Organizational Climate for Inclusion Among Nurses: A Mixed-Methods Analysis.

OBJECTIVE: The aim of this study was to answer the research question: What factors predict sense of belonging among nurses?The connection between inclusion (an element of diversity and equity) and a nurse's sense of belonging is poorly understood. METHODS: In this mixed-methods research, regression analysis of Climate for Inclusion Scale subscales and Sense of Belonging score plus thematic content analysis of questions assessing sense of belonging were conducted. Nurses (n = 131) attending a research conference in June to July 2022 were invited to participate; 131 (72%) participated. RESULTS: Climate for Inclusion Scale was positively associated with and predictive of sense of belonging (F3,113 = 71.7, P < 0.001). Themes reflecting actions to enhance sense of belonging were as follows: authentic leadership, embracing social justice, team unification, feeling heard, being seen, professional development, developing a healthier work environment, and integration of differences. CONCLUSIONS: Leaders can promote a sense of belonging among nurses by focusing on actions reflected in the themes.

Entangled: A mixed method analysis of nurses with mental health problems who die by suicide.

Nurses die by suicide at a higher rate than the general population. Previous studies have observed mental health problems, including substance use, as a prominent antecedent before death. The purpose of this study was to explore the characteristics of nurses who died by suicide documented in the death investigation narratives from the National Violent Death Reporting System from 2003 to 2017 using thematic analysis and natural language processing. One thousand three hundred and fifty-eight subjects met these inclusion criteria. Narratives from 601 subjects were thematically analyzed and 2544 individual narratives were analyzed using natural language processing. The analyses revealed five themes: "mental health treatment," "poor general health and chronic pain," "substance use," "worsening mental health after bereavement," and "repeating a family member's suicide." Mental health/substance use, chronic illness, and chronic pain were seen to coexist in a complex, interdependent manner that appeared to be entangled in the nurses' narratives before death. These findings echo the need for reducing the stigmatization of mental health problems in nursing and removing barriers to help-seeking behaviors as early preventative interventions. Future research is needed to determine if a comprehensive healthcare integration approach to address these entangled problems would reduce suicide vulnerability in nurses and improve their quality of life.

American Academy of Nursing Expert Panel Consensus Statement on leveraging equity in policy to improve recognition and treatment of mental health, substance use disorders, and nurse suicide.

Rates of nurse mental health and substance use disorders are high. Heightened by the COVID-19 pandemic, nurses are challenged to care for patients in ways that often jeopardize their own health and increase risks for their families. These trends exacerbate the epidemic of suicide in nursing underscored by several professional organization clarion calls to nurses' risk. Principles of health equity and trauma-informed care dictate urgent action. The purpose of this paper is to establish consensus among clinical and policy leaders from Expert Panels of the American Academy of Nursing about actions to address risks to mental health and factors contributing to nurse suicide. Recommendations for mitigating barriers drew from the CDC's 2022 Suicide Prevention Resource for Action strategies to guide the nursing community to inform policy, education, research, and clinical practice with the goals of greater health promotion, risk reduction, and sustainment of nurses' health and well-being are provided.

A deductive thematic analysis of nurses with job-related problems who completed suicide during the early COVID-19 pandemic: A preliminary report.

BACKGROUND: Prior to the novel coronavirus (COVID-19) pandemic, nurses died by suicide more frequently than the general population. Antecedents prior to death include known job problems, such as disciplinary action; diversion of medications; inability to work due to chronic pain; and physical and mental illness. AIM: The aim of this study was to explore the suicide experience of nurses who died with known job-related problems during the early phase of the COVID-19 pandemic compared to what has been previously described. METHOD: Deductive reflexive thematic analysis was used to analyze narratives of nurses with known job problems who died by suicide from the Centers for Disease Control and Prevention's National Violent Death Reporting System. RESULTS: Forty-three nurses with known job-related problems completed suicide between March and December 2020. Factors associated with death were similar to previous findings with notable exceptions, increased prevalence of suicidal ideation and post-traumatic stress prior to the event. Pandemic-specific issues were noted including reduction in hours, fear of disease transmission, civil unrest, and grief-related trauma. LINKING EVIDENCE TO ACTION: Suicide prevention programs need to address both institutional and individual factors associated with nurse suicide. As previously recommended, transitions into retirement and job loss are vulnerable times warranting psychological support. Further, strategies to reduce the impact of stressors and increase support for nurses are needed at the organizational level. A systems level approach to hardwire coping strategies is indicated pre-licensure and throughout nurses' careers. A new focus on how to process personal and professional grief is warranted. Resources are needed for nurses traumatized by life (rape, childhood trauma) or work-related experiences.

