Suicide Risk Assessments: A Mixed-Methods Study of Nurses’ and Patients' Experiences With Evidence-Based Practice

2.50
Hdl Handle:
http://hdl.handle.net/10755/621551
Category:
Full-text
Format:
Text-based Document
Type:
Presentation
Level of Evidence:
N/A
Research Approach:
N/A
Title:
Suicide Risk Assessments: A Mixed-Methods Study of Nurses’ and Patients' Experiences With Evidence-Based Practice
Other Titles:
Factors in Suicide
Author(s):
Santa Mina, Elaine E.; McCay, Elizabeth; Rose, Donald N.; Hamer, Beth
Lead Author STTI Affiliation:
Lambda Pi-at-Large
Author Details:
Elaine E. Santa Mina, PhD, RN, Professional Experience: Dr. Elaine Santa Mina Interim Director and Associate Professor at the Daphne Cockwell School of Nursing, Ryerson University, in which Dr. Santa Mina teaches research and statistics. She is currently the co-chair of the Canadian Federation of Mental Health Nurses (CFMHN), Education Committee. Elaine was a contributing author on the following CFMHN documents: CFMHN’s (2016) CFMHN’s 3rd position paper and statement: Mental health and addiction curriculum in undergraduate nursing education in Canada; CASN & CFMHN’s (2015) Entry-to-practice mental health and addiction competencies for undergraduate nursing education; and CFMHN’s (2014) Canadian standards for psychiatric-mental health nursing (4th ed.), and was team lead for the RNAO best practice guideline on Suicide Risk Assessment. Author Summary: Elaine Santa Mina PhD, MSc, BA, BAAN, RN, is an Associate Professor, Interim Director, Faculty of Community Services, Daphne Cockwell School of Nursing, Ryerson University (RU), Toronto, ON, Canada. Dr. Santa Mina is co-chair of the Canadian Federation of Mental Health Nurses (CFMHN) Education Committee. Elaine’s teaching and research interests specifically are childhood trauma, self harm and suicide. Dr. Santa Mina is a member of the Lambda Pi-at-Large Chapter of STTI.
Abstract:

Background: Suicide remains a serious safety concern. In 2012, suicide was the 15th leading cause of death as the global rates remain persistently high despite the focus on prevention http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/retrieveddec 2 2016Suicide risk assessments are fundamental to prevent suicidal behaviours and death by suicide (Boudreaux et al, 2016). Nurses, as front-line clinicians, are pivotal in the accurate diagnosis and the delivery of care to prevent suicide through the identification and documentation of risk, in the clinical record, as per evidence-based best practice (Canadian Federation of Psychiatric and Mental Health Nurses, 2014). A Centre for Mental Health Care developed and implemented a policy for sucide risk assessment and documentation, in response to jurisdictional accreditation requirements and to meet the needs of their patient population. The policy was informed by evidence-based practice guidelines. Nursing leaders implemented the policy within the institution over the subsequent 1.5 years. This study provides a unique opportunity to explore nurse and patient perspectives of suicide risk nursing assessments. Patient narratives may sensitize nurses to important aspects of the nurse-patient relationship during this critical interaction and may enhance nursing assessment skills. The research questions were: 1) What is the evidence that suicide risk assessments, as measured by proxy via nursing documentation, adhere to best practice recommendations? 2) What are nurses' perspectives of their knowledge of suicide risk assessment and practice? 3) What are the patients' experiences of the assessments of their suicide risk by nurses?

Purpose: This study investigated evidence of nurses’ congruence with and patients’ experience of suicide risk assessment post implementation of evidence-based practice education.

Methods : This study used a cross sectional, mixed-method, post-intervention (guideline implementation and education) design in which the qualitative and quantitative methods were conceptualized, designed, and implemented within the pragmatist paradigm. This mixed-method design with a complementarity purpose sought elaboration, enhancement, illustration, and clarification of the results from one method with the results from the other approach. Interpretation and meaning was enhanced by via the inherent strengths of each method (quantitative: patient record / documentation audit and qualitative: focus group with RNs and RPNs plus individual interviews with patients), while counteracting the respective inherent methodological biases. Quantitative and qualitative methods were used to measure overlapping but also different facets of the phenomenon, yielding an enriched, elaborate understanding. The expansion purpose was used to measure different and distinct phenomena (i.e. nurses’ and patients’ perceptions of the nursing assessments of patient suicide risk versus documentation of assessment and response to suicidal ideation). This extended the breadth and range of inquiry through different methods for different inquiry components. The triangulation purpose was based on the logic of convergence. This logic required that the quantitative and qualitative methods be different from one another with respect to their inherent strengths and limitations (biases) and that both method types be used to assess the same phenomenon. Data was collected from one acute care and one long term care unit plus the outpatient department. Quantitative Methods: The researchers collected key nurse and patient demographic data to describe the sample. The Principal Investigator and the Co-Principal Investigators conducted patient record audits of nurses’ notes to measure nurses’ suicide risk assessment documentation. The researchers used the audit data from the patient record nurses’ notes instrument, created by the investigators for this study, to measure congruence with the guideline recommendations, via compliance indicators as measured on a 3-point likert scale. The quantitative data was analyzed with SPSS version 20. Qualitative Methods: The Investigators conducted three (3) – 30 minute nurse focus groups (5-7 persons per group) in order to provide adequate time for all participants to contribute and discuss their perceptions of their assessment and documentation of patients’ suicidal ideation and/or behavior. The investigators conducted nine (9) individual out-patient interviews to assess patients’ perceptions of nurses’ assessment of their suicidal feelings and behaviours. Each individual interview required approximately one-half (1/2) hour of each patient’s time. The qualitative data was analyzed using methods consistent with constructivism. Ethics approval was granted from the University and the Health Care Centre.

