So I think it's time we've discussed why this is so important. Suicide is on the rise. Male nurses are at higher risk for suicide than males in the general population. Female nurses are higher than the females in the general population. And make no mistake, suicides are not a new issue. Unfortunately, it has been an issue we haven't dealt with. Maybe we felt uncomfortable asking, so we haven't asked. So that's what we're going to do. We're going to look today at what we can do. Knowing full well we can't prevent all suicides, but if we prevent one, I think this presentation is worth it. I think everybody has a phone, a cell phone, a smart phone in here. And I would encourage everyone to take down one of these phone numbers. These are the suicide crisis hotlines. And maybe not necessarily for your own self. You may never need it, but you may. And if you do, that's okay. But if you're talking to someone and they're suicidal or you think they might be, and you don't know what to say, these are trained professionals. They know what to say. And they'll know what to tell you to do, and they'll give you the best advice, particularly if you have someone who is at risk to themselves immediately. So please take a moment. Excellent resources, free of charge, 24 hours, 7 days a week. So to begin with, some myths about suicide. Myths are that it happens without warning. If somebody's going to kill themselves, they're going to kill themselves. There's nothing you can do about it. The truth is, 80% of people will actually tell somebody prior to trying to commit suicide. And 80% of the time, that is a nurse, maybe a health care provider. It may be faculty that someone trusts. So please listen. Individuals who talk about suicide do not follow through. That's not correct. These are warning signs. They are helping you to understand what they're feeling on the inside. Maybe they can't express it to you. Previous attempts will decrease future risks. That is absolutely not true. Statistically speaking, someone will attempt suicide twice before they're successful. So our job is, if we can, intervene before the first attempt, because it will only become more lethal as they develop confidence, or maybe they may even feel that they weren't successful. So they may be depressed that they can't go through with it. Threats are attention-seeking. No, they are not. They're a cry for help. Treat them as such. The truth is, individuals who are suicidal are helpless. They feel helpless. They feel worthless. They feel hopeless. They don't see shades of gray. They don't see an alternative way out. They see pain, and they want the pain to stop. And they're at the point where the only way for it to stop would be for them to die. What we need to do, we can't solve their problems, but we can intervene and get them help, and we can offer them a solution. There is another option. You don't have to kill yourself. There are other options. Some statistics. Suicide is the tenth-leading cause of death in the United States. It is the third-leading cause of death in college-age students. There are a lot more attempts than there are successes for suicide, thank God, but we have over 47,000 people per year dying, and that is equivalent to about 129 people per day. So if we think it doesn't impact us, it most certainly does. We may be the nurse that they tell. We may be the faculty member. This may be our friend. So we need to be thoughtful in our communication. There are some occupations that have a higher incidence of suicide than others. There are professions that have availability of lethal means. We're one of those. Nurses have access to medications. Nurse anesthetists have access to lethal medications, and we have the ability to understand how they work. So when we use them, we're generally successful. There are studies that show that nurses are at higher risk, but nurse anesthetists are higher than even nurses as a whole. Availability of lethal means also for our police officers, that would indicate that they have access to firearms. Something I found interesting in the research was that nurses die by medication overdose. That's our top suicidal means, but second is firearms. This is not any type of political stance. I have no thoughts on that. But if someone is suicidal or speaking in a suicidal way to you, and you know they have a firearm, you need to be able to try to contact someone so that they can get that, or you can see if they'll safely let you hold it, or you can even take them. I'm not a big weapons person, but a gentleman told me you can actually take the pin out so it doesn't fire. If that doesn't make sense, please don't quote me on it. But you can ensure they can't use it. You want to make suicide hard for them to do. Other occupational risks are low job security, low pay, or job stresses. I don't know about you all, but I think my job is fairly stressful. I think I have a pretty stressful job. Low job security and low pay, again, we're CRNA, so we think we've got pretty good job security. But if we look into what our market has been changing into, and that, I mean, me, for example, I worked as a hospital employee and was told on a Friday that I had the option of taking a contract with a company or I could have a seven-day severance package. So I lost my retirement. I lost all my benefits. And that, to me, is low job security. Not with the university. This was a while back. But just, you know, there are things that happen that can put additional stress. So when we look at the occupations, we look at our physician colleagues, and their numbers are about 300 to 400 per year are committing suicide. Our police officers are about 108. And nurses have a big question mark, and that is because it's not really tracked. Employers don't generally track nurses' suicides. And they tend to be shrouded in