Utilizing Tools to Assess Nurse Suicide Risk


Years ago, a nurse at a sister facility spent a gloriously sunny morning raiding her Intensive Care Unit’s emergency intubation bag, stealing just enough neuromuscular blocking agent (Alcuronium) to get the job done. None of the nurses working that day have forgotten the horrifying way this nurse chose to end her life, or the fact that no one surrounding her saw it coming.

No one had a clue.

Years later, I grieve, thinking of her alone and unable to move or breathe, wondering what thoughts had driven her to take such a gruesome step. Of all the nurse colleagues I have known and lost over the years, this death haunts me more than any: it was potentially, preventable. This year, I have lost more colleagues to a menacing invader, a pandemic that has threatened the lives of our frontline workers, and exhausted those who work ceaselessly to save those who are struggling to overcome the plight of coronavirus. Will it begin to tip more nurses over the edge?

The Risks

Even for those who love it, nursing can be a challenging profession, and statistics tell us it is growing more so over time. Although it is rarely mentioned by the media, nurse suicide has increased. Female nurse suicide rates from the years 2005 to 2016 were significantly higher than the general population at a rate of 10 per 100,000 as opposed to 7 per 100,000 for the general population. Male nurse suicides for the same period were higher at 33 per 100,000 compared to 27 for 100,000 for the general population. Although the method of suicide was different between males and females, the use of firearms is rapidly becoming a common thread between the two.6

Prior to recent years, females had chosen medication(s) as the method of choice.

In the UK, a study disclosed that more than 300 nurses in England and Wales took their lives by suicide in the years between 2011 and 2017. Unfortunately, as in the US, these deaths rarely made the news, so government action, research, and planning has been gradual. With the global pandemic in the forefront of healthcare needs, nurse suicide has fallen behind more urgent concerns as a priority.5

Recognizing the Risk

One of the reasons nurses do not seek assistance through programs at work is due to fear of reprisal, whether the risk is real or perceived. For that belief alone, suicide assessment/risk evaluation programs must be anonymous. Nurses, sandwiched between demands of patients and those of administration, feel ever-increasing pressure on all sides. This year has been especially egregious. Either nurses are facing enormous risk as frontline providers, or they are asked to stay home to save funds. If they complain, they risk being “not part of the big picture.” Nurses are the cornerstone of patient care, yet females today could be 23% more likely to commit suicide than women in general when they are stressed.4

Are we giving nurses a chance to discuss the toll this year has taken on them? Do they have a place to debrief or find support? The pressures of daily life added to those of healthcare can be overwhelming, and without peer support, the risk of self-harm may rise even further. Get to know the colleagues around you. Is horizontal bullying a practice on the unit? A study by Vanderbilt University identified bullying as a reason for 60% of new graduate nurses leaving their roles within the first year on the job. If you believe horizontal violence (bullying) is an issue in your work environment, get assistance to change those behaviors. If it is confined to one or two employees, work with your supervisor or HR to promote positive change.4

Learn to identify what psychological distress could look like, even before learning more advanced assessment tools. There are FIVE signs that may be a signal someone is feeling considerable angst.

Five Signs

  1. Any unusual changes in behavior: a quiet person becomes agitated and verbose or vice versa
  2. Substantial changes in sleep patterns: sleeping all the time or extreme episodes of insomnia.
  3. Accessing lethal means: if opioids are missing at work, question who and why. If a quiet friend has purchased a firearm, why?
  4. Emotional distance: from the world, from feelings, from grooming, life.
  5. Physical pain: if someone complains often of generalized and/or recurrent pain, be alert for depression.


