Pediatric Suicide: Supporting Nurses on the Front Lines

In the United States, suicide is the second-leading cause of death among children aged 10 to 14.1 The rising suicide rates have sounded alarm bells for health care professionals, particularly nurses, who are often the first line of defense in patient care. Estimates from the Centers for Disease Control and Prevention suggest that for every suicide death, there are 3 hospitalizations for self-harm, 8 emergency department visits related to suicide, 38 self-reported suicide attempts, and 265 individuals seriously contemplating suicide.2 These figures demonstrate the numerous opportunities for intervention that nurses encounter, placing them in a position to address this major public health issue.A nurse’s role when assessing, diagnosing, and treating patients at risk of suicide involves evaluating suicidal tendencies and promoting a safe environment for both the prevention of suicide and the recovery of patients. However, challenges exist in accurately assessing risk, particularly among nurses lacking specific training in this area. Furthermore, the emotional impact of dealing with suicidal patients can negatively influence nurses, affecting their own mental health and increasing their own suicide risk.3 This impacts nurses’ delivery of care and consequently decreases patient safety.When it comes to patient suicide, the emotional toll on nurses is substantial, encompassing feelings of sadness, grief, guilt, self-doubt, and concerns about legal repercussions.4 Such experiences underscore the importance of also addressing nurses’ emotional well-being to protect their mental health and maintain high-quality patient care. Despite the significance of this issue, existing research on nursing care for suicidal patients is limited. Therefore, this column seeks to analyze the available evidence, aiming to integrate findings and provide new insights fundamental for enhancing nursing care in the context of suicide prevention and management.Youth suicide in the United States is a complex and multifaceted issue, marked by various intersecting risk factors. The distressing disparities in suicide rates among young people across age, gender, race, ethnicity, and sexual orientation demand attention to these differences. Developmental stages significantly influence suicidal thoughts and behaviors, with rates escalating with age.1 Males, for instance, have consistently shown a higher propensity toward suicide, with rates nearly triple those of their female counterparts.5 Particularly disconcerting are the statistics among American Indian/Alaska Native youth, whose suicide rates considerably exceed those of White youth and other racial groups.5 This trend is not confined to adolescents; younger children, especially Black children under the age of 13, show alarmingly high suicide rates compared with their White peers.6The landscape of youth suicide is dynamic, with social factors playing a substantial role. Research indicates that aspects such as parental mental health, familial conflict, and parental monitoring influence the risk of suicide attempts in young people. Studies have consistently linked specific family conditions, such as those involving high conflict or inadequate supervision, to a heightened likelihood of suicide attempts among adolescents.7,8 This evidence highlights the need for family-focused strategies in suicide prevention efforts, aiming to create supportive home environments that can mitigate these risks. Moreover, the detrimental effects of child maltreatment, particularly sexual abuse, are linked to an increase in suicidal behavior in youth.9 Additionally, as adolescents navigate the challenging psychosocial phase of identity formation, they become particularly susceptible to external social influences.10 This developmental stage is characterized by exploration and uncertainty, making adolescents more vulnerable to societal pressures and peer influences. Bullying, including its digital form, cyberbullying, emerges as a potent threat during this period. It has been established that bullying contributes to mental health issues, including depression, anxiety, and increased suicidal behaviors.11 This risk is even more pronounced among LGBTQIA+ youth, who often face higher rates of bullying.12,13Media portrayal of suicide and an individual’s use of social media add another layer of complexity to social and environmental factors. Such portrayals can shape adolescents’ perceptions and behaviors toward suicide, sometimes in harmful ways, increasing contagion.14 However, it is important to recognize the complicated nature of digital media. Although certain aspects can be detrimental, social media and the internet also offer platforms for support and community building.15 This dichotomy highlights the need for nuanced approaches to understanding and addressing the impact of media on adolescent mental health.Beyond the social and environmental influences, biological factors are crucial in the discussion of youth suicide. Mental health conditions such as depression, anxiety, and bipolar disorder are associated with an increased risk of suicide in teens.16 Developmental changes in the adolescent brain can exacerbate underlying mental health issues, thus influencing suicidal ideation and attempts. Data also point to a potential genetic predisposition to suicidal behavior, suggesting an interplay between hereditary factors and environmental stressors.8 A key aspect of adolescent vulnerability to suicide lies in their cognitive development, particularly in the realms of stress processing and impulse control.17 Despite their awareness of life stressors, adolescents often lack fully developed capacities for impulse control and long-term planning, increasing their susceptibility to consider and execute suicidal plans.17Nurses are at the juncture of providing clinical care and offering emotional support to both patients and families. The dual responsibilities inherent in this position not only demand clinical expertise but also necessitate strong emotional resilience and coping mechanisms.Constant exposure to high-stress situations, particularly when working with suicidal youth, can lead to severe compassion fatigue and burnout. This reality emphasizes the need