secrecy where the family may not release it or colleagues may not want it released. So we really don't know, but we do know an estimated number, and that is high. So why? It can't be just the fact that we have access to legal means. We all do in this room, and none of us are using them, right? You know, why are CRNAs dying? Why are ASRNAs dying? How about this? We're human, and we come to our profession with all the imperatives of humanity. We all have problems, right? We focus our training on we want to make sure we're taking care of the patient and that, you know, we're superhuman, in other words. But we're not. We're human. It's okay to have a bad day. It is okay for a student to be depressed. What is not okay is kind of turning a blind eye to that. And again, I'm not trying to say dumb down the profession and we don't hold them to standards. We do. We need to because I don't want somebody dumb taking care of my family. I know you all don't. But I do know that they're human, and when they're going through something, even if it's you or me going through something, there are mental health professionals that can help us. Our physician colleagues, anesthesiologists are the second highest rate, the first being surgeons. But if you take into consideration only those that are currently practicing, then anesthesiologists are the highest in their specialty. As I said, nurses have an increased risk, although it's largely uncharted. And I said CRNAs and retired nurses are at a higher risk over the whole. And some of the reasons stated why health care workers are at a higher risk are shift work, long hours, lateral violence, a lot of the work that I know some of us in here have been doing on perioperative loss. So blame, moral distress, lots of things play into that. Being in an area with high production pressure, the lack of preparation for the role, which I feel like we prepare our students appropriately. But when you go to a completely independent model, that can be terrifying for someone. And then, like I said, changes to different environments. So change to a new work environment. So if you're taking a job in a new location. But also I think of our students that travel to numerous locations, how stressful that can be on them as well. And speaking of students, we know they have lots of stress, and we don't want to take their stress away because stress makes us learn. Stress makes us vigilant. We want them to have that. We just want to stop it before it becomes an abnormal level of stress. We know that they're spending hours on copious amounts of complex knowledge. Some of it, to be honest, we may have forgotten along the way, but they are learning it for the first time. We equate it to drinking water from a fire hydrant. Clinical stress, so they're not only worried about setting up for the case, what's the case they're doing, but also what is CRNA ODA like in her room as opposed to what the other CRNA wants. So they're under a little additional stress as well. They're loss of income, so they may be living on student loans that may or may not be making their bills, especially if they have an issue, maybe a car breaks down. Role ambiguity, it's hard to go from being the top dog and knowing everything to being the lowest run. I was with a CRNA one time, that's what he told me. He said, it rolls downhill, Crystal, and you're the lowest one in here. Of course, it was funny, now it wasn't then. Also, we don't see it, but somebody who's a top in their class who's always scored A's through undergraduate, when they come in and make a B, that to us is no big deal, right? B's equal CRNA, but to them, that may be their identity. So they may perceive it as a loss, but we don't necessarily perceive it as a loss. Eighty-one percent of students who have attempted suicide never disclosed anything to their programs or the university where they attended that had any mental health problems. Twenty-eight percent of medical residents, and again, we don't have the complete picture of nurse anesthesia, so I have to refer to our medical colleagues some in this lecture, but twenty-eight percent of medical residents stated they have been depressed or had a major depressive episode during their training. And then from the study with Chippis, it's 47.3 percent of SRNAs stated they have been depressed, and 21 percent of those stated they've experienced suicidal ideation. So again, if we don't think it's happening, it's happening around us, and we just might not be seeing it. So a lecture about suicide cannot be complete, or depression if we don't talk about burnout, because I think there is a lot of people who experience burnout. And burnout is defined by Webster's Dictionary as exhaustion of physical or emotional strength, usually as a result of prolonged stress. The provider, we can have practice issues that relate to that or provider-specific. Some of the practice are additional assignments that maybe we don't feel are appropriate for us to do, such as clerical, changing to a computer system. I know that I fought it tooth and nail with Epic, and the one day that the computer system was down, I was so happy, did my little paper chart. But provider, the sense of duty we have for our patients, we expect excellence, right? That's who we are. Responsible for the patient outcome. And delving back into research from perioperative loss, 60 percent of people who've experienced a perioperative death blamed themselves, even though they could tell you there was no reason for it. Nothing could have been done to change the outcome. They still feel that. So that bears on someone's soul. And then, as I said, job stresses. Some of the major symptoms of burnout are exhaustion. That can be physical or mental exhaustion. You just get to that point you just can't do anymore. Depersonalization, and that's where you kind