Last week, MedPage Today began a series on suicides among nurses, investigating the reasons, reactions from colleagues, and what can be done to prevent them. In our first installment, we shared the story of an emergency room nurse who took her life this past November and shared experts' views regarding some of the risk factors for suicide.

In this second installment, we examine a program designed in response to a series of clinician suicides at the University of California San Diego (UCSD).

Nearly every year from 2000 to 2008, a physician, resident, or medical student died by suicide at UCSD.

By 2008, the school's Physician Well-Being Committee had had enough. "We have to do something" was the consensus, remembers committee member William Norcross, MD. When asked for help, the American Foundation for Suicide Prevention recommended a module it had first piloted with undergraduate students known as the Interactive Screening Program, to identify at-risk individuals and connect them to treatment.

UCSD implemented the program, which also included an educational component on mental health and the stigma surrounding it. That initiative is known today as the Healer Education Assessment and Referral (HEAR) program.

The program seemed to work, with only two suicides since 2009 among the groups targeted. But because it started on the physician side, nursing staff were not included.

When three UCSD nurses took their lives in a short period from 2012 through 2015 (the details are shrouded in secrecy), program leaders realized that had to change.

"One of the things that we recognized as this occurred is there just wasn't much data" about nurse suicide, said UCSD psychiatry professor Sidney Zisook, MD, who helped set up the HEAR program.

"It was as though it never happens, but it does happen," he said.

Hearing of the nurses' deaths, Judy Davidson, RN, DNP, a nurse scientist in the psychiatry department, felt driven to act.

Davidson began to scour the literature for the prevalence of suicides among nurses, with little success, while at the same time consulting with others to find ways to stop them.

She reached out to Norcross, with whom she was already involved on another project aimed at developing a more compassionate culture in health systems, and was shocked when he told her about HEAR. She hadn't heard of it before.

Norcross told MedPage Today he was a "bit ashamed" for not having included nurses from the start in the HEAR program.

"But I'm a member of a tribe" -- that is, physicians -- "and I did not think that way," he said.

So, with Norcross's encouragement, Davidson requested and received permission and funding from UCSD to pilot a HEAR program expansion that would include nurses. The pilot began in 2016.

"When we put the suicide prevention program into place to detect high-risk nurses and hospital workers, the same way that doctors were doing, we found many people just under the surface who were really struggling and needed help," Davidson said.

A report on the 6-month pilot phase said that 2,475 nurses were sent an anonymous survey asking about suicide risk factors. Some highlights of the results included:

172 completed the survey

74 were rated as high risk

98 were rated as moderate risk

12 reported "active thoughts or actions of self-harm"

19 said they had previously attempted suicide

44 received in-person or telephone counseling

17 accepted referrals for continued treatment

The survey's low response rate doesn't trouble Davidson. She suspects those who don't need the help just delete the email.

"There's very few low risk people that answer the survey and that's because it is touching people who need it," she said.

Davidson and colleagues noted in the report, "To our knowledge, there has been no previous research or clinical programs focused on nurse suicide prevention."

Now with 2 years of full implementation, Davidson said the HEAR program has helped more than 40 nurses access treatment for mental health issues. And over a decade, the overall HEAR program has moved nearly 400 people into treatment -- including nurses, physicians, and other clinicians.

And since the program was test-piloted in nurses in 2016, there have not been any new nurse suicides, Norcross and Davidson noted.

"If you can get 400 [people into treatment] in 10 years out of one organization, multiply that times every organization. They're right there under the surface and fairly easy to find if you reach out to them."

The program now covers all hospital staff.

Bridge to Treatment

The HEAR program consists of two core components: an encrypted online survey tool, which is used to identify at-risk individuals and help connect them to mental health services in the community; and presentations delivered during Grand Rounds that aim to raise awareness about depression, clinician burnout, and suicide and reduce stigma around help-seeking.

