Suicide is at epidemic proportions both in the United States and across the globe. Yet, it is a preventable public health problem. Nurses practice on the front-lines and have the greatest number of opportunities to identify and intervene with suicidal patients. Most registered nurses (RNs) have little or no training in how to assess, evaluate, treat, or refer a suicidal patient. Because of this lack of training, RNs feel ill-prepared and afraid to talk to patients about suicide. The purpose of this article is to review the state of the science of suicide assessment training for nurses. Training RNs in how to assess, evaluate, treat, and refer a suicidal patient is key to suicide prevention. Research suggests that once RNs are trained in suicide assessment, they realize it is no different than assessing for any other type of illness and are then able to help those with suicidal tendencies. The article conclusion offers implications for education, research, and practice.
Key words: no keywords
Suicide is a preventable public health concern. Globally, nearly 1 million people die each year at their own hands, by an act of suicide. In the United States, more than thirty thousand people die annually by suicide. Suicide is a preventable public health concern (World Health Organization [WHO], 2014). To put this number in perspective, 58,000 service people lost their lives during the Vietnam War (1968-1973); during the same period, 220,000 U.S. citizens lost their lives to suicide (Institute of Medicine [IOM], 2002). Another statistic of concern is that the number of suicides exceeds homicides by a ratio of three to two, a ratio that has remained constant over the past 100 years (Minino & Smith, 2001). There is an abundance of literature on the topic of suicide and suicidal behavior, a point that exemplifies the complexity of suicide as a topic. The suicide literature also includes evaluation and outcomes of prevention programs.
The majority of people who complete suicide have visited a healthcare provider in the previous month of their suicide... Primary prevention programs are aimed at preventing people from attempting and completing suicide. These types of programs utilize public education and awareness messages or campaigns targeting people in the community. Crisis telephone lines, and other resources available for suicidal persons reaching out for help, are considered primary prevention strategies. Educational training programs aimed at health professionals are also part of primary prevention strategies. The goal of secondary prevention is to keep those that have previously attempted suicide from going on to complete suicide.
The majority of people who complete suicide have visited a healthcare provider in the previous month of their suicide (Luoma, Martin & Pearson, 2002); therefore, it is logical to target healthcare providers to intervene and watch for warning signs of mental health disorders. Mann and colleagues (2005) reported in their systematic review of the suicide prevention literature that educating physicians about depression recognition and treatment decreases suicide rates.
Nurses routinely treat patients that are considering suicide, but these patients are rarely identified as at-risk. Perhaps as a result, suicide is the second leading sentinel event in hospitals. Registered nurses (RNs) are considered “front-line” in suicide prevention, at both primary and secondary levels, because of their significant amount of contact with patients (Berlim, Perizzolo, Lejderman, Fleck & Joiner, 2007). Nurses routinely treat patients that are considering suicide, but these patients are rarely identified as at-risk. Perhaps as a result, suicide is the second leading sentinel event in hospitals (Neville & Roan, 2013). In the National Patient Safety Goals for 2014, The Joint Commission, a national organization providing accreditation to health care facilities, has called for hospitals to conduct risk assessments for patients at risk for completing suicide (Joint Commission, 2014).
In this article, we will describe current efforts in the field of suicide assessment training for nurses. Topics found in the literature include beliefs and attitudes of nurses towards suicide and suicide attempters; general lack of knowledge related to suicide assessment; and suicide assessment training programs that have been used by nurses. We will present the main themes identified from review of the suicide literature and conclude with recommendations appropriate for any nurse to improve nursing assessment of potentially suicidal patients.
The terms 'suicide prevention training for nurses,' 'suicide prevention training for RNs,' 'suicide prevention and training for registered nurses,' 'healthcare professionals and suicide prevention training,' 'training of nurses in suicide prevention,' and other various combinations of nurses, training, and suicide prevention phrasing were all used to find relevant literature We utilized the following search engines: PubMed, CINHAL, Psyc-INFO, MEDLINE, and MEDLINE Plus under the categories of Nursing, Health Sciences and Social Sciences. To provide a current review, the search was limited to articles published within the past seven years.