of lose your identity. And I think sometimes we may lose our identities, and we also happen when our students, they lose their identity as a person. When I counsel students and they come in, they're crying. I'm like, you are not only an anesthesia student. You're a person. Lack of personal accomplishment, and that is, again, feeling like what you're doing doesn't matter. You're just going through the motions. In training, 49% of medical students that were surveyed stated they've experienced burnout, and 43% of nurses as a whole stated they've experienced emotional exhaustion. And we know that if burnout isn't treated, it can turn to depression, which can lead to suicidal ideation. So, again, when we recognize these symptoms in ourselves or others, intervention would be appropriate at this stage. And just a little sidebar on the personal accomplishment or feeling that what you do doesn't matter. I have a student who is a very mature student, and we were in a room. We had a brand-new surgeon who was unhappy with his location and felt as though it was a personal attack against him, I suppose, that he had to come and provide care for our patient. Anyway, at the end, he insulted the scrubs, the circulator, and basically told them that this was the most, you know, just went on on this complete rant. And my student, when the circulator looked like she was going to cry, my student said, but think of what you've done today. You've taken care, and she listed the patients, and she said, and we were doing urology, so, again, saving lives one stone at a time. But she said, I really, you know, you helped us, and we relieved their pain, and this guy's going to be, and it was like I seen a light come on in the circulator's eyes. It took my student 30 seconds to make that statement, but I thought it was very impactful, and I thought I can learn from her because I don't, you know, I didn't do that. I didn't say anything to try to fix the situation. So risk factors as a whole, we said we come to this profession as a person, and we have all those issues. So mental health conditions, depression and anxiety are a high risk. In depression, about 50% of people who were suicidal have undiagnosed or untreated depression. So, again, very important things. Substance abuse. Substance abuse and suicidal ideation is intertwined for multiple reasons, but it's estimated about 40% to 60% of people who have had suicidal ideation were on some kind of medication. So this is intertwined with our opioid epidemic, so it's something for us to be thinking of as well, especially providers who may have had an issue with substance abuse as well. Traumatic brain injury, having a debilitating disease that puts you at higher risk. Environment. So access to lethal means, we've discussed that. Experience of prolonged stress. Some stressful life events, such as the loss of a loved one. Change in financial situation. The unwanted divorce, and I like that that was the statement, unwanted because sometimes divorces are needed. But childhood stress. Historical factors are previous suicide attempts. So those are good screening tools to know if someone's ever attempted suicide before. Like I said, it takes about two times before they're actually successful. So this is our iceberg, and this is really what we know about anybody beside us. We can be very close to them, but we know what they let us see. So you may never know really what's under the surface. So what we need to be is investigators and look for some clues. So when people are suicidal, they'll give us clues usually. Not always. Sometimes it is impulsive, but most of the time they'll give us clues. And direct verbal clues would be, I'm going to kill myself. I've been thinking about killing myself. They may tell you directly, I felt suicidal. Or they may be indirect, like, I'm worthless. What's the point? My family would be better off without me. Those types of indirect clues are still telling you the same thing. Some behavioral clues, they had a complete change in what they normally do. Maybe they're giving away their prized possessions. Maybe they're withdrawn and they used to be extroverted. Maybe they're, you know, maybe they've just decided they're not going to do anything in class and they've always been the high achiever in your class. These are all clues that something's wrong. Situational, and we mentioned those, or, you know, changes in their environment, loss of a loved one. If they've experienced suicide previously, such as maybe a friend died or maybe a family member, or maybe they've just seen a suicide that was glamorized. So that's one of the things we have to worry about is making suicide glamorous. So when we talk about suicide or if a student dies or a colleague, we don't need to focus on the gory details of the death, right? We need to focus on the loss and how there were multiple factors that led up to their death, not just one. And then signs and symptoms, and those can vary. They can be rage, they can be recklessness, inability to provide you a reason to live, and also, you know, no plans for the future. And I talked to a few people today about this. My student, previous student, turned out he was not suicidal, but he came in, he was supposed to come in for a final exam, didn't show up, didn't call, didn't let us know, nothing. I tried to call him, he wouldn't answer the phone. Assistant program director tried to call, wouldn't answer the phone. We finally had one of his friends in the class call, he answered. But when I called him in, and I think it's because I've been studying this so closely, I asked him point blank, are you suicidal? Because, and I started with, what I've seen is, you know, you're acting out of character. You are a top achiever in my class, and now you're not even going to do the exams. So I just laid it on the line, and