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It is well understood that preventing suicide is often very possible. Moreover, it is also well understood that health care personnel in various settings often encounter persons at risk of suicide. Since nursing is the largest single discipline involved in health care, it is apparent that nurses hold key positions to facilitate suicide prevention [1]. Nursing education prepares future nurses with critical life-saving skills. Suicide prevention is a life-saving skill. However, most registered nurses have little training or education in suicide prevention [1] in education or practice settings. This opinion paper addresses five critical questions concerning the ‘Who’, ‘What’, ‘Where’, ‘How’ and ‘Why’ of embedding understandings of suicide prevention in nursing education and nursing practice. It calls forth action of nurse educators and nurses involved in orientation to health care facilities and continuing education, drawing on the author’s extensive professional experiences. These experiences include: national and international collaboration as a psychiatric community mental health nurse educator and researcher; a certified instructor in the evidenced-based suicide prevention training called Question-Persuade Refer; a dedicated board member of a state chapter of the American Foundation of Suicide Prevention; and, an long time active member of a local suicide prevention coalition located in a state with among the highest rates of suicide deaths.

‘Who’ should embed understandings of suicide prevention in nursing education and practice?’ In nursing education, the curriculum is shaped by views of nursing faculty; in nursing practice, policies are shaped by views of supervisors/administrators. These views should be guided by professional and ethical standards [2] that ensure patient safety [3]. The American Psychiatric Nurses Association (APNA) [4] has endorsed competencies in suicide risk assessment. Even though nursing leadership groups in the United States, including the American Nurses Association (ANA) [2], the American Association of Colleges of Nursing (AACN) [3] and the National League for Nursing [5], are responsible for forming and reforming nursing education, suicide prevention remains invisible in their documents. As advocated across the globe by the World Health Organization [6] and others [7], a primary goal for suicide prevention is “reforming health professional education to increase the competency of health professionals in assessing and managing suicide risk” [7].

‘What understandings about suicide prevention should be embedded in nursing education and practice?’ What we embed in teaching and in practice should be guided by the focus of our discipline [8,9] and by evidenced-based and evidenced-informed knowledge [10]. What is known is that there has been limited published nursing literature focused on suicide prevention. Some research reveals lack of skill and lack of competency [1,11] and negative attitudes toward suicidal patients in various setting [12,13].

Two aggregate studies guide what understandings are needed to facilitate suicide prevention One study addressed nurses’ responses (n=26 full text articles) to suicide and suicidal patients [14]; the other addressed how psychiatric nurses (n=11 full-text articles) respond to suicide and suicidal patients [15]. Both were review articles based on peer reviewed, published articles with reflexive, iterative designs. While the results from both studies reveal that suicide prevention is ‘challenging and burdensome’, the results can guide nurses in practice to facilitate suicide prevention and recovery. The ‘What’ question is also addressed in a modified Delphi study on competencies for baccalaureate nursing [7]. The results report 42 individual competencies for baccalaureate nursing categorized as pre-assessment (n=13), assessment (n=14) and management (n=13). These competencies are applicable to nursing staff orientation and credentialing, as well as nursing education.

‘Where’ should suicide risk assessment & intervention skills be located?’ In nursing education, suicide risk assessment has most often been relegated to mental health-psychiatric nursing courses [16]. However, to “prepare students for current practice, suicide risk assessment needs to be located not just with a mental health context, but in a wide range of clinical settings” [17]. Knowing that persons at risk of suicide are encountered in various health care settings, many of which have a nursing presence, it is imperative that nurses and ‘all staff in direct patient care’ can facilitate suicide prevention [18]. Within nursing education and nursing practice, suicide prevention needs to be considered a life-saving skill as much as is cardio-pulmonaryresuscitation.

‘How’ should we embed understandings of suicide prevention in nursing education and nursing practice? Three strategies shown to be effective in conveying understandings of suicide prevention are Modelling, Gatekeeper training and use of Scenarios.

