Although this study focused only on cases of completed suicide, more than half (55.0%) of respondents had had experience with patient suicide. Previous studies on psychiatric nurses exposed to patient suicide reported rates of 58.3% [10
] and 32.4% [11
]. Another study indicated that 66% of psychiatric hospitals or hospitals with psychiatric wards (the total number is 106) reported suicidal events [7
]. These previous reports, however, include unsuccessful suicide attempts. In this regard, a very high rate was obtained from the current study. In Japan, the annual number of suicides has exceeded thirty thousand for 12 consecutive years, and the suicide rate is exceptionally high compared to the figures in other advanced countries. The suicide rate in the prefecture, where respondents to the current questionnaire survey are located, is one of the highest in Japan[13
]. The present survey results may reflect this regional tendency.
More than half of the nurses who encountered suicide by patients stated that they had had at least some contact with them. Patient suicide is an extremely serious incident for medical professionals. The few studies published suggest that it is quite common for residents to encounter patient suicide during their training and that they undergo significant levels of psychological stress [14
]. Sudak suggested that the feelings experienced by residents and clinicians following the suicide by patient are quantitatively smaller than in the case of suicide by a family member but are similar to them qualitatively [15
Despite some difficulties in comparison arising from the use of different methods and other factors, similar IES-R scores have been reported for significantly disastrous events. In a study evaluating general traumatic events (e.g., physical abuse, sexual harassment, obsessive relational intrusion, becoming the target of unwanted romantic attention, and patient suicide) among 124 psychiatric nurses, the mean IES-R score was 13.4, and 18 nurses (14.5%) were classified in the high-risk group [16
]. The mean IES-R subscale scores (avoidance, intrusion, hypervigilance) obtained in this study were compared with those in a preceding study [16
In this study, most of the nurses indicated the desire for mental health care programmes for health care workers who have experienced a shocking event on the ward. This indicates that most psychiatric nurses are aware of the need for staff-oriented mental health care services. In actual terms, however, only 15.8% of the respondents reported the availability of mental health care programmes for health care workers following a suicide event. In Japanese medical practice, it is often the case that when a patient completes suicide, the situation is not conducive to the provision of psychological assistance for nurses in charge of the patient [17
]. The results obtained in this study reflect in part current style of Japanese psychiatric practice management, as shown above.
Nonetheless, inadequacies at facilities overseas have been reported as well. For example, Mangurian and colleagues reported that, when they encountered patient suicide during their own residencies, they found that emotional support and support by medical institutions were lacking [18
The patient suicide-related issues considered here derive from both the circumstances of the profession and nurses' perception of their own social role. Expressing bitter feelings is often considered by nurses and other medical professionals to be giving in to one's weaknesses and exposing one's helplessness to others. Nurses fear that disclosure of their weaknesses would damage their professional reputation, and this fear could be one of the reasons for not speaking up.
Consequently, nurses who have lost a patient due to suicide are troubled by the thought that they may be responsible for the death. This sense of guilt and self-condemnation can result in depression and other PTSD symptoms and can affect professional identity and nursing skills and duties [6
]. In addition, other nurses may develop a fear of going through a similar event again [19
], which can lead to a dysfunctional medical care system.
For these reasons, the timely implementation of appropriate mental health care programmes for nursing staff who have been through a patient suicide is a significant part of creating an effective medical care environment. Providing staff-oriented post-suicide mental health care programmes falls under the category of postvention activities. Postvention activities should enable verbal expression of the emotional shock of the bereaved. They also serve to liberate staff from the vicious circle of the depression that may result from the mistaken belief that the affliction is their own and no one else's. Moreover, they help staff members to unite through mutual support [5
]. Group meetings can help nurses realize 'the universality of grief and reduce self-blame and excess responsibility' [20
]. The daily practice of examining and sharing one's feelings paves the way for sharing deep emotional feelings associated with a patient's suicide [21
]. This is not an issue exclusively for nurses. Sudak points out the importance of sharing opinions on suicide and freely discussing concerns with other residents [22
]. In addition, Balon discusses the significance of the impact of patient suicide, looking back at an experience which he himself had during his residency, and asserts the usefulness of psychological autopsies shared with others for metal health care [23
Among other interventions, nurses need suicide prevention education. As revealed by the present study, however, only a very low proportion of medical institutions provide on-site suicide-related seminars. Suicide-related issues may be dealt with at seminars on risk management, which were held frequently according to our results. Risk management approaches can be applied to intervention and the prevention of inpatient suicide. Patients' risk factors for suicide are evaluated from information collected from admissions, and therapeutic and nursing plans are developed based on the results of the evaluation. Implementation of these plans helps identify subtle changes in behaviour. Such systems involve patients, their families, nurses, physicians, and other health care workers in the risk management programmes for suicide prevention [6
Practical examples of suicide prevention education for medical and nursing students and nurses have been reported [24
]. However, a majority of these programmes have been tailored to those engaged in prevention; relatively few programmes have provided information and support based on the assumption that the attendees might be affected by a patient's suicide. Suicide prevention education is invaluable. Nurses should be aware that they may be forced to deal with the suicide of patients or persons close to them.
This study revealed that in the medical institutions targeted for the survey, there is a lack of awareness of the impact of completed patient suicide in nurses, and that the need to educate nurses on issues related to suicide has not gained wide recognition. These conclusions are expected to apply to many different regions throughout Japan. Accordingly, we hope that this study will provide grounds for improving the present situation.