Gender, masculinity and ageing

Suicide rates vary by age and gender, with significant differences between low/middle- and high-income countries (Nock et al., Reference Nock, Borges, Bromet, Cha, Kessler and Lee2008). According to the WHO (2014), the rates of suicide among men aged ⩾70 years are consistently high in many countries around the world. Although women are twice as likely to attempt suicide, men are up to four times more likely to die by suicide (Blisker and White, Reference Blisker and White2011; Freeman et al., Reference Freeman, Mergl, Kohls, Székely, Gusmao, Arensman, Koburger, Hegerl and Rummel-Kluge2017). In part, this is due to the higher lethality of means with which men attempt suicide (e.g. firearms versus poisoning) (Cibis et al., Reference Cibis, Mergl, Bramesfeld, Althaus, Niklewski, Schmidtke and Hegerl2012; Mergl et al., Reference Mergl, Koburger, Heinrichs, Szekely, Toth, Coyne, Quintao, Arensman, Coffey, Maxwell, Varnik, van Audenhove, McDaid, Sarchiapone, Schmidtke, Genz, Gusmao and Hegerl2015). Other explanations of these gender differences in suicidal behaviour implicate cultural narratives and norms of masculinity that emphasise strength, aggressiveness, financial success, lack of sympathy towards ‘unsuccessful’ suicidal behaviour or help-seeking among men (Gunn and Lester, Reference Gunn and Lester2011; Schrijvers et al., Reference Schrijvers, Bollen and Sabbe2012). The suicide death of journalist Hunter Thompson (1932–2005) serves as a case-in-point. Thompson allegedly shot himself while at home with his son and grandson and on the phone with his wife (Allen, Reference Allen2005). Canetto (Reference Canetto2017) writes that Thompson's family and friends originally accepted his suicide as a courageous and premeditated act of strength. This was later contested when his suicide note revealed desperation and fear of a person ‘unprepared’ for the contingencies of ageing (Canetto, Reference Canetto2017). Arguably, this suicide of a journalist revered by many, exemplifies a painful tension between cultural norms of masculinity, personal fears of shame and stigma embedded within social perceptions of ageing. This is particularly relevant in LTC settings, where suicidal behaviour may be viewed as more acceptable or ‘permissive’, given that the majority of residents are living with multiple medical conditions and functional impairment (Winterrowd et al., Reference Winterrowd, Canetto and Benoit2017).

LTC as an institutional site for suicide prevention?

Residential LTC facilities can be viewed as organisations nested within social structures designed to serve a particular social function, in this case, caring for older adults. They are institutions much like schools, prisons and hospitals, in that each occupies a physical place where individuals are voluntarily or involuntarily admitted, often for a prolonged period of time. Many effective suicide prevention programmes have been implemented within institutions such as the United States Air Force Suicide Prevention Program, or the Signs of Suicide (SOS) programme for middle and high school students (http://www.sprc.org/resources-programs). As such, LTC organisations offer potentially key settings for developing cost-effective and evidence-based suicide prevention strategies, specifically tailored for the particular risk factors and needs of the institutionalised population (SAMHSA, 2011; Jobes et al., Reference Jobes, Gregorian and Colborn2018).

Like other social institutions, LTC organisations have a responsibility and duty not only to the individuals they serve (whether these are residents, students, patients or inmates) but also to the broader community (families, community, governments, investors, etc.) What differentiates LTC from other institutions is that instead of individuals graduating or being released or discharged, those residing in LTC often only leave when they die (81% of nursing home residents in Australia (AIHW, 2017b) and 70% of nursing home residents in the USA (Temkin-Greener et al., Reference Temkin-Greener, Zheng, Xing and Mukamel2013)) making LTC ‘the last stop’ for the majority of residents (Ball et al., Reference Ball, Kemp, Hollingsworth and Perkins2014). This may contribute to the reluctance to prevent suicide in these settings: why bother to act if death is imminent? However, this attitude is contrary to the original social function LTC organisations are designed to serve: caring for older adults. Moreover, LTC is not hospice care: residents may not be able to be live independently, but that does not equate to being in the active stages of dying. Indeed, while the average length of stay in a US nursing home may be relatively brief (approximately nine months) (Statista, 2015), the average length of stay in an assisted living facility in the USA is much longer at 28 months (Byala et al., Reference Byala, Grimes, Bersani, Kyllo, Maag, Bernstecker, Schless, Kramer, Horan and Singer2009), and the average length of stay in a residential aged care service in Australia is 2.9 years (AIHW, 2017b). These are not simply places where people die, but where people live for a substantial period of time, in most cases equivalent to the period of time spent in university or college accommodation.