for pediatric nurses to develop and employ effective personal coping strategies. Available evidence highlights the importance of resilience training and mindfulness practices in helping nurses maintain their mental health and the quality of care they provide.18The emotional challenges faced by pediatric nurses in managing suicide risk are profound. When treating suicidal patients, remaining aware of one’s own emotional reactions and being mindful is important. This can help reduce the stress of suicide assessments and enhance clinical decision-making. Furthermore, the attitudes and beliefs of nurses toward suicide, influenced by factors such as knowledge of the topic, cultural beliefs, and prior experiences with suicidal patients, significantly impact patient safety and the quality of health care provided.19,20 Addressing these psychosocial barriers and understanding the dual role of nurses is essential for effective risk management and patient care.The field of pediatric nursing faces a major gap in terms of training and education, particularly regarding suicide intervention and assessment.21 This lapse is evident in the lack of a consistent set of standards across nursing education programs for suicide assessment and intervention. Puntil et al22 emphasize this challenge, highlighting the absence of suicide-specific intervention training in educational programs. This lack of training is a critical gap, given the complex nature of pediatric mental health and the increasing rates of pediatric suicide. Additionally, there’s a noted discrepancy in training concerning lethal means restriction, a core strategy in suicide prevention, as supported by the American Psychiatric Nurses Association (APNA).23 Khubchandani et al24 found that a majority of nursing program directors had not considered providing firearm injury prevention training, despite the prevalence of firearms in suicides.The American Association of Colleges of Nursing has established standards for baccalaureate-prepared nurses, which include injury prevention.25 However, these standards do not specifically mention suicide prevention or assessment, pointing to a meaningful opportunity in curricular development. The APNA acknowledges this gap and supports the development of guidelines and competencies for nurses at both undergraduate and graduate levels, specifically for the care of suicidal patients.23 This commitment is a step toward addressing the educational needs in this area. Enhancing training in ethics and self-awareness is also essential for nurses. Such training can improve their ability to provide compassionate care, helping them explore patients’ problems effectively and conveying nursing values, including empathy, acceptance, and the instilling of hope in patients.26Cultural perceptions and attitudes toward suicide can greatly influence the training and practice of pediatric nurses. For instance, in Ghana, suicidal persons are perceived as immoral by some nurses. Osafo et al27 noted that emergency department nurses in their study viewed suicide as a crime and believed the suicidal person was blameworthy. Nurses’ negative attitudes included avoidance, rejection, hostility, and anxiety. The consequences of nurses’ attitudes impacted the quality of care that patients received and resulted in the reinforcement of patient’s negative feelings, including worthlessness, hopelessness, and rejection.27 In one study, the dominant attitude toward suicidal patients was often hostile and nonempathetic.28 Negative attitudes were more apparent in general hospital staff as compared with psychiatric hospital staff.29 Such cultural attitudes accentuate the need for culturally sensitive training, awareness of personal biases, and education for nurses.Nurses play an integral part in identifying and responding to signs of suicidal ideation and behavior in pediatric patients, a central aspect of effective mental health care. Statistics reveal that many individuals who die by suicide had seen a health care provider in the month before their death.30 Often the first point of contact in health care settings, nurses are instrumental in both primary and secondary levels of suicide prevention due to their extensive interaction with patients.28 Despite this, suicide remains a major sentinel event in hospitals, leading The Joint Commission to urge comprehensive risk assessments for at-risk patients.31Health care professionals, including nurses, often fail to conduct adequate suicide risk assessments. The American Academy of Pediatrics recommends that primary care providers screen for suicidal ideation and manage mental health conditions to ensure proper care continuity, highlighting that many needing behavioral health interventions do not receive it.32,33 This reinforces the need for more training and effective utilization of nurses at all levels.33Notably, Valente29 reports that most nurses are uncertain about how to communicate with suicidal patients and often remain silent due to fear of saying something wrong or lacking experience in dealing with suicidal patients. This apprehension is echoed in the findings of Betz et al,34 who note that skepticism about the preventability of suicide is prevalent among emergency department providers, including nurses and physicians.Thus, recognizing suicide risk factors is key for psychiatric and acute care nurses. The potential for preventing suicide through comprehensive risk assessments suggests that diligent evaluation of all patients could dramatically reduce incidents of suicide.35 Implementing both self-report and interview methods for assessing suicidal ideation is recommended, as research has shown that appropriate evaluations facilitate effective interventions and safe discharge planning.36 Contrary to misconceptions, screening for suicide does not increase suicidal thoughts.37Most primary care clinics use self-report mental health questionnaires for screening, such as the Patient Health Questionnaire (PHQ), with a particular focus on question 9, which addresses suicide. Tools like the PHQ-9 and Ask Suicide-Screening Questions (ASQ) have built-in components to ask about suicidal thoughts and behaviors. The ASQ Toolkit, validated for both youth and adults, is a tool for suicide risk screening. Developed by the National