX10.1177/1078390315588286Journal of the American Psychiatric Nurses AssociationAdams
Board of Directors’ Column
APNA’s Suicide Competencies for Inpatient Psychiatric Nurses: “Saving Lives . . . One at a Time”
Journal of the American Psychiatric Nurses Association 2015, Vol. 21(3) 175–179 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078390315588286 jap.sagepub.com
Susie Adams1 Suicide is the 10th leading cause of death in the U.S. across all age categories (Centers for Disease Control and Prevention [CDC], 2015a, 2015b). This major U.S. public health problem is being addressed on multiple fronts across different health professions (American Psychiatric Association Work Group on Suicidal Behaviors, 2003; CRICO/RMF, 1996; Suicide Prevention Resource Center, 2006), including the development of suicide risk assessment and management competencies. Yet prior to 2015, none of the suicide competencies addressed the unique responsibilities of psychiatric mental health [PMH] inpatient nurses who provide 24-hour care for the most acutely distressed individuals including those hospitalized for suicidal and homicidal thoughts and behaviors. Providing emotional as well as physical care while creating a safe milieu or environment is the responsibility of the PMH nurse generalist for psychiatric inpatient facilities. Based on American Psychiatric Nurses Association (APNA) annual organizational surveys of member needs, PMH nurse generalists expressed the desire for educational content and best practices regarding management of individuals with suicidal thoughts and behaviors (APNA, 2015a). Additionally, literature reviews (Combs & Romm, 2007; Knesper, 2011; Large, Smith, Sharma, Nielssen, & Singh, 2011) and an analysis of Essentials of Baccalaureate Nursing (American Association of Colleges of Nursing, 2008) further supported gaps in nursing education regarding suicide risk assessment and management. In 2012, APNA •• Acknowledged that there are serious gaps in nursing education specifically in the area of suicide risk assessment, prevention, and intervention •• Recognized that despite the development of suicide prevention therapeutic frameworks, core competencies, guidelines, and standards of care for psychiatrists, psychologists, social workers, and advanced practice nurses, none have been developed specifically for inpatient PMH nurse generalists •• Identified that although generalist nurses represent the largest professional workforce in inpatient psychiatric units with 24-hour accountability for the
care and safety of the most vulnerable persons with mental illness, they have limited training in the assessment and management of persons at risk for suicide •• Recognized that there are no developed structures and processes for the education and training of generalist nurses who provide care and treatment to people at risk for suicide in psychiatric settings To address this knowledge gap among nurse generalists, the APNA Board of Directors convened a task force with the charge to develop suicide risk assessment and management competencies for inpatient PMH nurse generalists along with core course content in 2012 (Puntil et al., 2013). This column highlights the culmination of the work of this task force with the recent press release and online posting of APNA’s Suicide Risk Assessment and Competencies for PMH Nurse Generalists, APNA’s Position Statement for Dissemination, next steps in delivering the course content, providing certificate of course completion, and future plans for modifying the competencies and course content for application to general medical-surgical nurses, intensive care unit nurses, and other non-PMH nurse populations.
Significance of the Problem Since 2006 suicide has consistently ranked as the second leading cause of death for ages 15 to 24 and 25to 34, the third leading cause of death for ages 10 to 14, the fourth leading cause of death for ages 35 to 44, the fifth leading cause of death for ages 45 to 54, and the eighth leading cause of death for ages 55 to 64 (CDC, 2015c). Suicide rates in the United States have steadily climbed from a low of 10.4 per 100,000 in 2000 to the most recent rate of 12.6 per 100,000 in 2013, taking 41,149 lives that year 1
Susie Adams, PhD, RN, PMHNP/CNS-BC, FAANP, Vanderbilt University School of Nursing, Nashville, TN, USA Corresponding Author: Susie Adams, Vanderbilt University School of Nursing, 313 Godchaux Hall, 461 21st Avenue South, Nashville, TN 37240, USA. Email: [email protected]
