Journal of Psychiatric and Mental Health Nursing, 2006, 13, 641650

The national suicide prevention strategy for England: the reality of a national strategy for the nursing profession
M. ANDERSON 3 R. JENKINS MA
1 1,2

PhD MSc BA

(Hons)

RN

(Mental Health)

DipHE

&
2

MB BCHir FRCPsych

Senior Lecturer in Mental Health, School of Nursing, University of Nottingham, Nottingham, Regional Fellow 3 in Suicide Prevention, National Institute for Mental Health in England, East Midlands, and Director, WHO Collaborating Centre for Research and Training for Mental Health, Institute of Psychiatry, London, UK

Correspondence: M. Anderson School of Nursing Faculty of Medicine and Allied Health Sciences University of Nottingham Room B50 Medical School Queens Medical Centre Nottingham NG7 2UH UK E-mail: martin.anderson@nottingham.ac.uk

ANDERSON M. & JENKINS R. (2006) Journal of Psychiatric and Mental Health Nursing 13, 641650 The national suicide prevention strategy for England: the reality of a national strategy for the nursing profession Suicide is recognized as a global phenomenon and many countries now have national suicide prevention strategies. International guidance on suicide prevention and accepted epidemiological and treatment-based research underpins healthcare policy relating to suicide reduction. There has been an established comprehensive strategy in England since 2002. However, the rate of suicide continues to be a concern and nurses hold a key role in the implementation of national, regional and local policy into practice. The aim of this paper is to consider the current implications of the national suicide prevention strategy in England for nursing. This discussion paper draws upon both empirical evidence-based literature, governmental guidance and policy-related documentation. The national suicide prevention strategy for England currently continues to have a multifaceted impact on the nursing profession. This ranges from clinical practice issues such as risk assessment through to broader public health responsibilities. If nurses and allied health professionals are to be effective in their role within suicide prevention, they will need to be supported in building awareness of the wider context of the national policy. In particular, this will mean working effectively and collaboratively with the voluntary sector, service users and other non-medical agencies. Keywords: mental health, nursing, policy, suicide prevention
Accepted for publication: 20 April 2006

Introduction
Suicide is a global phenomenon. It is estimated that between 500 000 and 1.2 million people die by suicide each year worldwide (Hawton & van Heeringen 2000). Concern is based on the personal, psychological social, political, cultural and economic impact the behaviour has on societies. A number of governments across the world have developed suicide prevention programmes. One of the main reasons for this has been the marked increase in suicide among young people, particularly men in different countries (Haw 2006 The Authors. Journal compilation 2006 Blackwell Publishing Ltd

ton & van Heeringen 2000). This increase is reected in the escalation of global suicide rates reported by the World Health Organization (WHO) (WHO 1999). A 60% increase can be observed between 1950 and 1995 from 10.1 per 100 00016 per 100 000 worldwide (WHO 1999). The distribution of global suicide rates according to age and gender highlights an increase in most male age groups compared with those of female age groups (WHO 1999). More recent evidence shows that the suicide rate in the general population and in young men in England is on a downward trend, yet as in other countries the overall suicide rate con641

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tinues to cause concern (DoH 2006). This provides a strong rationale for national strategies for the prevention of suicide to be established, implemented and maintained. While the need for such health policy is clear, comprehensive strategies have signicant implications for all healthcare practitioners. For nurses, the impact of national suicide prevention strategies is signicant as they are very often working with people of all age groups who may engage in suicidal behaviour. Front-line nurses are key players in the care provided to the suicidal patient. Indeed, nurses remain central within the healthcare profession group in facilitating the implementation of policy into practice. This paper focuses on the national suicide prevention strategy for England and examines some of the implications of the strategy for nurses. Research and policy guidance literature is drawn upon to examine the reality of the policy for nurses. The aim of the paper is to raise awareness among nurses and allied health professionals on the various themes relating to suicide prevention. Key factors are highlighted as a starting point to enhance contemporary knowledge in nursing and allied health professions in terms of policy, practice, education and research relating to suicide prevention.