Longitudinal analysis of suicides among pharmacists during 2003-2018.

BACKGROUND: Suicide is one of the leading causes of death worldwide, and estimates of suicide among health professionals are higher than the general population. High rates of suicide among physicians and nurses have been described previously, but there is a lack of data for suicides completed by pharmacists. OBJECTIVE: The purpose of this study was to quantify the incidence, means, and characteristics of pharmacist suicides in the United States. METHODS: Data were obtained from the Centers for Disease Control and Prevention's National Violent Death Reporting System (NVDRS) for the years 2003-2018. The dataset contained all suicides, coded by occupation, reported by medical examiners and law enforcement from 39 states and Washington DC and Puerto Rico. Suicide characteristics were compared between pharmacists and nonpharmacists. Age-adjusted rates were calculated for 2004, 2009, and 2014. RESULTS: During 2003-2018, the NVDRS contained 316 pharmacist suicides compared with 213,146 nonpharmacist suicides. The age-adjusted rates per 100,000 people were 19.6, 20.1, and 18.2 for 2004, 2009 and 2014, respectively. The most common means of suicide was firearm. Associated factors for suicide included job problems, current mental illness treatment, and suicide note. CONCLUSION: Suicide rates among pharmacists are higher than the general population. Future research is needed to evaluate the context of job-related problems to mitigate risk. Encouraging help-seeking behaviors to identify and treat pharmacist depression is warranted.

Nurses' values on medical aid in dying: A qualitative analysis.

Aim: Explore nurses' values and perceptions regarding the practice of medical aid in dying. Background: Medical aid in dying is becoming increasing legal in the United States. The laws and American Nurses Association documents limit nursing involvement in this practice. Nurses' values regarding this controversial topic are poorly understood. Methodology: Cross-sectional electronic survey design sent to nurse members of the American Nurses Association. Inductive thematic content analysis was applied to open-ended comments. Ethical Considerations: Approved by the institutional review board (#191046). Participants: 1213 nurses provided 3639 open-ended comments. More than 80% of participants self-identified as white 58% held a graduate degree; and half were of Christian faith. Results: Values ranged on a continuum expressed through four themes: "Honoring Patient Autonomy without Judgment," "Honoring with Limitations," "Not until...," and "Adamantly against." Some felt it was a duty to honor the patients' wishes, set aside own beliefs, and respect patients' choices often with a spiritual connotation. Nurses held concerns about the process, policy, potential psychological harm, legal risk, and the need to learn more about MAID. Nurse who were adamantly against MAID associated the practice with murder/suicide and against religious beliefs. Disparate values were expressed about changing the MAID legislation to allow patient support with taking MAID medications and allowing MAID via advance directive. Conclusions: Nurses desire more education on MAID. There is not one universally held position on the nurse's role during MAID. Healthcare policy/standards need to accommodate the wide variation in nurses' values. Implications: Nurses desire education regarding their role in MAID. Nurses are encouraged to participate in policy discussions as the practice becomes increasingly legal. Managers need to expect that nurses, patients, and families will need psychological support to participate in MAID. Careful construction of policy/standards is needed to minimize conflict, moral distress, and psychological harm amongst nurses. Further research is needed.

Associations between caregiver-detected delirium and symptoms of depression and anxiety in family caregivers of critically ill patients: a cross-sectional study.

BACKGROUND: Witnessing delirium can be distressing for family caregivers (i.e., relatives or friends) of critically ill patients. This study aimed to evaluate associations between caregiver-detected delirium in critically ill patients and depression and anxiety symptoms in their family caregivers. METHODS: Consecutive adult patient-caregiver dyads were enrolled from a 28-bed medical-surgical intensive care unit. Patient delirium was screened for daily by family caregivers using the Sour Seven instrument. Family caregivers completed the Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7) instruments daily to assess their own depression and anxiety symptoms. Response feature analysis was used to handle repeated measures. Descriptive statistics and regression analyses were completed. RESULTS: One hundred forty-seven patient-caregiver dyads were enrolled. Clinically significant symptoms of depression and anxiety occurred in 27% and 35% of family caregivers, respectively. Caregiver-detected delirium occurred in 65% of patients, and was not associated with clinically significant caregiver depression (Odds Ratio [OR] 1.4, 95% Confidence Interval [95%CI] 0.6-3.1) or anxiety (OR 1.2, 95%CI 0.6-2.6) symptoms. When stratified by Sour Seven scores, scores 1-3 and 4-9 were associated with increased symptoms of anxiety (OR 3.1, 95%CI 1.3-7.0) and depression (OR 2.6, 95%CI 1.1-6.1) in family caregivers. Caregiver-detected delirium score was associated with severity of family caregiver anxiety symptoms (coefficient 0.2, 95%CI 0.1-0.4), but not depression symptoms (coefficient 0.2, 95%CI -0.0-0.3). CONCLUSIONS: Caregiver-detected patient delirium was associated with increased depression and anxiety symptoms in family caregivers of critically ill patients. Further randomized research is required to confirm these associations.