I said, have you or are you thinking about suicide? And he assured me no, and then I contacted counseling at the university. He talked to a counselor, and then he came back and told me he just, anesthesia wasn't for him, and he had plans to work as a travel nurse. That made me feel a little bit more comfortable, the fact that he could tell me there was a reason to live, and that he had a plan, but I was a little bit scared. So warning signs and risk factors, we've talked about the risk factors, but warning signs are more of like the red flag over their head, right? A little allergy band on their arm. And this should hold a disproportional amount of weight to you. So when someone tells you, it's basically what's happening right now, what's my behavior right now in this minute? This is going to tell you the short-term outcome, maybe minutes, hours, maybe even a week of what I'm going to do. This is what I'm verbally saying. This is what my behavior is. Somebody can commit suicide without any risk factors. You may not know my risk factors, right? You may not know. And just one of the other risk factors is cyberbullying. People who have been cyberbullied are twice as likely to commit suicide than people who have not. And when I think about that, or when I thought about it before, I always think, well, that has to be a high school student. No, it's not. Get on one of the Facebook pages and say something that is not in agreement with other people. They will take you down. I mean, honestly, sometimes I'm a spectator. I'm just like, oh, my God. I mean, I've seen a student go on and ask for advice on how to do a case, and they've ripped them to shreds. My thought is, you know, we're not doing any work for you. Well, you know, how about just scrolling by without saying something mean to the person? How about that? That's what I would do. But, like I said, you may not know that's going on in this person's life. They may not tell you, but they may tell you that they're thinking about it. So if you see these signs, these are, you need to do something. If you see something, say something, do something. It's better than nothing. There are a lot of screening tools, and I'm, obviously it's outside the scope of this presentation to talk about them all. And I'll be honest, our university doesn't have a screening in place, and I wish we would. That's kind of one of the things I'm going to be champing soon. But there is the self-report 21 item BEX depression inventory, and that can be done to see, you know, if the patient, if a patient student's at high risk, or patient, whatever. Depression hopelessness scale. There's also QPR training, which is kind of a screening tool, because there's a screening component, but it's really a real quick, down and dirty, easy way to be able to question somebody about their intent, persuade them to seek treatment, because we, you know, unless we're specialized in psych mental health as well, which some of us are, most of us are not. We need to send them to somebody who can take care of them, and then refer them to, persuade them to go, and then refer them to the appropriate person. And that's where those suicide hotline numbers will come in handy, because if you don't know anybody else, you can call them, and they can help you. There is the Healer Education Assessment Referral Program, and there's also the Columbia Suicide Severity Rating Protocol. Like I said, these are just a part of what's available. There are lots of tools, and I think it's more important that it's the concepts you're addressing rather than the specific tool you're using. The HEAR program is from UC San Diego, and is currently used in 125 universities, about 60 hospitals and medical schools, and some law enforcement agencies. And this has some really good concepts that can be adapted to other programs, but it's web-based, anonymous. When somebody goes in and fills out the inventory, they provide an email address, which is encrypted, so the counselors don't know who they're talking to. So it's completely anonymous. Faculty students are encouraged to fill it out, and it links them to a counselor so that they can get the right referrals quickly. And like I said, our university doesn't have this, but I would love for us to have something in place for our students. This is the Columbia Suicide Severity Rating Scale. The good thing about this, it's free. It is an assessment tool, and if you contact them, they will help develop it for your practice setting. So what it's doing is asking those big key questions, you know, have you wished you were dead, or if you wished you could go to sleep and not wake up, have you ever had actual thoughts of killing yourself. So it just helps you screen for those big red flags of what you need to do from there. And if you don't have a tool, but you're trying to think, what would be the highest risk factors, who should I be concerned about, there's a mnemonic called sad persons. It goes, sex, which would be male, it's a higher risk. Age, greater than 50. Depression history. Previous attempt. Alcohol and drug abuse. Rational loss, thinking loss. If there was a suicide in the family, or a friend, or a glamorized suicide. Organized plans, they can tell you that they've got a plan and that they are really intent on following through if they don't have a support system in place. And sickness, which is for debilitating disease. So sometimes people are diagnosed, it will put them at higher risk. But this is just one of those kind of tools. Remember, people can be suicidal and not have a risk factor that we know of. So we have to be vigilant in looking for the signs as well. So if you suspect someone's suicidal, what do you do? How do you deal with it? How do you engage the individual? And this is where our QPR training comes in. And it's question, persuade, and