Main challenges to preventing suicide in residential LTC

Reforms in the USA such as the Omnibus Reconciliation Act of 1987, and subsequent similar laws, were designed to develop a regulatory framework through standardised measures of quality assessment and accountability (i.e. readmissions, staffing ratios, medication costs and errors, unplanned discharges, falls and emergency hospitalisations, etc.) with the intent of improving co-ordination and quality of care. These measures were criticised as insufficient to capture the intended quality of care as they focus predominantly on outcomes rather than processes of care (Walshe and Harrington, Reference Walshe and Harrington2002). Critics say these quantitative measures of compliance fail to address fundamental psycho-social aspects of quality of care, such as life and work satisfaction among staff, social connectedness (of residents and staff, of residents and their broader community), and sense of ‘home’ and belonging (Gloth and Gloth, Reference Gloth and Gloth2011; Haque and Waytz, Reference Haque and Waytz2012). Furthermore, despite stringent regulatory practices enacted in LTC, evidence suggests that LTC residents were less likely to always have been treated with respect at the end of life (68.2%) compared to those cared for in hospitals (79.6%) or home hospice services (96.2%) (Teno et al., Reference Teno, Clarridge, Casey, Welch, Wetle, Shield and Mor2004).

Is person-centred care a suicide prevention strategy in LTC?

In parallel with global processes of dismantling of welfare institutions under the auspice of deinstitutionalisation, person-centred care (PCC) initiatives began to emerge in the USA and have been the dominant model since the 1990s. While the deinstitutionalisation movement focused on transitioning to community-centred care and away from large-scale institutions, the PCC model was focused on the culture change within LTC and other health-care institutions. The person-centred movement was buoyed by a 1986 report by the US Institute of Medicine which emphasised the need for change in regulatory practices (Institute of Medicine (US) Committee on Nursing Home Regulation, 1986). Subsequent changes in policy triggered a grassroots movement that focused on small-scale, family-like and individualised nursing care (McCormack and McCance, Reference McCormack and McCance2006; Koren, Reference Koren2010). Among others, these initiatives include The Pioneer Network (Fagan, Reference Fagan2003), Eden Alternative (Barba et al., Reference Barba, Tesh and Courts2002), Green House Project (Rabig et al., Reference Rabig, Thomas, Kane, Cutler and McAlilly2006) and Wellspring Model (Kehoe and Van Heesch, Reference Kehoe and Van Heesch2003). A common theme of these models of care pertains to their orientation towards promoting personal autonomy through meaningful participation in one's care and improving quality of life in the LTC setting (White-Chu et al., Reference White-Chu, Graves, Godfrey, Bonner and Sloane2009). These innovative care models aim to embody features of social support and individual autonomy (Brownie and Nancarrow, Reference Brownie and Nancarrow2013; Boelsma et al., Reference Boelsma, Baur, Woelders and Abma2014). These features include the adaptation of the institutional built environment to resemble personal homes, introduction of spiritual practices and selection of geriatric nurses, trained to offer care-giving, guided by collaborative engagement between staff and residents (Puchalski, Reference Puchalski2013; Miller et al., Reference Miller, Mor and Burgess2016).

The expansion of the person-centred paradigms of LTC created new challenges. This included challenges in defining and measuring quality of care (Shier et al., Reference Shier, Khodyakov, Cohen, Zimmerman and Saliba2014), and inability to examine the efficacy and effectiveness of the different person-centred models of care (Williams et al., Reference Williams, Hadjistavropoulos, Ghandehari, Yao and Lix2015). When evaluations are completed, these show large variations between facilities, and the impact of different models of PCC also vary (Desrosiers et al., Reference Desrosiers, Viau-Guay, Bellemare, Trudel, Feillou and Guyon2014; Yoon et al., Reference Yoon, Brown, Bowers, Sharkey and Horn2015). There is an overall lack of empirical evidence (Miller et al., Reference Miller, Mor and Burgess2016), and what exists is inconsistent. Some commentators have even raised concerns about the safety of the PCC model in LTC settings (Brownie and Nancarrow, Reference Brownie and Nancarrow2013; Low et al., Reference Low, Fletcher, Goodenough, Jeon, Etherton-Beer, MacAndrew and Beattie2015). Fundamental challenges also lie in care implementation and operations. PCC requires differently trained staff managers and care-givers, who emphasise personal decision-making, engaged care, and social integration in a work or living environment; this type of professional is characterised by increased adaptability and ability to multi-task (Tellis-Nayak, Reference Tellis-Nayak2007; Low et al., Reference Low, Fletcher, Goodenough, Jeon, Etherton-Beer, MacAndrew and Beattie2015). At the same time, within the person-centred paradigms, staff who directly care for the residents (e.g. nurses, nursing aides) report gains in overall job satisfaction (Brownie & Nancarrow, Reference Brownie and Nancarrow2013). Other studies show evidence that among LTC residents, person-centred care is associated with improved mental health (Hill et al., Reference Hill, Kolanowski, Milone-Nuzzo and Yevchak2011), spirituality (Puchalski et al., Reference Puchalski, Vitillo, Hull and Reller2014), higher life satisfaction (Roos et al., Reference Roos, Silen, Skytt and Engstrom2016) and positive adjustment during the transition to LTC (Boelsma et al., Reference Boelsma, Baur, Woelders and Abma2014; Yoon, Reference Yoon2018).