Common themes for national suicide prevention strategies

Given the impact of suicide and recognized social, health and mental health problems precipitating the act, a multidimensional approach to suicide prevention is accepted. The WHO has recognized suicide as a key phenomenon within the public health arena (Taylor et al. 1997). Subsequently, it publicized guidelines to member states in order to facilitate the development of co-ordinated comprehensive national and international strategies. The WHO recommendations to respective states were: 1. to recognize the problems associated with suicidal behaviour as priorities in public health; 2. to develop national preventive programmes, where possible interlinked to other public health polices; 3. to establish national co-ordinating communities (WHO 1990). In addition, the United Nations provided guidelines on national suicide prevention comprising ve main components (UN 1996): an open government policy; a coherent model for suicidal behaviour and subsequently prevention; general aims and goals; measurable objectives, monitoring and evaluation. A traditional model of prevention, as described by Gerald Caplan, involves primary, secondary and tertiary pre642

vention (Caplan 1964). Primary prevention strategies focus on reducing the risks of turning to self-harm. This includes providing early treatment and care pathways that would be accessible to all individuals at risk of harming themselves, and people with an identied mental health problem (Diekstra 1992, Jenkins & Singh 2000). Secondary prevention strategies would mean designing and implementing treatment and care pathways for individuals that had already self-harmed to prevent further repeats of the behaviours. Furthermore, it would involve providing appropriate education and training to front-line mental health and emergency professionals. Tertiary prevention strategies would encompass designing and implementing treatment and care pathways for people affected by the suicidal death of others, including family, friends and survivors. However, it can be accepted that by identifying possible steps towards preventing the eventuality of suicide, a set of caring actions could be focused on, in juxtaposition to each step (Table 1). In their evolution general population strategies on suicide prevention have come to focus on the treatment of depression. In addition, there has been growing recognition of the role of alcohol and other substance misuse in the progression towards suicide (Jenkins & Singh 2000). This is backed up by established and convincing evidence that suicides rarely occur without a history of depression or some other form of breakdown in mental health well-being (Jenkins & Singh 2000). Table 1 highlights accepted general population strategies/interventions for suicide prevention. These are mapped against steps in the progression towards suicide. Each can be seen as way of minimizing the possibility of moving to the next step towards suicide. A review carried out by Taylor et al. (1997) highlights the level of global suicide prevention policy development. Nations with comprehensive strategies such as England, Finland, New Zealand, Norway, Australia and Sweden share common themes (Jenkins & Kovess 2002). The themes included in many of these strategies are detailed in Table 2. These common themes are crucial elements of national suicide prevention strategies. The strategies for Finland, England and New Zealand provide examples of the way in which these themes have been integrated in suicide prevention programmes. The Finnish model has been recognized as a template for other countries to follow (Taylor et al. 1997, Singh & Jenkins 2000).

A national strategy for England

In 1992, the Health of the Nation White Paper (DoH 1992) launched a strategic health initiative for England. The
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Table 1 General population strategies in minimizing progress to suicide Steps in pathway to suicide Factors causing depression Specic actions to prevent suicide Policy on employment, education, social, welfare, housing, child abuse, children in care and leaving care, and substance abuse Media guidance, public education School mental health promotion (coping strategies, social support, bullying) Workplace and mental health promotion Action on alcohol and students Action on physical illness and disability Support of high-risk group detection Professional training about prompt assessment, diagnosis and treatment Good risk management in primary care Building safety into routine assessment Taboo enhancement Good practice guidelines on looking after suicidal people in primary or secondary care Controlling access to means of suicide Prompt intervention Good assessment and follow-up of suicide attempters Audit and learn lessons for prevention Responsible media policy

Depression illness and other illnesses and other illnesses with depressive thoughts Suicidal ideation Suicidal plans Gaining access to means of suicide Use of means of suicide Aftermath
Adapted from Jenkins & Singh (2000).