Patients, family members and providers perceive family-administered delirium detection tools in the adult ICU as feasible and of value to patient care and family member coping: a qualitative focus group study.

PURPOSE: While studies report on perceptions of family participation in delirium prevention, little is known about the use of family-administered delirium detection tools in the care of critically ill patients. This study sought the perspectives of patients, their family members, and healthcare providers on the use of family-administered delirium detection tools to detect delirium in critically ill patients and barriers and facilitators to using family-administered delirium detection tools in patient care. METHODS: In this qualitative study, critical care providers (five physicians, six registered nurses) and participants from the Family ICU Delirium Detection Study (seven past patients and family members) took part in four focus groups at one hospital in Calgary, Alberta. RESULTS: Key themes identified following thematic analysis from 18 participants included: 1) perceptions of acceptability of family-administered delirium detection (e.g., family feels valued, intensive care unit (ICU) care team may not use a family member's results, intensification of work load), 2) considerations regarding feasibility (e.g., insufficient knowledge, healthcare team buy-in), and 3) overarching strategies to support implementation into routine patient care (e.g., value of family-administered delirium detection for patients and families is well understood in the clinical context, regular communication between the family and ICU providers, an electronic version of the tool). CONCLUSIONS: Patients, family members and healthcare providers who participated in the focus groups perceived family participation in delirium detection and the use of family-administered delirium detection tools at the bedside as feasible and of value to patient care and family member coping. TRIAL REGISTRATION: www.ClinicalTrials.gov (NCT03379129); registered 15 December 2017.

RéSUMé: OBJECTIF: Bien que certaines études rapportent les perceptions concernant la participation de la famille à la prévention du delirium, on connaît peu l'utilisation d'outils de détection du delirium administrés par la famille dans les soins aux patients gravement malades. Cette étude a cherché à connaître les points de vue des patients, des membres de leur famille et des fournisseurs de soins de santé concernant l'utilisation d'outils de détection de delirium administrés par la famille pour dépister le delirium chez les patients gravement malades. Nous nous sommes aussi intéressés aux obstacles et aux éléments facilitateurs d'une utilisation d'outils de détection du delirium administrés par la famille dans les soins aux patients. MéTHODE: Dans le cadre de cette étude qualitative, les fournisseurs de soins intensifs (cinq médecins, six infirmières) et les participants de l'Étude sur la détection familiale du delirium aux soins intensifs (sept anciens patients et des membres de leur famille) ont participé à quatre groupes de discussion dans un hôpital de Calgary, en Alberta. RéSULTATS: Les principaux thèmes identifiés à la suite de l'analyse thématique de 18 participants étaient les suivants : 1) les perceptions de l'acceptabilité de la détection du delirium administrée par la famille (p. ex., la famille se sent valorisée, l'équipe de soins intensifs (USI) pourrait ne pas utiliser les résultats d'un membre de la famille, l'augmentation de la charge de travail), 2) les considérations concernant la faisabilité (par ex., connaissances insuffisantes, endossement par l'équipe de soins), et 3) les stratégies globales pour appuyer la mise en œuvre de cette modalité dans les soins de routine (p. ex., la valeur de la détection du delirium administrée par la famille pour les patients et les familles est bien comprise dans le contexte clinique, la communication régulière entre la famille et les fournisseurs de soins intensifs, une version électronique de l'outil). CONCLUSION: Les patients, les membres de la famille et les fournisseurs de soins de santé qui ont participé aux groupes de discussion ont perçu la participation de la famille à la détection du delirium et l'utilisation d'outils de détection du delirium administrés par la famille au chevet comme étant faisables et utiles pour les soins aux patients et les membres de la famille. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT03379129); enregistrée le 15 décembre 2017.

