Running head: SUICIDE SCREENING TOOLS IN ADOLESCENTS 1

Suicide Screening Tools in Adolescents

Veronica Aguilar

Chamberlain College of Nursing

NR505 Advance Research Methods: Evidence Based Practice

Christina Garcia

November 2017
SUICIDE SCREENING TOOLS IN ADOLESCENTS 2

Suicide Screening Tools in Adolescents: A Need Based on the Evidence

The challenges in working with adolescent patients with mental health issues in the

emergency department are a significant issue in health care (Issel & Wells, 2017). Suicide is the

third leading cause of death among adolescents. The incidence of bullying and behavioral issues

has marked the steady increase in suicide among adolescents through the last several decades.

Emergency departments are becoming the gateway for healthcare visits and thus the basis of

evaluation of adolescents during such crisis. The number of suicide attempts in adolescents is

increasing and emergency departments have to improve current practice to reduce the recurrence

of suicide attempts in this already vulnerable age group. The current standard practice in

emergency department is to utilize a 2-question Suicide Questionnaire. The Questionnaire

consists of two questions: (1) do you have thoughts to harm yourself? and (2) do you have

thoughts to harm other? As the incidence of suicide attempts and recurrence increases, current

practice must be evaluated and a standardized questionnaire to help emergency room nurses

identify potential risk and ultimately reduce suicide attempts and recurrence must be initiated.

With that statistic alone, it is important that the nursing profession strive to work toward not only

recruiting new nurses but also retaining the current workforce. The constant flow of chaotic

emergency room and its quick two-question suicide screening tool may overlook key factors that

would other identify a potential suicide risks in adolescents. This evidence-based project

proposal seeks to address this problem through creation of a comprehensive nursing suicide

screening tool to identify potential suicidal risks thus decreasing recurrence of suicide attempts

and mortality in this population. Despite the current standard for assessing suicide initially in the

emergency room; it is crucial to further evaluate current evidence based practice and other brief

suicide questionnaires at triage to increase suicide risk identification and subsequently decrease
SUICIDE SCREENING TOOLS IN ADOLESCENTS 3

mortality.

Application to MSN Program Track

More Family Nurse Practitioners are finding their way into emergency departments to

treat lower acuity patients. As a Family Nurse Practitioner in an emergency department, a large

volume of patients seen are adolescents presenting with an array of issues. Family Nurse

Practitioners are expected to evaluate and identify subtle risk factors among such vulnerable

populations that might have been easily overlooked by the current two question screening tool in

place in most emergency departments. As emergency departments are becoming the forefront for

routine care, Family Nurse Practitioners must partake in improving current screening standards

to reduce suicide incidence in adolescents. The research study can provide further evidence

based practice to conduct suicide questionnaires at triage to improve the identify of suicide risks

and decrease suicide deaths in adolescents.

Nursing Issue

The current standard practice in emergency departments in the United States

today in assessing the risk of suicide consists of a simple questionnaire asked by the emergency

department triage registered nurse. The emergency department triage nurse asks the patient two

standard questions to screen any possibility of suicidal intention. The two questions are: (1) “do

you have any thoughts of harming yourself”; and (2) “do you have any thought of harming

other.” This standard practice in such a vulnerable population will not always achieve the desired

result in identifying potential risks for suicide in the given adolescent age group. If a

standardized questionnaire may be proposed to include a series of other questions such as but not
SUICIDE SCREENING TOOLS IN ADOLESCENTS 4

limited to: Do you feel depressed? Isolated? Do you have someone to talk to at home? Do you

feel safe? Do you have any chemical dependency issue? Do you have any recurrent symptoms

such as headaches, nausea, and pain, or fatigue? These questions move beyond the scope of

asking the patients about the act of attempting suicide but address other factors that could be the

reason for the attempt. It also assesses for the factors that could lead to suicidal attempts. By

using these questions, the direct to suicidal attempts but rather they revolve around what can lead

to the patient desiring to commit suicide. If the current practice could be modified to dive a bit

further into the aforementioned questions, it may potentially increase the probability of

identifying the subtle signs of depression and ultimately suicide risks among adolescents ages

twelve to nine-teen. The proposed questionnaire would ultimately reduce the incidence of suicide

attempts in adolescents and recurrent attempts in the emergency departments.

