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CHAPTER 11 ■ Suicide Prevention
means, there must be recognition that patients are not always forthcoming or truthful in their answers to such questions. Several strategies for enhancing a collaborative, therapeutic relationship and commu- nication about suicide assessment have been elab- orated. Because nurses are often at the front line of this assessment in medical-surgical, emergency department, outpatient care, schools, and other health-care settings, they must be thoughtful, com- prehensive, and conscientious in this pursuit regard- less of the practice setting and whether or not the patient has been identified as having mental health issues. Shea (2009) states that nurses need to assess not only what the patient is directly stating about their suicidal intent (stated intent) but also the amount of thinking, planning, and behaviors associ- ated with suicide ideation (reflected intent) and the
suicide intent that is withheld from the nurse (with- held intent). A summary of guiding principles in sui- cide risk assessment is included in Table 11–2. One model for enhancing communication in sui- cide assessment is the CASE (Chronological Assess- ment of Suicide Events) approach. It is described as a flexible guide for interviewing that includes commu- nication techniques designed to elicit and enhance detailed, valid feedback from patients about sensitive topics such as suicide. Several examples, as elabo- rated by Shea (2009), follow: ■■ Normalizing communicates that the patient is not the only one who experiences suicidal ideation. Example: “Sometimes when people are in a lot of emotional pain, they have thoughts of killing themselves. Have you had any thoughts like that?”
TABLE 11–2 Guiding Principles for Suicide Risk Assessment PRINCIPLES EXPLANATIONS
Screening for suicide risk should be conducted as an essential component of health assessment, and risk factors, warning signs, and threats should be taken seriously. Establishment of a therapeutic relationship is foundational to effective suicide risk assessment. Suicide risk assessment is complex and challenges the nurse to use many different communication strategies. Suicide risk assessment is an ongoing process, and level of risk can increase or decrease over time. Collaboration with the patient and other sources of information facilitates confidence in clinical judgments.
This includes identifying through detailed assessment the individu- al’s unique situation to discern additional resources, consults, and interventions needed to ensure patient safety.
This includes establishing trust through empathy and respect, which provides a safe environment for the patient to tell their story. This includes exploring the patient’s thoughts, feelings, and behav- iors from a variety of perspectives. This includes assessing over time for fluctuations in risk factors, changes in stress level, changes in intensity of ideation, changes in intention to act on suicide ideation, and changes in support systems. This includes information provided by other people who are famil- iar with the patient from home, work, or school and other clinical team members. Collaboration also implies that all those involved in the patient’s care are working together. This includes using terminology such as “suicide” and “death” rather than “not happy with living” or other indirect statements. It also com- municates to the patient that these are acceptable topics to discuss. This includes attempting to discern when the patient is communi- cating unbearable distress, feeling trapped, feeling hopeless, and/ or feeling driven to avoid additional emotional or physical pain. This includes recognizing that anyone regardless of race, religion, or culture may be at risk for suicide. Some cultural or religious prohibitions may influence someone’s willingness to openly dis- cuss personal feelings. This includes risk factors, warning signs, underlying themes, level of risk, clinical judgments, and recommended interventions.
Suicide risk assessment uses direct rather than indirect language.
Suicide risk assessment attempts to discern the underlying message.
Suicide risk assessment considers cultural context.
Suicide risk assessment is documented in detail.
Source: Adapted from Perlman et al. (2011).
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