Table 2 Common themes in suicide prevention strategies (Jenkins & Kovess 2002) Public education Responsible media reporting School-based programmes Detection and treatment of depression and other mental disorders Attention to those abusing alcohol and drugs Attention to individuals suffering from somatic illness Enhanced access to mental health services Improvement in assessment of attempted suicide Postvention Crisis intervention Work and unemployment policy Training of health professionals Reduced access to lethal methods

government outlined objectives and targets in each key area and the White Paper set out a framework for initiating, developing, monitoring and reviewing the strategy. The objective for the mental illness key area is that of reducing ill health and death caused by mental illness. In that key policy document, the government wanted to reduce the overall suicide rate by at least 15% by the year 2000; and reduce the suicide rate of people with severe mental illness by at least 33% in the same time period. More recently, the current Labour Government has targeted mental illness, and highlighted the reduction of suicide rate as a key area in Our Healthier Nation (DoH 1999a), and Saving Lives (DoH 1999b). A new target was set within these documents to reduce the death rate from suicide and undetermined injury by at least a further sixth (17%) by 2010. Further, the National Service Framework for Mental Health included the prevention of suicide as one of the key
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standards to be met as part of the modernization of mental health services (DoH 1999c). For example, Standard 7: Preventing Suicide specically requires local health and social care communities to help prevent suicide by ensuring that staff are competent in assessing the risk of suicide among individuals at greatest risk. This encompasses a similar line of thinking as reected in recommendations made within the Finnish suicide prevention strategy (Anderson & Jenkins 2005). More recently, England has become another nation with a comprehensive strategy. The National Suicide Prevention Strategy for England (DoH 2002) documents the six key goals as part of programme of activity to reduce suicide. These include: Goal 1: reduce risk in key high-risk groups; Goal 2: promote mental well-being in the wider population; Goal 3: reduce the availability and lethality of suicide methods; Goal 4: improve reporting of suicidal behaviour in the media; Goal 5: promote research on suicide and suicide prevention; Goal 6: improve monitoring of progress towards the Saving Lives/Our Healthier Nation target for reducing suicide. Currently, there are three annual reports highlighting the progress of the suicide prevention strategy (DoH 2004, 2005, 2006). The reviews demonstrate the need to continue to monitor statistics on suicide rates in order to demonstrate the effectiveness of the national strategy. Research and continued clinical audit, particularly within primary care trusts, will be essential and a national Primary Care
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Trust (PCT)-based suicide audit toolkit has been developed (DoH 2006). The National Institute for Mental Health in England has also produced a Suicide Prevention Toolkit which is aimed at auditing the acute care of suicide and suicide risk (NIMHE 2003). Yet, the national strategy clearly points to key areas of intervention, in which healthcare professionals, particularly nurses, will need to contribute, implement, manage and evaluate.

The reality of the national suicide prevention strategy

When examining the reality of a national strategy on suicide prevention for nurses, it is worth looking back to themes and commonalties of established strategies. Examination shows a ubiquitous approach. The task is multifaceted, which means that nurses may be engaged in a wide range of interventions. The national strategy is based on a range of clinical practice and research-related issues. It focuses on practical (individual, group and populationbased) interventions. These include: 1. assessment of suicidal behaviour; 2. psychotherapeutic interventions in care and treatment; 3. pharmacological approaches in mental health care; 4. access to means of suicide, alcohol and substance misuse; 5. mental health promotion. Each of these hold a range of policy, practice, education and research-related implications for nurses, which will now be discussed.