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(CDC, 2015b). Suicide rates are highest among people 45 to 64 years at 19.1, followed by people 85 years and older (18.6; CDC, 2015b). Although suicide rates are high among the elderly, suicide is not among the top 10 leading causes of death for individuals 65 and older (CDC, 2015c). By contrast, suicide rates among youth and young adults (10.9) are lower than older age groups, yet suicide is the second leading cause of death for young adults ages 15 to 24 and adults ages 25 to 34 and the third leading cause of death for youth ages 10 to 14 (CDC, 2015c). In 2013, someone ended their life by suicide every 12.8 minutes (CDC, 2015b). In 2013, men had a suicide rate of 20.2, and women had a rate of 5.5 (CDC, 2015a). Of those who died by suicide in 2013, 77.9% were male and 22.1% were female (CDC, 2015a). In 2013, the highest U.S. suicide rate (14.2) was among Whites and the second highest rate (11.7) was among American Indians and Alaska Natives. Much lower and roughly similar rates were found among Asians and Pacific Islanders (5.8), Blacks (5.4), and Hispanics (5.7; American Foundation of Suicide Prevention, 2015). Nearly 70% of all suicides in 2013 were White men (CDC, 2015a). Increased suicide rates among veterans with both combat and noncombat duties have been the focus of public, Congressional, and Veterans Health Administration concern since 2003 with the engagement of Operation Enduring Freedom/ Operation Iraqi Freedom in the Middle East (Nicks, 2014). Among male veterans the suicide rate increased from 38.7 in 2009, 37.4 in 2010, to 40.0 in 2011 (Kemp, 2014). Among female veterans the suicide rate increased from 12.9 in 2009, 15.1 in 2010, and 14.4 in 2011 (Kemp, 2014). Among male veterans this reflects a suicide rate increase of 44% between 2009 and 2011. Among female veterans this reflects a suicide rate increase of 11% in the same time period. These statistics indicate that nearly two veterans take their lives by suicide each day (Nicks, 2014). In 2013, firearms were the most common method of death by suicide, accounting for half (51.4%) of all suicide deaths (CDC, 2015b). The next most common methods were suffocation (including hangings) at 24.5% and poisoning at 16.1% (CDC, 2015b). Among male veterans, 70% suicide deaths were by firearms, 12.2% by poisoning, and 12% by strangulation or suffocation (Kemp, 2014). Among women veterans, 39% of suicide deaths were by poisoning, 37% by firearms, and 19% by strangulations or suffocation (Kemp, 2014). The increased occurrence of suicides on inpatient psychiatric units correlate with the overall increase in U.S. suicide rates over the past decade (Knoll, 2012). As early as 2003, the American Psychiatric Association estimated that 1,500 suicides annually occurred on inpatient units (American Psychiatric Association Work Group on
Suicidal Behaviors, 2003). More recent estimates project 1,800 inpatient suicides each year (Jabbarpour & Jayaram, 2011). The most common methods of inpatient suicide or suicide attempts include hanging or jumping from a roof or window (McBroom, 2012). Root cause analysis of suicides on medical units identified problems with communication of suicidal risk, the need for staff education on suicide assessment and management, the need for improved systematic suicide assessment and management. Root cause analysis of suicides on inpatient psychiatric units include inadequate monitoring and 15-minute suicide checks, reduced supervision especially during night shifts, change of shift handoffs, and unsupervised areas (Bowers, Banda, & Nijman, 2010). Since it only requires 4 to 5 minutes of moderate pressure on the carotid arteries of the neck to result in death by lack of oxygen to the brain, 15-minute suicide observation checks allow ample time for a patient to asphyxiate by hanging and almost any item of clothing can be used to form a noose (Maris, Berman, & Maltsberger, 1992). It is estimated that a psychiatric nurse will experience a completed suicide by a patient every 2½ years on average (Nijman, Bowers, Oud, & Jansen, 2005). The emotional toll of a completed suicide or suicide attempt on family and friends is widely recognized (Cerel, Jordan, & Duberstein, 2008; Parrish & Tunkle, 2005), yet the impact on the inpatient nurses who care for patients who complete suicide is not well studied in the United States. Studies in Norway and Japan note the need for emotional support and the risk of posttraumatic stress disorder among inpatient psychiatric nurses coping with traumatic events surrounding the suicide of a patient in their care (Gilje, Talseth, & Norberg, 2005; Takahashi et al., 2011). These researchers note the limited availability of systematic post-suicide mental health care programs for these nurses and the lack of suicide-related education as problematic (Takahashi et al., 2011). This correlates with APNA’s recognition to develop suicide competencies and educational content to prepare inpatient psychiatric nurses to assess and manage patients with suicidal thoughts and behaviors.
