Suicide Prevention Workgroup Report

Becky Austin Morris, Amanda Schuh, Breanne Starks, & Mary Ellen Stolder
Advisor: Barbara L. Drew


Suicide is the 10th leading cause of death in the US with nearly 37,000 deaths by suicide in 2009 (Center for Disease Control, CDC, 2012). It was estimated that in 2008 and 2009, an annual average of over 1,100,000 people attempted suicide with 8.4 million adults experiencing serious suicidal thoughts (SAMHSA, OAS, 2010). Psychiatric-mental health nurses are key providers of screening services, crisis intervention, postvention after an attempt, and education about suicide. As a result, the APNA Board of Directors has convened a task force of APNA Janssen Scholars in order to update the Board on this critical topic. Specifically, the questions we were to answer were:

  1. What do we know about the current PMH nursing environment related to suicide? (What’s going on out there?)
  2. What do we know about PMH nurses’ and stakeholder needs/wants/preferences related to suicide?
  3. What are some of the ethical implications related to this topic?

Process for Gathering Information

During our first conference call it was noted that the All-Purpose Discussion Forum on Member Bridge included a number of questions and comments about the care of people who were suicidal. Thus, our first task was:

  • Categorization of the Member Bridge comments

Additional tasks were to:

  • Identify organizations that have suicide prevention as a primary mission.
  • Solicit member viewpoints through Survey Monkey. Specific questions we asked were:
    1. What concerns or worries do you have about how we care for people who are suicidal?
    2. How should APNA focus its efforts on suicide prevention?
    3. What other organizations do you turn to for information about suicide and suicide prevention?
    4. Are you affiliated with any organization(s) listed in question 3?

Findings

Categorization of the Member Bridge comments:
The topics that were most frequently addressed related to these five categories:

  1. Prevention:
    • on medical units, emergency departments, and psychiatric units.
    • evidence for the use of safety contracts
  2. Assessment/screening
    • daily suicide assessment on inpatient units
    • what are the best evidence based assessment tools
  3. Suicide prevention/assessment/screening of specific populations
    • children & adolescents
    • older adults
    • military members & veterans
  4. Education
    • nursing education
      1. use of suicide simulation
      2. curriculum guidelines
      3. exposure/experience with suicidal patients
    • Educational resources for patients & families
  5. Policy
    • policies and procedures for patients on suicide precautions (frequency of checks, 1:1s, reassessment of suicide risk, when to decrease level of observation)
    • use of restraints with suicidal patients

There were some additional conversations about documentation after a patient suicide, items allowed in the rooms of suicidal patients, and process for dealing with crisis calls to a psychiatric unit.

Organizations with suicide prevention as a primary mission:

  1. American Foundation of Suicide Prevention: http://www.afsp.org/
  2. American Association of Suicidology: http://www.suicidology.org/home

Website with focus on suicide:

  1. Suicide Prevention Resource Center: http://www.sprc.org/

Mental health associations/organizations with suicide-specific web pages:

  1. National Alliance on Mental Illness: http://www.nami.org/Content/ContentGroups/Helpline1/Suicide_-_Learn_more,_learn_to_help.htm         
  2. Mental Health America: http://www.nmha.org/go/suicide
  3. National Institute of Mental Health: http://www.nimh.nih.gov/health/topics/suicide-prevention/index.shtml
  4. American Psychiatric Association: http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1673332
  5. Substance Abuse & Mental Health Service Administration: http://www.samhsa.gov/ (suicide-related info scattered throughout website)                                 

Survey of Members

Q1. What concerns or worries do you have about how we care for people who are suicidal? (N = 489)
The five general themes that emerged are:

  • Safety concerns: no harm contracts, frequency of checks, contraband, personal and facility liability and a lack of family and public awareness to identify those at risk for self harm, particularly in the case of vulnerable groups; self-care behaviors
  • Continuity of care: lack of follow-up and education for patient and family, ER assessment and care post-discharge
  • Lack of resources and funding: Premature discharge due to insurance constraints, lack of inpatient beds, ineligibility for admission or other care, and staff workloads
  • Insufficient assessment and management skills of health care providers and nursing staff: including an inability to establish a therapeutic relationship, a tendency to stigmatize patients, an over-reliance on assessment scales in lieu of clinical judgment, restrictive behaviors on the part of staff, and an inability to distinguish between suicidality and self injurious behaviors. There was also a concern that current nursing students are not given sufficient clinical training.
  • Lack of clear evidence for suicide prevention and safety practices currently in place
     