The proposed suicide screening questionnaires emphasizes the need for evidence based practice

to identify suicide risks in adolescents. The is a lack of information among the current standards

as to how to conduct brief screenings upon arriving the emergency room. Now, the proposal

discussing the screening questionnaires when a patient arrives to the emergency department. This

brief questionnaire conducted at triage categorizes the patient’s initial acuity level. The current 2-

question suicide screening indicates the efforts of ensuring an emergency department in a

healthcare setting with the intent to meet standards to screen patients for suicide risks but study is

still requiring validating whether other questionnaires tools are better at identifying risks in

adolescents and improving the odds for survival. Emergency nurses are equipped to handle

emergent situations but there is a lack of appropriate conducting suicide screening for mental

health needs. The adolescent patients will require the necessary care and training to identify

suicide factors indicating any risks; appropriate evidence based practice in care delivery is
SUICIDE SCREENING TOOLS IN ADOLESCENTS 5

essential (Randall, Colman & Rowe, 2011).

PICOT Question

Emergency departments across the country are currently using the two self-harm

questionnaires as a standard suicide screening tool. The issue is that adolescents among the age

group discussed will not always verbalize a simple yes to the question but may demonstrate other

subtle cues assisting nurses and practitioners to the propensity for suicide. An improved

standardized suicide screening tool replacing the current two question harm/suicide screening

may pose a great benefit in identifying suicide and decreasing mortality in adolescents. Based on

the identified need for an improved suicide screening questionnaire with the aforementioned

proposed questions, the PICOT question is created to guide this project. What is the Adolescents

aged 12-19 presenting to the emergency department will have standardized suicide screening tool

asking, do you feel depressed? Isolated? Do you have someone to talk to at home? Do you feel

safe? Do you have any chemical dependency issue? Do you have any recurrent symptoms such

as headaches, nausea, and pain, or fatigue? Compared to the current 2 questions, harm/suicide

screening practice improved identification of potential suicide risk and decreased suicide

attempts in the emergency department within six-months of performing new standardized suicide

screening tool? For adolescents presenting to the emergency department (P) will a

comprehensive suicide screening tool (I) compared to current practice (C) improve suicide risks

identification; decreasing recurrent suicide attempts and suicide deaths (O) within a six-month

period (T)?

The Research Literature Support

Horowitz et al. conducted study to develop a brief screening instrument tool to assess the

pediatric patient arriving at a pediatric emergency department. (Horowitz et al., 2014). The
SUICIDE SCREENING TOOLS IN ADOLESCENTS 6

study was conducted in urban pediatric emergency departments evaluating 1170 participants

ages 10-21. This was a prospective and cross-sectional study evaluating 17 candidate screening

questions over a 2-year period. The initial 17 question questionnaire was performed after triage.

Although, the study concluded a model compromised of 4 questions that yielded over 95%

identification of suicide they were performed after the initial triage screening. Limitations

include the use of convenience sampling in urban settings as a potential introduction for bias; not

a reflection of most emergency departments. It also was not used to validate cohort.

In a study published in 2015, the King et al. analyzed the implementation of adolescent

suicide risk screening in medical emergency departments (King, Berona, Czyz, Horwitz, &

Gipson, 2015). His study denoted a higher incidence of suicide identification in the adolescent

population using a more comprehensive screening tool. There was a six percent increase of

suicide risks from that of initially reported on the current simplistic guideline. The study

analyzed the use of several screening methods and the likelihood of a future suicide attempt

following the emergency visit. A comprehensive non-experimental design was utilized as over

600 participants were screened for suicidal risks. Strengths of the study include the inclusion of

all adolescents presenting to an emergency room. Although, the general population was recruited

from the emergency department setting researchers approach patients in the department and

conducted follow up comprehensive screenings after positive suicide identifications made with

initial questionnaire. The studies offering of monetary or in this case financial gain to a

participant may be a limitation.