Partnering With Family Members to Detect Delirium in Critically Ill Patients.

OBJECTIVES: To evaluate the diagnostic accuracy of family-administered tools to detect delirium in critically ill patients. DESIGN: Diagnostic accuracy study. SETTING: Large, tertiary care academic hospital in a single-payer health system. PATIENTS: Consecutive, eligible patients with at least one family member present (dyads) and a Richmond Agitation-Sedation Scale greater than or equal to -3, no primary direct brain injury, the ability to provide informed consent (both patient and family member), the ability to communicate with research staff, and anticipated to remain admitted in the ICU for at least a further 24 hours to complete all assessments at least once. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Family-administered delirium assessments (Family Confusion Assessment Method and Sour Seven) were completed once daily. A board-certified neuropsychiatrist and team of ICU research nurses conducted the reference standard assessments of delirium (based on Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition, criteria) once daily for a maximum of 5 days. The mean age of the 147 included patients was 56.1 years (SD, 16.2 yr), 61% of whom were male. Family members (n = 147) were most commonly spouses (n = 71, 48.3%) of patients. The area under the receiver operating characteristic curve on the Family Confusion Assessment Method was 65.0% (95% CI, 60.0-70.0%), 71.0% (95% CI, 66.0-76.0%) for possible delirium (cutpoint of 4) on the Sour Seven and 67.0% (95% CI, 62.0-72.0%) for delirium (cutpoint of 9) on the Sour Seven. These area under the receiver operating characteristic curves were lower than the Intensive Care Delirium Screening Checklist (standard of care) and Confusion Assessment Method for ICU. Combining the Family Confusion Assessment Method or Sour Seven with the Intensive Care Delirium Screening Checklist or Confusion Assessment Method for ICU resulted in area under the receiver operating characteristic curves that were not significantly better, or worse for some combinations, than the Intensive Care Delirium Screening Checklist or Confusion Assessment Method for ICU alone. Adding the Family Confusion Assessment Method and Sour Seven to the Intensive Care Delirium Screening Checklist and Confusion Assessment Method for ICU improved sensitivity at the expense of specificity. CONCLUSIONS: Family-administered delirium detection is feasible and has fair, but lower diagnostic accuracy than clinical assessments using the Intensive Care Delirium Screening Checklist and Confusion Assessment Method for ICU. Family proxy assessments are essential for determining baseline cognitive function. Engaging and empowering families of critically ill patients warrant further study.

The association of delirium severity with patient and health system outcomes in hospitalised patients: a systematic review.

BACKGROUND: delirium is an acute state of confusion that affects >20% of hospitalised patients. Recent literature indicates that more severe delirium may lead to worse patient outcomes and health system outcomes, such as increased mortality, cognitive impairment and length of stay (LOS). METHODS: using systematic review methodology, we summarised associations between delirium severity and patient or health system outcomes in hospitalised adults. We searched MEDLINE, EMBASE, PsycINFO, CINAHL and Scopus databases with no restrictions, from inception to 25 October 2018. We included original observational research conducted in hospitalised adults that reported on associations between delirium severity and patient or health system outcomes. Quality of included articles was assessed using the Newcastle-Ottawa Scale. The level of evidence was quantified based on the consistency of findings and quality of studies reporting on each outcome. RESULTS: we included 20 articles evaluating associations that reported: mortality (n = 11), cognitive ability (n = 3), functional ability (n = 3), patient distress (n = 1), quality of life (n = 1), hospital LOS (n = 4), intensive care unit (ICU) LOS (n = 2) and discharge home (n = 2). There was strong-level evidence that delirium severity was associated with increased ICU LOS and a lower proportion of patients discharged home. There was inconclusive evidence for associations between delirium severity and mortality, hospital LOS, functional ability, cognitive ability, patient distress and quality of life. CONCLUSION: delirium severity is associated with increased ICU LOS and a lower proportion of patients discharged home. Delirium severity may be a useful adjunct to existing delirium screening to determine the burden to health care system resources.

Effectiveness of an intensive care unit family education intervention on delirium knowledge: a pre-test post-test quasi-experimental study.

