If you are a nurse educated before the 2018 NMC undergraduate standards1 (when the competencies of assessing and responding to a suicidal person was the sole domain of the mental health nurse), there is a good chance you have not received education in suicide awareness and prevention.
The literature informs us that nurses struggle to have conversations about suicide, but suicide is everyone’s business. A 2018 report by the National Confidential Inquiry into Suicide and Safety in Mental Health2 revealed two-thirds of people who take their life are not in touch with mental health services, challenging the myth that suicide is purely the remit of those services. So, how can nurses engage in conversations about suicide? They already have the skills to have difficult conversations – they do this every day – and understand the principles of compassionate communication that are inherent in commencing and holding a conversation about suicide.
Engaging with personal struggle with suicide
Like any other difficult conversation, it is imperative to start with our own thoughts, fears, and feelings in relation to the subject matter. What are our emotions, judgments, cultural influences and biases? Research reveals negative attitudes among nursing staff working with suicidal people.3,4,5 These affect the intention of engagement with the person in need.
Engaging with the suicidal person
There are a number of programmes and websites that have excellent resources, education, and training packages (see Resources, below). One of these, PAPYRUS, was referred to for the conversation starters and safety plans below.
The mnemonic TALK is helpful to remember when engaging in conversations about suicide:
T = Talk It is okay to talk about suicide, it reduces stigma and can support the person towards recovery. Research shows it can be a huge relief for them to share their thoughts.
A = Ask Be direct – ask the person: ‘Are you thinking about suicide?’ By using the word suicide, you are telling the person it is okay to talk openly about their thoughts with you. If your intuition tells you suicide could be an option for the person, ask the question. This can be a scary conversation for the suicidal person and for the nurse on the precipice of asking the question and fearing what to do with the response. There is no evidence asking about suicide leads to suicide. Another approach is to ask: ‘Sometimes when people feel like you describe, they think about suicide. Is it like this for you?’
L = Listen If someone is suicidal, listen to what they need to say and allow them to express their feelings. Use prompts such as: ‘It sounds as though things are really hard at the moment. Can you tell me a bit more?’ or ‘It must be so painful for you to feel like there is no way out. I want to listen and help.’ People carry stories that brought them to this point; be curious and ask open-ended questions to keep them talking, such as: ‘Tell me more about that’.
Summarise what the person has said to show you have understood and encourage them to keep talking. Showing care and compassion is essential for engagement and a meaningful encounter.
K = Keep safe Reassure the person they are not alone, and you can look for support together. Express this by saying: ‘It’s not uncommon to have thoughts of suicide. With help and support many people can work through these thoughts and stay safe. Let us do this together.’
If the person has shared that they have plans and are at immediate risk of death, follow emergency procedures and local policy and keep communicating with the person. Ask if there is anyone you can to contact to support them. If risk to life is not immediate, tell the person you care about their safety and that you can work together to make a safety plan. Ask questions such as: ‘What will get you through this moment?’ and explore situations that make the person safer. This means the person is no longer alone with their thoughts.
Be aware of useful places to signpost for help (see Resources, below) and agree follow-up if the person has known NHS input. Ask for help if needed during a conversation. It is okay to say, ‘I want to help but I’m not sure, I’ll find out.’
Caring for self and each other
Emotional demands on nurses are high when supporting suicidal patients. There may be limited emotional capacity, especially given current staff shortages and the pandemic.6 Research reports nursing itself is a high-risk occupation for suicide7, so conversations about suicide could include our colleagues, although negative attitudes and stigma can prevent staff from speaking out.8 Actively engaging in compassionate conversations about suicide with people we meet in care could encourage colleagues to speak out, look out for each other and reach out in times of deepest need.
CALM Tel: 0800 585858, 5pm to midnight every day
PAPYRUS – for under-35s. Tel: 0800 0684141, 9am to 12am every day. Text: 07860 039967
Samaritans Tel: 116 123 (24/7)
SOS Silence of Suicide Tel: 0300 1020 505, 8pm to midnight weekdays, 4pm to midnight weekends
Breathing Space (Scotland) Tel: 0800 838587, Mon-Thurs 6pm-2am; Weekend: Fri 6pm-Mon 6am
C.A.L.L (Wales) Tel: 0800 132737; Text ‘help’ to 81066 (24/7)
Lifeline (NI) Tel: 0808 8088000 (24/7)
NHS in England Find a local NHS urgent mental health helpline
Stay Alive App Suicide prevention resource
Zero Suicide Alliance Free education for staff
1 NMC (2018) Future nurse; standards of proficiency for registered nurses. London: NMC, 2018
2 National Confidential Inquiry into Suicide and Safety in Mental Health. Annual Report, 2018.
3 Sun F et al. A quasi-experimental investigation into the efficacy of a suicide education programme for second-year student nurses in Taiwan. Journal of Clinical Nursing 2011; 20(5-6): 837-846
4 Valente S. Nurses’ psychosocial barriers to suicide risk management. Nursing Research and Practice 2011;18:650765
5 Vedana K et al. Attitudes towards suicidal behaviour and associated factors among nursing professionals. Journal of Psychiatric and Mental Health Nursing 2017; 24(9): 651-659
6 Maben J and Bridges J. Covid 19: supporting nurse’s psychological and physical health. Journal of Clinical Nursing 2020;29:15-16.
7 Office for National Statistics. Suicide by Occupation, England: 2011-2015. Newport: ONS, 2017.
8 Rebair A and Hullat I. Identifying nurses needs in relation to suicide awareness and prevention. Nursing Standard 2016; 31(27): 44-51