Policies
Hospitals and other healthcare organizations should develop and implement policies related to self-harm and suicide attempts that may occur prior to arriving or during the hospital stay. These policies should include standardized requirements for patient assessment and follow-up (Australian Commission on Safety and Quality in Health Care, 2017; National Institute for Health and Care Excellence, 2013, 2019; The Joint Commission, 2020). Requiring suicide training at the organization level can improve attitudes and confidence when interacting with suicidal patients (Donald et al., 2013). Nurses and non-clinical hospital staff should have comprehensive training to improve their knowledge and skill in caring for patients with suicide ideation (Berlim et al., 2007; Navin et al., 2019) and be required to work with a multidisciplinary team when caring for patients expressing suicide ideation (Grant & Lusk, 2015). Physicians should be formally trained to appropriately administer and score suicide risk assessments to ensure proper use and determination of risk (Grant & Lusk, 2015; Wortzel et al., 2013). Additionally, policy change should address better monitoring and reporting of suicide and self-harm attempts during a patient stay to improve surveillance and measurement.
Other
In addition to the above recommendations, healthcare providers can also discuss with the patient the desire to involve family and friends during treatment, which may help improve care (National Institute for Health and Care Excellence, 2019). Additionally, protective factors for suicide such as close relationships, and overall social and emotional well-being can help reduce inpatient suicide risk (World Health Organization, 2014). The goal of healthcare providers should be to improve quality of a patient stay while seeking to reduce the risk related to self-harm and suicide.
Special Considerations
While this paper has mostly focused on inpatient hospital settings, nursing homes and other long-term care facilities are also in a unique position to address and mitigate suicide risk among residents. Similar to inpatient settings, the suicide attempt rate among residents of long-term facilities is unknown (Mezuk, Rock, Lohman, & Choi, 2014; O’Riley, Nadorff, Conwell, & Edelstein, 2013). However, recent reports suggest over two percent of the older adult population living in or transitioning to long-term care in the United States completes suicide (Mezuk, Ko, Kalesnikava, & Jurgens, 2019), which makes this population a concern for prevention efforts. Since 2010, long-term care facilities in the United States that receive Medicare or Medicaid payments are required to gather suicide ideation information upon intake of new residents, which is a limited yet helpful assessment tool (O’Riley et al., 2013).
In the United States, The Substance Abuse and Mental Health Services Administration has created guidance to help long-term care facilities promote social and emotional well-being among residents and how to address suicide behaviors and deaths (2015). Many individuals in long-term care facilities face depression and other comorbid conditions which affect quality of life (Murphy, Bugeja, Pilgrim, & Ibrahim, 2018). Compared to hospitals, long-term care facilities are in a better position to facilitate community and social interactions among residents to reduce suicide ideation (Substance Abuse and Mental Health Services Administration, 2015). However, long-term care facilities face different issues related to monitoring and treatment of suicidal individuals. Residents in long-term care are generally older and often widowed or unmarried (O’Riley et al., 2013; Substance Abuse and Mental Health Services Administration, 2015), and have had many major life stressors (Murphy et al., 2018), which may lead to increased suicide risk. However, many long-term care facilities require screening and frequent monitoring of patients with suicide ideation which can be protective (O’Riley et al., 2013). It is estimated that only about one third of nursing home staff in the United States have received proper suicide prevention training and even less felt confident in handling suicidal behaviors (Couillet, Terra, Brochard, & Chauliac, 2017). Nonetheless, long-term care facilities can adopt policies and practices from short-term care settings to better help manage suicide risk among their patients.
First, assessment of risk is critical in understanding suicide ideation among patients. It can be challenging for caretakers to understand nuances between desires for death versus suicide (O’Riley et al., 2013). Long-term facilities may benefit from community partnerships with behavioral health specialists to help navigate suicide situations (O’Riley et al., 2013; Substance Abuse and Mental Health Services Administration, 2015). Additionally, it is vital that suicidal behaviors are extinguished as soon as possible to prevent strain on other residents and staff of the facility (O’Riley et al., 2013). Generally, long-term care facility may enact constant observation or 15-minute interval check-ups for suicidal individuals, which can lead to frustration and disdain from the residents (O’Riley et al., 2013). However, other facilities choose to send suicidal individuals for care in psychiatric units in hospitals, but these hospitalizations accrue many costs and often do not improve risk (O’Riley et al., 2013). Thus, facilities should determine a plan of action to respond to suicidal behavior, whether it involves in-house care or transport to a psychiatric hospital and make the transition as smooth as possible (O’Riley et al., 2013; Substance Abuse and Mental Health Services Administration, 2015). Long-term facility staff as well as volunteers should be trained on protocol for addressing suicidal ideation and behavior among residents (Substance Abuse and Mental Health Services Administration, 2015). This training may include gate-keeper training which has shown significant improvements in staff interaction with suicidal patients (Chauliac, Leaune, Gardette, Poulet, & Duclos, 2019). With attention to social interaction and an appropriate plan of action, long-term care facilities can help prevent suicide attempts among residents.
Limitations
Notwithstanding the research and policies related to inpatient self-harm and suicide attempts, there are many barriers to adequately addressing these issues. Many studies cited a lack of data or inconsistency in the reporting of suicide and self-harms as limitations. The lack of consistent data makes it difficult to measure how effective a treatment may have been, and which treatments are more or less effective than others. Additionally, countries vary dramatically in the reporting of suicide and self-harm rates making comparisons difficult (Walsh et al., 2015). Limited evidence has been published regarding suicide prevention in nursing homes and other long-term care facility (Chauliac et al., 2019).
Also, published guidelines are general clinical practice guidelines, rather than a clinical pathway to treatment (Wilhelm et al., 2017). Clinical practice guidelines are generally less specific with less information provided on how to implement them in hospital settings. Thus, clinical practice guidelines are more difficult to put into place (Wilhelm et al., 2017).
Finally, suicide and self-harm are often caused by distinct types of stressors and emotional distress. A variety of objects and places within the hospital may be used to carryout self-harm or suicide attempts. Therefore, standardization of care may be difficult as no two patients will be alike. Nonetheless, having established guidelines that include a patient assessment can help staff identify risk levels and focus their efforts. The uniqueness of each patient is another reason nurses and hospital staff need to be well-trained and confident in their skills in order to provide the best care possible while maintaining standards.
Future Research
There are several areas where future research may be beneficial. While the focus of this paper is inpatient suicide, hospitals should consider how to address suicide that occurs after a patient returns to the community following hospital stay or emergency room visit, since post-discharge suicide is known to be a frequent occurrence (Riblet et al., 2017). In additional, more globally accepted standards should be developed to help improve patient care and reduce suicide risk around the world, especially in nursing homes, long-term care, and other skilled nursing facilities. More specific standards such as a clinical pathway may be beneficial and more easily implemented than the less specific guidance that exists. Finally, improved surveillance systems need to be deployed to accurately track the number of attempted and completed suicide and self-harm episodes. A better tracking system will allow for more accurate measurement of interventions.