Results : Thirty-four patient records (long term care n = 15, acute care = 19) were audited for evidence of congruence and/or divergence of suicide risk assessment according to guideline recommendations. Fourteen nurses (female n = 10, male = 4) participated in three focus groups. Nine patients (female n = 6, male n = 3) participated in individual interviews. Data triangulation revealed practice congruence with and divergence from recommendations specific to suicide risk assessment constructs. Descriptive analyses demonstrated that all patient records had at least some dimension of suicide risk assessment documented by nurses. However, nurses more frequently documented patients’ future plans to attempt suicide (100 %) than the suicide plan that prompted admission to hospital (46%), or previous history of suicide attempts (57%). Documentation of suicidal ideation, suicidal behaviour, and suicide attempt method were also less frequent (66%, 78%, 44%, respectively). Documentation of other risk factors for suicide attempts and protective factors against suicide was also less frequently documented (85% and 76% respectively). Thematic analysis of narratives complemented the quantitative results and supported the quantitative evidence that suicide risk was assessed by nurses. However, both patients and nurses described ‘the dance-who will invite whom?’ between them that may facilitate or hinder assessment. This theme may indicate that nurses and patients may be reluctant to approach the other to engage in a conversation about suicidality and timing of that approach was described as similar to the timing involved in an invitation to ‘dance’.

Conclusion: Study findings demonstrate the richness of triangulation of nurse-patient data to evaluate implementation outcomes and understanding of the phenomenon: suicide risk assessment. Although there is substantive evidence from suicide risk assessment documentation as well as nurse and patient experience of such assessments, some crucial dimensions of assessment may not be as fully assessed and documented as appropriate to patient needs. If both patients and nurses experience a tentative approach to each other to discuss this risk dimensions, then critical intervention opportunities to provide safe care may be missed. Issues around this ‘dance’ may be grounded in the foundations of the nurse-patient therapeutic relationship. Therefore, the study highlights the limitations of a linear approach to application of recommendations from one guideline without integration with, reference to, and education of other related guidelines. It also highlights the limits of a purely positivist approach to understanding and applying evidence in practice; and that a more holistic, intuitive approach may be appropriate to complex nursing care (Welsh & Lyons, 2001). This presentation highlights the importance of including the patients’ voices in addition to the nurses’ perspectives to expand upon the traditional, objective metrics in evaluation of evidence-based practices to inform clinicians, educators, and researchers.

Implications: Findings provide direction for guideline education for nurses. Related guidelines, such as a guideline for the nurse-patient therapeutic relationship, need to be considered and included in nursing education of suicide risk assessment. Suicide risk assessment guidelines are not linear per se and need to be taught simultaneously, within the context of holistic patient care. Nursing education and practice need to focus on areas of risk that are less likely to be assessed and documented. Nursing research on evaluation of evidence-based practice needs to include the nurse and patient narratives to more fully understand dimensions of practice. Larger multi-site studies would be beneficial to explore potential, broader similarities and differences across practice settings and demonstrate a global reach to improve risk assessment and suicide prevention.

Keywords:
Evidence-Based Practice; mixed-methods design; Suicide Risk Assessment
Repository Posting Date:
20-Jun-2017
Date of Publication:
20-Jun-2017
Other Identifiers:
INRC17C07
Conference Date:
2017
Conference Name:
28th International Nursing Research Congress
Conference Host:
Sigma Theta Tau International
Conference Location:
Dublin, Ireland
Description:
Event Theme: Influencing Global Health Through the Advancement of Nursing Scholarship