PURPOSE: To create, validate, and refine an intensive care unit (ICU) delirium education intervention to prepare family members to partner with the ICU care team to detect delirium symptoms and prevent and manage delirium using nonpharmacological strategies. METHODS: In this pre-test post-test quasi-experimental study, consecutive eligible family members of critically ill patients admitted to an ICU completed an ICU Family Education Delirium intervention in two parts: 1) six-minute video on ICU delirium (risk factors, prevention/management, symptoms, communication with the ICU care team), and 2) two case vignettes to practice detecting delirium using family-administered delirium detection questionnaires (Family Confusion Assessment Method [FAM-CAM] and Sour Seven). Family members' delirium knowledge was measured before, immediately after, and two weeks following the intervention using the Caregiver ICU Delirium Knowledge Questionnaire (CIDKQ). RESULTS: Of 99 family members recruited over eight months, 81 (82%) completed the intervention and 63 (63/81, 78%) completed all follow-up questionnaires. Family members' delirium knowledge improved significantly following the intervention (pre-CIDKQ, 14; 95% confidence interval [CI], 13 to 15; post-CIDKQ, 17; 95% CI, 16 to 17; P < 0.001) and was retained two weeks after the intervention (CIDKQ 16; 95% CI, 16 to 17; P < 0.001). This included increased knowledge regarding delirium risk factors (e.g., medication, mechanical ventilation), prevention/management (e.g., orientation, day/night routine), and symptoms of delirium. More family members correctly detected delirium symptoms in case vignettes using the Sour Seven (92%) compared with the FAM-CAM (78%). CONCLUSIONS: A video-based ICU delirium education intervention is effective in educating family members about prevention, detection, and management of delirium.

RéSUMé: OBJECTIF: Notre objectif était de créer, valider et améliorer une intervention de formation sur le delirium à l'unité de soins intensifs (USI) afin de préparer les membres de la famille à coopérer avec l'équipe de soins de l'USI pour dépister les symptômes de delirium ainsi que prévenir et prendre en charge le delirium à l'aide de stratégies non pharmacologiques. MéTHODE: Dans cette étude quasi expérimentale avant après, les membres éligibles consécutifs de familles de patients en état critique admis dans une USI ont pris part à une formation familiale sur le delirium à deux volets : 1) le visionnement d'une vidéo de six minutes sur le delirium à l'USI (facteurs de risque, prévention/prise en charge, symptômes, communication avec l'équipe de soins de l'USI), et 2) deux vignettes pour pratiquer le dépistage du delirium à l'aide de questionnaires de dépistage du delirium administrés par la famille (Méthode d'évaluation de la confusion par la famille [FAM-CAM] et Questionnaire de dépistage du delirium 'Sour Seven'). Les connaissances sur le delirium des membres de la famille étaient mesurées avant, immédiatement après et deux semaines après l'intervention à l'aide d'un Questionnaire sur les connaissances des aidants concernant le délirium à l'USI (CIDKQ). RéSULTATS: Parmi les 99 membres de famille recrutés au cours d'une période de huit mois, 81 (82 %) ont complété l'intervention et 63 (63/81, 78 %) ont complété tous les questionnaires de suivi. Les connaissances des membres de la famille sur le delirium se sont significativement améliorées après l'intervention (pré-questionnaire, 14; intervalle de confiance [IC] 95 %, 13 à 15; post-questionnaire, 17; IC 95 %, 16 à 17; P < 0,001) et étaient retenues deux semaines après l'intervention (questionnaire 16; IC 95 %, 16 à 17; P < 0,001). Cette amélioration était notable dans les catégories de connaissances en matière de facteurs de risque de delirium (par ex., la médication, la ventilation mécanique), de prévention et de prise en charge (par ex., l'orientation, la routine jour/nuit), et des symptômes de delirium. Un nombre plus élevé de membres des familles est parvenu à dépister correctement les symptômes de delirium dans les vignettes à l'aide du questionnaire Sour Seven (92 %) comparativement au FAM-CAM (78 %). CONCLUSION: Le visionnement d'une vidéo de formation sur le delirium à l'USI est efficace pour former les membres des familles quant à la prévention, le dépistage et la prise en charge du delirium.

A study protocol for a randomized controlled trial of family-partnered delirium prevention, detection, and management in critically ill adults: the ACTIVATE study.

