Hello, I'm Chuck Griffiths, and I'm joined today by my colleagues, Dr. Maria Van Pelt and Dr. Elizabeth Bamboucher, and we thank AANA for this opportunity to present important information to you all in our presentation entitled Suicidality and Suicide Prevention. The purpose of our presentation is to discuss the suicide epidemic found in all walks of life in the United States, including nurses in health care. Our presentation outline includes the following. We will discuss the suicide epidemic in the United States today. We will review what is known about the psychology underlying suicidality. We will offer a database explanation of how stress and depression can lead to suicide in CRNAs and rRNAs. And finally, we will describe some of the methods from the psychology literature that may work to prevent suicide, including the approach known as Q for question, P for persuade, and R for refer, QPR. The presentation is intended for both practitioners and for residents as an overview lecture that can be shaped and tailored to different populations of nurse anesthesia professionals as needed. Now, this presentation, of course, contains sensitive material. There are 24-7 AANA resources available online and at AANA Helpline for drug and alcohol problems. For mental health challenges, the National Mental Health Crisis Helpline is available at 988-AGAIN-247. The AANA Wellness Initiative is an important component of what AANA does for members. AANA has always been dedicated to the welfare of its members. In the early 1980s, in the face of increased loss of members to suicide and drug overdose, and using the nascent psychologically driven movement toward recognizing the value of wellness and living a balanced life, AANA launched its Wellness Initiative. The Wellness Initiative consists of offering many materials online relevant to wellness and suicide prevention and supportive programs like this wellness micro-credential. Now, there are some sobering statistics that we're going to go over now concerning the suicide epidemic in this country. Suicide is the 11th leading cause of death in the United States in the latest year for statistics of 2021. 47,000 people were lost to suicide in 2018, but 48,183 in 2021. Suicide is the second leading cause of death, ages 20-14 and ages 25-34, the third cause of death for 15-24 age group, and the fourth leading cause ages 35-44. A suicide rate per 100,000 per year is as follows, 10.4 for 100,000 in the year 2000, but 14.0 for 100,000 in the year 2021, which represents a 34.6% increase. Based on the loss of life, suicide really is a national public health epidemic. There is an epidemic of suicide by nurses in the United States, nearly twice the incidence of the total population. There is a definite lingering stigma surrounding mental health diagnoses, which may lead to the under-reporting of suicide cases. All of us need to take action to prevent suicide wherever and whenever possible. Now let's explore some definitions and facts about suicide. Suicide is defined as death that's caused by self-directed injurious behavior with intent to die. A suicide attempt is a non-fatal, self-directed, potentially injurious behavior with intent to die, which may or may not result in injury. Suicidal ideation is thinking about, considering, or planning suicide. And finally, suicidality is the risk of suicide usually indicated by suicidal ideation or intent, especially as evident in the presence of a well-elaborated suicidal plan. In this slide, we present a model that may represent a way in which persons might engage in a suicidal response to stress based on Lazarus and Folkman's transactional model of stress and coping. The person encounters sources of stress and engages in an appraisal process where the stress is considered in a number of different ways, including the magnitude of threat that stress represents. To this appraisal process, the person brings their own internal resilience as one factor. That's an internal factor. External factors that impact on how the stress affects the person are also brought to bear to the appraisal process, and these include social support from friends, very critical, family and colleagues, and the use of helpful resources like professional counseling. Hopefully the response to the stressor is some moderation of anxiety and a successful adaptive coping and learning and improvement, but without adequate support or resources, depression and severe anxiety may actually lead to maladaptive coping and self-harm behaviors up to and including suicide. In the general population, suicidality is associated strongly with mental health disorders such as anxiety and depression. Mental disorders have a stigma that the person with a mental disorder may feel that it is a characteristic conveying to themselves and others a low value of personal and social worth. Mental disorders are not regarded in the same way as physical diseases or disorders. Depression may lead to beliefs that the self is damaged goods not worth saving and lead to feelings of helplessness and hopelessness with no options and no way out. Nurses have mental health disorders at higher prevalence than the general population. Multiple factors are thought to contribute to this sobering fact. Nurses often work around people who are impaired or ill or injured or depressed over their circumstances. Nurses are there when every other health care provider has departed to bear witness to the ravages of disease and poor choices on human beings, yet nurses often do not have the authority to act to treat or help those in need. This inability to control the suffering