Nurse Suicides: Talk To A Colleague

This story is Part 3 of a series by MedPage Today on suicides among nurses. The first addressed contributing factors and the second focused on how the University of California San Diego, a leader in recognizing the problem, connects troubled nurses and other staff to professional counseling. Here, we describe other ways UCSD is addressing depression, burnout, and suicide in health care.

Sitting in her living room in the hills of Ramona, California, it is difficult to picture Janet Mendis depressed to the point of suicide.

Mendis, a NICU clinical nurse specialist and bedside nurse for about 40 years in the UCSD medical system until her retirement this year, has a kind face — soft, dimpled cheeks, bright eyes and a gentle smile. Her whole demeanor exudes warmth.

"I wasn't depressed every single day of my life," she said, but some days were worse than others.

As a young nurse overseeing a night unit, when she was at work and "in the moment," she felt useful, but sometimes she'd be struck by a kind of hollow numbness, she said.

She'd be standing with a group of nurses, chatting, and she'd see the others thought something was funny. But she couldn't even make herself smile.

Other days her self-esteem suffered — she felt "undeserving" and "stupid".

At her lowest moments, she would notice ways of ending her life and think, "This would be so easy."

Nearly a dozen times she came close — mere seconds from death.

What stopped her each time were her four children, Mendis said.

"I didn't want them to think that they weren't important enough for me to live for, because that's how I felt as a kid," she said.

Mendis' mother suffered from depression and never sought help.

After the final time Mendis nearly took her own life, she contacted UCSD's employee assistance program. Her family physician brought her to meet with a psychiatrist and together they convinced her she could not "tough" out her depression.

She started on medication the next day. After a few months, the curtain of depression drew back.

"It was like, 'Is this what life is really like for most people? Wow. This is great,'" Mendis said. So great, in fact, that a few weeks later she decided she could stop the medication.

A week passed and she felt fine. But one night she noticed spots on the outside of her house and could not stop thinking about them.

Around midnight she threw off her covers, went to her garage, got some paint, and with a flashlight began painting over the spots — "feeling completely normal" despite still wearing pajamas, she recalled.

The next morning she noticed the paint was the wrong color. It occurred to her that maybe having stopped the medication was a factor in her fixation on the spots.

The whole thing seemed funny, so she told a few of the other nurses about the incident and what led up to it.

"I got a lot of, 'You? I wouldn't think that you were depressed,'" she said.

A few weeks later, a nurse stopped Mendis in the lounge and thanked her for sharing her late-night painting adventure, but more importantly, her need for antidepressants.

She told Mendis that she also had had a suicide plan and was ready to act. But after hearing Mendis's story, she went home and called her doctor.

"And now I'm feeling okay," the nurse told Mendis.

For years, whenever the other nurses at UCSD saw a colleague who seemed to be battling depression or another emotional problem, they'd say, "Go talk to Janet."

Second victim

Nurse manager Jeremy Cabrera is bald and broad-shouldered with an irrepressible smile.

When he came into the critical care environment, all he wanted to do was help people, Cabrera said, "but I never really had someone to talk to about the things I was seeing and doing."

Nurses are trained to empathize with their patients "to really put yourself in their shoes ... And when you do that it's a good thing, but it really takes a toll on you," he said.

He worked in a burn unit, one of the most emotionally taxing assignments a medical professional can have.

About nine years ago, he was caring for a patient who was about the same age as his own toddler son. They were even about the same size, he said.

Every day coming home was a struggle, he said.

When he looked at his own son, all he saw was a patient in pain. Instead of immediately hugging and playing with his children, he'd stand in the shower and cry.

It's called "second victim" syndrome or secondary trauma — seeing bad things happen to others and becoming traumatized oneself in turn.

At one point, he told his wife, "If this patient dies, I'm quitting."

She didn't say anything, he remembered.

What got him through those periods was realizing he couldn't face his problems alone and building connections with colleagues. "We were able to support each other," he said.

"You have to have that kind of culture," he said, where it's possible to open up and "not worry about 'did I share too much of myself?'"

"I can't even count to you how many people I've cried in front of," he told MedPage Today. "It's because I trust them and I feel comfortable ... that I'm able to do that. If you're not comfortable to share those feelings and you just bottle it up ... I think that's where you are actually hurting yourself more."