BACKGROUND: Delirium is very common in critically ill patients admitted to the intensive care unit (ICU) and results in negative long-term outcomes. Family members are also at risk of long-term complications, including depression and anxiety. Family members are frequently at the bedside and want to be engaged; they know the patient best and may notice subtle changes prior to the care team. By engaging family members in delirium care, we may be able to improve both patient and family outcomes by identifying delirium sooner and capacitating family members in care. METHODS: The primary aim of this study is to determine the effect of family-administered delirium prevention, detection, and management in critically ill patients on family member symptoms of depression and anxiety, compared to usual care. One-hundred and ninety-eight patient-family dyads will be recruited from four medical-surgical ICUs in Calgary, Canada. Dyads will be randomized 1:1 to the intervention or control group. The intervention consists of family-partnered delirium prevention, detection, and management, while the control group will receive usual care. Delirium, depression, and anxiety will be measured using validated tools, and participants will be followed for 1- and 3-months post-ICU discharge. All analyses will be intention-to-treat and adjusted for pre-identified covariates. Ethical approval has been granted by the University of Calgary Conjoint Health Research Ethics Board (REB19-1000) and the trial registered. The protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist. DISCUSSION: Critically ill patients are frequently unable to participate in their own care, and partnering with their family members is particularly important for improving experiences and outcomes of care for both patients and families. TRIAL REGISTRATION: Registered September 23, 2019 on Clinicaltrials.gov NCT04099472.

Exploring correlation of nurse manager meaning and joy in work with employee engagement.

AIM: To determine the correlation between meaning and joy in work among managers with employee engagement. BACKGROUND: The Institute of Healthcare Improvement and the National Patient Safety Foundation both recognize the link between joy and meaning in work and an optimally performing healthcare system. The relationship between manager joy and employee engagement is unknown. Furthermore, the Meaning and Joy in Work Questionnaire (MJWQ) has not been previously used with nurse managers. METHOD: A descriptive correlational design was used with results from a prospective survey of nurse managers correlated with pre-existing employee engagement quality data. Chronbach's alpha was used to measure internal consistency of the tool in this population. RESULTS: No significant correlation was found between nurse manager meaning and joy in work and employee engagement (r = 0.216; NS (n = 28)) or employee perception of their manager (s = 0.227, NS (n = 28)). A significant strong correlation between employee engagement scores and employee perception of their managers (r = 0.774. p < .001 (n = 28)) was identified. Internal consistency was moderately high: value/connections (alpha = 0.736), meaningful work (alpha = 0.933), caring (alpha = 0.817) and total instrument score (alpha = 0.923). Effect size = 0.28. IMPLICATIONS FOR NURSING MANAGEMENT: While we did not find significant correlation between manager meaning and joy in work with employee engagement, the MJWQ may be a valuable tool to explore nurse manager's meaning and joy in work and the potential relationship of this construct to employee engagement and associated outcomes. The expansion of the sample size across multiple healthcare systems may lead to different results.

A Longitudinal Analysis of Nurse Suicide in the United States (2005-2016) With Recommendations for Action.

BACKGROUND: Previous studies have demonstrated nurses are at risk of suicide. This is the first national longitudinal study of U.S. nurse suicide. AIMS: To identify the longitudinal incidence, method, and risks of nurse suicide in the United States. METHODS: 2005 to 2016 Centers for Disease Control and Prevention National Violent Death Reporting System retrospective analysis of suicide incident rate ratios (IRR). RESULTS: A total of 1,824 nurse and 152,495 non-nurse suicides were evaluated. Nurses were at greater risk of suicide than the general population (female IRR 1.395, 95% confidence intervals [CI] 1.323, 1.470, p < .001; male IRR 1.205, 95% CI 1.083, 1.338, p < .001). Female nurses who completed suicide did so most frequently by pharmacologic poisoning (n = 399, 27.2% vs. n = 8,843, 26.9%), whereby male nurses and the general public used firearms (n = 148, 41.7% vs. n = 57,887, 48.4%). Job problems were more likely in nurses (female odds ratio [OR] 1.989, 95% CI 1.695, 2.325, p < .001; male OR 1.814, 95% CI 1.380, 2.359, p < .001), as well as mental health history (female OR 1.126, 95% CI 1.013, 1.253, p < .027; male OR 1.302, 95% CI 1.048, 1.614, p = .016) and leaving a suicide note (female OR 1.221, 95% CI 1.096, 1.360, p < .001; male OR 1.756 [1.412, 2.181], p < .001). LINKING EVIDENCE TO ACTION: The increased risk of suicide in nurses is congruent with previous reports. The consistency in results increases confidence that findings are generalizable and warrant action. The use of pharmacologic poisoning as a method of suicide, most often by opioids and benzodiazepines, indicates a need for improved identification and treatment of nurses with substance use. Workplace wellness programs need to focus on reducing workplace stressors. Further research is indicated to determine best prevention methods. Policy indications include the need to accurately track gender in nursing, enhance substance use disorder programs, and mandate suicide prevention activities.