Approximately 54 articles were found between 2006 and 2013 using the above criteria. A review of abstracts eliminated non-research articles. Articles were also excluded if nurses were not part of the research focus. Nineteen articles were then reviewed. Search results included information regarding psychiatric mental health nurses (MHNs), oncology nurses, medical-surgical nurses, emergency department (ED) nurses, and community nurses even though the search itself was not limited to these specialty areas.
We identified four relevant themes: 1) beliefs and attitudes of nurses, 2) lack of education in suicide prevention for nurses, 3) training programs for nurses and 4) examples of successful training programs. The identified themes overlap and are interconnected. In the next section, we explain each of the four themes in greater detail. The article conclusion offers a subsequent summary of implications for education, research, and practice.
Evidence suggests that lack of knowledge, lack of training and poor attitudes of nurses toward the suicidal patient often unfavorably impacts healthcare delivery and patient safety. Beliefs and attitudes of RNs about suicide. Many factors have been identified that influence nurses’ attitudes and beliefs towards suicide, such as, level of education, religion, and prior experience with suicidal patients (Neville & Roan, 2013). Evidence suggests that lack of knowledge, lack of training and poor attitudes of nurses toward the suicidal patient often unfavorably impacts healthcare delivery and patient safety (Anderson & Standen, 2007; Osafa et al., 2012; Valente, 2011).
Psychosocial barriers play a part in the resistance to suicide evaluation and assessment. Psychosocial factors are described as emotions, personal experiences, values, and judgments. “Psychosocial barriers such as the nurse’s emotions, beliefs, knowledge or attitudes can impair risk management”(Valente, 2011, p. 1). Earlier, Anderson & Standen (2007) found in their study with 179 nurses and physicians that complex attitudes towards suicidal youth can impact providers’ ability to screen, prevent, and refer for treatment.
Complex attitudes and beliefs can cross cultures. For example, in Ghana suicidal persons are perceived as immoral by some nurses. Osafo et al. (2012) noted that ED nurses in their study viewed suicide as a crime and believed the suicidal person was blameworthy. Nurses’ negative attitudes included avoidance, rejection, hostility, and anxiety.
Consequences of nurses’ attitudes impacted the quality of care that patients received and resulted in patient feelings of worthlessness, hopelessness, and rejection (Osafo et al., 2012). The dominant attitude toward suicidal patients was often hostile and non-empathetic (Berlim et al., 2007), Negative attitudes were more apparent in general hospital staff as compared to psychiatric hospital staff (Valente, 2011). Regardless of setting, negative attitudes by healthcare providers had an impact on patients.
...most RNs did not know what to say to a suicidal patient; many, therefore, remain silent. Our review of the literature also suggested that most RNs did not know what to say to a suicidal patient; many, therefore, remain silent. Nurses were afraid they would say something wrong; they felt that their lack of experience in dealing with a suicidal patient may lead to further harm (Valente, 2011). Other RNs noted they were not sure if patients are serious when they talk of suicide, so they may ignore the problem. Betz et al. (2013) concluded that most ED providers, including nurses and physicians, are skeptical about suicide preventability. Furthermore, many RNs have their own intense emotional responses to the idea of suicide, which leads to difficulty in assessing a patients’ suicidality. An overall theme was “... [there is a] fear that I am unable to help and the feeling that I’m a personal failure if the patient commits suicide” (Valente, 2011, p. 3). Because of these emotional responses, nurses face the possibility of not identifying patients that might be suicidal and thus miss a chance to intervene.
Another problematic attitude about suicidal patients noted in RNs was apathy. Many RNs, especially in the ED, don’t think of a suicidal patient as seriously ill. For example, a young man went into the ED and stated he felt suicidal. “The call priority on the report was graded a four on a scale of one to four with one requiring immediate treatment and four being the least serious. It [suicidal ideation] was roughly on par with having a bad toothache” (Staines, 2010, p. 8). Because his complaints were not taken seriously, he was allowed to leave the ED. He killed himself a few hours later. An apathetic attitude toward suicidality can be lethal.