In addition to the signs above, there are tools that can be used to identify risk for suicide among nurses. As a brilliant psychological professor once stated, do not try to make up assessment methods when we have proven tools that work. Use the standards. One of the tools utilized has been the HEAR system, which was initially developed to assess risk for physician suicide. When it was used for that purpose, MD suicides began to decline. Since its inception with nurses, 500 have been enrolled, with meaningful results.2

The HEAR program (known as the Healer Education Assessment and Referral program) was developed in 2009 by UC San Diego and has since been recognized as a Best Practice program for identifying medical professionals at risk for self-harm. Although the program was developed to address issues related to medical students, residents, and faculty physicians, it has since been expanded to include pharmacists, nurses, and clinical staff, with noteworthy results. The HEAR program has been implemented at over 125 universities, 20 hospitals/medical schools, in addition to a few law enforcement and corporate facilities. The focus remains on screening as well as referral of at-risk individuals to decrease suicide ideation/harm in healthcare professionals.2

The issues facing nurses in 2020 include those of an escalation in violence on the job, which results in added stress for nurses who may already be pushed beyond their limits. According to recent statistics by the ANA, one in four nurses is physically assaulted on the job, especially in high risk areas such as the Emergency Room or the Intensive Care Unit. Assaults in these areas may range from “getting cursed at to grabbing and kicking.” While many nurses are abused on the job, the ANA found that few nurses report the instances, leading to an internalization of low self-esteem over time. Nurses who work these high stress environments need to work to promote a healthier environment, such as joining the #SilentNoMore Campaign, which works to shine a light on the violence in nursing roles.1

While monitoring colleagues for risk, the most-commonly utilized tool to assess suicide risk is the ASQ (called the “ask”), which involves a mere four questions. The ASQ is available for youth, for adults, it is provided in multiple languages, and is also available to be printed as a PDF for easy access. If the patient (nurse/colleague/friend) answers “yes” to any of the four questions at the top of the ASQ questionnaire, follow-up instructions are provided on the printout. The questions are very blunt. If approaching a colleague with the tool, it may be more helpful to do so over coffee, away from the workplace, or with the assistance of another colleague. Here are the four questions on the ASQ:3


  1. In the past few weeks, have you wished you were dead?
  2. In the past few weeks, have you felt that you or your family would be better off if you were dead?
  3. In the past week, have you been having thoughts about killing yourself?
  4. Have you ever tried to kill yourself?3

These are yes or no questions. A “yes” response to any of the above signifies a positive response, which requires further follow-up via a mental health professional for safety.3


Nursing is a profession that could take the best professionals, wear them out, pummel them around, spit them out, and break their hearts one patient at a time. The funny thing is, most of us have loved every moment of our careers; we gratefully got out of bed to repeat the process the next day; we would not choose to do anything else if offered. However, along the way, more nurses, especially the ones we never expected to do so, quietly chose to end their lives by horrific means. That is unforgivable. We cannot let this happen.

September is National Suicide Awareness Month. Let us be more aware from this day forward. We need to find nurses at risk and stop them, ASAP. Beautiful sunny mornings should be enjoyed. If anyone is thinking otherwise, please call, or stay with them and place the call for them:

The National Suicide Prevention Hotline



  1. Businessinsider.com “Suicides among nurses are on the rise. Here’s why one of America’s fastest-growing jobs is facing a major crisis.” Akhtar, A., August 20, 2019. Business Insider.
  2. Health.ucsd.edu “National study confirms nurses at higher risk of suicide than general population.” Carr, J., February 3, 2020. UC San Diego Health, 1-888-657-7000
  3. Nimh.nih.gov “Webinar for nurses-how to use the ASQ to detect patients at risk for suicide.” Horowitz, L., June 20, 2019. National Institute of Mental Health.
  4. Nurse.org “suicide in nursing: much more common than you think.” Yazdi, M., September 282017, info @ nurse.org.
  5. Nursingtimes.net “High nurse suicide risk gone ‘unaddressed for years.’” Stephenson, J., February 5, 2020. Nursing Times.
  6. Studyfinds.org “Nurses face increased risk of suicide; alarming national study confirms.” Anderer, J., February 4, 2020. Published in WORLD views on Evidence Based-Nursing.

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