Modelling involves learning by observation. Attitudes and perceptions impact responses to persons at risk of suicide. It is well known that stigma has long been associated with suicide. The burden of shame and guilt of suicide often silences the topic of suicide, which, in some cultures [19], is taboo. Suicidal patients and survivors of suicide loss often tell that stigma is a barrier in their recovery [20]. Studies report nurses’ negative attitudes toward at-risk persons [14]. Similarly, such attitudes are reported in studies of suicidal patients [21]. Of importance is for nursing education and nursing practice to teach self-reflection, self-examination, to gain awareness of attitudes and perceptions and confront various myths about suicide.

A second strategy that addresses ‘How’ to embed understandings of suicide prevention is gatekeeper training. The term ‘gatekeeper’ refers to someone who keeps the gates to suicide closed. Question-Persuade- Refer (QPR) [22] is one of various gatekeeper trainings listed on the U.S. National Registry for Evidenced-based Programs and Practices (NREPP) [23]. Other gatekeeper trainings, such as Applied Suicide Intervention Skills Training (ASIST), are available at Living Works [24]. QPR is a three-step approach intended to develop knowledge, skills and attitudes toward suicide prevention by teaching secondary interventions and emergency responses modelled after CPR. The three steps are: How to ask the question; How to persuade; and How to refer. QRP has been studied with various populations with positive outcomes [16]. In nursing education, a descriptive study [16] explored senior baccalaureate students’ responses to QPR. The data was generated from self-report, pre-post written surveys (n=147) based on a 9 item Likert scale. The post-survey included a comment section from which textual data was generated. Results showed statistically significant (p<0.0005) differences between pre-post analysis and a main theme of ‘becoming capable intervening with persons at risk’.

The third strategy addressing ‘How’ to embed understandings of suicide prevention is use of scenarios. “Scenarios involving suicide should become routine for skills development” [1]. One kind of scenario, role play, has been incorporated into gatekeeper training with mixed results. Some studies found role play increased knowledge and skill [25], while others found it did not [26]. Simulation, a widely used instructional strategy involving an activity or technique that mimics a real-life experience [17], can potentially influence attitudes as well as develop skills. A review article explored potential use of simulation for teaching suicide risk assessment [17]. While acknowledging limitations of simulation, i.e., lack of authenticity, the authors describe and critique use of standardized patients, virtual reality, voice simulation and medium to high fidelity, noting that development of such approaches related to mental health and suicide risk assessment, has been very limited. While simulations can present scenarios that help reduce anxiety and increase some communication and critical thinking skill, except for the standardized patient approach, they lack the complexity of human expressions, especially non-verbal communication (e.g. tone of voice, affect and body language). Nonverbal communication is crucial in accessing risk of suicide.

‘Why’ should understandings of suicide prevention be embedded in nursing education and nursing practice?’ There are many and various global and local initiatives that address suicide prevention training for health personnel and inclusion of suicide prevention in educational curricula. Some examples are the World Health Organization Mental Health Plan 2013-2020 [6] and, in the U.S., National Patient Safety Goals [18] that specify suicide prevention training for all patient care staff. These initiatives have been instituted because of the worldwide incidence and prevalence of suicide deaths. In the U.S. suicide is the 10th leading cause of death; the U.S. suicide rate is 12.6 deaths per 100,000 [27].

Considering the incidence and prevalence of suicide and the various initiatives, in 2017, the American Foundation for Suicide Prevention launched a bold goal to reduce suicide 20% by 2025 [27]. The strategy for implementing this goal is education and training directed at emergency departments, health care facilities and firearm communities. Various initiatives have been launched focused on voluntary secure firearm storage. Please visit www.afsp.org for more information on secure firearm storage. Why are emergency departments & health care facilities identified as target groups? There are various reasons. Key reasons include: at-risk persons are often encountered in healthcare [28,29]; the majority who die by suicide have visited a health care professional within a month of their death [30]; suicide is second most common sentinel event in health care agencies [13]; health provider education is ‘woefully inadequate’ [29]; and, registered nurses feel unprepared and uncomfortable to talk with suicidal patients [1].

Embedding understandings of suicide prevention in nursing education and practice clearly responds to global, national and state initiatives that address the urgent need to prevent suicide. It is of critical importance that understandings of suicide prevention be embedded in nursing education and practice. When? Now is the time; a time to call nurse educators and nurses in continuing education to act on embedding understandings of suicide prevention in nursing education and nursing practice.