Assessment of suicidal behaviour

The national strategy for England, as for other countries, demonstrates a commitment to maintaining and developing healthcare professionals skills in the assessment of suicidal behaviour (NRDC 1993, Ministry of Health 2001, DoH 2002). This is true for all nurses and particularly for nurses in mental health (Bowers et al. 2000, Gournay & Bowers 2000, Stein 2002, Cutcliffe & Barker 2004, Barr et al. 2005). Training in risk assessment, ongoing development and evaluation of professionals competence is seen as an essential component of various comprehensive strategies. Such preparation and education of professionals should be a sustained and continuous process (Ministry of Health 2001). At the centre of the debate associated with effective suicide risk prediction has been clinical judgement and what such judgement is based on (Maris 1991). Clearly, in practice, the use of prediction scales, psychological tests, suicide checklists and so on can only take practitioners so far. Clinical judgement should also allow the assessor to ask how does the person make me feel?
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Am I concerned about that persons possible suicidal behaviour? Subsequently, there has been criticism over the ambiguity, lack of denition and standardization of suicide risk assessments (Maris 1991). Beck et al. (1979) developed a classication system of suicidal behaviours, assessment scales and a model of suicidal behaviour in which hopelessness is a key psychological variable (Beck et al. 1979, Beck & Weishaar 1990). The assessment scales are an accepted, reliable and valid method used by mental health and medical professionals around the world. It is commonly accepted that mental health assessments should be carried out only when a person has recovered from the neurotoxic effects of self-poisoning. For example, when the method of overdose by paractetmol (tylenol) has been used (Hawton 2000). The preferred approach to the assessment of risk is to carry out an interview with the person that covers a range of factors, which would include exploring and identifying any mental health problem; family and personal history; alcohol misuse; current circumstances; risk of further attempts of suicide and coping mechanisms. Clearly, practitioners should be competent and condent in assessing the level of suicide intent. The relevant psychological scales described above continue to be recommended by experts in this eld (RCP 1994, Hawton 2000). Naturally, all suicides and suicide attempts should be taken very seriously. Evidence demonstrates that nurses should carry out a close assessment of the motives for selfharm and the factors that suggest high suicidal intent (Barker 1997). Hawton (2000) provides specic guidance on commonly identied motives, whereby the person may express the wish: to die; to escape from unbearable anguish; to get relief; to escape from a situation; to show desperation to others; to change the behaviour of others; to get back at other people/make them feel guilty; to get help. Recent research in England has demonstrated that nurses and doctors are aware of such motives, particularly when incongruent personal relationships appear to be present (Anderson et al. 2003). Findings from other research illustrate the need to maintain an understanding of the overlap and risk of suicide among people who have previously self-harmed (de Wilde 2000). This phenomenon has been particularly recognized in young people aged between 15 and 24 years old (de Wilde 2000). Recent research has indicated that increases in self-harm among young people have important implications for providing care in general hospital and specialist mental health ser 2006 The Authors. Journal compilation 2006 Blackwell Publishing Ltd

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vices (Hawton et al. 2000). An association has been found between the number and frequency of repeated selfharming and higher levels of suicide in the future (Hawton et al. 2000). People who self-harm need to be identied as a high-risk group, which requires targeting coupled with more specic interventions following episodes of self-harm. Further, it is essential that expertise is maintained in the assessment of suicidal behaviour. In a number of countries, specic guidelines have been developed for staff in accident and emergency departments and specialist mental health services (and allied services) (RCP 1998, Jenkins & Kovess 2002). There is a need to focus on the assessment of young people who self-harm; it is essential to recognize the issues in communication between specialist services, such as child and adolescent mental health, adult mental health services, education, etc. Therefore, the development and implementation of high-quality hospital services aimed at people who self-harm should be a major target in all local and national suicide prevention strategies (Hawton 2000, Jenkins & Singh 2000). In the United Kingdom, people who have engaged in self-harm are often admitted to accident and emergency departments or to medical wards before being seen by mental health nurses, social workers or psychiatrists (mental health professional). This pre-assessment time is an important period. However, ndings from studies demonstrated that general medical and nursing staff held some negative attitudes towards people admitted with self-harm (Hawton 2000, McAllister et al. 2002). More recent evidence suggests that attitudes are more complex than simply being negative and appear to involve elements of frustration and feeling unskilled when working with these patients (Anderson et al. 2003). The perceptions and attitudes of staff towards suicidal people are often overlooked in policy guidelines on suicide prevention. Yet, staff attitudes play a pivotal role in the provision of effective and safe care. Therefore, it is essential to raise staffs selfawareness, particularly nurses involved in the assessment and management of suicidal behaviour (Talseth et al. 1999, 2001).