Institute of Mental Health (NIMH), it includes a set of 4 questions that can identify individuals at risk for suicide. Notably, in an NIMH study, a “yes” response to any of the 4 questions identified 97% of youth (aged 10–21 years) at risk for suicide.38 This tool has been shown to be effective in various medical settings, including emergency departments, inpatient medical/surgical units, and outpatient clinics. The Joint Commission endorses the ASQ for all ages, recognizing its utility in early identification and assessment of medical patients at high risk for suicide.31Similarly, the Columbia-Suicide Severity Rating Scale (C-SSRS) is another extensively validated tool used across developmental stages, administered to children as young as 5 years old.17 It serves as a multifunctional screener designed to standardize the classification of suicide risk. The tool uses straightforward questions to assess the intensity and type of ideation, as well as associated suicidal behaviors. It is instrumental in determining the level of risk and appropriate services needed for the youth.39Given the alarming prevalence of suicide, early detection through screening becomes a necessary prevention strategy. The Joint Commission recommends universal screening for suicide risk in all medical settings as a proactive approach to suicide prevention.31 Implementing evidence-based clinical pathways, like those provided in the ASQ Toolkit, can guide the process of identifying at-risk youth and providing efficient care, thus saving time and resources. Considering this evidence, there is a compelling case for the implementation of universal screening for suicide risk in all emergency departments and other health care services. This approach is not only a pivotal step in suicide prevention but also aligns with the best practices recommended by leading mental health organizations and accrediting bodies.Emma, an experienced pediatric nurse at a busy city hospital, arrives for her shift and starts reviewing her assignment for the night. Her sense of routine is disrupted when she receives an alert about a new urgent admission to the emergency department.Alex, a 14-year-old high school student with a history of depression and recent family trauma, arrives following a self-harm incident. Alex is quiet, withdrawn, and shows reluctance to communicate, presenting a challenge for Emma.Emma quickly realizes the complexity of assessing Alex’s mental state. She struggles to engage Alex, who is resistant to answering questions about how he is feeling or about the incident. Alex’s parents do most of the talking but are not able to provide insight into the specific event since Alex was alone in his room. The parents shared that Alex is having trouble with some boys at school but has support from a guidance counselor. Alex’s parents are concerned about his well-being at home, as his appetite and sleeping have declined the last few weeks. They were not aware of any previous self-harm and were shocked to find him in this state but are now worried that they may have missed something. Alex does not speak up when his parents are sharing concerns and seems to have a neutral demeanor throughout the conversation. When asked to elaborate, Alex states that there is nothing else to add. Emma, who does not have specific training in adolescent mental health crises, still attempts to engage Alex and employs open-ended questions. This creates a reassuring and low-pressure environment that fosters communication.Throughout the process, Emma grapples with feelings of inadequacy and guilt, compounded by the fear of exacerbating Alex’s condition. She reflects on the emotional toll such cases take on health care professionals and the importance of having support systems like peer discussions and debriefing sessions to process these complex emotions. Emma recognizes the benefit of having open communication with her supervisor at this time to get support and advice.Using the hospital’s suicide screening tools and collaborating with a mental health specialist, Emma gains a deeper understanding of Alex’s condition. She learns that Alex’s reluctance to answer questions is a critical indicator in the assessment. She provides immediate medical care, ensuring Alex’s safety, and facilitates a referral for specialized mental health treatment in addition to strengthening existing supports.The incident with Alex deeply affects Emma. Witnessing the physical manifestation of Alex’s psychological pain in the form of self-harm leaves her emotionally drained. After stabilizing Alex, Emma seeks a quiet moment to process the day’s events. She reflects on the need for mental health support for nurses, especially after handling such intense cases. Emma decides to attend a support group for health care professionals, realizing the importance of addressing her own emotional well-being to continue providing compassionate care. She also recognizes the urgent need for comprehensive training in suicide prevention and the value of practical tools and strategies in pediatric nursing.After her shift, while debriefing with her colleagues and supervisor, Emma discusses the emotional challenges of their profession, emphasizing the need for more dedicated mental health support within their work environment.The complexities of suicide care in pediatric nursing are evident and require a multifaceted approach. In a recent systematic review, effective strategies for nurses to address the prevention, management, and treatment of suicide included interventions based on psychological therapies, pharmacological treatment, the nurse-patient relationship, and education for the general public.40 As we transition from understanding these challenges to proposing solutions, it is imperative to focus on practical recommendations. Most importantly, the emotional and professional challenges nurses encounter need robust support mechanisms. This support not only bolsters nurses’ capacity to effectively assess and intervene but also safeguards their well-being. These to nurses with the necessary and to address the of pediatric suicide prevention and for higher education in nursing a consistent set of standards for training in suicide assessment and intervention. 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