Nursing Process

- The nursing process is a systematic method of providing individualized care for patients with suicidal ideation or behavior. It consists of five steps: assessment, diagnosis, planning, implementation, and evaluation.

Assessment

- The assessment phase involves collecting data about the patient’s physical and mental health status, suicide risk level, protective factors, coping skills, and support system. The data can be obtained from various sources, such as interviews, observations, medical records, laboratory tests, and standardized tools. Some of the tools that can be used to assess suicide risk are:

• Columbia-Suicide Severity Rating Scale (C-SSRS): a clinician-administered scale that measures the severity and intensity of suicidal ideation and behavior in the past month.
• Patient Health Questionnaire-9 (PHQ-9): a self-report questionnaire that screens for depression and suicidal ideation in the past two weeks.
• Suicide Behaviors Questionnaire-Revised (SBQ-R): a self-report questionnaire that assesses suicide-related thoughts and behaviors in the past year.
• Suicide Assessment Five-step Evaluation and Triage (SAFE-T): a clinician-administered protocol that guides the evaluation and triage of patients with suicidal ideation or behavior based on five steps: identify risk factors, identify protective factors, conduct suicide inquiry, determine risk level and intervention, and document.

- The assessment phase also involves establishing a therapeutic relationship with the patient, which is essential for providing effective care and preventing suicide. The nurse should use the following skills to build rapport and trust with the patient:

• Active listening: paying attention to what the patient says and how they say it, using verbal and nonverbal cues to show interest and empathy, and reflecting back the patient’s feelings and thoughts.
• Open-ended questions: asking questions that allow the patient to express their feelings and thoughts in their own words, without leading or judging them.
• Validation: acknowledging the patient’s feelings and thoughts as real and understandable, without agreeing or disagreeing with them.
• Empowerment: encouraging the patient to take an active role in their care and recovery, by involving them in decision making, goal setting, and problem solving.
• Respect: showing respect for the patient’s dignity, autonomy, values, beliefs, and preferences, without imposing one’s own views or opinions.
• Honesty: being honest and transparent with the patient about the purpose and process of the assessment, the limits of confidentiality, and the possible outcomes and interventions.

Diagnosis

- The diagnosis phase involves analyzing the data collected from the assessment phase and identifying the nursing diagnoses that reflect the patient’s actual or potential problems related to suicide. The nursing diagnoses should be stated in terms of human responses (e.g., hopelessness, impaired coping) rather than medical diagnoses (e.g., depression, bipolar disorder). The nursing diagnoses should also be prioritized according to Maslow’s hierarchy of needs, which states that physiological needs (e.g., safety, air, water) are more important than psychological needs (e.g., love, esteem, self-actualization). Some of the common nursing diagnoses for patients with suicidal ideation or behavior are:

• Risk for suicide: at risk for self-inflicted, life-threatening injury
• Hopelessness: subjective state in which an individual sees few or no alternatives or personal choices available
• Impaired coping: inability to use appropriate skills to cope with stressors
• Chronic low self-esteem: long-standing negative self-evaluation or feelings about self or self-capabilities
• Social isolation: aloneness experienced by an individual as a negative or threatening state
• Ineffective family coping: compromised or disabled family coping
• Grieving: normal response to loss

Planning

- The planning phase involves developing a plan of care that specifies the goals, outcomes, and interventions for each nursing diagnosis. The plan of care should be individualized, holistic, and collaborative, involving the patient, the family, and other members of the health care team. The plan of care should also be flexible, realistic, and measurable, allowing for adjustments based on the patient’s changing needs and responses. Some of the general principles for planning care for patients with suicidal ideation or behavior are:

• Prioritize safety: ensure that the patient is safe from harm by removing any potential means of suicide (e.g., weapons, medications, sharp objects), providing constant or intermittent observation (depending on the risk level), implementing a no-suicide contract (a verbal or written agreement between the patient and the nurse that the patient will not harm themselves), and following institutional policies and protocols for suicide prevention.
• Promote recovery: provide evidence-based interventions that address the underlying causes and factors of suicide (e.g., mental health disorders, substance use disorders, psychosocial stressors), such as psychotherapy (e.g., cognitive-behavioral therapy, dialectical behavior therapy, interpersonal therapy), pharmacotherapy (e.g., antidepressants, mood stabilizers, antipsychotics), electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), or ketamine infusion.
• Enhance coping: teach the patient positive coping skills that can help them manage their emotions, thoughts, and behaviors in stressful situations, such as relaxation techniques (e.g., deep breathing, progressive muscle relaxation, meditation), cognitive restructuring (e.g., identifying and challenging negative thoughts), problem-solving skills (e.g., defining the problem, generating alternatives, evaluating consequences), assertiveness skills (e.g., expressing one’s needs and rights respectfully), distraction techniques (e.g., engaging in hobbies, activities, or social interactions), or crisis hotline numbers (e.g., National Suicide Prevention Lifeline 1-800-273-TALK).
• Foster hope: help the patient develop a sense of hope for the future by identifying their strengths, values, goals, and reasons for living. Assist the patient in creating a hope box (a container filled with items that remind them of positive aspects of their life) or a safety plan (a written document that outlines steps to take when they feel suicidal) that they can use when they feel hopeless. Encourage the patient to participate in activities that give them meaning, purpose and joy, such as volunteering, spirituality, or hobbies. Provide positive feedback and praise for the patient’s efforts and achievements.

Implementation

- The implementation phase involves carrying out the interventions that were planned in the previous phase. The nurse should monitor the patient’s response to the interventions and document the outcomes. The nurse should also communicate and collaborate with other members of the health care team, such as physicians, psychologists, social workers, pharmacists, and case managers, to ensure continuity and quality of care. The nurse should also provide education and support to the patient and their family about suicide and its prevention, such as:

• The nature and causes of suicide and suicidal ideation
• The signs and symptoms of suicide risk and how to recognize them
• The treatment options and modalities for suicide prevention and recovery
• The coping skills and strategies to deal with stressors and emotions
• The resources and services available for help and support
• The importance of follow-up care and adherence to treatment plan

Evaluation

- The evaluation phase involves evaluating the effectiveness of the plan of care and determining whether the goals and outcomes were met. The nurse should compare the patient’s current status with the baseline data and the expected outcomes. The nurse should also solicit feedback from the patient and their family about their satisfaction with the care provided. Based on the evaluation results, the nurse should modify or revise the plan of care as needed to achieve optimal outcomes.