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Suicide - Everybody’s business

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Rates of suicide are on the rise

Suicide prevention should be part of every nurse's basic education, many in the profession believe. But can non-specialist nurses be given the confidence to broach the subject with their patients? And if they do, will it really save lives? Craig Kenny writes

In a near unanimous vote this year at the RCN Congress, delegates voted to 'influence' schools of nursing to include suicide prevention in all pre-registration training. This followed an emotional debate, during which some delegates spoke of friends, colleagues, sons or daughters who had self-harmed or attempted suicide.

The case was strongly made that suicide prevention should not be left only to mental health specialists, or be confined to optional postgraduate modules. As the proposer Annessa Rebair of the RCN's North of Tyne branch put it: 'Suicide is everybody's business.'

'People who are thinking about suicide rarely share these thoughts,' said the motion's seconder, Bronwyn Roberts of Calderdale and Huddersfield branch. 'We need to be able to open the conversations. We need to recognise when someone is in complete distress, feeling too isolated to speak to someone, feeling unable to ask for help.

'We need the skills of nurses to be able to reassure people that they can get through this.' Nicholas White, clinical education and training manager from Plymouth, told the conference: 'If every single one of you here today was able to have that conversation with an individual there will be many thousands of lives saved and preserved.'

In recent years, the long-term trend of a decline in suicide rates has been reversing in the UK. In 2002, there were 12.1 suicides per 100,000 people. By 2012, this was down to 11.6 per 100,000. However, up until 2007, the rate had been declining, down to a minimum of 10.8 per 100,000, after which it began to rise again.1

These figures mask big differences between the four nations in the UK. Over the same decade, the suicide rates rose in Wales and Northern Ireland, while England saw a small reduction, from 10.9 down to 10.4 per 100,000 people.

Scotland has had the most success in reducing suicides, having set itself a target of cutting the rate by 20 per cent between 2002 to 2012. Two years ago, the suicide rate was 14 per 100,000, down 18 per cent on a decade earlier.2

It has been suggested by some authorities that the recent rises in the suicide rate may be linked to the economic recession. A recent report by The Samaritans highlighted the particular risks to unemployed middle-aged men from lower socio-economic groups.3

High stress occupations – including nursing and medicine – also increase the risk. According to figures released by the Liberal Democrats in 2000, nurses are one and a half times more likely to take their own lives than the general population. For female nurses the picture was worse – their likelihood was four times that of women in general.

A key study published this year found that 60 per cent of people struggling with suicidal thoughts receive no help at all. However, there is little evidence to indicate what helps for those who do get support.4

An essential nursing skill?

The NMC in its 2010 standards for pre-registration nurse education lists as an essential nursing skill the ability to respond appropriately when faced with an emergency or sudden deterioration of a patient's physical or psychological condition, including self-harm or attempted suicide.

However, a responsibility to work 'positively and proactively' with people at risk of suicide is confined to mental health specialists. They are expected to use evidence-based models of suicide prevention, intervention and harm reduction to reduce risk.

The standards for training specialist community public health nurses date from 2004 and make no mention of suicide risk prevention.

In a statement, the NMC said it was currently reviewing the current standards and expects to publish an evaluation next summer. 'The NMC is an independent regulator, but in evaluating and reviewing standards, we collect evidence and feedback from a range of stakeholders and organisations, including the RCN.'
Ian Hulatt, the RCN's adviser on mental health, said the college is holding discussions with the NMC and Public Health England,

while reviewing evidence with the aim of writing a curriculum to include suicide prevention in all nurses' pre-registration training.

'You would expect there would be a degree of confidence and competency in suicide prevention with mental health nurses, but the phenomenon of suicide is widespread – not just among people with a mental health label,' he said.

'We are keen that this expertise should be prevalent in other areas of nursing and midwifery. Take practice nurses, who work with people with long-term conditions. Suicide prevention is traditionally seen as outside their remit, but suicide is everybody's business.

'We are determined to lobby for this, so that it's something that all nurses feel confident with,' said Hulatt.

'Its about having the right conversations, feeling confident to ask the right questions and signposting people on. Asking people how determined were they to take their own life? What assistance do you need? It's a very worthwhile thing to do. You could argue this is another form of safeguarding.'

This is certainly the thinking of many commissioners at the moment. Lucy Botting, chief nurse at Vale of York CCG, said: 'CCGs are working towards their five-year strategic plans, which are very much about care in the community, prevention, and health and wellbeing.

'We are looking for a highly skilled workforce that looks at more complex issues than in the past. As a commissioner and a nurse I would argue that pre-reg nursing students need to have suicide prevention training, but I would widen that further.

'If we are looking at the nuances of our population, then it's about proper mental health training, including suicide prevention, dementia training and also aspects of safeguarding, for instance around domestic violence which, like suicide, is also on the rise.

'We are going to see more complex illness and mental health illnesses in the community, and need a highly skilled workforce that deals with that from cradle to grave.'

Preparing staff gets results

The English government's 2012 suicide strategy paper identifies groups at high risk of suicide, but does not discuss workforce-related issues such as staff training.
However, the decision to train front-line staff with the requisite skills was taken in Scotland over a decade ago. Scotland's Choose Life initiative set a target of training half of its front-line staff in suicide prevention by 2010, and almost hit its target of reducing suicides by 20 per cent in 10 years, producing an 18 per cent reduction by 2012. Northern Ireland now aims to take a similar approach, according to its recent suicide prevention strategy paper 5.