of patients is often a source of mental health stress for nurses and can cause second victim syndrome. We only have to go to some of the CRNA blogs, some of the online blogs, to grasp that nursing is an oppressed population under attack and stress from multiple directions that seek to control our actions and roll back our abilities to act effectively on behalf of our patients. Living in environments where there is political pressure and senseless action designed to enforce a power imbalance leads to feelings of vulnerability and discomfort. This may result in burnout, anxiety, depression, and low self-esteem, all risk factors for self-destructive behavior. CRNAs and RRNAs die by suicide. Many of us have lost friends and colleagues to suicide. RRNAs continue to die by suicide. There was a double suicide in 2018, and a recent case was presented at the 2023 Annual Congress. Yet, mental health experts believe that suicide is preventable with appropriate intervention. So learning more about suicidality may help us prevent the loss of colleagues, residents, friends, and family to suicide. And now I'm going to turn this over to my colleague, Dr. Maria Van Pelt. Thank you, Dr. Griffiths. Your remark about the importance of understanding suicidality to prevent the loss of our CRNA colleagues and RRNAs is a powerful reminder of why discussions like this are so crucial. Building on that critical point, I'd like to delve deeper into the mental health challenges faced by our community of CRNAs and RRNAs. There are important data that have provided us valuable insights into the stressors and coping mechanisms within our profession. Understanding these factors is a crucial step in addressing the overall mental health of our colleagues and potentially preventing tragic outcomes. What we know from the data is that the major stressors for CRNAs include job changes and regulatory burdens, moving, chronic illness and death of a family member, and lastly, personal illness and injury. For our RRNAs, this includes quitting their nursing jobs, moving self and family, starting the nurse anesthesia program, changing jobs and careers, death or becoming a caregiver of a family member, personal illness and injury, and financial challenges. As we can see, while there's some overlap, our RNAs face a unique set of stressors related to their transitional status as students. On a 10-point Likert scale to measure stress levels across different groups, our RNAs reported the highest stress levels, averaging 7 out of 10. Educators came in second with an average stress level of 6 out of 10. These findings highlight the intense pressure and stress faced by students and educators in our field, and what we know is that suicidality is an outcome of stress. As Dr. Griffiths mentioned earlier, suicide is a critical issue affecting young adults. I would like to highlight that the age range that he mentioned of suicide in the U.S. is the age range of our RRNAs. Some startling statistics from a pilot study of wellness and suicide prevention for student-registered nurse anesthetists included the following findings. 21.3% of students reported experiencing suicidal ideation at some point during their anesthesia education. 16.8% felt that one of their classmates was at risk for suicide. Tragically, 2.5% reported losing a classmate to suicide. Perhaps the most alarming, 34.6% reported having suicidal thoughts since beginning their training. These figures underscore the urgent need for awareness and action within our profession. But to effectively address this issue, we need to understand what contributes to it. Let's now examine some of the key risk factors for suicidal ideation in RRNAs. These include family and friend relationship problems, what RRNAs consider as frequent crises like tests, clinical, evaluations, and high-stakes exams like the self-evaluation examination and the national certification examination. Mental health problems coupled with little time for self-care, having a mental health disorder, loss of housing, changing entire self-identity and starting new in a new setting. Financial problems including low to no income and having a substance use disorder. As we move from discussing our student body into professional practicing as CRNAs, it's crucial to recognize that CRNAs face similar risk factors but also have their own set of risk factors that contribute to mental health challenges. Let's examine some of those key risk factors that can lead to suicidal ideation among CRNAs. These factors span both personal and professional aspects of life, demonstrating the complexity of the interplay between our work and personal experiences. Understanding these risk factors is the first step in developing effective support systems and interventions. Risk factors include family and friend relationship problems, major life events or crises such as birth, death, illness, moving, physical health problems, family problems, whether that be marital, young children and child care issues for the working professional to caring for your aging parents, having a mental health disorder, experiencing loss of autonomy and or restricted practice rights, job burnout in politics, both regional and national, financial problems and substance use disorder. To better understand how these risk factors can converge and affect a CRNA, let's examine a case study. The scenario that I will present to you illustrates how personal and professional stressors can accumulate, potentially leading to a crisis situation. Consider the following interaction between two CRNAs, Jane and Terry, in the locker room. Jane, a CRNA with a