refer. There, unfortunately, is not a universal script to use, so we all need to individualize it. And I always tell people at this point, think about how you feel. Bracket your thoughts. So if you're a person that thinks suicidal people or depressed people are weak, you're not the person to do an intervention. And if you feel like that, that's okay. Feel like that. Just know you're probably not the best person to engage an individual at this time. So when you do it, you need to plan to talk to the person and have at least an hour of uninterrupted discussion time. So this is uninterrupted, not I'm on my phone, this is somebody calling your office and you're scheduling appointments, or other students come and knocking on the door, or if it's other faculty or a colleague, the same. You don't want interruptions. You need complete, take your phone off the hook, turn your iPhone off, whatever you need to do. Because could you imagine finally getting enough courage to come and tell somebody you're suicidal and they're playing on their phone? It would be, that would just be insult to injury. And they probably wouldn't talk to you anyway. They would quit talking. So you want to establish rapport. And sometimes that's maybe not you, maybe you're a program director and students don't have, you know, they see you in a different role. Maybe it's another faculty member that would be more adept to that. And that's okay, as long as somebody is. But be willing to ask the hard questions. So you want to ask directly, have you or have you ever thought about killing yourself? If they say yes, or if they allude to yes, you need to go ahead and ask, do you have a plan? What's your plan? Have you thought about the consequences? You know, maybe they have not thought about the consequences. Have you thought about alternatives? And then you need to follow that up with a little red bow and say, what can I do for you? And be sincere. Is there something you can officially do for them to help? As I said, be empathetic. And if you're not the person who's empathetic, then, you know, have someone else do it. Remember if they say, no, no, I'm not suicidal, don't say, oh, thank God. Because they may just have not told you. So by you saying that, that just ensures the fact that they shouldn't tell anybody. Because, you know, obviously this isn't something. So refusal to help doesn't mean that they don't need help. If they are immediately suicidal and a harm to themselves or others, you may need to seek involuntary treatment. And that, again, if you don't know who to call, if somebody is in the process of 911, call the suicide hotline. If you are at a university, call the mental health provider and just follow their guidance. But I said, you know, make sure you are empathetic. And I joke around with this, but I work with a provider who is the old school CRNA, salt of the earth. And if somebody told them they were depressed, she would say, suck it up. She is not the empathetic one. So she would not be on the suicide watch with me. I would be the person to talk to. As we said, we recognize, we question. Once we get the positive answer, then we are going to persuade them. We are going to talk to them that there is another option. Death is not the only option. And when we persuade them, we are going to refer them. As I said to a mental health provider, a psychiatrist, a psych mental health nurse practitioner, a psychologist, someone, a counselor, and I said, if in doubt, contact the suicide hotline for free consultation. As I said, if you are like me, you want everything to go right, the best way for it to go right, treat this as your malignant hyperthermia hotline. So if you had somebody have an MH, you would call the hotline, right? No questions asked. Somebody suicidal, call them, just the same. You are in a life-threatening situation the same way. Your best plan, if they decide, if they accept your treatment, the best plan is for you to physically get up from what you are doing, take them, and take them to the visit. If it is on the university, you go with them, make sure they get there. It is like you are turning them over to another level of care. If that is not feasible or they do not want you to do that, the next best thing is to make sure that they have made an appointment and that they are going to follow up. And then lastly, if they will not do anything else, just the fact that they tell you they are going to seek treatment and if they agree to treatment in the future, maybe it is not enough, but it is a positive step, because the alternatives, they could completely refuse and shut you completely out. So, this is a key statement. Suicidal thoughts or symptoms may resolve with proper intervention. So, we can make an impact. Sometimes people are impulsive and commit suicide and that is it. But most of the time people are thinking, this has been a thought process, they may actually feel better once they have made the decision to commit suicide. But be proactive. Try to engage the individual. The Centers for Disease Control has developed a technical package of policies that can be accessed that talks about some of the steps they are taking to try to reduce suicide throughout the nation. Obviously, this is way outside of our scope, but I just wanted to put them up there because I think there are some that we can actually make an impact to, at least for our own personal areas. For example, to promote connectivity or connectedness through peer normalizing programs. And that is where peers can say it is okay to seek counseling. We now have our school counselor come to what we call Grand Rounds and he comes the first day every semester. Without us there, we leave because sometimes they think we are forcing something down their throats or we may be trying to know what is going on in their lives. So, send