NHS Lothian, for instance, has given suicide assessment and prevention training to half of its key staff in primary care, A&E, mental health and substance misuse services. The group, which includes practice nurses, district nurses, health visitors and general nurses, took the three-and-a-half hour safeTalk course, which aims to help them identify people with thoughts of suicide and connect them to relevant services. The more intensive STORM training, which lasts a day, was given to senior nursing staff.

Derek Barron, associate nurse director for Mental Health Services at NHS Ayrshire and Arran, stressed that health boards worked in partnership with local authorities in Scotland. 'If you just take this as a single organisation approach you will fail,' he said. 'Mental health professionals are not in contact with people in the community who may be at risk of suicide – they are teachers in schools, they are local binmen, they are nurses, they are teenagers.'

Mr Barron said the training gave non-specialist nurses and social workers the confidence to broach the subject of suicide with people who may be at risk.
'People say I don't want to ask about suicide because that might put the thought in their head. SafeTalk gives people the confidence to do that. It's about when to ask and when to refer people on. Knowing when to refer on is a critical point.'

The University of West of Scotland gives the safeTalk training to all mental health and adult nursing students in the first year of training, progressing to ASIST and STORM training in later years for mental health specialists.

Many English schools of nursing are also incorporating suicide prevention work into pre-registration training. For instance, Bradford University teaches Cognitive Behavioural Therapy to students to 'develop competency in asking about a person's thoughts and feelings in distressing situations and developing distress tolerance skills.' In addition, there are workshops on how to talk to patients about suicidal thoughts and feelings, risk/safety planning, working with self-harm, overdosing and suicidal ideas.

And the University of Birmingham teaches all first year students about the causes, demographics and management of suicidal people. However, some organisations have found that theoretical training is not enough, and that extra steps need to be taken to help staff gain the confidence they need to tackle the subject of suicide with patients.

Berkshire Healthcare NHS Foundation Trust therefore built reflective peer review into its staff training on suicide prevention. 'We used to have a three hour theory session in class, with the focus on high risk groups, but we found it didn't equip people with the skills to really work with someone with suicidal ideation,' said Sue McLaughlin, nurse consultant in inpatient mental health services at the trust. 'We found in our own training that people were avoiding asking questions, and they didn't know what to do with the information.' The trust brought in an approach that used anonymised case studies. Individuals made assessments of these patients, which were then peer reviewed. 'We are trying to tap into ways we can improve staff confidence in making assessments,' said McLaughlin.

They also adopted Thomas Joiner's model, published in his book Why People Die by Suicide in 2006, for suicide risk assessment. 'Joiner's model is really helpful,' said McLaughlin. 'You don't want to overload people, you just want them to detect risk and refer on.'

Together with the University of West London, the trust's model has been adapted for pre-registration nurse training in the region.
Meanwhile, specific work is being done to improve the training of primary care and community nurses in mental health. The QNI is due to publish its proposals for new standards for district nurse education in September next year.

Dr Crystal Oldman, chief executive of the QNI, said: 'One of the challenges for district nurses and general practice nurses is that the NMC standards for specialist practice are very old. These nurses work with people with long-term conditions who see no hope. We will be taking these factors into account in deciding what should be in the standards.'

A recent initiative in Sutton and Merton saw 166 school nurses given training to improve recognition and assessment of mental health problems in children. The QUEST project incorporates annual training updates, which have included specific training in suicide prevention, self harm and eating disorders from specialists at the Tavistock Clinic and others.

However, as Rosalind Godson, professional officer with the CPHVA, notes: 'This just reflects the picture in Sutton and Merton. We really need a national standard for within the workplace and in the specialist community public health nurse training.

'We definitely need something for both pre- and post-registration,' she says. 'There should be a compulsory mental health module in
pre-reg training followed by an in-depth module within two years of qualifying – especially for looked-after children's nurses, school nurses and those working in the youth justice and adult judicial systems.

'This would need to be part of an entire mental health learning package, as suicide is not a "stand alone" issue,' Godson argues. 'Nurses would likely only be seeing someone for a particular health reason, so they need to be trained to assess via 'making every contact count'. Health checks are usually taken up by the worried well.'

The next few years could see a cultural shift in how suicide prevention is dealt with in the NHS, perhaps the kind of paradigm change that has already been achieved in child protection. Scotland has already shown that giving training to front-line nurses can make a difference and save lives

Suicide prevention: training packages

Figure caption: Rates of suicide are on the rise

References: 1. Office for National Statistics. Statistical bulletin. 18 February 2014.
2. General Register Officer for Scotland. Probable suicides: Deaths which are the result of intentional self-harm or events of undetermined intent. ]
3. Men, suicide and society. Samaritans. 2012.
4. O'Connor R, Nock MK. The psychology of suicidal behavior. 2014. Lancet Psychiatry. 2014; 1(1): 73-85.
5. Department of Health Social Services and Public Safety.

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Suicide prevention training might be useful for all healthcare professionals.
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