One of the most popular posts on my blog is the article on the Nurses Global Assessment of Suicide Risk. The purpose of this article is to review a number of suicide risk assessments, screening tools and other elements that make working with potentially suicidal individuals easier for nurses.
Suicide Education in Nursing Programs
Nurses receive little to no education in suicide awareness, risk assessment or intervention in their program. (Pullen, Gilje & Tesar, 2015) Luebbert and Popkess (2015) examined a number of teaching techniques for suicide assessment and found that techniques like roleplay and human simulation were superior compared to standard lecture formats.
Suicide screening is the process of asking individuals some brief questions about whether they are feeling suicidal. They can be patients who have presented to the ER or who are on a unit for other physical or mental health issues.
There are three types of screening:
- Indicative, where you screen only those whose affect or other elements make you believe the individual may be suicidal
- Selective, where you screen only high risk groups (e.g. those admitted for substance abuse)
- Universal, where you screen everyone regardless of presenting problem
In a study involving 3 Emergency Departments in the US, rate of detected suicide doubled after universal screening was implemented. (Boudreaux, et. al., 2015) Suicide screening is clearly important, though few emergency departments require it currently.
The screening tool used in Boudreaux’s emergency department studies was called Emergency Department Safety Assessment and Follow Up Effectiveness (ED-SAFE); the ED-SAFE Patient Screener is comprised of the following questions:
- Over the past two weeks, have you felt down, depressed, or hopeless?
- Over the past two weeks, have you felt little interest or pleasure in doing things?
- Over the past two weeks, have you wished you were dead or wished you could go to sleep and not wake up?
- Over the past two weeks, have you had thoughts of killing yourself?
- Have you ever attempted to kill yourself?
- When did this happen?
- Within the last 30 days (but not today)
- Between 1 and 6 months ago
- More than a six months ago
If the person completing the screener is positive on any of these items, they should be asked whether they are feeling suicidal. This is especially important if they have indicated positive on items 3, 4, or 5.
Suicide Risk Assessment
Suicide risk assessments are more indepth examinations of a patient’s suicide risk. One example of an assessment tool designed for nurses is the NGASR, which has demonstrated fair reliability (Shin et. al, 2012; van Veen et. al., 2015)
Bolster et. al., in their 2015 metareview found that once nurses were provided training in suicide risk assessment, they realized that it was no different than any other assessment (e.g. for physical illness), and therefore it was easy to fall back on their existing assessment skills with the new knowledge, while Luebbert & Popkess (2015) found that nurses who watched a lecture on suicide risk assessment and then got first-hand practice speaking to a standard patient felt much more confident.
Other examples of suicide risk assessment tools that can be used by nurses are the DCIB Suicide Risk Assessment tool and the CPR Risk Assessment, profiled on other pages on this blog.
Guidelines for Working with Suicidal Patients
The Registered Nurses Association of Ontario (RNAO) has published Assessment and Care of Adults at Risk for Suicidal Ideation and Behaviour, which includes 14 recommendations for nursing practice working with adults who are suicidal, as well as an extremely detailed appendices on topics like cultural sensitivity, environmental safety (important in hospitals), risk factors, interview questions, risk assessment tools and more.
Suicidal Youth and Nursing
Children and youth may require a different approach given their lack of coping skills and lack of life experience to draw on when they feel suicidal. Working children and youth isn’t my specialty but my blog post Clinical and Legal Aspects of Suicidal Children and Youth gives a brief overview, although not from the nursing perspective.
Tishler, Reiss & Rhodes (2007) review a number of risk factors for children:
- Mothers with psychiatric problems
- Previous suicide attempts
- Presence of psychiatric disorders and psychopathology
- Preoccupation with death
- Family history of psychopathology and suicidal behaviour
Their article also notes that “[p]overty, poor family cohesion, divorce, witnessing or experiencing violence, experiencing multiple transitions in the living situation, and a history of maltreatment are all linked to suicidal behavior…[in] addition, experiencing stressful events, including physical and/or sexual abuse and losses of emotionally important people through death, separation, or termination of the relationship, are all associated with suicidal behavior…[and h]igh levels of assaultive behavior in relatives is also common”
Their review indicates that a poor home life, abuse and unwanted children are all at increased risk for suicidality and these are all elements that a watchful nurse can pick up on. They continue to discuss triggers for suicide that tend to focus on the relationship between the parental figures and the child and recommends suicide screening and a clinical interview.
Suicide risk assessment and intervention with children and youth is best left to specialists where available because of the importance of clinical judgement and the infancy of the research where it exists.