Sustainability and Outcomes of a Suicide Prevention Program for Nurses.

BACKGROUND: We now know that nurses are at greater risk for suicide than others in the general population. It is known that job stressors are prevalent in nurses who die by suicide. Yet, little is known about targeted suicide prevention for nurses. The first nurse-centric Healer Education Assessment and Referral (HEAR) suicide prevention program was piloted for 6 months in 2016. The HEAR program was effective in identifying at-risk nurses. AIM: The purpose of this paper is to report the 3-year sustainability and outcomes of this nurse suicide prevention program. METHODS: Descriptive statistics are provided of program outcomes over the course of 3 years. RESULTS: Over the 3 years, 527 nurses have taken advantage of the screening portion of the program. Of these, 254 (48%) were Tier 1 high risk, and 270 (51.2%) were Tier 2 moderate risk. A startling 48 (9%) had expressed thoughts of taking their own life, 51 (9.7%) had a previous suicide attempt, whereas only 79 (15%) were receiving counseling or therapy. One hundred seventy-six nurses received support from therapists electronically, over the phone, or in person; 98 nurses accepted referral for treatment. The number of group emotional debriefs rose from eight in 2016 to 15 in 2017 to 38 in fiscal year 2019. Many of the debriefs are now requested (vs. offered), demonstrating the development of a culture open to reaching out for mental health treatment. LINKING EVIDENCE TO ACTION: The initial success of this pilot program has been sustained. A nurse suicide prevention program of education, assessment, and referral is feasible, well-received, proactively identifies nurses with reported suicidality and facilitates referral for care. The HEAR program has provided service to physicians and residents for 10 years and now supports effectiveness in nurses. The HEAR program is portable and ready for replication at other institutions.

Gender differences among medical students, house staff, and faculty physicians at high risk for suicide: A HEAR report.

BACKGROUND: In comparison with the general population, physicians, and physicians-in-training are at greater risk for suicide. Although key gender differences in suicide risk factors and behaviors have been identified in the general population, the extent to which these differences apply to physicians and physicians-in-training is unclear. Here, we aimed to identify gender differences in risk factors, clinical presentation, and help-seeking behaviors of medical students, house staff, and physician faculty at high risk for suicide. METHODS: We explored gender differences among 450 physicians and trainees meeting criteria for high suicide risk on anonymous online questionnaires completed between 2009 and 2017. RESULTS: High-risk female trainees and physicians had higher mean Patient Health Questionnaire-9 (PHQ-9) scores compared with the males (11.1, standard deviation [SD] 5.1 vs. 9.8, SD 4.7) and were more likely to endorse feeling worried (73.8% vs. 61.2%), irritable (60.4% vs. 49.4%), and stressed (79.6% vs. 70%). High-risk male trainees and physicians were more likely than females to endorse suicidal thoughts (31.2% vs. 22.1%), intense anger (24.3% vs. 16.1%), drinking too much (31.2% vs. 22.3%), and recreational drug or prescription medication use without clinically appropriate follow-up (9.4% vs. 4.3%). There were no gender differences in help-seeking behaviors. CONCLUSIONS: This is the first study to report gender differences among risk factors, presentation, and help-seeking behaviors of physicians, and trainees at high risk for suicide. Our findings are mostly consistent with those of the general population and show that only a minority of at-risk men and women in healthcare sought treatment, highlighting the importance of intervention and suicide prevention in this population.

Case Study Investigation Decreases Burnout While Improving Interprofessional Teamwork, Nurse Satisfaction, and Patient Safety.