Psychotherapeutic interventions in care and treatment

Psychological autopsy studies involving people who have committed suicide have become an accepted method of research (Hawton et al. 1998a). Such studies have highlighted the presence of depression and other mental health problems. There is strong argument that adequate prevention and treatment of specic mental health problems could reduce suicide rates (WHO 2001). The treatment approaches available to professionals (particularly mental health nurses) cover a range of pos 2006 The Authors. Journal compilation 2006 Blackwell Publishing Ltd

sible therapies. Naturally, depending on therapist, the approach used will depend on that professionals school of thought. For example, some models of treatment are grounded mainly in psychoanalytic principles, as found in psychodynamic psychotherapy (Firestone 1997). However, two of the most commonly accepted ways of working with people are problem-solving therapy and cognitivebehavioural psychotherapy (Heard 2000, Collins & Cutcliffe 2003). Problem-solving therapy is recognized as holding some clinical efcacy and is most easily taught to clinical practitioners (Heard 2000). These psychotherapeutic approaches may well be offered by nurses in addition to providing outreach and intensive interventions. These therapies could complement and support people who are already receiving direct individual help (as detailed above) at points of crisis. Outreach programmes may involve telephone calls and home visits (Heard 2000). Despite the global acceptance of therapeutic approaches (and amount of professionals, worldwide, trained in the use of such therapies), there is debate over the efcacy of such treatment approaches used in practice (Heard 2000). While there is adequate clinical research available to demonstrate the association between suicidal behaviour and mental health problems, there remains a need for more empirical research evidence on the use of psychotherapeutic interventions. Heard (2000) argues that there should be an increase in the number of controlled clinical treatment trials, although this may raise considerable ethical implications. However, there is an obvious difculty in examining the effects of treatments on rates of completed suicide. Interventions following an episode of self-harm/suicidal behaviours are more amenable to evaluation (Hawton et al. 1998b). Randomized controlled trials of psychosocial aftercare (including problem-solving and outreach approaches) in the United Kingdom have each shown signicant improvements among people receiving the interventions compared with those offered routine care (Owens & House 1995). One study found that patients who repeat suicide attempts and who were treated using a cognitive behavioural problem-solving approach scored signicantly better than the control group on factors relating to depression, hopelessness and suicidal ideation (Salkovskis et al. 1990). A more recent systematic review of available treatment studies has demonstrated that there may be support for using the problem-solving approach (Hawton et al. 1998b). Studies aimed at investigating the effectiveness of psychological treatments are too small, particularly in sample size (Hawton et al. 1998b). More work is required in terms of establishing a rm research base. Yet, the current national strategy for England acknowledges the importance of including effective methods of therapeutic treatment interventions
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(cognitivebehavioural therapy, dialectical behaviour therapy, etc.) for people who attempt suicide. These can be offered mainly by therapists, nurses, doctors, psychologists and, in some cases, other allied health and social professionals. The National Institute for Clinical Excellence has provided guidelines on a number of key areas, including the management of self-harm (NICE 2004a), depression (NICE 2004b) and anxiety (NICE 2004c) in primary and secondary care. These guidance documents provide an overview of what is considered to be the best-known practice, and outline levels of interventions for nurses (and other professionals). The frontline interventions that are provided most frequently by nurses require being complemented by broader prevention work targeting depression and other mental health problems connected with suicidal behaviour.