...medical-surgical nurses who were older, had a higher level of education and/or had religious convictions were more likely to have positive attitudes toward suicidal patients. Not all nurses have negative attitudes toward suicidal patients. Neville and Roan (2013) found that medical-surgical nurses who were older, had a higher level of education and/or had religious convictions were more likely to have positive attitudes toward suicidal patients. Valente (2010) found that caring for suicidal patients appeared to be most difficult for oncology nurses whose values are committed to preserving life. The literature reviewed did not address the alternate idea that a positive attitude towards suicidal patients can help protect against patients completing suicide. Beliefs and attitudes of nurses toward suicide and suicidal behavior should be addressed in education and training programs.
Lack of education in suicide prevention for nurses. Our review supported the notion that nurses lack education related to suicide prevention. Institutes for higher education in nursing have not adopted a consistent set of standards for training nurses in suicide assessment, and “…there is a gap in suicide-specific intervention training in educational programs” (Puntil et al., 2013, p. 206). Betz et al. (2013) found that there were “large gaps in provider training, bias in treating patients with mental health issues, and skepticism about the effectiveness of suicide prevention approaches” (p. 5). For example, researchers surveyed 85 graduate psychiatric nursing program directors and found 87% of the respondents had not thought about providing firearm injury prevention training to their students, even though it is known that a majority of suicides are accomplished via firearms (Khubchandani, Wiblishauser, Price, & Thompson, 2011). Lethal means restriction is a significant suicide prevention strategy that should be taught in nursing programs as supported by The American Psychiatric Nurses Association (APNA) however, this is currently not included in curricula as a rule (Khubchandani et al., 2011).
RNs consistently stated they felt their education did not prepare them for working with suicidal individuals, regardless of what level of education was achieved. (Palmieri et al., 2000). The American Association of Colleges of Nursing (AACN, 2008) has published standards for baccalaureate prepared nurses, including injury prevention at the individual and population levels. The standards do not specifically identify suicide prevention/assessment as an area to include in nursing curricula, and “...an actual reference to suicide is absent in all the documents critical for curricular development” (Puntil et al., 2013, p. 208). APNA (2013) supports a commitment to the development of guidelines and competencies for undergraduate as well as graduate nurses who care for suicidal patients. The APNA board of directors has made a commitment to convene a task force to address this issue in the future (Puntil et al., 2013). Both the American Association of Suicidology (AAS) and the Suicide Prevention Resource Center (SPRC) developed evidence-based competencies and training programs for suicide assessment in the 1990s. However, nurses have not been targeted for training, nor have they incorporated this evidence-based training into education or practice.
Many RNs, especially those in who work in the ED, operate from a biomedical model which is not always an appropriate context for a psychiatric patient (McAllister, Billet, Moyle & Zimmer-Gembeck, 2009). These nurses may lack knowledge and understanding, and have minimal communication skills, to provide suitable treatment to address patients’ rights to access care (McAllister et al., 2009). The goals of an ED are to see patients quickly, treat their problems, and discharge them in a timely manner. RNs in the ED, therefore, often do not have time to assess each patient for suicidality. Lack of time and lack of training has been identified as a barrier for ED nurses to properly and thoroughly assess suicidal patients.
Training programs for nurses. A third consistent theme noted in the literature was that training helps change attitudes and improve detection skills, yet the trainings provided can be drastically different. For example, Chan, Chien & Tso (2009) recruited 54 medical-surgical RNs from two hospitals in Hong Kong. They offered an 18 hour education intervention that focused on increasing nurses’ knowledge about suicide prevention and the management of patients who have attempted suicide. The outcome measurements showed significant positive changes in both attitude and competence of the nurses involved.
In contrast, Jones (2010) educated 132 health professionals about risk factors in a training session of just 6.5 hours. During training, Jones (2010) noted significant increases in confidence and knowledge; 93% of the participants indicated they would apply what they learned to their clinical practice.
...the elderly (over age 65) do not get assessed for suicidality; yet statistically, adults over age 65 successfully commit suicide more than any other age group. Tsai, Lin, Chang, Yu, & Chou (2011) found the same improvement in attitude and willingness to apply suicide training into practice in their randomized control trial of a 90 minute gatekeeper awareness program implemented in hospitals in Taiwan. Taur and colleagues (2012) provided a two hour training to oncology nurses on the use of a suicide screening tool to identify suicidal clients in those that are chronically ill. Again, findings were consistent with other training programs for nurses in that nurses appeared to be more comfortable assessing and dialoguing with suicidal clients after receiving some sort of formal training.