The inconsistencies in the current evidence about the impact of PCC may stem from the use of different definitions (Morgan and Yoder, Reference Morgan and Yoder2012), and the degree to which implementation and adherence has occurred. This is due to the complexity of achieving larger structural changes at the institutional and policy levels (Epstein et al., Reference Epstein, Fiscella, Lesser and Stange2010), including administrators who understand and support the need for person-centred care, alongside new regulations and norms that support the change (Moore et al., Reference Moore, Britten, Lydahl, Naldemirci, Elam and Wolf2017; Jacobs et al., Reference Jacobs, Snow, Parmelee and Davis2018). In order to enact a much needed, but fairly radical (in light of all historical evidence) organisational change, a new training model for nursing care is needed (e.g. diversity training, cultural competence) (Low et al., Reference Low, Fletcher, Goodenough, Jeon, Etherton-Beer, MacAndrew and Beattie2015; Meyer et al., Reference Meyer, Ogrin, Al-Zubaidi, Appannah, McMillan, Barrett and Browning2017). Other reasons might include the lack of appropriate measures of care quality, as well as limited availability of rigorous research evidence that shows clear effect of PCC to be used to guide new care practices (Edvardsson et al., Reference Edvardsson, Winblad and Sandman2008; Li and Porock, Reference Li and Porock2014).

Social impact of suicide bereavement of older adults

Suicide bereavement is different from other types of mourning (Jordan, Reference Jordan2001). These differences are present in terms of both the personal emotional response and the impact on one's social network – which, for older adults in LTC, includes not only family and friends, but also other residents and staff (Cerel et al., Reference Cerel, Jordan and Duberstein2008, Reference Cerel, Brown, Maple, Singleton, van de Venne, Moore and Flaherty2018). Individuals experiencing suicide bereavement may have strong feelings of confusion, guilt and anger not always associated with the loss of a loved one (Jordan, Reference Jordan2001). Empirical evidence on bereavement responses to older adult suicides is lacking, particularly in how this may differ from suicide of younger people. However, research has shown that bereaved relatives and friends of older adults who died from suicide experience higher levels of stigmatisation, shame and sense of rejection compared with those bereaved through natural death (Harwood et al., Reference Harwood, Hawton, Hope and Jacoby2002). Suicide can also impact family interactions, with a lack of open communication about the death and a heightened risk of suicide among family members, friends and acquaintances (Jordan, Reference Jordan2001). Furthermore, interpersonal interaction and social support is often problematic following a death from suicide compared to other types of loss, due to the social stigma that still remains (Jordan, Reference Jordan2001).

LTC institutions, distinct from other residential settings, have to contend with the fact that death is not uncommon; nearly 40 per cent of Medicare beneficiaries die in a nursing home annually (Teno et al., Reference Teno, Gozalo, Trivedi, Bunker, Lima, Ogarek and Mor2018). Just as with other causes of death, residents in LTC facilities are affected by suicide deaths. In practice, residents are often not told directly about the death of a fellow resident, but rather hear it informally through word-of-mouth (Ball et al., Reference Ball, Kemp, Hollingsworth and Perkins2014). This lack of communication about death has the potential to be confusing and traumatic for other residents (Rivolta et al., Reference Rivolta, Rivolta, Garrino and Di Giulio2014). SAMHSA encourages staff and residents affected by a suicide death to openly discuss the decedent and to support each other in their grief, and advises facilities to name a specific contact that residents and staff can reach out to help cope with suicide bereavement (SAMHSA, 2011). These types of efforts emphasise empathy and communication, and can have a positive impact on the sense of community in LTC settings.

Societal

Studies have shown that public perceptions of suicide are generally not consistent with the empirical epidemiologic data (Morgan et al., Reference Morgan, Rowhani-Rahbar, Azrael and Miller2018). Increased public discussions of suicide among older adults, including among those residing in LTC, is required to address this misconception. Such discussions could be informed by media reports; for example, CNN published a comprehensive and thoughtful article regarding the suicide death of an 82-year-old farmer (Ravitz, Reference Ravitz2018). Another example of a constructive public dialogues can be found in the Men's Sheds initiative in Australia (https://mensshed.org/), an effort that supports mental health and psycho-social wellbeing for older men as they experience transitions in later life (e.g. retirement, development of physical limitations) (Taylor et al., Reference Taylor, Cole, Kynn and Lowe2018).