Pharmacological approaches in mental health care

The management of the care of people who could be at risk of suicide often includes an integrated approach utilizing pharmacological and psychotherapeutic interventions coupled with family and social support (NICE 2004b). Nurses involved at all levels of care and intervention should hold sound knowledge of the benets and side effects of medications used in mental health care. Maris (2002) points out that in standard treatment, medical practitioners would take it that the person who has engaged in suicidal behaviour would have one or possible two psychiatric diagnoses that respond to pharmacological interventions. This is important in that not all mood disorders are identied, as discovered in studies conducted in Sweden and the United States of America (Maris 2002). Depending on the diagnosis, the medical practitioner is able to select from a range of common anti-depressants, mood stabilizers or anti-psychotic medication that are currently used to treat people who are suicidal. For example, evidence shows that prescribed lithium is effective in reducing suicide rates in people with a bipolar disorder (Coppen et al. 1991, Jenkins & Kovess 2002). Much of the research is focused on providing evidence for the effects on major depression and the subsequent impact of lowering suicidal ideation (Verkes & Cowan 2000). Contrasting opinions among healthcare professionals arise from the pharmacological studies carried out on specic anti-depressant drugs targeting a reduction in suicidal behaviour. For example, there seems to be a favouring of drugs such as the selective serotonin re-uptake inhibitors (SSRI). Evidence has demonstrated the effectiveness of paroxetine over standard tricyclic medication such as imipramine in the treatment of suicidal behaviour (Mont646

gomery et al. 1995). More important in the context of the preceding information on interventions is further contemporary research on the possible links between self-harm and anti-depressant use. Some research has shown that signicantly more self-harm events occurred following the prescription of an SSRI than that of a tricyclic medication (Donovan et al. 2000). Finally, nurses and other healthcare professionals need to consider the management of suicidal behaviour during experiences of psychosis. Epidemiological research has shown that aytipical anti-psychotic clozapine does impact on suicide risk in people experiencing this condition (Munro et al. 1999). The exact causal effect of this on suicidal intent is unclear. Verkes & Cowan (2000) identify one study carried out in the United Kingdom that focused on people experiencing psychosis and displayed suicidal behaviour. The study revealed that increasing psychosocial interventions alone may not make a signicant difference in the reduction of suicidal behaviour in psychosis. Often a combination of psychological treatments such as cognitive behavioural therapy and optimal pharmacological interventions such as clozapine is implemented (Munro et al. 1999, Walsh et al. 2001). Indeed, recent research would suggest a combined approach of treatments should be favoured for any mental health problem (Ministry of Health 2001).

Access to means of suicide

Nurses need to be aware of the vulnerability of people prescribed anti-psychotic and/or anti-depressant medications, who could also be a high suicide risk. In England, recommendations focus on careful monitoring of the prescription of anti-depressant medication in primary care/general practice settings (NICE 2004a). Excessive availability of such drugs presents a risk of serious overdose, even if some medications are now seen holding lower overdose toxicity, such as SSRIs (Verkes & Cowan 2000). Yet, the reduction in access to high-risk analgesic medication is also paramount. Paracetemol presents a particular risk and is identied clearly in both the national strategies for England and other countries (Ministry of Health, DoH 2002). The Centre for Suicide Research in Oxford has carried out an evaluative study of the effects on suicidal behaviour of legislation limiting the size of packs of paracetemol and salicytates sold over the counter (Hawton et al. 2001). This study found that following the pack size reduction, the annual number of deaths from paracetemol poisoning decreased by 21% and the number of self-poisoning from salicytates decreased by 48%. These results suggest that the legislative move to reduce pack sizes of paracetemol and salicylates in the United Kingdom has been effective. A
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maximum over the counter sale of paracetemol and other analgesics (32 for pharmacies and 16 for other outlets) has had considerable effects on mortality and morbidity connected to self-poisoning using these specic drugs (Hawton et al. 2001). Despite this evidence, there are pitfalls in using legislation of pack sizes as an intervention in reducing suicide. It has been pointed out that some of the responsibility will be with prescribers of analgesics such as co-proxamol (now removed from sale). These drugs have been identied as frequently used methods of overdose in suicides, particularly in young people who have not been prescribed the medication themselves (Rutherford 2001). The issue of access to means covers availability in highrisk groups (e.g. farmers, people in acute inpatient units). This includes methods such as rearms, ligature points for self-strangulation and high places for suicide by jumping. For nurses, public health intelligence on access to means of death by, for example, train track hotspot areas has to be covered in national strategies as these means present most fatalities.