Q2. How should APNA focus its efforts on suicide prevention? (N = 483)
The members clearly indicated that APNA should focus its efforts on education about suicide. There were general statements about education of health care providers, including PMH nurses and the public. Methods for education of HCPs were specified by some members including:

  • identification of evidence-based practices
  • development of practice guidelines
  • collaboration with other organizations
  • presentations at national and state conferences
  • emphasizing need for education across all levels of nursing curricula

The focus of educational need was on support with assessment of suicide risk particularly in populations known to be high risk including youth, Native Americans, and the elderly. Suggestions for methods for education of the public included mobilization of APNA chapters, public service announcements, preparation of brochures for consumers, highway billboards. Other foci for education are families, 3rd party payors, teachers, and legislators. Two other foci are also noted: APNA should also support relevant research and emphasize the importance of the therapeutic relationship/talk therapy. Additional issues that were addressed included advocacy for reducing stigma, mental health parity, aftercare following an episode of suicidality, and improved access to mental health services.
 

Q3 & 4. What other organizations do you turn to for information about suicide and suicide prevention? Are you affiliated with any of those groups?
Seventy-five survey participants identified an affiliation with local organizations and 82 participants identified an affiliation with the following national organizations other than APNA that they turn to for information about suicide and suicide prevention:

  • NAMI (25)                                                                                                          
  • Veterans Administration/military (19)
  • ANA (9)
  • American Association of Suicidology (6)
  • American Foundation for Suicide Prevention (6)
  • ISPN (5)
  • NIMH (4)
  • American Association of Nurse Practitioners (4)
  • APA (2)
  • SAMHSA (2)
Organization
Referenced for Information
Member Affiliation
NAMI
64
25
VA/military
30
19
ANA
12
9
American Association of Suicidology
32
6
American Foundation for Suicide Prevention
35
6
ISPN
7
5
NIMH
33
4
AANP
2
4
APA
28
2
SAMHSA
17
2


Recommendations to the Board:

We learned through this process that members are searching for guidance in the assessment and treatment of people who are suicidal. APNA can facilitate access to a number of already existing resources but further education of PMH nurses, nursing students (BSN, MSN, doctoral) other health care professionals, and the public is seen as a priority. We submit these recommendations to address the identified needs:

  1. Under "Resource Center" on APNA's home page include a link to a "Suicide" page.
    • The page will include links to already developed resources such as:
      • Best Practices Registry for Suicide Prevention (Suicide Prevention Resource Center)
      • AAS
      • AFSP
    • And suicide-specific pages in the websites of:
      • VA
      • NAMI
      • SAMHSA
      • NIMH
      • APA
  2. APNA will collaborate with one of the above organizations to distribute a brochure about suicide prevention for public access
  3. A pre-conference at the annual conference dedicated to suicide prevention, assessment, and interventions
  4. A JAPNA issue focused on suicide
  5. Review undergraduate curriculum guidelines for adequacy of content about suicide prevention, assessment, and interventions. Incorporated advanced skills into curriculum guidelines for graduate students.

We recognize that we did not specifically address the Board’s question about ethical implications. Ethical considerations abound in the care of people who are suicidal and were inherent in some of the responses but were not directly stated. For example, comments about the use of increased observation and restraints raises questions about treatment in the least restrictive environment and autonomy rights of patients. These types of  issues deserve serious ethical analysis.
 

References

Centers for Disease Control and Prevention (2012). WISQARS Leading Causes of Death Reports, National and Regional, 1999 – 2009. Retrieved from http://webappa.cdc.gov/sasweb/ncipc/leadcaus10_us.html

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (2010). The NSDUH report: Suicidal thoughts and behaviors among adults: 2001-2009. Retrieved from http://www.oas.samhsa.gov/2k10/212/SuicidalThoughtsHTML.pdf

 

Submitted to the APNA Board of Directors February 2012