In addition, there is a need for community mental health campaigns and increased funding for suicide research on older adult populations. Public campaigns and participatory research initiatives should focus on changing public perception that not only is suicide preventable in any age group, but that it is worth preventing for all persons, including older adults living in LTC. Does the public tend to accept late-life suicide as rational and expected? Do these perceptions influence the culture, policies and practices of care? These challenging questions must be voiced for changes to start taking root. Both research and policy efforts should aim to identify the nature and extent of the impact of ageism on suicide prevention among older adults.

Organisational

Suicide prevention in LTC is particularly important from an organisational perspective. Aged care is a human-made institutional system created and continually developed to support a natural stage of human ageing with due dignity, comfort and integrity. As such, it is imperative that this system be structured and evaluated to ensure it is achieving its intended goal, and modified as warranted. LTC staff and managers have a duty of care to residents, akin to the duty that any institution has to its constituents.

In light of the evidence that poor social support is strongly associated with suicide among older adults (Duberstein et al., Reference Duberstein, Conwell, Conner, Eberly, Evinger and Caine2004; Mezuk et al., Reference Mezuk, Prescott, Tardiff, Vlahov and Galea2008), active implementation of the person-centred LTC alternatives which emphasise social engagement and personal autonomy are worth exploring as strategies that can promote mental health and quality of life of residents, and potentially reduce risk of suicide (Araujo et al., Reference Araujo, Ribeiro, Teixeira and Paul2016). Researchers, providers and policy makers should work together to develop evidence-based guidelines and implement suicide prevention strategies based on PCC models. For example, in 2013 O'Riley et al. proposed a framework for assessing and managing suicide risk in LTC settings (O'Riley et al., Reference O'Riley, Nadorff, Conwell and Edelstein2013), and in 2017 the state of Illinois developed policies and procedures for assessing risk and responding when a LTC resident expresses suicidal ideation (Illinois Department on Aging, 2017); these are welcome first steps towards recognising the role of institutions in supporting the mental health of residents.

In addition, researchers and clinicians should consider ways to improve the measurement of mental health and psycho-social wellbeing of LTC residents by incorporating validated measures of social engagement, social satisfaction and connectedness into assessments of both residents and staff (Chan et al., Reference Chan, Chun, Man and Leung2018). Better data are needed to understand the links between organisational policies and procedures and resident mental health.

Individual

From an individual perspective, it is important to continue to engage and communicate effectively with stakeholders around late-life suicide and its prevention in LTC. This should include assessing the gaps in care identified by residents, family members and staff. For example, previous research has identified several areas considered important by older adults when developing practice improvements in LTC; these include a balance between maintaining resident's independence and autonomy (i.e. feeling at home and maintaining own hobbies and lifestyle) and developing a sense of community through interpersonal conduct between residents and care-givers (Boelsma et al., Reference Boelsma, Baur, Woelders and Abma2014). Any changes to LTC policy and practice to prevent suicide must take into account the wishes of older people who will be directly affected and who are the intended beneficiaries of such change. Another concrete step would be to establish suicide bereavement support for staff, family and other residents. Through enactment of appropriate bereavement policies that promote transparency and dialogue, grief interventions facilitate mechanisms for coping, processing and understanding intense emotions and fears around death and dying (Katz et al., Reference Katz, Sidell and Komaromy2001; Rickerson et al., Reference Rickerson, Somers, Allen, Lewis, Strumpf and Casarett2005; Marcella and Kelley, Reference Marcella and Kelley2015).

Implications for public policy

Suicide prevention and improvement in life quality of older adults in residential care through service provisions require implementation of new budget and regulatory policies. To facilitate a shift in policies at federal and local settings, it is important to conduct stakeholder engagement with residents, family members, staff, management and policy makers to ensure that any measures identified will be appropriate and feasible in a real-world environment. This has been conducted to an extent by consulting with individuals in senior management and policy positions to develop recommendations for prevention of suicide in Australia (Ibrahim, Reference Ibrahim2017) and as a part of Zero Suicide Initiatives in the USA (Labouliere et al., Reference Labouliere, Vasan, Kramer, Brown, Green, Rahman, Kammer, Finnerty and Stanley2018), but requires further research engaging with residents, their family and staff. Intuitively, this would be followed by strategy and policy development to prepare selected and stakeholder-approved strategies ready for policy enactment. The final stages involve policy enactment, repeated evaluation and implementation (i.e. drafting and passing of new legislation or internal process documents). This is likely to be a slow and incremental process and is heavily reliant on changes in community attitudes towards late-life suicide and end-of-life care, but fertile seeds planted through small-scale initiatives, growing research evidence on PCC and clear need for continuous improvement show promise.