Huh et al. (2012) contended that the elderly (over age 65) do not get assessed for suicidality; yet statistically, adults over age 65 successfully commit suicide more than any other age group. Huh et al. (2012) noted,
Given the strong association between age and completed suicides and the evidence that older adults are more likely to come into contact with health professionals outside of mental health in the management of their mental healthcare needs, it is imperative that a variety of healthcare professionals be competent in suicide risk assessment. Barriers to conducting adequate suicide risk assessment may include lack of access to training and low confidence in existing skills for assessing and managing risk, suggesting a need for better access to effective training (2012, p. 779).
Despite different lengths of training, Palmieri et al. (2008) suggested essential content is interview skills to detect suicidal intent and ability to communicate by indirect interrogation.; Gatekeeper training appeared the most helpful. Such training programs educate the ‘gatekeeper’ on how to recognize the warning signs of suicide. Two different types of Gatekeeper training is currently available to nurses in the United States (see Table 1).
Gatekeeper Training for Nurses
Length and Brief Description
Regardless of the type of Gatekeeper training, attitudes of nurses changed and this made a difference in the ability to assess for suicide and ultimately prevent further tragic deaths. In addition, many researchers agreed that a single training is inadequate; on-going training is needed across all dimensions to effectively decrease suicidal attempts and successes (Chan et al., 2009; Jones, 2010; Keller et al., 2009; Osafo et al., 2012; Tsai et al., 2011).
...many researchers agreed that a single training is inadequate; on-going training is needed across all dimensions to effectively decrease suicidal attempts and successes. Examples of successful training programs. In addition to the Gatekeeper trainings mentioned above, some communities are developing successful suicide prevention training programs to meet their specific community needs. The Oklahoma Department of Mental Health and Substance Abuse Services and Mercy Health Center created a partnership to develop a suicide prevention program. The program has two parts: 1) provide healthcare workers (including RNs) in clinics and hospitals with an educational program aimed at helping them identify young persons who may be experiencing suicide ideation; and 2) provide clinics with an up-to-date referral sheet to make referrals easy (Parker et al., 2009). As a result of their research, more than 4,000 health care workers had been taught how to recognize signs and symptoms of suicide and how to offer hope to these individuals.
In the Tennessee Lives Count Project (TLCP), researchers developed suicide prevention strategies targeting adults who are in regular contact with high risk youth. They formed a public-private partnership at state and regional levels to provide Gatekeeper training to 14,000 professionals, including nurses, in an attempt to increase awareness of suicidal risk factors (Keller et al., 2009). The results showed improvements in knowledge and self-efficacy around suicide prevention techniques. This project was the first statewide implementation of a Gatekeeper training designed for long-term effects to decrease suicide rates among young people.
Four themes identified from review of suicide training and prevention literature included beliefs and attitudes of nurses; lack of education in suicide prevention for nurses; training programs for nurses; and examples of successful training programs. The themes offered specific areas to consider when developing suicide prevention assessment guidelines for nurses. Nurses have voiced a desire for educational offerings to provide them with the necessary assessment tools required to successfully identify patients who may be at risk for suicide, and programs that would teach skills needed to prevent further suicide attempts.
Missing a suicidal patient is lethal. The literature regarding RNs and suicide assessment suggests several nursing implications. Areas of concern include nursing education, research, and practice. RNs are in a prime position to detect and prevent suicidal behaviors due to their numbers and strategic placement in communities. Dr. M. Justin Coffey (in Wood, 2010) notes that “Nurses serve the most vital role [in preventing suicide] because they spend more time with patients than any other health care worker…We need to feel comfortable talking about suicide in the same way we are in talking about chest pain” (para 2). RNs must be educated and trained to successfully assess, evaluate, treat, and/or refer suicidal patients. Missing a suicidal patient is lethal.