complex personal life, is facing multiple challenges. She has a history of depression and describes herself as feeling burned out. She has said in the past that she likes her work, but she hates the people she works with and that her CRNA supervisor does not understand her. Her marriage most recently ended, leaving her without spousal support. She has a 17-year-old son named Merrill with high-functioning autism who is in a very expensive special education program. She's still coping with the loss of her daughter in a car accident five years ago. Financial pressures are mounting due to the rising costs and the loss of her spousal income. Terry, Jane's colleague, notices changes in Jane's demeanor and appearance. So let's observe their interaction when Terry sees Jane in the locker room when she is on her break. Terry says to Jane, Hey Jane, what's up? You seem to be down these days. Jane shakes her head and she says, I've been so stressed lately, I feel like nothing's going my way. I'm nothing but a burden to those around me. And I just, I just worry about what would happen to Merrill if I were gone from this stupid world. Terry, laughing it off, says, I hear you, I'd rather like to escape from this crazy world we live in. Get away from my husband, kids, and this toxic work environment myself. Chin up, things will get better. Terry then leaves and Jane is left alone. What Terry doesn't realize is that Jane has reached a critical point. In her distress, Jane thinks to herself, that's it, I've had enough, I'm out of here. Jane leaves a note on her locker. She enters one of the restroom stalls. She takes out of her pocket a cocktail of propofol, midazolam, and sufentanil. She enters her antecubital vein. She injects the mixture. She doesn't feel it when her body hits the floor. We've just witnessed a deeply troubling interaction that tragically ended with Jane attempting to take her own life. This scenario illustrates how easily warning signs can be missed and how critical proper response is in these situations. Now let's rewrite the script and explore how this interaction could have gone differently if Terry had recognized the severity of Jane's distress and responded more appropriately. In this revised scenario, we will see how a colleague's attentiveness and willingness to engage can potentially make a life-saving difference. Let's revisit the beginning of their conversation. Terry says to Jane, hey Jane, what's up? You seem down these days. Jane shakes her head and says, I've been so stressed lately, I feel like nothing's going my way. I'm nothing but a burden to those around me, and I just worry about what would happen to Meryl if I was gone from this stupid world. This time, instead of dismissing Jane's concerns, Terry recognizes the seriousness of Jane's words. She takes a deep breath. She responds, Jane, I'm really concerned about what you just said. It sounds like you're going through a really tough time. Can we talk about this? I'm here to listen, and I really want to help. Terry gently places her hand on Jane's shoulder and continues to say, what you're feeling is important and you're not alone in this. Let's sit down together. You can tell me more about what's been going on. There are people and resources that can support you through this. Jane, seeing the genuine concern in Terry's eyes, feels a small spark of hope. She nods slowly and says, I think I'd like that. It's been so hard trying to handle everything on my own. Terry guides Jane to a quiet corner where they can speak privately and she says, I'm so glad you're willing to talk. I'm really worried about you and I want to ask you if you're thinking about suicide. Jane responds with her head down and says, yes, I'm so scared and she breaks down crying. Terry hugs her and says, come with me and we'll get through this together. I'll get you the help that you need. This revised interaction demonstrates how attentiveness, empathy, and direct communication can potentially prevent a crisis. By taking Jane's words seriously and offering and getting her immediate support, Terry opens the door for Jane to seek help rather than feeling isolated, overwhelmed, and potentially taking her life. What we know is that death by suicide is a result of maladaptive coping mechanisms. We already reviewed the risk factors associated with suicidal ideation, but I'd like to highlight the ones that Jane has. She has a history of depression, financial burdens, family difficulties, burnout. Additionally and crucially, Jane expressed feeling like a burden to others. This feeling of burdensomeness is a significant risk factor that deserves special attention. The perception of being a burden is a key component in many theories of suicide. When individuals feel that they are a burden to their loved ones or society, they begin to believe that others would be better off without them. This distorted feeling can lead to the dangerous conclusion that their death would be worth more than their life to those around them. In Jane's case, we see this manifesting in her concern for her son Merrill. Her statement, I just worry about what would happen to Merrill if I were gone from this stupid world, suggests that she's contemplating her absence and its impact on her son. However, her perception is likely skewed by her depression and overwhelming stress. It is important to note that feelings of burdensomeness often concur with other risk factors. For Jane, her financial struggles, the stress of caring with a child for special needs, and her history of depression all contribute to and amplify this feeling. Recognizing and addressing