The survey is emailed at least once a year to each member of each department, along with a letter from a person leading that department. If the HEAR committee gives a talk to a particular department, they may re-send the survey over email, or set aside time following the presentation for the audience to complete the survey on their iPads.

When participants complete the survey, they can also leave comments or ask questions of the HEAR counselor in a free text space.

Often respondents will describe certain stressors, such as the death of a loved one, a break-up, [or] a financial hardship, explained Courtney Sanchez, LCSW, a HEAR counselor.

Work stressors are often cited, too: inadequate staffing, frustrations with mandated overtime, poorly trained management, favoritism. Some people will comment that they feel bullied and fear retaliation, Sanchez said.

Responses are sorted through a back-end algorithm into three tiers of risk -- high, moderate, or low -- and the comments, along with the screening results, are reviewed by HEAR counselors who then contact the respondent individually.

Anyone at any level of risk, based on past history of suicide attempts, current suicidal ideation, levels of depression, drinking or substance abuse, or other risk factors will be strongly encouraged to respond, said Zisook, who now heads the HEAR committee.

HEAR program coordinator and counselor Rachael Accardi, LMFT, told MedPage Today, "We list our numbers for them to contact us directly by phone, if that's something that they'd want to do, or they have the option of dialoguing with us over the ISP," referring to the encrypted website.

One strength of the program is that it's proactive, Davidson said.

Most health systems have an employee assistance program (EAP), typically a contract service. "They just wait at the other end for the phone to ring. There's no outreach," she said.

Naomi Kelley, RN, an emergency nurse based at a different California hospital, sought help from her work's employee assistance program, after one of her close friends and colleagues died by suicide. (That suicide and reactions from colleagues and friends, including Kelley, were described in part one of this series.)

When she phoned the hotline, an operator answered, not a counselor, and requested her email address. She was emailed a list of about 30 therapists the next day. Fortunately, a friend had recommended one of the names on that list, or she would not have known what to do, Kelley said.

She is very happy with the therapist she found through the EAP, but other friends have told her that the EAP system was too difficult, and that they weren't able to get appointments with anyone they phoned.

"When you're in that position of needing a therapist ... you need it to be easy and simple and almost someone to hold your hand to get there. If you have to wait for an email and call people, people are going to give up. They're not going to necessarily do it, if it's too hard," she said.

Zisook explained that part of the HEAR Committee's role is to cultivate relationships with providers in the community.

HEAR counselors don't just give someone a list of phone numbers, Zisook said.

"We give [the name of] someone we've already talked to, who we know is available and willing to see that person at a time when they can be seen," Zisook said.

Seeking Help, Staying Hidden

Counselors often hear things that they wish they could share, but confidentiality is paramount. For example, in some cases, "you know they're going to work intoxicated," Accardi said. "We still maintain confidentiality. We're not taking that information anywhere."

Another challenging aspect of the American Foundation for Suicide Prevention's screening and referral tool, at least for counselors, is that respondents can remain anonymous for as long as they choose, and once they complete a survey there's no obligation to respond to counselors.

When she receives an email from someone flagged as "Tier 1 A," the highest risk category -- which usually means the person reported having suicidal thoughts -- this anonymity feature can put counselors in a "conflicted place," said Accardi.

"Your heart kind of drops into your stomach a little bit and you hope it's not as bad as it really is," Accardi said.

Sometimes it isn't and sometimes it is, she said.

"We've had people who have been really honest and said, 'I hurt myself and I do have a plan,'" Accardi said.

So, Accardi then crafts a personalized response. She'll express concern about the fact that the person is thinking of harming themselves, she'll ask what's contributing to their feelings about suicide and what their support system is like, she said.

"I can ask all the right questions. I can be compassionate and nurturing in my response and this person still might not respond," she said. "I have to be okay sitting with that."

Throughout the process, her goal is to continue the conversation online or over the phone or in-person and ultimately persuade at-risk individuals to get care.

Even after that, she still maintains contact, Accardi said.

