Ongoing safety assessment in the psychiatric milieu
Editor’s note: This column was written by Julie D’Apollo, RN. D’Apollo has more than 20 years of experience in behavioral health at various psychiatric facilities in Massachusetts and New Hampshire with an interest and background in restraint and seclusion and suicide risk assessment. She is involved in staff training and publishing of various training modules and documentation templates for the nursing staff at Hampstead (NH) Hospital.
NPSG.15.01.01 requires that patients being treated for emotional or behavioral disorders be identified for the risk of suicide. Meeting this goal has required a number of interventions using a multidisciplinary team approach. This requires ongoing training on many different levels.
Nurses will gather information at admission to perform an initial safety assessment of the patient. This involves not just asking the patient about his or her suicidal ideation, but also obtaining information on any current suicide plan, feasibility of following through with the plan, and past attempts.
Rating the intensity of the patient’s suicidal ideation is important in determining the level of supervision that the patient requires. For example, patients who are depressed may have non-suicidal thoughts of death. They wish to die but would not take any action for this to happen. A patient who is restricting oral intake in order to die has less suicidal intensity than a patient who has a plan to overdose on medication.
Rating suicidal ideation should be done by the patient and the assessing nurse. Frequently, the subjective reports from each party are distinctly different.
It is important for the assessing clinician to be aware of established suicide risk factors that increase the threat of self-harm and suicide completion. A thorough assessment will include the identification of these risk factors.
Violence risk factors and the risk of escape from the facility must be identified to fully understand whether the patient is violent and/or whether he or she may escape from the facility with a specific plan that could be followed through outside of the hospital.
Upon admission, each patient undergoes a mental status exam, which is a systemic assessment of the quality of mental functioning to serve as a baseline of information and to be used for later comparison. The patient’s psychiatrist and nurse complete an initial assessment, but the assessment of mental status and safety is an ongoing process, not a single event, that requires input from all mental health professionals throughout hospitalization.
When a patient is admitted to an inpatient psychiatric unit, maintaining the safety of the hospital environment and the patients is the primary objective of milieu staff. As mental health professionals, the milieu staff must be aware of how each patient presents on a daily basis. Milieu staff are responsible for noticing the comprehensive changes that patients exhibit to ensure safety. Training for all staff should include mental status exam information and suicide risk factors.
Any patient with suicidal ideation requires constant reassessment to ensure that appropriate safety measures and supervision are in place. This reassessment should include a review of the patient’s subjective responses to questioning about suicidal ideation and a review of how the patient presents in the milieu. Suicide risk assessment in the acute phase of treatment must be completed frequently, but also should continue on a less frequent basis as the risk diminishes.
A final word on the universal reliance on a patient verbally “contracting for safety.” Historically, clinicians have asked suicidal patients to enter into verbal agreements that they will not harm themselves, or at least communicate if their suicidality increases. These contracts are certainly not legally binding and in no way alleviate the responsibility of staff in maintaining the patients’ safety. There is no reliable information as to the effectiveness of this kind of contract. It is not a dependable tool to measure suicide risk. The only instance in which the contract is valuable in assessing suicide risk is when a patient refuses to enter into the agreement.