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Abstract

Background: Suicide is the second leading cause of death among adolescents; age-adjusted suicide rate increased 30% from 2000-2016. Medical illnesses are a known risk factor for suicide, establishing medical settings as a key venue for detecting suicide risk. Nurses have the potential to play a critical role in early detection of medically ill patients at elevated risk for suicide. Conducted in tandem with a larger instrument validation study, this study examines nurses’ awareness of pediatric medical inpatients’ experiences with being asked about suicide, their opinions about whether nurses should screen for suicide risk in the medical inpatient setting, and perceived barriers to suicide risk screening. It also examines whether nurses accurately perceived whether their patients had been screened previously for suicide risk.

Methods: Data was collected adjunctive to a larger instrument validation study of the Ask Suicide Questions (ASQ) a 4-item self-report measure developed to rapidly detect suicide risk with pediatric medical inpatients ages 10-21. Patients were asked if they had ever been screened for suicide risk previously and their opinions about whether nurses should screen. Upon completion of pediatric data collection, nurses employed on the medical inpatient units from which patients were recruited completed an exit survey about whether they believed nurses should screen for suicide risk, whether they believed their patients’ had ever been previously asked about suicide, the degree to which they were comfortable screening for suicide risk, and potential real-world barriers to screening. Chi square analyses were used to compare patient and nurse opinions about suicide risk screening and to examine whether nurses accurately perceived that their patients had been previously screened. Pearson’s correlations examined relationships among nurse opinions about whether they should screen for suicide risk and perceived barriers to doing so.

Results: Two hundred pediatric patients at the study site participated in the instrument validation study; while 81.0% of patients reporting pro-screening opinions, only 38.0% of patients reported that they had been previously screened for suicide. Of the 68 who had been asked about suicide, only 5 (6.7%) indicated that they had been asked by a nurse. Of the 64 nurses who completed the exit survey, 84.4% (n=54) supported suicide risk screening by nurses; most (64.1%) believed their patients had been screened for suicide previously, but only 4.6% (n=3) believed that screening had been completed by a nurse. Chi squared analyses showed significant discordance between nurses’ beliefs that their patients had been previously screened for suicide risk and their patients’ self-reported experiences (p<.001; df=1, f=19.8). While half of nurses (n=32) reported that they were at least fairly comfortable engaging in suicide risk screening, all but one reported at least one barrier to engaging in the practice. The most frequently reported barriers to suicide screening included parental presence in the room (73.4%), fear of patient discomfort (56.3%), fear of parental discomfort (51.6%), and their own level of discomfort with screening (45.3%).

Implications: Consistent with previous research exploring patient opinions on whether nurses should screen pediatric patients for suicide risk, the majority of patients and nurses supported suicide risk screening in medical inpatient settings. Very few patients and nurses reported nursing engagement in suicide risk screening practices. According to nurses, the most frequently reported barriers perceived to interfere with screening behaviors included parental presence in the room, fear of parental and patient discomfort, and personal discomfort. Brief in-service interventions for nursing staff that provide training in evidence-based suicide risk screening protocols must include strategies for facilitating meetings with patients alone, ways to manage provider discomfort, and effective interdisciplinary team communication accompanied with appropriate follow up processes ensuring linkage to care.

Key Take Away Points

  • Over 80% of pediatric medical inpatients and the nurses who treat them believe nurses should screen for suicide risk.
  • While the majority of nurses believed that their pediatric patients had been screened for suicide previously, only 38% of patients reported that they had been asked about suicide before.
  • According to nurses, major barriers to suicide screening include parental presence in the room, fear of causing patient and parental discomfort, and their own discomfort with asking suicide screening questions.
  • Implementation of universal suicide risk screening protocols should be accompanied by brief in-service interventions for nursing staff that dispel common myths about suicide, provide nurses with information about patient and family preferences, and directly address their own discomfort with asking questions about suicide.

Author Biography

Dr. Abigail M. Ross, MSW, MPH, PhD is an Assistant Professor at Fordham University Graduate School of Social Service. Dr. Elizabeth A. Wharff, MSW, PhD is a senior social worker at Boston Children’s Hospital and faculty at Harvard Medical School. Dr. Lisa Horowitz, PhD, MPH, is a staff scientist/pediatric psychologist in the National Institute of Mental Health Intramural Research Program at the National Institutes of Health (NIH) and lead developer of the Ask Suicide-Screening Questions (ASQ), a tool created to screen pediatric medical/surgical patients for suicide risk.

Acknowledgements

Lisa Horowitz is supported by the Intramural Research Program of the National Institute of Mental Health of the National Institutes of Health (ZIAMH002922-11).

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