Bolster, C., Holliday, C., Oneal, G. & Shaw, M., (2015) “Suicide Assessment and Nurses: What Does the Evidence Show?” OJIN: The Online Journal of Issues in Nursing. 20(1). DOI: 10.3912/OJIN.Vol20No01Man02
Boudreaux, E., Allen, M., Goldstein, A.B., Manton, A., Espinola, J., Miller, I. (2015) Improving Screening and Detection of Suicide Risk: Results from the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) Effectiveness Trial. Society for Prevention Research 23rd Annual Meeting. Accessed Nov 14 2015 from https://spr.confex.com/spr/spr2015/webprogram/Paper23206.html
Luebbert, R., & Popkess, A. (2015). The Influence of Teaching Method on Performance of Suicide Assessment in Baccalaureate Nursing Students. Journal Of The American Psychiatric Nurses Association, 21(2), 126-133 8p. doi:10.1177/1078390315580096
Pullen, J. M., Gilje, F., & Tesar, E. (2015). A descriptive study of baccalaureate nursing students’ responses to suicide prevention education. Nurse Education In Practice, doi:10.1016/j.nepr.2015.09.007
Shin, H.Y., Shin, Y.S., Ju, J.H., Jang, H.S., Hong, J.Y., Jeon, H.J. & Yu, B.H. (2012) A Study on Reliability and Validity of the Nurses’ Global Assessment of Suicide Risk (NGASR) for Psychiatric Inpatients. Journal of Korean Acadademic Psychiatry and Mental Health Nursing. 21(1):21-29.
Tishler, C.L., Reiss, N.S., Rhodes, A.R. (2007) Suicidal Behavior in Children Younger than Twelve: A Diagnostic Challenge for Emergency Department Personnel. Academic Emergency Medicine. 14(9).
van Veen, M., van Weeghel, I., Koekkoek, B., & Braam, A.W. (2015) Structured assessment of suicide risk in a psychiatric emergency service: Psychometric evaluation of the Nurses’ Global Assessment of Suicide Risk scale (NGASR). International Journal of Social Psychiatry. 61(3):287-96. doi: 10.1177/0020764014543311.
Crisis line reference checks and interviews are one part of the process for becoming a volunteer. A reference check usually involves the volunteer coordinator, distress line manager or other individual who is responsible for screening volunteers calling two or three individuals that you have written down (often an academic or employment reference, and then a personal reference.)
The purpose of the interviews are to determine your suitability for volunteering and to ensure that you won’t be negatively impacted by your helpline work. Below are some potential questions you might be asked on your interview
Common Interview Questions
What do you know about our service?
This question is important because a lot of people come into this field with an incorrect view of the day to day. For instance, some people believe that every call that they take will be someone who is highly suicidal. Certainly, on some lines there will be a bigger proportion of suicidal callers than others, but the majority of calls to most crisis lines (even suicide hotlines) are not imminent risk situations. Being aware of this is helpful.
Additionally, you may want to research how many calls the crisis line gets and how many volunteers they have. For example, some crisis lines get one call an hour, or even go stretches with no calls. (This is common for Samaritans branches where calling a single number gets a call bounced to the next available branch.) Other lines are much, much busier.
What made you interested in becoming a volunteer?
Sometimes people have visions of wanting to become a helpline, crisis line or suicide hotline volunteer because they want to save people. They imagine themselves as a counsellor who is able to fix people’s problems. Unfortunately, a lot of people’s problems can’t be fixed, and when we try to, we promote dependence.
On the other hand, there’s nothing wrong with wanting to become a volunteer to learn if social work or crisis intervention is right for you. Building skills, learning to network, and giving back to your community are all great reasons for joining a crisis line.
As well, it’s important to recognize if you’re interested in becoming a volunteer to fix your own problems. This will likely result in you being negatively affected by the work – and you should probably complete counselling or therapy first before approaching helpline work.
What relevant experience do you have, if any?
You may not have any experience as a peer counsellor or other kind of experience, and you may lack coursework in social work, but communication courses are helpful, as is customer service or call centre experience.
Remember that crisis lines will provide all the training you need, but anything that helps improve your ability to communicate helps. The most important thing is to be empathic, non-judgemental and to listen!
Have you ever dealt with stressful or crisis situations?
Obviously stressful situations can be common on crisis lines. The important thing is to consider whether you’ll be able to handle the pressure. Certainly, you may not have intervened in a suicidal crisis before, but any crisis experience can help.
Do you have personal experience with suicide?
It’s important that if you were suicidal yourself, or you lost someone to suicide, that you’ve taken time to work through your issues before beginning crisis line work. This can be triggering.
Are there any issues you may be uncomfortable talking about? For instance, some people have issues with intimate partner violence, abortion, or other issues that you may need to remain neutral in on the crisis line.
Finally you may have to perform a roleplay. For instance, you may be given a statement like, “Me and my husband got into a fight again. It’s the same thing all the time, he just never listens!” And you have to say how to respond. A good response that incorporates crisis line empathy statements would be something like “Wow, that sounds like it’s really frustrating for you.”
There are some important definitions that may improve your interview performance.
Active Listening – Active listening is a form of listening that involves listening to really understand what the individual is saying. This involves elements of the active listening process, which includes voice tone and body language, pace, open and close-ended questions, and demonstrating empathy.
Empathy – Empathy is the ability to put yourself in someone else’s shoes and recognize the emotions they’re experiencing. This involves the use of empathy statements.