Full metadata record

DC FieldValue Language
dc.language.isoen_USen
dc.type.categoryFull-texten
dc.formatText-based Documenten
dc.typePresentationen
dc.evidence.levelN/Aen
dc.research.approachN/Aen
dc.titleSuicide Risk Assessments: A Mixed-Methods Study of Nurses’ and Patients' Experiences With Evidence-Based Practiceen_US
dc.title.alternativeFactors in Suicideen
dc.contributor.authorSanta Mina, Elaine E.en
dc.contributor.authorMcCay, Elizabethen
dc.contributor.authorRose, Donald N.en
dc.contributor.authorHamer, Bethen
dc.contributor.departmentLambda Pi-at-Largeen
dc.author.detailsElaine E. Santa Mina, PhD, RN, Professional Experience: Dr. Elaine Santa Mina Interim Director and Associate Professor at the Daphne Cockwell School of Nursing, Ryerson University, in which Dr. Santa Mina teaches research and statistics. She is currently the co-chair of the Canadian Federation of Mental Health Nurses (CFMHN), Education Committee. Elaine was a contributing author on the following CFMHN documents: CFMHN’s (2016) CFMHN’s 3rd position paper and statement: Mental health and addiction curriculum in undergraduate nursing education in Canada; CASN & CFMHN’s (2015) Entry-to-practice mental health and addiction competencies for undergraduate nursing education; and CFMHN’s (2014) Canadian standards for psychiatric-mental health nursing (4th ed.), and was team lead for the RNAO best practice guideline on Suicide Risk Assessment. Author Summary: Elaine Santa Mina PhD, MSc, BA, BAAN, RN, is an Associate Professor, Interim Director, Faculty of Community Services, Daphne Cockwell School of Nursing, Ryerson University (RU), Toronto, ON, Canada. Dr. Santa Mina is co-chair of the Canadian Federation of Mental Health Nurses (CFMHN) Education Committee. Elaine’s teaching and research interests specifically are childhood trauma, self harm and suicide. Dr. Santa Mina is a member of the Lambda Pi-at-Large Chapter of STTI.en
dc.identifier.urihttp://hdl.handle.net/10755/621551-
dc.description.abstract<p><em>Background: </em><span>Suicide remains a serious safety concern. In 2012, suicide was the 15th leading cause of death as the global rates remain persistently high despite the focus on prevention </span><a href="http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/retrieveddec%202%202016"><em>http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/retrieveddec 2 2016</em></a><em>. </em><span>Suicide risk assessments are fundamental to prevent suicidal behaviours and death by suicide (Boudreaux et al, 2016). Nurses, as front-line clinicians, are pivotal in the accurate diagnosis and the delivery of care to prevent suicide through the identification and documentation of risk, in the clinical record, as per evidence-based best practice (Canadian Federation of Psychiatric and Mental Health Nurses, 2014). A Centre for Mental Health Care developed and implemented a policy for sucide risk assessment and documentation, in response to jurisdictional accreditation requirements and to meet the needs of their patient population. The policy was informed by evidence-based practice guidelines. Nursing leaders implemented the policy within the institution over the subsequent 1.5 years. This study provides a unique opportunity to explore nurse and patient perspectives of suicide risk nursing assessments. Patient narratives may sensitize nurses to important aspects of the nurse-patient relationship during this critical interaction and may enhance nursing assessment skills. The research questions were: 1) What is the evidence that suicide risk assessments, as measured by proxy via nursing documentation, adhere to best practice recommendations? 2) What are nurses' perspectives of their knowledge of suicide risk assessment and practice? 3) What are the patients' experiences of the assessments of their suicide risk by nurses?</span></p> <p><em><strong>Purpose: </strong></em>This study investigated evidence of nurses’ congruence with and patients’ experience of suicide risk assessment post implementation of evidence-based practice education.</p> <p><em><strong>Methods</strong></em><strong> </strong><strong><em>:</em></strong> This study used a cross sectional, mixed-method, post-intervention (guideline implementation and education) design in which the qualitative and quantitative methods were conceptualized, designed, and implemented within the pragmatist paradigm. This mixed-method design with a complementarity purpose sought elaboration, enhancement, illustration, and clarification of the results from one method with the results from the other approach. Interpretation and meaning was enhanced by via the inherent strengths of each method (quantitative: patient record / documentation audit and qualitative: focus group with RNs and RPNs plus individual interviews with patients), while counteracting the respective inherent methodological biases. Quantitative and qualitative methods were used to measure overlapping but also different facets of the phenomenon, yielding an enriched, elaborate understanding. The expansion purpose was used to measure different and distinct phenomena (i.e. nurses’ and patients’ perceptions of the nursing assessments of patient suicide risk versus documentation of assessment and response to suicidal ideation). This extended the breadth and range of inquiry through different methods for different inquiry components. The triangulation purpose was based on the logic of convergence. This logic required that the quantitative and qualitative methods be different from one another with respect to their inherent strengths and limitations (biases) and that both method types be used to assess the same phenomenon. Data was collected from one acute care and one long term care unit plus the outpatient department. Quantitative Methods: The researchers collected key nurse and patient demographic