Mental health promotion

Public health education as the bedrock of national suicide prevention programmes can be seen as an essential part of building awareness and understanding on range of related issues (Jenkins & Kovess 2002, Anderson & Jenkins 2003). An example is the associated dangers of medication. Involving and helping people in the management of their medication is part of nursing practice across the board. Teaching people about the effects and risks of antipsychotic and anti-depressant treatments is helpful, as identied in research analysing the relationships between safer (in overdose) medication (Donovan et al. 2000). Education for those prescribing painkillers such as paracetemol is also indicated in national strategies (Ministry of Health 2001). Alongside the promotion of mental health among people who misuse alcohol or drugs is an area for wider national public education programmes. Such programmes, although integral to a national strategy, have to be coordinated with other associated national policy on substance misuse (DoH 2002). While public education on factors such as medication is incorporated into all current national strategies, a core issue for public health and mental health promotion relates to stigma surrounding suicide (Jenkins & Singh 2000). In England, the national strategy forms part of the implementation of other broader national strategies National Service Framework for Mental Health (which includes standard 1 for Mental Health Promotion) (DoH 2002). Yet, as in other national strategies, there is a specic focus on policy for health promotion relating to the media and suicide. New Zealand and England include specic objectives relating to the media portrayal of suicide. The United States of America have published recommendations for the media on the reporting of suicide (AFSP 2001). Norway has proposed educational programmes on television and radio aimed at tackling the stigma of suicide. Finland has developed a health promotion approach using public education with the intention of enhancing individuals personal resources and coping abilities; engendering constructive experiences in childhood by promoting different parenting styles. It is explicit about the need for a cultural environment to be less stigmatizing and punitive (Taylor et al. 1997). As such programmes have been developed, it is now recognized that other countries have taken notice of the importance of media images of suicide and incorporated media interventions into their programmes. England is a particular example (DoH 2002). Despite the need to include interventions with the media in suicide prevention programmes, reviews of research on the imitation effects of mass media portrayal of suicidal behaviour reveal controversial ndings (Schmidtke &
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Alcohol and substance misuse

Nurses in all specialities are involved in promoting the mental well-being of the wider population. However, a target group is young men who engage in alcohol and drug misuse and who may also experience self-harm. While research indicates that suicide rates are higher in men than women, further studies show that more men than women appear to engage in substance misuse worldwide (Murphy 2000). In a psychological autopsy study carried out in Finland, alcoholism was most common among middle-aged men (45%), whereas middle-aged women showed a high rate of depressive symptoms (88%) (Heila et al. 1997). In England, research has conrmed that heavy drinkers are judged to be at higher risk of suicide. There is a need therefore to highlight alcohol as an independent risk factor for suicide in the training of healthcare professionals, particularly nurses practising in accident and emergency departments (Taylor et al. 1999). Despite the accepted relationship between alcohol and other drug misuse and suicide, only a few countries have specically included it as part of their national strategy. Finland proposes a range of interventions for better comprehensive services and support of families of people who misuse alcohol and substances. The strategy for England identies people with drug and alcohol problems as a high-risk group, so nurses in all specialities have a responsibility to be aware of the issues (Anderson & Jenkins 2005). More importantly, nurses can facilitate collaborative approaches with relevant agencies (Drug Action Teams, voluntary agencies, self-help groups, service user-led groups).
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Schaller 2000). While the evidence in relation to the impact of the media may remain contentious, it is clear that the role of the media is critical in general population strategies for the reduction of suicide (Jenkins & Singh 2000). Leading international health organizations accept the inclusion of plans to support more responsible reporting of suicide in the press and representations in programme content (UN 1996). Nurses can play a leading role in working with the media, for example, educating journalists on the impact of suicide on relatives, friends and the experience of grief, all of which contributes to developing more responsible reporting of suicide in the media.