Peers recognizing peers

What if nurses everywhere had a Janet or a Jeremy to talk to about their emotional struggles? Would they suffer less, find healing more quickly if their needs were recognized and validated? Would they be less inclined to consider ending their own lives?

Judy Davidson, a nurse scientist for the UCSD School of Medicine in the Department of Psychiatry, tends to think so. Davidson and her colleagues piloted their own intervention which they modeled on a University of Missouri program called "forYOU" based on peers helping peers in a protected environment. The forYOU program focuses particularly on the "second victim" syndrome that Cabrera experienced.

Before developing a select network of "clinician lifeguards" whose job it would be to identify struggling colleagues and guide them to care, Davidson and several colleagues — researchers, another nurse, and a physician — wanted to first lay the foundation, by creating a more compassionate, nurturing hospital environment.

The idea was simple. Make an "intentional act of kindness," a small token indicating that their workmates care, along with a small nudge in the direction of help.

Davidson and colleagues developed "Code Lavender" packets containing a piece of chocolate, some lavender oil, a comforting message, a card to the employee assistance program and a small lavender starfish sticker.

The Code Lavender packets are given by one colleague to another, explained Patty Graham, a clinical nurse specialist in critical care at UCSD.

When something tragic happens, some clinicians may not be able to find the right words to express their concern for a colleague, or even feel comfortable saying them, she added. The Code Lavender packet acknowledges that someone has just been through something difficult, Graham said, and it didn't go unnoticed.

The group piloted the initiative in four high-stress units. Not everyone was enthusiastic about the project.

"Some people gave us a hard time," and laughed off the packets if they were given one, Graham said. Others would put the sticker on the front of their scrubs, as a way of signaling, "I'm a little fragile today."

"The nurses would joke some days that they wanted 20 stickers across their forehead," she said.

"Feeling alone and disjointed from your team is one risk factor for suicide," Davidson explained. "Just recognizing somebody is having a bad day is a suicide prevention technique."

Davidson and colleagues published a review of their initial experience in 2017. They found no significant changes in the professional quality of life scores with the intervention, but they did see an improvement in the "emotion of feeling cared-for."

Notably, "[o]f those who received the Code Lavender intervention, 100% found it helpful, and 84% would recommend it to others," the group wrote. They concluded that the results warranted "continuation and further dissemination of Code Lavender."

Throwing a lifeline

While UCSD's Code Lavender initiative was getting underway, another more intensive peer support intervention was taking shape there as well.

Called the "Caregiver Support Team," it shared the goal of developing a more compassionate working environment but also included a deliberate focus on preventing nurses and other hospital staff from succumbing to burnout, depression, and suicide.

William Norcross, clinical professor of family medicine and public health in UCSD's School of Medicine, realized the health system needed a better way to identify staff in crisis. (Norcross was also instrumental in developing the so-called HEAR program described in the second part of this series, linked in the first paragraph at the top of this story).

"The closer you get to the people at work on the ground, the more successful you will be," said Norcross.

As with Code Lavender, Graham, Norcross and Davidson chose four high-intensity, high-stress units in which to pilot the program.

It started with a survey that included one very basic question, said Davidson: Who would you go to if you were having a hard day?

The ones named often weren't those one might expect. They weren't the "boss's favorite," or the unit leader. The chosen peer supporters were from all levels from physicians and nurses to technicians, she said.

Once nominees were chosen, Davidson and her colleagues asked them if they would serve as volunteer peer supporters or "emotional first-aiders."

Nearly everyone did, she recalled.

The peer supporters — 100 in all — engaged in eight hours of training, where they learned about depression, burnout and risk factors for suicide. Afterward, they met monthly to debrief about their experiences.

From hurt comes healing

Cabrera wasn't nominated but he volunteered anyway.

As a bedside nurse, his job was to serve the patients. In his role as a nurse manager, it's his job to care for his staff, he explained.

He was excited to be able to help others through the same challenges he had dealt with as a bedside nurse, and he was proud to let others know his role. Peer supporters were given blue sweatshirts with "Caregiver Support Team" written across the front.

"I still wear them," he said, smiling.

Cabrera sees his colleagues at work just as much as he sees family at home. He knows his staff and can spot changes in their behavior.

In the peer supporter training, Cabrera was taught to notice signs of burnout or compassion fatigue.

"For me when someone does something that's not their norm ... raising their voice, losing their temper ... those are all kind of key signs for me," Cabrera said.

