The prevalence of suicide in Australia is a growing concern. In 2017 the number of lives lost through intentional self-harm was 3128. This is an increase of 9.1% from the previous year ('Causes of Death, Australia, 2017', 2019). The Australian State and Federal Governments have acknowledged this crisis in recent years. In 2016, the Victorian Government released a 10-year plan to reduce suicide rates called the ‘Victorian Suicide Prevention Framework 2016- 2025’. This aims at halving the current suicide rate by half (Department of Health & Human Services, 2016).
There are various policy documents that have been released that look what can and should be done to reduce suicide rate, as well as a report evaluating what measures Australia has already taken. According to the World Health Organisation, suicide is defined as “an act deliberately initiated and performed by a person in the full knowledge or expectation of its fatal outcome” (World Health Organisation, 2001, p.37 ). In Australia for a death to be deemed a suicide, a colonial enquiry must determine that the death has resulted from the deliberate act from the deceased with the intentional knowledge of ending his or her own life. Intentional self-harm is different to suicide as it does not include the suicidal intent when causing deliberate harm to the body (Suicide Prevention Australia, 2014).
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Determining the true statistics of suicide poses some limitations. Many suicides are completed alone which leads to difficulty in determining whether the death was intentional, accidental or even a homicide. The Australian Bureau of Statistics data for 2017, had the (age- specific) suicide rate at 12.7 per 100,000. This is an increase from 11.7 in 2016 ('Causes of Death, Australia, 2017', 2019).
For every individual who dies through suicide, it is estimated that nearly 30 people have likewise attempted to end their life ('Statistics on Suicide in Australia', 2019). The death of someone through suicide causes a ripple effect into the community. A life lost through suicide is a preventable death. Some populations in the community are more vulnerable and the reasons (or culmination of reasons) people choose suicide can vary from individual to individual. (National Suicide Prevention Project Reference Group, 2019).
In preventing suicide, we must look at these factors and help these vulnerable individuals contemplating suicide to get the right support. Health professionals have the potential to effect change in a greater arena and the role of Mental Health Nurses will continue to grow. Mental Health Nurses have the potential to reducing the suicide rate by implementing change at ward and/ or community level whist also at a policy level. Nurses are often at the front-line when delivering care. It is here that mental health nurses have the ability to make a genuine impact on assisting in reducing the suicide rate. Ensuring mental health nurses are appropriately trained to deliver patient centred care, ensures that people who have contemplated suicide receive the best treatment, therapy and resources to move forward in their lives.
The stigma associated with suicide is still prevalent in todays society. Granted mental health is a more common topic in 2019, there are still people every day who do not seek help and those who do not support the vulnerable due to the stigma associated with suicide. A suicide has been estimated to greatly impact on at least 10 people (Erlich et al., 2017). The people bereaved by suicide are more vulnerable to ongoing mental health issues and even at risk of suicide themselves ('Standards and Guidelines for Suicide Bereavement Support Groups', 2009). The process of postvention ensures this vulnerable group can receive the resources and/ or treatment for their situation.
Mental Health nurses have the ability to decrease the suicide rate. This can be achieved through ensuring that nurses are able to provide appropriate clinical care and interventions for individuals who have expressed interest in or attempted suicide. It is imperative that nurses are trained appropriately and maintain the skills to be able to assist in reducing the suicide rate. When nurses have developed competent clinical skills they can deliver more efficient clinical care. It is additionally important for nurses to examine their own personal attitudes and beliefs regarding intentional self-harm and suicide. When nurses can deliver more effective assessments and treatments they are able to provide quality patient care which will lead to better patient outcomes (Manuel, Crowe, Inder & Henaghan, 2017).
In 2014 the World Health Organisation released ‘Preventing Suicide: A global imperative’ which highlighted 11 elements of a system-based approach to suicide prevention. Elements ‘Training and Education’ and ‘Treatment’ acknowledge the importance of education and training for nurses and other health professionals in providing the necessary care for consumers (World Health Organisation, 2014). The World Health Organisation report has been adapted throughout the world as national strategy or policy for suicide prevention, highlighting the importance of these two elements.
The importance of having a skilled and compassionate workforce of nurses and other health professionals’ will assist in reducing the suicide rate.