Discussion
This paper has aimed to demonstrate that all nurses are directly inuenced by the focus of the national suicide prevention strategy. A pivotal role for nurses is able to assess people who may be at risk of suicide. Nurses are required to be aware of the specic risk factors in a diverse range of people in different age groups with different social, cultural, ethnic backgrounds. Knowledge of the high-risk groups is essential. Those nurses working in specialist roles (psychiatric liaison, Child and Adolescent Mental Health Services (CAMHS), primary care) have to have indepth knowledge and skills in order to carry out comprehensive assessments with individuals. Anderson et al. (2003) demonstrated that nurses may believe that they do not have the skills to work with people who engage in suicidal behaviour. Regular up-to-date ongoing risk assessment training targeted on people most at risk, for front-line clinical staff, particularly nurses, is needed (Barr et al. 2005). Nurses working in diverse settings should be aware of possible options in psychotherapeutic interventions. The national strategy supports the view that mental health nurses should hold expertise in specic psychotherapeutic interventions. Collins & Cutcliffe (2003) argue that while cognitivebehavioural techniques are shown to be effective when dealing with hopelessness, it is clear that the therapeutic relationship is crucial for successful engagement with the suicidal client. The assessment and ongoing care of people who may be at risk of suicide is perhaps a fundamental element for nurses (in a range of specialities). Yet, the nursing profession has to see suicide prevention in terms of the broad common themes (clinically based as well as public healthbased interventions) and as a phenomenon of the general population (Taylor et al. 1997). Placing together the dimensions of such an approach, including employment, education, housing, public health, physical illness, mental health promotion etc. is at the centre of a strategy to reduce the suicide rate.
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It has not been possible to cover all aspects of the strategy for England in this paper. There are other areas sharing equal importance in the overall plans for reduction of suicide, such as work with prisons and postvention aftercare/work with people bereaved by suicide. These are interventions shared by most nations with national strategies. Both the strategies for England and New Zealand (and other nations) recommend the need for further research into specic factors associated with suicide (Ministry of Health 2001, DoH 2002). The inclusion of an objective for improving the research base for suicide prevention reects the paucity in evidence on the efcacy of specic interventions and treatments (Hawton 2000). It is clear that strategies relate to the need for specically targeted research funds. National co-ordinated, collaborative research is desirable, with the task of investigating priority areas (DoH 2002). Supplying adequate evidence through welldesigned, rigorous research should be at the centre of evaluating the progress of the national strategy. The strategy for New Zealand offers a clear argument for the involvement of culturally diverse groups, such as Maori, in the evaluation of services and the associated strategy. The strategy for England sets action to improve the well-being of other ethnic groups but, as such, their place in related research and the evaluation of suicide prevention strategy is not identied (Hawton 2000). If we take England as an example, it is evident that service users with experience of mental health problems are a key element in future development of other related policy, health education and practice (Campbell 1999).

Conclusion
It becomes apparent that many of the tasks or interventions for nurses can only be carried out, if they collaborate with a wide range of agencies working together in suicide prevention. Some of the most important work might be in facilitating suicide audits, or generating information on public health issues, both of which require multi-agency action. Professionals such as nurses will also need to work with a range of non-statutory organizations e.g. Survivors of Bereavement by Suicide, Re-think, Mindout, with Samaritans and PAPYRUS. Indeed, making contact with people in different ways is the reality of suicide prevention work for nurses, yet it may also be the cornerstone of the national policy itself.

References
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