Dissemination of Task Force Suicide Competencies On March 12, 2015, APNA issued a press release announcing the Psychiatric-Mental Health Nurse Essential Competencies for Assessment and Management of Individuals at Risk for Suicide, the first competencies specifically developed for registered nurses that provide a guide for evidence-based best practice in nurses’ assessment and management of hospitalized patients who may be at risk for suicide (APNA, 2015b). The overall aim of the competencies is to improve the standard of inpatient
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Adams nursing care for suicide prevention and to reduce suicide morbidity and mortality in persons who are hospitalized for inpatient psychiatric treatment. The nine competencies aim to increase nurses’ comfort, confidence, and competence in suicide assessment and management of suicide risk and cover the following areas: the phenomenon of suicide; managing personal reactions, attitudes, and beliefs; developing and maintaining a therapeutic relationship; collecting accurate assessment information; communicating suicide risk to appropriate persons; formulating a risk assessment; developing an ongoing nursing plan of care; assessing the safety of the patient environment; legal and ethical issues; and documenting suicide risk. They provide a foundation for training curricula and measuring the knowledge, skills, and attitudes necessary for expert care in this area. A task force of APNA members with expertise in suicide prevention, including one member with lived experience of suicide, adapted these competencies for psychiatric-mental health nurses from existing national competencies (see Acknowledgments section). In addition, an external panel of national experts in suicidology validated the competencies (see Acknowledgments section). The competencies align with broader national strategies to enhance behavioral health workforce competencies in suicide prevention. According to Janet York, PhD, PMHCNC-BC, FAAN, of Robert H. Johnson VAMC, who participated in the APNA task force, There has been a gap in training and education in suicide prevention for inpatient nurses, although they provide services to patients in acute psychiatric crises. . . . These competencies were adapted from the national Assessing and Managing Suicide Risk (AMSR) Competencies developed by the Suicide Prevention Resource Center and the American Association of Suicidology, and are consistent with the goals of the 2012 National Strategy for Suicide Prevention.
Implementation of Task Force Recommendations This same APNA task force has also developed an educational curriculum to support the adoption and implementation of the competencies. The curriculum has been piloted and refined to ensure that the suicide competencies can be met. In June of 2015, the first course on suicide competencies, Saving Lives . . . One at a Time, will be offered in Baltimore, MD, prior to APNA’s Clinical Psychopharmacology Institute. Participants who complete the 8-hour course will receive certificates in Suicide Risk Assessment and Management. Subsequent courses including “train the trainer” will be offered so that other nurses can use the APNA materials to teach this course, providing certification to all who complete the course requirements. The goal of the task force is that each nurse
trainer will reach 100 nurses and the ongoing certificate program can reach all inpatient psychiatric nurses. In conjunction with the release of these competencies, APNA issued a position statement that stresses that these competencies “address serious gaps in education for nurses who provide care to persons with mental health and substance use needs and that their dissemination will improve outcomes in suicide risk assessment, prevention, and intervention, ultimately increasing safety.” The position statement calls on “health care facilities and academic settings to adopt these nursing competencies in order to increase patient and nurse safety, and to enhance nurses’ confidence and competence in caring for patients at risk for suicide, ultimately improving patient outcomes.”
Future Steps The original task force for suicide competencies has been “sunsetted” and the APNA Board of Directors has appointed a new task force to develop universal competencies for nurses to use when assessing and managing individuals at risk for suicide across a variety of health care settings, including medical/surgical and critical care hospital settings. In addition to developing universal suicide competencies and refining “train the trainer” courses, the task group will publish findings once pilot and follow-up data collection is completed and analyzed. The dissemination of suicide competencies for nurses across academic and health care settings is intended to ultimately improve patient care and save lives. We are indebted to this team of APNA nurses who have developed the suicide competencies and course content that will serve as a foundation and catalyst to support psychiatric nurses across the country make a difference in saving lives. We look forward to the next iteration of task force suicide competencies and content for nurse generalists applicable to other practice settings. Who better than psychiatric mental health nurses to lead this initiative? Acknowledgment of Task Force Members Core Leaders:
Barbara J. Limandri, PhD, PMHNP, BC Cheryl Puntil, MN, APRN, PMHCNS-BC Janet York, PhD, PMHCS, BC, FAAN Pamela K. Greene, PhD, RN Deborah Hobbs, PhD, RN Content Contributors:
Eric Arauz, MLER Barbara Bonney, APRN
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Journal of the American Psychiatric Nurses Association 21(3)
Benjamin M. Evans, DD, DNP, RN APN, PMHCNS-BC Cynthia Kane-Hyman, MS, RN, CNS Dorothy Kassahn, MS, MEd, RN, PMHCNS-BC Pamela E. Marcus, RN, APRN/PMH-BC Joanne M. Matthews, DNP, APRN, PMHCNS-BC Esther Meerwijk, PhD Charmaine Platon, BSN, RN Amanda L. Schuh, MS, RN, PMHNP-BC Acknowledgment of External Validation Reviewers Jane Pearson, PhD Chair, Suicide Research Consortium National Institute of Mental Health (NIMH) Laurie Davidson, MA Project Manager, Provider Initiative Suicide Prevention Resource Center & American Association of Suicidality Caitlin Thompson, PhD Deputy Director of Suicide Prevention US Department of Veterans Affairs Peter Mills, PhD, MS Department of Veterans Affairs National Center for Patient Safety Field Office Psychologist, VAMC White River Junction Jane Englebright, PhD, RN At-Large Nursing Representative Joint Commission Board of Commissioners Richard McKeon, PhD Chief, Suicide Prevention Branch Center for Mental Health Services Substance Abuse and Mental Health Services Administration (SAMHSA) Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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