this perception of burdensomeness is crucial for suicide prevention. It often requires professional help to challenge these distorted beliefs and help the individual recognize their inherent worth and the positive impact that they have on others' lives. In an effort to support colleagues and friends like Jane, we must be alert to suicidal ideation risk factors, including the expressions of feelings like a burden, and be prepared to respond compassionately and effectively. This rewriting of the script is important because it demonstrates how attentive listening and appropriate responses can potentially save a life. As we've seen through Jane's case, recognizing the signs of suicidal ideation and responding appropriately can make a life-saving difference. To wrap up, I would like to leave you with a simple yet powerful three-step approach that anyone can use when they suspect a colleague might be considering suicide. This approach is often referred to as QPR. Q. Question. Directly and compassionately ask whether the person is thinking about suicide. Don't be afraid to use the word suicide. It won't put an idea in their head, but it will show them that you're taking their pain seriously. P. Persuade. If they indicate that they're considering suicide, your next step is to persuade them to get help. R. Refer. Guide them to professional help. If possible, offer to accompany them to counseling or stay with them while they make a call to a suicide prevention helpline. Your presence can provide crucial support during this vulnerable time. Remember, you don't need to be a mental health professional to use QPR. These steps can be taken by anyone who cares enough to ask and is willing to listen. Now, to delve deeper into QPR strategies for supporting colleagues at risk and implementing effective suicide prevention measures in our healthcare settings, I'd like to hand over to Dr. Bamboucher. Thank you, Dr. Bamboucher, for sharing and joining with us to continue this critical conversation. Thank you, Dr. Van Pelt. Fortunately, an advocate and expert in suicide prevention, Dr. Paul Quinette, founded the QPR Institute in 1999. What he recognized was that the utility of CTR in our general population, day after day and likely hour after hour, is saving lives. And if we can teach both healthcare professionals and just about anyone to perform safe and effective CTR, is there a way to safely and effectively teach the lay population and healthcare providers how to recognize and potentially prevent suicide? And his ability to do this was going to be honed via the use of the QPR methodology. Dr. Quinette explains quite profoundly that if one person is able to prevent a suicide in a hundred people, a hundred people being educated in the QPR methodology can save thousands and if thousands of people are educated, perhaps we can reach out to millions. The training in QPR is guided through professionals and anyone has the availability to access this training. It's about 90 minutes and the certification is achieved and can then be employed into the general community and of course into any of our healthcare or educational settings. The certification is actually renewed every three years to ensure that any new found knowledge and information can be shared with those who are considered advocates and experts in suicide prevention education. To reiterate what Dr. Van Pelt touched on, QPR starts with a question. Although we may see our colleagues or our nurse anesthesia residents or perhaps just a family member or friend every day and the signs may be subtle, if something seems different or off in someone that you know or care for, it just starts with asking the simple question. The QPR method employs the use of guiding someone who you are unsure is in a safe place to someone professional and that may be via a phone call or of course guiding them to someone physically that can help them. But the underlying basis of QPR is to ensure that a person who is in distress or crisis is referred to someone that can help them. The recognitions of warning signs of suicidality are profound and tend to be all over the spectrum. You may recognize that someone seems that they are becoming more isolated in any given setting or perhaps the hellos that you typically get in the morning turn into just a head nod or maybe you don't see that person at the normal time in the morning as you walk into work or into your educational setting. It may also be a change in behavior or a feeling of hopelessness or helplessness that they express to you. Whatever the warning sign may be that feels different to you, it always warrants a question. I think one of the things that I have found and we have found in our research is that there seems to be a perceived burden to some extent on health care professionals that if they don't feel that they are able to adequately help someone else that perhaps not offering to help at all is the safest bet. But what we have learned in via the QPR method and the many experts who are advocating for prevention of suicide is to start with a question whether you know how to help your colleague or friend or student or not. The CDC has quite a bit of information in helping those in the community to recognize how to prevent suicide but also how to potentially increase access and resources for those who may be at risk for suicide and suicidality. Perhaps we can take some of the education and knowledge that they share and integrate that into our RNA educational programs. We understand that going back for a doctorate degree is a financial burden. We understand that access to mental health care