Prevention of burnout is a national imperative, and blame-free investigations of clinical events are advocated. Reflective inquiry techniques are helpful in processing adverse events while minimizing blame. The purpose of this project was to develop an interprofessional peer review program (Case Study Investigation) to process emotions, improve teamwork, and optimize patient outcomes. This evidence-based practice project was conducted in a 12-bed intensive care unit using reflective inquiry techniques to perform peer case review across disciplines. Significant improvements were seen in percent strongly agree to the 2 satisfaction questions asked: "I feel free to speak up regarding issues that may affect patient care" (increased from 37% to 73%, χ = 6.19, P < .05), and "There is open communication between physicians and nurses" (rose from 33% to 73%, χ = 7.53, P < .05). In total, 95% perceived improvement in interprofessional teamwork. Burnout decreased significantly at 6 months (n = 22, M = 18.40, SD = 3.36) from baseline scores (n = 27, M = 21.96, SD = 4.47), F2,72 = 4.48, P < .02. Central line-associated infections decreased from 3.6 per 1000 to 0 per 1000 catheter-days. Catheter-related urinary tract infections decreased from 2 per 1000 to 0 per 1000 patient-days. Both were sustained below benchmark. Reflective inquiry decreases nurse burnout while improving perceived interprofessional teamwork and employee satisfaction, and measurements of patient safety.

Nurse suicide in the United States: Analysis of the Center for Disease Control 2014 National Violent Death Reporting System dataset.

OBJECTIVE: This study explored nurse suicide in the United States. METHODS: Characteristics were compared between occupations using 2014 National Violent Death Reporting System data. RESULTS: Female nurse suicides were significantly higher (11.97/100,000) than in the female population (7.58/100,000) (p < 0.001); similarly male nurses (39.8/100,000) compared to the male population (28.2/100,000) (p < 0.001). Benzodiazepines and opioids were the most commonly used substances used in clinician suicide. CONCLUSION: These results suggest a public health imperative for future research and development of effective preventative strategies for nurses; a largely understudied population.

Ethics of Outbreaks Position Statement. Part 1: Therapies, Treatment Limitations, and Duty to Treat.

OBJECTIVES: Outbreaks of disease, especially those that are declared a Public Health Emergency of International Concern, present substantial ethical challenges. Here we start a discourse (with a continuation of the dialogue in Ethics of Outbreaks Position Statement. Part 2: Family-Centered Care) concerning the ethics of the provision of medical care, research challenges and behaviors during a Public Health Emergency of International Concern with a focus on the proper conduct of clinical or epidemiologic research, clinical trial designs, unregistered medical interventions (including vaccine introduction, devices, pharmaceuticals, who gets treated, vulnerable populations, and methods of data collection), economic losses, and whether there is a duty of health care providers to provide care in such emergencies, and highlighting the need to understand cultural diversity and local communities in these efforts. DESIGN: Development of a Society of Critical Care Medicine position statement using literature review and expert consensus from the Society of Critical Care Medicine Ethics committee. The committee had representation from ethics, medical philosophy, critical care, nursing, internal medicine, emergency medicine, pediatrics, anesthesiology, surgery, and members with international health and military experience. SETTING: Provision of therapies for patients who are critically ill or who have the potential of becoming critically ill, and their families, regarding medical therapies and the extent of treatments. POPULATION: Critically ill patients and their families affected by a Public Health Emergency of International Concern that need provision of medical therapies. INTERVENTIONS: Not applicable. MAIN RESULTS: Interventions by high income countries in a Public Health Emergency of International Concern must always be cognizant of avoiding a paternalistic stance and must understand how families and communities are structured and the regional/local traditions that affect public discourse. Additionally, the obligations, or the lack of obligations, of healthcare providers regarding the treatment of affected individuals and communities must also be acknowledged. Herein, we review such matters and suggest recommendations regarding the ethics of engagement in an outbreak that is a Public Health Emergency of International Concern.

Ethics of Outbreaks Position Statement. Part 2: Family-Centered Care.

OBJECTIVES: Continue the dialogue presented in Ethics of Outbreaks Position Statement. Part 1, with a focus on strategies for provision of family-centered care in critical illness during Pubic Health Emergency of International Concern. DESIGN: Development of a Society of Critical Care Medicine position statement using literature review, expert consensus from the Society of Critical Care Medicine Ethics Committee. A family member of a patient who was critically ill during a natural disaster served on the writing panel and provided validation from a family perspective to the recommendations. SETTING: Provision of family-centered care and support for patients who are critically ill or who have the potential of becoming critically ill, and their families, during a Pubic Health Emergency of International Concern. INTERVENTIONS: Communication; family support. MEASUREMENTS AND MAIN RESULTS: Family-centered interventions during a Pubic Health Emergency of International Concern include understanding how crisis standards may affect regional and local traditions. Transparently communicate changes in decision-making authority and uncertainty regarding treatments and outcomes to the family and community. Assess family coping, increase family communication and support, and guide families regarding possible engagement strategies during crisis. Prepare the public to accept survivors returning to the community.