Assessing Suicide Risk in Nursing

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

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.

Screening Tools

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:

1. Over the past two weeks, have you felt down, depressed, or hopeless?
2. Over the past two weeks, have you felt little interest or pleasure in doing things?
3. Over the past two weeks, have you wished you were dead or wished you could go to sleep and not wake up?
4. Over the past two weeks, have you had thoughts of killing yourself?
5. Have you ever attempted to kill yourself?
6. When did this happen?
   1. Today
   2. Within the last 30 days (but not today)
   3. Between 1 and 6 months ago
   4. 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.

Bibliography

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

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.
http://dx.doi.org/10.12934/jkpmhn.2012.21.1.21

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.