Implications for Education
With simulation becoming a standard educational delivery modality in nursing programs, scenarios involving suicide should become routine for skills development. The most common finding from the literature was the importance of educating nurses so they are competent in providing appropriate nursing care to patients suffering from suicidality. Education should be mandatory and available in programs for nursing students and for practicing nurses. Educational standards regarding suicide education for nurses need to be established and should be based on evidence-based best practices. There are examples of successful programs to train practicing nurses, such as the QPR Program (Smith, Silva, Covington, & Joiner, 2014). Increased education in suicide prevention is encouraged by professional nursing organizations but it has not been implemented in many higher learning organizations; this needs to be changed. Suicide prevention education in undergraduate, graduate, and post graduate programs needs to be evaluated and enhanced as needed. With simulation becoming a standard educational delivery modality in nursing programs, scenarios involving suicide should become routine for skills development. In addition, continuing education requirements need to include suicide assessment, evaluation, and referral skills for all RNs, regardless of specialty practice.
Implications for Research
...there is a huge need for evidence-based interventions and projects that reduce the rate of suicide. Further research could inform and support recommendations for education and policy change. Review of the literature demonstrated variety in relation to the type, frequency, and length of training available to RNs. Additionally, there is a huge need for evidence-based interventions and projects that reduce the rate of suicide. Possible examples include testing different screening tools, developing cultural responses, testing previous interventions within health care facilities, and measuring outcomes of suicide education. Research can inform curriculum so that schools of nursing prepare nurses who will be more comfortable and ready to provide suicide screening and care. Research can influence development of new policies to mandate public programs that can be delivered by nurses, such as suicide screening for teachers and parents.
Implications for Practice
Practicing nurses need evidence-based clinical care practices and standards, such as those developed by the Emergency Nurses Association for suicide risk assessment (Brim et al., 2012). Healthcare facilities need to implement such standards and develop training that incorporates the guidelines. Decision support tools that help nurses understand their roles and responses, such as the McKesson Interqual® Behavioral Health Decision Support Tool (McKesson, 2005), allow nurses currently encountering individuals contemplating suicide to be prepared and competent in their skills. Annual review with training for suicide screening would continue to provide nurses a way to update skills, in the same manner as cardiopulmonary resuscitation review and practice.
Annual review with training for suicide screening would continue to provide nurses a way to update skills... In conclusion, the four themes identified above can be utilized in the development of educational programs to focus on nursing assessment of suicidal patients. Nurse input should be an integral part of the creation of suicidal assessment programs. Successful suicide assessment education must consider the unique needs of the particular healthcare setting. For example, nurses in hospital settings may require a different set of assessment tools than nurses in primary practice settings. Several training programs are currently available as well as individual programs that fit specific needs. Table 2 lists potential resources and training programs available for RNs and examples of individual programs that evolved to fit specific needs.
Nurse and Public Health Resources
American Foundation for Suicide Prevention
American Psychiatric Nurses Association
American Association of Suicidology
National Institute of Mental Health
National Suicide Prevention Lifeline
Emergency Nurses Association Practice Guidelines
Indian Health Service
International Society of Psychiatric-Mental Health Nurses
International Association for Suicide Prevention
Question, Persuade, Refer (QPR) for Nurses
The literature suggests that as more nurses are trained in the prevention of suicide, more lives can be saved. Training RNs should become a primary goal across the globe to prevent suicides and improve patient care.
Cindy Bolster, MN ARNP
Cynthia Bolster MN ARNP has completed her Masters of Nursing at Washington State University in Pullman, WA. She is currently practicing in a rural community clinic as a Psychiatric Mental Health Nurse Practitioner at Riverfront Mental Health Center, in Hamilton, Montana.
Carrie Holliday, PhD ARNP
Carrie Holliday completed a PhD in Nursing Education and Research at Washington State University in Pullman, WA, where she is currently an Assistant Professor. Her area of research interest is suicide assessment, adolescent suicide, and suicide in the American Indian population. She is also a practicing Psychiatric Nurse Practitioner for a rural community clinic.
Gail Oneal, PhD, RN
Gail Oneal PhD, RN is an Assistant Professor of Nursing in Population Health at Washington State University College of Nursing in Pullman, WA. Her research interests and publications are in the areas of health risk messages, risk communication and health literacy, American Indian populations, and qualitative methodology. She is an advocate of using evidence to teach best practices to all levels of nursing students and nurses in the community.
Michelle Shaw, PhD, RN
Michele Rose Shaw, PhD, RN, Assistant Professor, Washington State University, College of Nursing in Pullman, WA. Dr. Shaw's research interests focus on health promotion and improving health outcomes for families and children.
© 2015 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2015
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