If a person doesn't like the therapist with whom they're connected -- typically a community psychiatrist, psychologist or social worker -- Accardi helps them find another.

And as stressful as it may be for counselors, anonymity is a key feature of the program and one core reason the HEAR committee believes that so many struggling clinicians have reached out for help.

"All of these people have gotten help and treatment because we took that risk. And they may not have opened up, they may not have engaged if it was done any other way," said Davidson.

'Little Boxes'

"It's kind of odd that in healthcare we do death and have to regroup so quickly," said Davidson.

"When a police officer is involved in a death, they get time off from work. When a fireman is involved in a death, they get time off from work. With us, we might get a friend that will cover for us for 15 minutes and then it's back into the trenches," she said.

What worries Accardi is that doctors and nurses are really good at compartmentalizing -- "putting those incidents away in little boxes," she said.

"I think they need to be able to do that," she said, "but it's that compartmentalization that winds up taking a toll on them at the end of the day, because they usually don't come back and revisit" those experiences.

Recently, HEAR counselors began receiving requests to lead "critical incident" debriefings. These are meetings intended to provide a safe space for anyone involved in a disturbing event to allow them to emotionally process what's happened, Accardi explained.

Reasons for debriefings might include the death of a colleague, an incident of workplace violence, a medical error that harmed a patient, or repeated or unexpected patient deaths, she said.

"It's not a place to pick apart what happened or find the things that may have gone wrong," Accardi said.

At the start of each debriefing, Sanchez, the HEAR counselor, said she emphasizes that the room is a "confidential space."

"We don't take any of the information that you share here today and report it to anybody to get anybody in trouble," Sanchez tells the group.

Counselors will, however, let UCSD's management know if a consistent theme emerges from the discussions -- such as patient assaults.

Learning to Cope

"In labor and delivery no one's expected to die so when a mom does die it's pretty horrible," said Ala Garza, MSN, RN, director of nursing for women and infant services at UCSD.

Last year, there was an unexpected death during a routine procedure and the HEAR team was called into action.

Garza wasn't working the day of the event and thus felt "helpless" when she received a series of text pages for blood, then anesthesia, then a trauma surgeon.

"People were calling me from the office crying," she said.

Zisook did a debriefing "on the spot" and additional debriefings were held later. She attended one of these in order to support her team.

Garza, who formerly worked in ambulances and with the fire department in helicopters, has first-responder post-traumatic stress disorder, she said. "I've spent a lot of money on therapy ... I've done a lot of work on, like, triggers. Because I know that I can get really angry really fast."

She can't drive down the highway without imagining crashes. Garza jokes that friends had threatened to call child services after she kept her son rear-facing in his car seat until he was nearly 5. She kept him in the middle seat, what firemen call "the orphan maker," because it's the safest spot in the car, she said.

"To me, I see death everywhere," Garza said.

When she goes to a debriefing, Garza thinks about her past experiences and all of the "gruesome accidents" she's seen and how she was never offered a chance to debrief.

"So, sometimes I don't really want to go ... because I know what I'm in for," and because some of her old traumas that were never fully addressed may come up, she said.

Debriefings make people feel vulnerable and people do cry -- a lot.

"It's so raw. It's not for the faint of heart," Garza said.

But, even when people begin describing "horribly traumatizing" stories, she remains grateful for the program.

If the HEAR program works, then perhaps other nurses won't be traumatized by their experiences and "they might not have all the sequelae that I have," Garza said.

But it's more than just avoiding trauma. Briefings are also about belonging, Garza explained.

"I see the staff connect to each other and to the other team members on an entirely different level, that nowhere in this universe they would except in a debrief," she said.

"It wouldn't happen on a team building night, it wouldn't happen on the unit. ... It would only happen in, like, a private therapy office, but none of those other team members would hear about it. So, as a team I think it just brings people together. That's really what I see, because they support each other."

Next: Peers helping peers.

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