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Dealing with Difficult Patients: Suicidal behavior


By Joan Monchak Lorenz, MSN, RN, PMHCNS-BC

Many nurses don’t feel comfortable completing a suicide assessment. Some nurses can’t imagine anyone thinking that killing him or herself is the best solution to any problem. However, many of the patients we serve have thought that way and some are actively suicidal, and we are not even aware of it. Being aware of the signs of suicide, and making a suicide assessment, can save your patient’s life. As with many other assessments, practice facilitates mastery. This chapter will give you lots of guidelines and tips to help.

It is important to remember that most suicide attempts are expressions of extreme distress, not harmless bids for attention. Also, any person who has expressed suicidal ideation should not be left alone and needs immediate treatment.

What if I think someone is suicidal?

One way to determine whether a person is thinking about suicide is to ask directly: “Are you thinking about suicide? Are you planning to kill yourself?” Doing this will not plant thoughts in the person’s head. Doing this will not cause the person to consider suicide if he or she was not thinking about it. Doing this will not cause the person to try suicide. By asking directly, you show you are not afraid to tackle the hardest of situations, and it is a way to show the patient that you can be trusted. Suicidal individuals seek out those whom they trust and feel connected to in some way. One of the most important factors in preventing a suicide is the presence of a supportive person.

Don’t panic: If a person does tell you that he or she is suicidal, here’s what you can do:

  • Stay calm and listen.
  • Let the person talk about his or her feelings.
  • Be accepting, and do not judge.
  • Ask whether the person has a plan, and if so, what it is.
  • Don’t swear secrecy.
  • Do not leave the patient alone. Take him or her with you if you must, so you can get help.


Don’t ignore the warning signs

All mentions of suicide must be taken seriously. Warning signs include:

  • Thoughts or talk of death or suicide.
  • Thoughts or talk of self-harm or harm to others.
  • Aggressive behavior or impulsiveness.
  • Previous suicide attempts, which increases the risk for future suicide attempts and completed suicide.


Assessing the possibility of suicidal thoughts

Ask the patient the following questions to assess the possibility of suicidal thoughts:

  • You have been through a lot lately: How has that affected your energy (appetite, ability to sleep)?
  • Many people in your situation may feel sad and blue or depressed: Do you feel that way?
  • Have you ever felt so sad and blue that you thought that maybe life was not worth living?
  • You have been in a lot of pain lately: Have you ever wished you could go to sleep and just not wake up?
  • Have you been thinking a lot about death recently?
  • Have you recently thought about harming yourself or killing yourself?
  • Have things ever reached the point that you’ve thought of harming yourself?


If the person says that he or she has thought about self-harm or suicide, the next step is to assess whether the person has a plan and the ability to carry out the plan. Ask questions such as these:

  • Have you made a specific plan to harm (kill) yourself? If so, what is it?
  • Do you have a gun (knife) available for your use? (Find out if the person has access to accomplish the plan.)
  • What preparations have you made? (This might include purchasing specific items, writing a note or a will, making financial arrangements, taking steps to avoid being found, and/or practicing the plan.)
  • Have you spoken to anyone about your plans?
  • Would you be able to tell someone if you were about to harm yourself?
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Keeping the patient safe

Your next step is to make sure the patient is safe. Most facilities have policies about levels of observation or supervision for patients who are a suicidal risk. There is also a process for further assessment of the patient. Again, never leave a person who has expressed suicidal thoughts alone. Take him or her with you to get help. Always read and follow your facility’s policies.

In general, there are some universal safety measures to take with a person who is suicidal:

  • Keep the person on continuous observation, such as 1:1 or in your line of sight.
  • Restrict the person’s environment for safety. Ask the person to remain in a certain area where staff members can see him or her at all times.
  • Do not allow the person to be alone in a room.
  • Check the person at intervals of five, 15, or 30 minutes.


Staff supervision is necessary when a patient uses items such as sharps (nail cutters, razors, or scissors), cigarettes, and/or matches; is around potential poisons, such as cleaning supplies; uses the bathroom or kitchen; and/or goes off the unit for treatments, therapies, or tests.

Joan Monchak Lorenz, MSN, RN, PMHCNS-BC is an HCPro author and contributed to the book Stressed Out About Difficult Patients.