1. Berry, Peggy Ann PhD, MSN, COHN-S, CLE, PLNC, FAAOHN

Article Content

What is it about health care where female nurses are twice as likely to die by suicide compared with the general population? The headline captured my attention (Bean, 2020) as the CoVID-19 pandemic continues to stress the health care system and the direct care nurses caring for these patients. The United States has incurred approximately 563,980 deaths (169 deaths per 100,000 people) as of April 17, 2021 (CDC, 2021b). What will be the number of suicides from nurses having feelings of helplessness associated with severe COVID-19 cases when statistics are gathered for 2020 and 2021?


Could future suicides be associated with a higher prevalence of moral injury? Moral injury is conceptualized as a symptom arising from the betrayal of justice by another person or organization (Griffin et al., 2019). However, moral injury exposure does not always create a psychological injury or posttraumatic stress symptoms. It may well be that moral injury and burnout equal posttraumatic stress disorder (Talbot & Dean, 2018). Whether a physician or nurse, the trauma seen can create a profound impact on well-being. Certainly, this past year (2020) has affected all health care personnel. Ellen Fink-Samnick's discussion on tackling collective occupational trauma (February 4, 2021, presentation) examined a clear connection from the stress, trauma, vicarious trauma, shared and collective trauma to posttraumatic stress disorder. Her presentation had sound merit addressing the ongoing issues of the pandemic. There are many issues impacting well-being.


As case managers, we must all be alert to our own state of well-being, as well as that of our coworkers. We are well attuned to signs of our clients' well-being, but how well are we addressing our own or that of our coworkers? We are all at risk, some more than others, in letting the pandemic, deaths, and challenges cloud what is still good in our lives. Unfortunately, thoughts of suicide may remain hidden.



Suicide is the second leading cause of death among individuals and the fourth leading cause of death for individuals between 35 and 54 years of age (CDC, 2021a). The World Health Organization (WHO, 2021) states that the stigma attached to suicide is a barrier to people seeking care. Risk factors for suicide include previous suicide attempts, mental health problems, harmful use of alcohol or drugs, job or financial hardship, relationship breakdown, trauma or abuse, violence, conflict or disaster, and chronic pain (WHO, 2021).


Along the aforementioned risk factors, the National Institute of Mental Health (n.d.) highlights other risk factors such as exposure to others' suicidal behavior, such as family members, peers, or celebrities. A family history of suicide is another risk factor. Prior incarceration, guns or firearms in the house, and family violence, including physical or sexual abuse, are additional risk factors. There are signs and symptoms of suicide that may be present. These behaviors are listed in Table 1.

Table 1 - Click to enlarge in new windowTABLE 1 Suicide Signs and Symptoms

Suicide Prevention Strategies at Work

What can you do at your place of work? First, ensure you have policies and procedures in place for referral to Employee Assistance Programs. In addition, determine the need for immediate transportation to a mental health facility. How do we identify coworkers at risk? Ask questions in your assessment. These questions may be hard to ask, but ask, nonetheless:


1. Have you felt down, depressed, or hopeless?


2. Have you had thoughts of killing yourself?


3. Have you ever attempted to kill yourself?



If you have not yet done so, take a course in Psychological First Aid (PFA). We all learn motivational interviewing, but how does your workplace provide safe space or education for PFA? Our ability to be resilient varies, dependent upon the internal (yes, internal) and external pressures experienced.


Psychological First Aid

Sim and Wang (2021) describe PFA as a humane and supportive response to any human experiencing suffering and needing support. Psychological First Aid fosters short- and long-term coping and adaptive functions. It is not computer-based training but requires another human being to create a "supportive and compassionate presence" at the time of distress and ensure continued care (Everly & Lating, 2017). The goal is to give employees (nurses) the knowledge, resources, and toolbox for empowering action with their psychological distress.


In any place of employment, employees need to have a safe place to go when overwhelmed by psychological stress. Bathrooms have been cited as nurses' safe place to cry. I have been there myself as a young nurse overwhelmed with the death of a patient and the distress of their family. Employers can do better than that! Chapels are wonderful, but access away from the floor may not be feasible for health care facilities. In industry, an office space could be identified and outfitted for decompression and PFA.


Borrowing from mental health first aid, use the mnemonic ALGEE to assess and assist your coworker or employee (National Council for Community Behavioral Healthcare, n.d.):


Assess for risk of suicide or harm.


Listen nonjudgmentally.


Give reassurance and information.


Encourage appropriate professional help.


Encourage self-help and other support strategies.




We are all stronger together if we watch out for one another. The COVID-19 pandemic is not over yet, and there will still be a higher rate of deaths we will need to cope through with our patients and families. As case managers, nurses, or social workers, we need to continue to take care of ourselves, assess our emotional honesty by addressing these emotions, and increase our resiliency strategies. Keep a gratitude journal, meditate, or pray daily, walk in the woods, and keep the oxygen mask on yourself so you can continue to help others during these times.




Bean M. (2020). Female nurses at high risk for suicide, study finds.[Context Link]


Centers for Disease Control and Prevention (CDC). (2021a). Leading causes of death.[Context Link]


Centers for Disease Control and Prevention (CDC). (2021b). United States COVID-19 cases and deaths by state.[Context Link]


Everly G. S., Lating J. M. (2017). The Johns Hopkins guide to psychological first aid. John Hopkins University Press. [Context Link]


Griffin B. J., Purcell N., Burkman K., Litz B. T., Bryan C. J., Schmitz M., Villierme C, Walsh J., Maguen S. (2019). Moral injury: An integrative review. Journal of Traumatic Stress, 32(3), 350-362.[Context Link]


National Council for Community Behavioral Healthcare. (n.d.). What is ALGEE?[Context Link]


National Institute of Mental Health. (n.d.). Suicide prevention.[Context Link]


Sim T., Wang A. (2021). Contextualization of psychological first aid: An integrative literature review. Journal of Nursing Scholarship, 53(2), 189-197.[Context Link]


Talbot S. G., Dean W. (2018). Physicians aren't "burning out." They're suffering from moral injury. Stat, 7(26), 18. [Context Link]


World Health Organization (WHO). (2021). Suicide.[Context Link]