There are currently various different trainings available to nurses and other health professionals in Australia. This includes Applied Suicide Intervention Skills Training, Mental Health First Aid and Advanced Training in Suicide Prevention by the Black Dog Institute (National Suicide Prevention Project Reference Group, 2019). ASIST is Applied Suicide Intervention Skills Training that started in Canada over 30 years ago but has been prominent in Australia since 1995 ('ASIST » LivingWorks Education Australia', 2019). It is widely used by health care providers but can be completed by anyone over the age of sixteen. It is a two-day workshop that teaches the participants to recognise when someone may be at risk of suicide and working with them to create a plan that will support their immediate safety. ASIST trains people to recognise early warning signs of suicidal behaviour and intervene early. In an evaluation of the ASIST program, the national crisis hotline Lifeline monitored 1507 calls from individuals contemplating suicide. Data denoted that individuals who spoke to ASIST trained counsellors reported feeling less overwhelmed, depressed and stressed (Gould, Cross, Pisani, Munfakh & Kleinman, 2013). Adequately training nurses and other health professionals in suicide prevention has the potential to yield similar results as the ASIST trained counsellors and assist in reducing the Australian suicide rate. ASIST is currently being piloted in Aboriginal in Torres Strait Islander Communities, empowering Elders and community members (National Suicide Prevention Project Reference Group, 2019).
In the Australian ‘National Suicide Prevention Strategy’ for 2020 to 2025, the proposed priority enabler of ‘building and maintaining a competent, compassionate workforce’ is relevant (National Suicide Prevention Project Reference Group, 2019). This proposed area hopes to support health professionals to provide compassionate and effective care for people with suicidal behaviours. While it is noted that mental health nurses with proficient skills and knowledge will lead to better care, treatment and outcomes for suicidal patients it is also essential that nurses evaluate their own personal feeling and beliefs regarding suicide and intentional self-harm (Chan, Chien & Tso, 2009).
The Australian Nursing and Midwifery Boards’ ‘code of conduct for nurses’ outlines the principles and standards expected of all nurses, including the professional responsibility to ensure the interests of the people are their first concern (Code of Conduct for Nurses, 2018).
It is essential that mental health nurses and all other health professionals acknowledge when their own beliefs may compete with the best interests of their patient and ensure their views don’t interfere with their patients receiving the best patient centred care. The potential that mental health nurses have in implementing care and treatment for consumers who have attempted suicide to reducing the rate is limitless. Mental Health Nurses have more training then general practice health professionals who usually have less specific training and knowledge to help recognise the symptoms in consumers who present to services.
Continuing to reduce the stigma associated with seeking mental health help and talking about suicide can help lowering the current suicide rate. There has been a vast increase in the amount of research surrounding suicide and prevention in the past ten years. Despite this, stigma of seeking mental health help is still prevalent in today’s society. This stigma results in people feeling alone and can even act as deterrent for people to support the people vulnerable to suicide in their lives. Mental Health Nurses can advocate for change in various different ways.
Through promotion of mental health and suicide awareness, nurses are supporting the reduction of suicide rates at a policy level. Additionally, through providing data for research, the effects of stigma and importance of reducing stigma can be analysed and can be formed into policies. Priority Action Area 1 of the Australian National Suicide Implementation Strategy looks at the importance of raising awareness and support of Australians seeking help for suicide (National Suicide Prevention Project Reference Group, 2019). Raising awareness about mental health in the community reduces negative beliefs regarding suicide and poor mental health (Stuart, 2016). Greater awareness and acceptance will increase the number of people accessing care and services, and hopefully lead to a reduction in the suicide rate.
The Australian Government provides funding to various campaigns, organisations and general awareness raising activities. Some of these activities include the R U OK? Campaign, Suicide Awareness day and Beyond Blue to name a few (National Suicide Prevention Project Reference Group, 2019). Campaigns including these, play an important role in improving suicide literacy and improving individuals’ ability to seek or provide help. The Australian Government has also implemented Gatekeeper training (National Suicide Prevention Project Reference Group, 2019). A program that develops various members of the community, with skills and knowledge of recognising suicide behaviours, knowing when and how to intervene and even where to refer people if necessary (Lipson, Speer, Brunwasser, Hahn & Eisenberg, 2014).
These gatekeepers generally have a high number of social interactions with their community. Gatekeepers have reported finding a positive change in suicide intervention, peoples attitudes surrounding it as well as more people intervening to help other. This training is also available to nurses and health professionals through the Wesley Lifeforce Campaign, a commonwealth funded initiative (National Suicide Prevention Project Reference Group, 2019). These forms of suicide prevention have built community resilience by encouraging people to play an active role in supporting people with suicidal behaviours. Raising awareness about mental health as well suicide will encourage conversations that allow people to become more educated, speak more freely about these topics and provide better support to those vulnerable.
One of the World Health Organisation’s 11 elements of ‘Preventing Suicide: A global imperative’ is ‘Stigma Reduction’ (World Health Organisation, 2014). These 11 elements which have been adapted internationally for suicide prevention strategies has highlighted the vital importance of increasing awareness and reducing discrimination of seeking mental health help. Stigma reduction is crucial so that people feel comfortable accessing mental health services whilst simultaneously allowing people to feel supported to seek assistance when contemplating suicide.
In efforts to reduce the stigma around suicide the language used should be adapted to encourage openness in conversations and reduce discrimination. More awareness regarding the language of suicide would be greatly be beneficial. At a ward or community level, Mental Health Nurses use direct language when asking about suicidal ideation and self harm.
