Date of Award

Spring 5-27-2023

Document Type

Doctor of Nursing Practice Final Manuscript

Degree Name

Doctor of Nursing Practice

Department

Nursing

First Advisor

Katherine Lais, DNP

Second Advisor

Joseph Burkark, DNSc

Abstract

Introduction: The purpose of this evidence-based Doctor of Nursing Practice project was to implement the Columbia-Suicide Severity Rating Scale (C-SSRS) as part of routine patient assessment at an outpatient mental health practice to increase the likelihood of identifying clients at risk for suicidal behavior and increase provider confidence in screening for suicidal behavior. The study site is a Southern California-based outpatient mental health practice that employs a variety of clinicians, including psychiatric-mental health nurse practitioners, to provide mental health care to clients across the lifespan.

Background: Approximately 57% of individuals who die by suicide had at least one contact with mental health providers during their lifetime, and 21% had contact within 1 month of dying. Early detection of suicidal ideation and behavior is key to reducing the occurrence of suicide in patients receiving mental health care. Traditionally, mental health clinicians use a variety of techniques to assess for the presence of suicidal ideation, but comprehensive suicide assessments should also determine whether an individual has intent or a plan to attempt suicide, as well as whether any suicide attempts have been made previously. The C-SSRS has been proven to be an effective tool to reliably screen for suicide risk in a variety of patient populations, with a focus on stratifying risk based on a number of contributing client factors, including previous suicidal behavior, current intent to commit suicide, and the presence of a method and/or plan for suicide.

Methods: A small outpatient mental health practice in La Jolla, California was partnered with for this implementation project. From 12/5/2022-2/5/2023, all new patients at the practice received an online version of the C-SSRS to complete prior to their initial evaluation. Those who screened positive for any degree of suicide risk continued to complete the C-SSRS prior to each subsequent visit. Data collected from this intervention period were compared to data collected via chart review for all new patient intakes that occurred over a 2-month preintervention period in fall 2022 to compare and contrast suicide screening rates and processes, as well as to identify themes in suicide assessment between the two samples. Providers at the practice also completed a modified version of the Zero Suicide Workforce Survey prior to receiving a recorded presentation on the C-SSRS and project overview; these providers then completed the same survey at the end of the intervention phase to assess for changes in their confidence in assessing for suicidal behavior.

Results: Adding the C-SSRS to new patient intake forms resulted in increased screening for suicidal ideation for new patients and improvements in suicide risk stratification. Providers also reported increased confidence in assessing and treating suicidal behavior. Qualitative evaluation led to identification of several opportunities to improve provider workflows in assessing, documenting, and treating suicide risk in the course of routine outpatient treatment.

Evaluation: Implementation of suicide screening with the C-SSRS at the project site led to an increase in suicide risk identification and elevated provider confidence in assessing for suicide risk factors. Accurate and standardized suicide screening is the first step in preventing suicide in outpatient settings. Future projects should be implemented to develop treatment protocols based on identified suicide risk levels and standardize documentation of completed suicide risk assessments.

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