resources they may have had as a full-time employed registered nurse may be minimalized. They also may feel that they are outside of a protective environment. If they feel they are being judged or evaluated or at risk for being dismissed from a program should they not be able to continue in the full capacity. We have to as program directors, administrators, and faculty understand that this is a set of coping skills that they may not have had in their previous employment or in their previous walk of life and that connecting them with a new community of people in addition to the community they already have may help to take away some of the isolation they feel as they enter into this new world of doctoral preparation to become a nurse anesthesiologist. And most important the CDC asks that we identify and support those at risk and the same can be employed in our educational programs that recognition is likely the best way to prevent suicide. Specifically actions that faculty can take in the educational programs is to ensure there is an open door policy. Ensure that the nurse anesthesia residents have a phone number that they can access at any time of day and that their wellness is embraced in their training. And although every day may not be perfect whether that be because their clinical experience didn't go well on a particular day or they didn't perform as well as they had hoped to on an exam that the door is always open for them to ask questions and feel that they are supported as we continue to help them progress towards graduation and joining the profession as a CRNA. We also as faculty must decry the stigma of mental health challenges. If we are able to create an open space for our nurse anesthesia residents to help us understand what their previous or perhaps new mental health challenges may be during their training we may be able to modify or assist them in navigating the many challenges they face in their training. As a faculty and administrator it's important to encourage other preceptors, faculty, students, and colleagues to say something if they see something. As our nurse anesthesia residents progress through their training they have less and less time in the classroom and ensuring that all eyes are on them as they in a clinical environment it is important that any changes are reported back to the faculty in a safe private and effective way. We also encourage that programs really make sure that their faculty feel supported and that they have the capacity for self-care. Perhaps the burden in their own lives is so great that they are not able to understand the mental health challenges or have space to be open to recognizing the mental health strains that others may feel. And our faculty are also at risk as CRNAs as educators for suicidality. We must all look out for each other. Mental health resources are becoming more common but are still far from abundant. The resources should be accessed both at the institutional level, in the clinical setting, in the educational setting, and fortunately nationally resources continue to grow. Integration of suicide prevention training into the curriculum benefits both faculty and our nurse anesthesia residents. Allowing for time and articulation of suicidality and how to recognize and prevent it opens a conversation. It allows for a safe place and it also creates an ability for the learners and those instructing to know that talking about this epidemic is okay and it isn't going to change the progression of anyone finishing a program. In fact, it might ensure they do so safely. There go significant mental health challenges. The Council on Accreditation explicitly states under the graduate standards that under our professional role as nurse anesthesiologists, the importance of wellness is critical. And as program faculty, we must take the standard seriously as we build it into curriculums not just to check the box but to integrate it throughout so that not only our learners but also those who graduate are able to carry the standard forward. In conclusion, we recognize that suicidality in both CRNAs and RRNAs is a national crisis. The AANA continues to respond with education and informational modules as well as presentations at national conventions. We hope that together we can save a life by taking simple steps, whether that be in the educational setting, in the clinical setting, or out in the community. The AANA helpline continues to be a resource, a confidential 24-7 resource with live professional help for those who are experiencing crisis or concerns regarding alcohol and drug use. A profound addition on the national level was the use the utility of having 988, a three-digit number similar to 911, as a resource for anyone who is experiencing mental health crisis such as burnout, adverse patient care events, suicidality, PTSD, stress, or any other event causing distress. And finally, I wanted to reiterate that the QPR method is something anyone in the community can become certified in. The QPR Institute continues to make efforts to ensure that suicide prevention is something that grows in numbers so that we can save the greater good of humankind. We leave you with both the national hotline for mental health crisis and the AANA confidential helpline open 24-7. Dr. Griffith, Dr. Van Pelt, and myself thank you for taking the time to hear us as we try and help the greater community of CRNAs and rRNAs nationwide. We can be reached at any of the contact details listed here.

Suicide Prevention

Healthcare Professionals

CRNAs

Mental Health

QPR

AANA Wellness Initiative

National Mental Health Crisis Helpline