Assessing Suicide Risk in the Medical-Surgical Setting
This article was originally published in the Q4 2023 issue of Med-Surg Nurse Life Magazine.
As a nursing professor of a prelicensure mental health nursing course, I often hear positive student experiences while in the psychiatric clinical setting, such as effectively utilizing therapeutic communication skills or successfully implementing deescalation skills with patients during a time of distress. Just as often, I hear the negative student experiences, such as witnessing patients in crisis and the subsequent need for restraint and seclusion. These stories stimulate many emotions for me as a nurse educator — such as inspiration, hope, and sorrow, to name a few. My favorite emotion to feel while these stories are shared is pride. Interestingly, one story that has stayed with me over the years, and one that exuberates this feeling of pride, occurred while a student provided care to a patient with a mental health concern on a medical-surgical unit.
This student cared for a patient admitted for pneumoniarelated complications who had been on the medicalsurgical unit for several days. While assessing the patient, the student recognized verbal and nonverbal signs of depression, which signaled her to ask the infamous question, “Do you have thoughts of wanting to end your life?” The patient quickly responded, “Yes,” and further disclosed to the student a plan, means, and intent to act on these suicidal thoughts later that evening while staying in the hospital. To this day, I often wonder if that simple yet complicated question saved that person’s life. I wonder if this question, when asked more, could save even more lives.
Given the prevalence of mental illness in the United States, nurses will most likely encounter patients who endorse suicidal ideations in various healthcare settings, particularly medical-surgical units. Many patients present with physical complaints rather than openly voicing their suicidal thoughts and plans unless they are directly asked (NIMH, 2017). Suicide in the medical setting is one of the most frequent sentinel events reported to The Joint Commission. In fact, 2022 data of sentinel events resulting in death were most commonly associated with patients’ death by suicide (The Joint Commission, 2023). According to the National Institute of Mental Health (NIMH, 2017), the lack of proper assessment of suicide risk by healthcare professionals was the leading cause of these reported suicides. These deaths by suicide are worrisome within the hospital setting, and actions must be taken to prevent these tragedies. Even more noteworthy may be the fact that registered nurses can play a role in recognizing suicidal ideations and providing behavioral health resources before the patients end their lives outside of the hospital. Early identification and treatment of those with high suicide risks is a crucial suicide prevention strategy, yet healthcare professionals do not often recognize highrisk patients (NIMH, 2017).
Assessing suicidal ideations on a medical-surgical unit often presents as trivial in nature, but more than anything, it is likely that this type of assessment is simply misunderstood. One common myth is that if you ask someone about suicide, this will put the idea in their head; however, a meta-analysis by Blades et al. (2018) concluded that asking about suicide does not increase suicide risk and, instead, can reduce suicidal ideations. In layperson’s terms, asking someone if they are having thoughts of suicide is more likely to save a life.
So, your question may be, how do I assess a patient for suicide? Thankfully, there are various screening tools available that can help guide us; however, one that is widely used in acute care settings is The Ask Suicide-Screening Questions (ASQ) tool. The ASQ is a valid suicide risk screening tool for all ages and in various medical settings, including the emergency department, inpatient medical-surgical units, and outpatient clinics. The tool is a four-item, yes/no, self-report suicide risk screening tool that assesses suicidal ideations, taking less than 20 seconds to administer. The questions include, “In the past few weeks, have you wished you were dead?”; “In the past few weeks, have you felt that you or your family would be better off if you were dead?”; “In the past week, have you been having thoughts about killing yourself?”; and “Have you ever tried to kill yourself?” If the patient answers “Yes” to any of those four questions, the nurse must ask, “Are you having thoughts of killing yourself right now?” If the patient answers “Yes” to this question, an imminent risk has been identified. The NIMH (2017) recommends that a STAT mental health evaluation occur and for the healthcare team to implement other safety precautions, such as not allowing the patient to leave until they have been evaluated for safety, keeping the patient in sight, and removing all dangerous objects from the room.
The ASQ tool is easily accessible on the NIMH website, along with various other resources to help the nurse navigate their suicide risk assessment and discussion. For example, there are guides that provide scripts for the nurse to assess suicide frequency and a suicide plan. There are also easy-to-follow instructions on making a safety plan with the patient, determining disposition, and providing appropriate resources.
Another question you may have is: When do I assess a patient for suicide risk? Some institutions have implemented universal suicide risk screenings on medical-surgical units during admission, and several studies have provided positive results of this strategy (Snyder et al., 2020; Sullivant et al., 2021). However, medical-surgical nurses must assess more often than just on admission. It is vital that all nurses can recognize the warning signs of suicide, which may be direct or indirect statements. For example, it may not be as clear as a patient stating, “I am planning to end my life.” Instead, a patient may state, “I wish I did not exist,” or “This nightmare will only be over when I die.” Or patients may express that they are feeling worthless, helpless, and hopeless. If you recognize these warning signs, it is crucial that you complete a suicide risk assessment by asking the patient directly if they are thinking about ending their life. We cannot ignore the fact that studies have shown that many individuals who die by suicide have had contact with a healthcare provider within three months of their death (NIMH, 2017).
When thinking back to the student, I think about the emotions she must have felt as she drove home that evening, knowing she could have stopped a preventable death: powerful, courageous, and capable. I encourage all medical-surgical nurses to embrace these emotions and become mental health advocates. View your patients holistically and prioritize mental health when needed, whether through assessment, intervention, or treatment.
References
• Blades, C. A., Striztke, W. G. K., Page, A. C., & Brown, J. D. (2018). The benefits and risks of asking research participants about suicide: A meta-analysis of the impact of exposure to suicide-related content. Clinical Psychology Review, 64, 1-12.
• National Institute of Mental Health. (2017). ASQ toolkit summary. https://sprc.org/wp-content/uploads/2022/12/asQToolkit_0-1.pdf
• National Institute of Mental Health. (2020). Suicide risk screening tool. https://www.nimh.nih.gov/sites/default/files/documents/research/researchconducted-at-nimh/asq-toolkit-materials/asq-tool/screening_tool_asq_nimh_toolkit.pdf
• Snyder, D. J., Jordan, B. A., Aizvera, J., Innis, M., Mayberry, H., … Horowitz, L. M. (2020). From pilot to practice: Implementation of suicide risk screening program in hospitalized medical patients. Quality and Patient Safety. (2020). Quality and Patient Safety, 46(7), 417-426.
• Sullivant, S. S., Brookstein, D., Camperer, M., Benson, J., Connelly, M., …Goggin, K. (2021). Implementing universal suicide risk screening in a pediatric hospital. The Joint Commission Journal on Quality and Safety, 47(8), 496-502.
• The Joint Commission. (2023). Sentinal event data 2022 annual review. https://www.jointcommission.org/-/media/tjc/documents/resources/patientsafety-topics/sentinel-event/03162023_sentinelevent-_annual-review_final-(002).pdf