Behavior change can also be more subtle. A person may come to work and start doing their daily tasks, like a machine, without greeting anyone, he said.

There are "critical moments," Cabrera said, when one clinician can talk to another and ask what the other person is dealing with.

Time away from work may actually make things worse, he noted. "I think that's where it gets kind of dangerous, where they're not expressing their thoughts and their feelings."

When he sees a change in someone's behavior, he will typically take the person aside, and just ask what's bothering him or her and how he can help.

And that's the point of the caregiver support group, "because it's really right there for you," he said.

Davidson stressed that peers aren't giving anyone "treatment." They respond to the colleagues' needs and decide whether to refer them to a higher level of care if it's necessary.

"Even the act of just saying, 'Hey I noticed you had a really bad day, I'm here for you' — that is a suicide prevention tactic," she stressed.

During the six months when the caregiver support program was piloted, Norcross said, "we know for sure that we prevented one suicide beyond the shadow of a doubt."

After completing the pilot, UCSD didn't immediately implement the Caregiver Support Team program. However, it will now be operationalized system-wide in the coming year, Davidson said.

Peers in action

One day a nurse came to Graham's office clearly in distress.

To those who didn't know her well, the nurse seemed fine. She smiled at times and did her work. But Graham knew she had been struggling with some personal problems and also that she had taken care of a few really sick patients.

"I knew how emotionally and physically draining that was on someone who already seemed depleted," Graham said.

In her office, the nurse ticked off a laundry list of stressors including lack of sleep, and Graham knew she needed to intervene.

"It was kind of a hard question to ask, 'Have you ever thought about killing yourself?'" Graham said, who had helped teach the training for peer supporters.

"But I asked it and I'm so grateful that I did."

The nurse said "yes." Graham did her best not to gasp, she said.

Even more worrying, the nurse had a plan and the means to carry it out. She wouldn't let Graham reach out to her husband because, she said, she didn't want to bother him.

And then she left, with Graham still in the office — petrified.

"I thought, 'Oh my gosh, oh my gosh' ... like I couldn't stop her."

Graham followed the Caregiver Support Team protocol and went up the "chain of command."

She phoned a colleague and said, "I think we have someone who may be trying to kill herself as we speak."

Graham contacted a friend of the nurse who met her at her house along with her husband.

The nurse didn't attempt suicide but instead sought treatment.

Whole system change

Susan Scott, who developed the forYOU program in Missouri, told MedPage Today that the key to peer-initiated intervention is culture change.

"Historically, when something happened people would just go home, tuck it in and process it internally, whether it was related to a medical error or not, and what we realized is we had to put in a purposeful habit that could change our culture," said Scott, now director of nursing-professional practice for MU Health Care in Columbia, Missouri.

"What we did was we gave permission to the 'peer supporters' that if they [were] worried about a colleague to just proactively reach out and make sure that they were okay. We also asked the leaders to do the same thing."

Making this a habit for staff eventually changed units' entire attitude toward work stresses. "What we've seen now in 10 years is that we now have this culture of supportive presence for staff."

All three programs at UCSD — Code Lavender, the Caregiver Support Team, and HEAR — fit together, Davidson said.

"You need to be able to shift your culture so people care and take action. You need to have people who recognize other people that they trust to go to, and then you need real ways to get people into treatment," she said, in nutshell summary of the three programs' respective goals.

Ultimately, said Norcross, what's important is being able to reach out to those people who are struggling and remind them that things won't always look so bleak.

Norcross said he remembers reading an article from the Western Journal of Medicine in the 1970s.

"Researchers did a study of everyone they could get ahold of who had survived a jump from the Golden Gate Bridge in San Francisco," he said.

That isn't many people, he noted.

"But the one thing I remember from this is that, of those survivors, the majority of them regretted their decision on the way down."

"And I think there's a lesson to be learned there. When we deal with people who are very depressed and thinking of taking their own lives, we can honestly tell them that there are likely to be better times ahead because the natural history of depression and many mental illnesses is one of peaks and valleys," Norcross said.

"There are good days and bad days and, of course, people think of taking their lives when they're suffering — when they're in a valley — and we can tell people honestly, especially with help and treatment, that there are better days ahead."

If you or someone you know is considering suicide, call the National Suicide Prevention Hotline at 1-800-273-8255.

Reporting for the series was supported by a grant from the Solutions Journalism Network.