the counselor and there is a real nice guy. He is trained to be nice. He goes in and he talks to them about what is available and it is free of charge and that there is no shame. And then the faculty, we encourage it. When people come in and are struggling in classes and have a meltdown with us, we talk about didactic training. We talk about how we are going to remediate. And then we say, have you talked to a counselor? Because if it is testing anxiety, because there is another component sometimes to what is going on. They usually do not make it to our programs without being smart enough to succeed. We also can teach coping and problem-solving skills. Some of our students do not have those. And those can be taught. There are studies that say computer-based training can help improve somebody's resilience. So, there are options. Less harm and prevent future risk through appropriate counseling, having counseling services available. Debriefing your students after an incident. So, if they had a patient die, if they have been involved in something, make sure they have access and let them know that it is okay to have feelings about that. Like I said, those are some things we can do. Obviously, we cannot solve the economic supports or access to delivery of suicide care. But we can take care of our organizations. So, what can you do as a person in here? Find out what your organization offers, what type of mental health service they offer. Are there suicide prevention programs that are available? Are there training programs like gatekeeper training that you can attend so that you will feel more comfortable maybe intervening? Preventative factors. You can help to promote a culture of safety. You can help destigmatize mental health disorders. We can try to let students know that it is okay to see a counselor and make it accessible to them. We want to provide training for red flags so the faculty know that if somebody has had a major change in behavior that we need to talk to them. That is okay. That is appropriate. Promote a wellness culture. It is okay to take a vacation. I know none of us in here really do, but it is okay. It is okay to do things for yourself. And as I said, I think if I could stress anything, it would be move beyond the stigma of mental health, mental illness. You know, it is okay if somebody has an issue, right? We do not think anything of if our patients were on an antidepressant. But if we know another nurse or another anesthesia provider is on it, it is like, they are human too. We are human. So to prevent, you need to reduce your risk of burnout. I think I am preaching to the choir, but find your sanctuary. Find something you enjoy and do it. Too many times we do everything we have to do, and we do nothing for ourselves. So try to do that. Take time to discover your true calling. Remember what you are doing. Do not just get bogged down in the accreditation reports, but you are probably an educator for a reason. A gratitude journal. There are actual studies stating people who do gratitude journals and write down the positive things and not just focus on the negative are less likely to experience burnout. Adequate sleep, nutrition, exercise, as well as take care of your spirituality. And take your needed breaks if you need to. Take your vacation and take a vacation and do not grade papers while you are at it. That is what I always do. I usually grade people's papers. But the COA has made a standard that tries to address some of the wellness issues that we are talking about to try to improve the overall wellness of our occupation. But demonstrate knowledge of wellness and substance use disorder in the anesthesia profession through completion of content and wellness and substance use disorder. And I think we all hit that mark that we are making our students do that. So that is one step that we are taking. Also, what can we do to help our students, or help our faculty, or help others? Offer stress management. And maybe we need to take it ourselves. That may be an option as well. Offer strategies and have healthy coping. I always tell the students to have a coping skill. Please just do not let it just be alcohol, because that is what a lot of them will say. Well, I just drink on the weekends. Well, no, that is not a coping skill. That is a negative coping skill. Have available resources. Counseling services. I found this one interesting, but a lot of articles will speak to clarity of policies will decrease student stress. If they know what to expect and not wishy-washy, but they know what the medical withdrawal policy is to let them know that if medically or mentally they cannot handle it, there is a withdrawal policy, it will not penalize them. There was also some statements that students have made that not to refer to everything as being about the NCE. Right? Do not use it as a scare tactic. I mean, it is okay to say, well, this will be on the NCE, but oh, you cannot pass this test, you will never pass the NCE. I mean, that is a scare tactic. We are not terrorists. Avoid the I had to mentality. So, if we are having them do an assignment and it is beneficial, do it. But if we are doing something because when I was a student, they had me do 45 care plans a day, and they did not care if I ate, they did not care if I slept, it may be true, but, you know, that is not the appropriate mentality to have. So, those are just some things we can do. I mean, like I said, we do not have all the answers, but that is what we want to do is open up that dialogue so as a body we can have some answers and maybe we can prevent some suicide. Aftercare, and this comes from a toolkit, and it is really about medical students, but it is really beneficial. And I did not know this existed, so I am going to try to let you all know it exists. God forbid you ever need to use