In 2011 Australian Press Council renewed the guidelines surrounding reporting suicide. This lead to the Australian media evaluating the way they presented and discussed mental health and specifically suicide ('Standard: Suicide reporting', 2011). This was done to ensure that it is reported responsibly and ensure people feel as if they can access care without discrimination. ‘Stigma Watch’ started by SANE Australia that regulates the way mental illness and suicide are represented in Australian media by provide constructive advice on how to report the information ('What is StigmaWatch?', 2019). It encourages people to report media coverage that stigmatises and irresponsibly reports suicide.
Mental Health nurses can play a vital role in the postvention process. Postvention is a term coined by the Psychologist and Suicidologist Dr. Edwin Shneidman in 1968 (Wilson & Marshall, 2010). It describes the counselling and the support provided to people bereaved of suicide. Suicide bereavement refers to the period of mourning and adjusting to daily life that is experienced by family, friends and anyone else effected by the loss of life (Australian Institute for Suicide Research and Prevention & Postvention Australia, 2017). In 2014, the World Health Organisation estimated that 800,000 people die annually from suicide, leaving between approximately 48 and 500 million individuals to be affected by the suicide. Postvention aims to “facilitate recovery after suicide and to prevent adverse outcomes including suicidal behaviour” (Andriessen, 2009, pp. 3).
These individuals also increased vulnerability to suicide themselves, as the grief they experience can be linked to higher prevalence of depression and anxiety ('Standards and Guidelines for Suicide Bereavement Support Groups', 2009). There is currently insufficient research done on the effects of postvention despite the link from the loss of someone to suicide to the mental health of those affected ('Standards and Guidelines for Suicide Bereavement Support Groups', 2009).
Many of the current policy recommendations and treatment options come from those with lived experiences. However for many of the bereaved avoiding the stigma have acted as deterrents to seeking care (Andriessen & Krysinska, 2011). This can lead to not having the ‘full picture’ of bereavement and what works best when developing treatments and effective service.
There needs to be further development in the guidelines and services from a clinical perspective to form better policies. Nurses have the ability to effect change in these policies by informing researchers on what is currently being done, and what can be done better in postvention care.
Many international countries, including Australia already have suicide prevention programs that have acknowledged and begun to implement postvention strategies. These postvention strategies are largely based around support-based resources such as support groups, brochures/ online resources, fundraising activities etc. In the Australian ‘Living is for Everyone’ Framework, the Outcome 5.3 ‘reduced incidence of suicide and suicidal behaviour in the groups at highest risk’ and Outcome 1.3 ‘application and continued development of the evidence base for suicide prevention among high risk populations’ notes the importance of supporting individuals bereaved by suicide (Department of Health and Ageing, 2007).
In the Victorian ‘Suicide Prevention Framework: 2016- 2025’, five objectives were released to approach to suicide prevention. Objective 1 is to ‘Build Resilience’ and Objective 2 is to ‘support Vulnerable People’ (Department of Health & Human Services, 2016). Objective 1 is about developing the ability to return from stress, difficult, distressing and traumatic situations. Objective 2 is about supporting the vulnerable groups and individuals a risk of suicide and specifically providing support for the individuals and communities bereaved by a suicide.
The vicarious trauma experienced through the loss, strain and grief of losing someone to suicide can make people vulnerable to self-harming and or suicidal behaviours. The Victorian ‘Suicide Prevention Framework: 2016- 2025’ aims to better involve support people, families and carers regarding discharge planning as well as further education and support (Department of Health & Human Services, 2016). Those bereaved by suicide, particularly family members may experience a lasting impact on their emotional, physical and mental health (Ramberg, Di Lucca & Hadlaczky, 2016). Different people will experience different levels of grief depending on various factors including their kinship to the person, the shock of the death or even being the person who finds the body.
Suicide is an important issue in 2019 Australia. As of 2017 the suicide rate was at 12.7 (age standardised) per 100,000 people. This an increase of from 11.7 in 2016. The number of Australians losing their life to suicide has grown by almost 10% in one year. The reasons people choose to intentionally end their lives varies from person to person. To prevent suicide, theses reasons must be carefully evaluated and acted upon.
Mental Health nurses have the potential to action change. Ensuring nurses maintain the skills and knowledge to treat and care for vulnerable individuals is important. The care nurses deliver must be person centred to ensure patients have the greatest chance at recovery. It is also important we continue working to reduce the stigma associated with suicide, so that people in our communities who need the help the most access it. In addition, we must also be aware of the psychological impact left behind on people who experience the loss of someone to suicide.
Whilst suicide is preventable, this does not mean it will be necessarily possible to reduce the rate to zero. We must work to reduce the rate so that more Australians have the opportunity to experience their best lives.
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