During a previous presentation on suicide prevention, two pictures were shown to the audience. The first depicted a well-dressed, middle-aged man, smiling while sitting in a park on a sunny day.
The second featured a neatly dressed older gentleman in a wheelchair, gazing out of his window on a dull, gray day. The audience was then asked, "Which patient is at greater risk for suicide?"
The not-obvious answer is both. you can never assume what is going on in someone's mind unless you're on the front line, asking the appropriate questions and observing the cues.
Organizations, including the Centers for Disease Control and Prevention and the World Health Organization, list suicide as a leading cause of death in the United States, with successful attempts occurring each year.
Who were these individuals? Many have been patients in healthcare settings. Given the high rate of mental health comorbidities in the U.S. population, it is likely that many individuals at risk for suicide in the future will be patients in nursing units and clinics outside of psychiatric settings.
These considerations led to the presentation of suicide prevention in the non-psychiatry setting during the Nursing Grand Rounds at James J. Peters Veterans Affairs Medical Center in the Bronx, New York.
Addressing this topic was timely and crucial, as it supports The Joint Commission’s National Patient Safety Goals for the Hospital Program — specifically Goal 15, which emphasizes identifying safety risks inherent in patient populations, including the risk of suicide in general hospitals.
Nursing Grand Rounds served as an effective platform for education, allowing for outreach to all nurses, including those working on the front lines in non-psychiatric settings as well as those in psychiatric units.
The nurse's role
Nursing's hands-on approach to patient care and our ability to create therapeutic connections with patients enables nurses to pick up on key cues. Identifying these cues starts with understanding that suicidal behaviors are neither considered an illness nor a condition but rather a complex set of behaviors that actually exists on a continuum that ranges from ideas and thoughts to eventual actions.
When these cues are identified and determined to be significant, they become part of the care plan and are reported and acted upon by the healthcare team.
Reading the signs
Identification of potential suicide behaviors starts with understanding the signs and symptoms that may be overlooked in a non-psychiatric setting. Picking up on these cues starts with excellent assessment skills and an assessment tool that is designed to cover the important risk factors and warning signs.
According to the Mayo Clinic, these include:
- A prior suicide attempt
- Having a psychiatric disorder, such as depression, schizophrenia, or bipolar disorder
- Alcohol substance use
- A family history of mental disorders or substance use
- A family history of suicide
- Firearms in the home
- Family violence, including physical or sexual abuse
- A significant medical illness, such as cancer or chronic pain
- Compulsive gambling
- Recent losses — physical, financial, personal
- Age, sex, race (elderly or young adult, unmarried, white, male, living alone)
- Recent discharge from an inpatient psychiatry unit
Although risk factors in themselves don't conclusively identify a patient at risk, they do help screen patients who are admitted to units or visit outpatient clinics. Those at risk, who exhibit any of the following warning signs, should clearly raise a red flag:
- Withdrawal from social contact
- Desire to be left alone
- Preoccupation with death and dying or violence
- Risky or self-destructive behavior, such as drug use or unsafe driving
- Changes in routine, sleeping patterns
- Changes in routine, including eating
- Giving away belongings or getting affairs in order
- Personality changes, such as becoming very outgoing after being shy
- Saying goodbye to people as if they won't be seen again
- Talking about suicide, including such statements as, "I'm going to kill myself," "I wish I were dead," or "I wish I hadn't been born."
What you can do
If the patient is talking about suicide specifically, don't ask tentative questions. Ask the patient directly whether they're having any thoughts of harming themselves. It is imperative that you be straightforward by asking such substantial questions as, "Do you want to hurt yourself?" and "Do you want to kill yourself?"
If the patient answers yes, don't leave the patient, and have someone contact their primary care provider, who should order a psychiatric consult. Psychiatry then can suggest that the patient be placed on a 1:1 observation.
Be sure to remove all items from the patient's possession that might pose a risk, such as shoelaces, sharps, or belts, and search the room, including adjacent bathrooms.
Nurses are in a unique position to assist in curbing the suicide rate in this country. Remember the gentlemen described in the two photos at the beginning of this article. You'll never know what is going on unless you ask the appropriate questions and you can't help unless you act on the cues.