it. But it goes step by step what to do, how to set up your crisis debriefing team, how to interact with the public, how to handle your social media. It goes step by step, easy to understand. But their primary thing is to be prepared and have it ready prior to the event, have your team picked out. And when you are talking about the student death, you should talk about it as any other death. You should talk about the loss, the grief process, and it is okay in person to mention that, you know, they killed themselves or you can even mention the method, but do not fixate on that method because then you are sensationalizing it. So, a sample schedule, and again, this is directly from that toolkit and it is available. You can get that off the website. But immediate notifications, that would be to the students that are in class with that particular student. Cancel classes if possible, if at all possible. And those who are the closest should be notified separately. You should pull them aside and let them know before you announce it as a group. You may also want to develop your response team if you have not at this time. And you need to have counseling services available 24-7 for at least two weeks so that students can approach somebody and maybe they do not feel comfortable debriefing as a group. Day two, additional announcements. You may want to talk to your clinical sites. You may want to talk to the clinical preceptors, faculty who maybe have taught that student but maybe not immediate faculty. You may want to notify them at that time. Again, you want to have mental health available for people to access at an as-needed basis. And you want to identify and check in on those at-risk students. So, students that were the closest, maybe students that do not seem to be coping as well. You will also need to start putting in some mechanisms, start monitoring absences and paying very close attention to clinical site evaluations because anybody that goes downward needs to be identified quickly. Days three to four, you can encourage informal gatherings of the students. Hopefully, you are returning to normal function. You are starting to put your classes back together and making up any needed work. But there may be some that need additional time off and that is okay. Again, you want to keep the crisis debrief team working. And the team's function is to communicate, follow up and make sure people are seeking counseling services necessary. Within the first week, again, check with student leaders or class representatives to see the pulse of the class. And I hate when the students come to me and say the pulse of the class is and then I'm using it. I'm using their terminology. As I said, crisis response teams will continue to monitor. And week two, you want to remind students that it's still early in the grief process. It's still okay to need help. And as we move further on out, you can consider more debrief sessions. But make sure, I guess the overall theme is to make sure you're still looking at who's struggling and who's coping. And beyond the first month, you want to, if you haven't already, hold a memorial service. It should be outside of the normal class time and it shouldn't be in one of their normal classrooms or in a place they work. It should be separate so it feels like a special event. Students should be encouraged to attend. And if they're doing evening shifts at a certain location, they should be given the time off so that they can mourn the loss of their classmate. So contacting, the emergency contact, when you first call them, your first phone call should be for support and condolences. Do not ask for the university computer bag. Do not ask for any of those type things. But, and find out before you call what they know because they have been contacted by the police department or the hospital. So you want to know what they're being told so that you can talk with them. And it's also important to ask what their, what their thoughts are on you sharing it with the class to kind of decrease the risk of suicide in the class. Tips for communicating the death, again, avoid contagion. So if you sensationalize it or focus on the act itself or you focus only on the strengths of the student, oh he was a good student, had a great life, beautiful car, you know, then people are going to say, why did he kill himself? You need to focus on although he died or although he had all these positive things, he still had something that led to suicide, then recognize that multiple factors lead to that and we don't always know what's going on in somebody's life. Don't sensationalize the suicide. Don't focus on that. Don't provide graphic details. Don't highlight the pictures of the location. Don't talk about it and avoid, like I said, describing the student only by strengths because if they were such, if they didn't have any problems, why did they, you know, why did they kill themselves? You need the students to understand there's multiple factors involved. And coping, again, this is probably one of the most important things is to keep up with the students and see who's coping, who's not. Faculty also need to be encouraged to see counseling one-on-one, especially those faculty who are closest, because they may blame themselves even if they don't tell you because we are all trained professionals and there may be some guilt. Why didn't I see these problems? Why, I should have noticed, but we need to remind them hindsight's 20-20 and just because we see that now doesn't mean they were showing it to us then, right? And you can mindfully share your experiences, especially if you're going to try to encourage them to seek help, that, you know, it's okay.

suicide prevention

nursing profession

mental health conditions

substance abuse

warning signs

aftercare

crisis response teams

communication sensitivity