data to describe the sample. The Principal Investigator and the Co-Principal Investigators conducted patient record audits of nurses’ notes to measure nurses’ suicide risk assessment documentation. The researchers used the audit data from the patient record nurses’ notes instrument, created by the investigators for this study, to measure congruence with the guideline recommendations, via compliance indicators as measured on a 3-point likert scale. The quantitative data was analyzed with SPSS version 20. Qualitative Methods: The Investigators conducted three (3) – 30 minute nurse focus groups (5-7 persons per group) in order to provide adequate time for all participants to contribute and discuss their perceptions of their assessment and documentation of patients’ suicidal ideation and/or behavior. The investigators conducted nine (9) individual out-patient interviews to assess patients’ perceptions of nurses’ assessment of their suicidal feelings and behaviours. Each individual interview required approximately one-half (1/2) hour of each patient’s time. The qualitative data was analyzed using methods consistent with constructivism. Ethics approval was granted from the University and the Health Care Centre.</p> <p><em><strong>Results</strong></em><strong> </strong><em>:</em> Thirty-four patient records (long term care n = 15, acute care = 19) were audited for evidence of congruence and/or divergence of suicide risk assessment according to guideline recommendations. Fourteen nurses (female n = 10, male = 4) participated in three focus groups. Nine patients (female n = 6, male n = 3) participated in individual interviews. Data triangulation revealed practice congruence with and divergence from recommendations specific to suicide risk assessment constructs. Descriptive analyses demonstrated that all patient records had at least some dimension of suicide risk assessment documented by nurses. However, nurses more frequently documented patients’ future plans to attempt suicide (100 %) than the suicide plan that prompted admission to hospital (46%), or previous history of suicide attempts (57%). Documentation of suicidal ideation, suicidal behaviour, and suicide attempt method were also less frequent (66%, 78%, 44%, respectively). Documentation of other risk factors for suicide attempts and protective factors against suicide was also less frequently documented (85% and 76% respectively). Thematic analysis of narratives complemented the quantitative results and supported the quantitative evidence that suicide risk was assessed by nurses. However, both patients and nurses described ‘the dance-who will invite whom?’ between them that may facilitate or hinder assessment. This theme may indicate that nurses and patients may be reluctant to approach the other to engage in a conversation about suicidality and timing of that approach was described as similar to the timing involved in an invitation to ‘dance’.</p> <p><em><strong>Conclusion: </strong></em><em></em>Study findings demonstrate the richness of triangulation of nurse-patient data to evaluate implementation outcomes and understanding of the phenomenon: suicide risk assessment. Although there is substantive evidence from suicide risk assessment documentation as well as nurse and patient experience of such assessments, some crucial dimensions of assessment may not be as fully assessed and documented as appropriate to patient needs. If both patients and nurses experience a tentative approach to each other to discuss this risk dimensions, then critical intervention opportunities to provide safe care may be missed. Issues around this ‘dance’ may be grounded in the foundations of the nurse-patient therapeutic relationship. Therefore, the study highlights the limitations of a linear approach to application of recommendations from one guideline without integration with, reference to, and education of other related guidelines. It also highlights the limits of a purely positivist approach to understanding and applying evidence in practice; and that a more holistic, intuitive approach may be appropriate to complex nursing care (Welsh & Lyons, 2001). This presentation highlights the importance of including the patients’ voices in addition to the nurses’ perspectives to expand upon the traditional, objective metrics in evaluation of evidence-based practices to inform clinicians, educators, and researchers.</p> <p><em>Implications</em>: Findings provide direction for guideline education for nurses. Related guidelines, such as a guideline for the nurse-patient therapeutic relationship, need to be considered and included in nursing education of suicide risk assessment. Suicide risk assessment guidelines are not linear per se and need to be taught simultaneously, within the context of holistic patient care. Nursing education and practice need to focus on areas of risk that are less likely to be assessed and documented. Nursing research on evaluation of evidence-based practice needs to include the nurse and patient narratives to more fully understand dimensions of practice. Larger multi-site studies would be beneficial to explore potential, broader similarities and differences across practice settings and demonstrate a global reach to improve risk assessment and suicide prevention.</p>en
dc.subjectEvidence-Based Practiceen
dc.subjectmixed-methods designen
dc.subjectSuicide Risk Assessmenten
dc.date.available2017-06-20T19:29:16Z-
dc.date.issued2017-06-20-
dc.date.accessioned2017-06-20T19:29:16Z-
dc.conference.date2017en
dc.conference.name28th International Nursing Research Congressen
dc.conference.hostSigma Theta Tau Internationalen
dc.conference.locationDublin, Irelanden
dc.descriptionEvent Theme: Influencing Global Health Through the Advancement of Nursing Scholarshipen
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