Boudreaux et al. analyzed data from the concurrent validity of a brief suicide screener for

adults in the emergency department (Allen, Bourdeaux, & Allen, 2015). The beck Scale for

Suicidal Ideation(BSSI) is a validated tool and widely utilized in emergency departments. The
SUICIDE SCREENING TOOLS IN ADOLESCENTS 7

BSSI scale was compared to patient screener 2 and 3 conducted by researchers. Research

approach was conducted in non-experimental statistical approach. The samples were randomly

selected and conducted data over 15 days of 12 hours shifts. Strengths in the study include that

trained research staff personally evaluated each patient presenting to the emergency department

and offered screening to participate. This enable researches to identify potential risks routinely

overlooked by the suicide measuring instrument utilized by the institution. They collaborated in

real time with emergency department to ensure participants were treated for such risks.

Limitations include lack of universal suicide screening in clinical practice for emergency

departments. Study was another limitation for the study in my case is that the studies were

conducted in adult emergency departments only during 12-hour time frames not with 24-hour

coverage.

In another study published in 2016, Babeva et al evaluated the suicide screening and

health risk in the emergency department. Given the current Joint Commission standard to

evaluate suicide and self-harm the evaluated emergency department screening and triage to yield

tools to improve suicide risk identification. The correlation design encompassed a large variety

of suicide screening tools currently utilized throughout emergency department. The study

compared their approach, feasibility within the department, and adaptability to facilitate

identification. The study does not readily validate any particular screening tool rather place the

emphasis on improving suicide risks or self-harm tools; in order to improve identification in

adolescents.

Flose et al. published a pilot study in the Journal of Psychosocial Nursing, to detect

suicide risk in patients presenting to the emergency department. In a quantitative non-

experimental approach a physchometric analysis was conducted. The goal was also test
SUICIDE SCREENING TOOLS IN ADOLESCENTS 8

reliability and validity of a 4-item Risk of Suicide Questionnaire(RSQ). During the study, it

incidentally gave the possibility that a 2- item Risk of Suicide Questionnaire would be beneficial

in risk for identification for adults. The recommendation of decreasing questions in adolescents

was discouraged as it lacked research in the adolescent population. Although, this information

was gathered by advance nurses the goal was to implement a brief risk of suicide questionnaire>

the recommendation stresses the importance for nurses to implement such tools to identify

potential suicide risk in adolescents.

Each research study examined seeks to analyze data regarding suicide or

screening tools. The goal of studies is that of evaluating current clinical suicide screening

guidelines in emergency departments and improve suicide screening tools. The brief suicide

screening tools discussed support the need for a revised suicide screening tool. The

reconstruction of an improved design for emergency triage nurses. Its implementation will

ensure that adolescents presenting to the emergency room are correctly identified as potential

suicide risks, decreasing suicide attempts, and adolescent mortality.

Ballard et al, conducted retrospective review of the implementation of a brief suicide

screening tool. The instrument was evaluated for pediatric patients in the emergency department.

Limitations of this study was conducting suicide screen on only psychiatric patients in the

emergency room. The screening instrument demonstrated that 53% of patients who were positive

did not present to the emergency for suicide-related complaints. The Ask Suicide Questions

demonstrated a 93% identification rate and 43% to predict return visits with suicide related

concerns. Thus, concluded the recommendation of the ASK instrument at triage to identify such

risks and prevent suicide deaths.

Research Approach
SUICIDE SCREENING TOOLS IN ADOLESCENTS 9

This evidence-based practice project will be completed utilizing a non-experimental

design approach. The project will be conducted as triage nurses complete the suicide screening

questionnaires thus researcher cannot control, manipulate, or alter subjects. The project design

does not manipulate predictor value instead the project relies on observation and interpretations.

Thus, following a correlation design will allow comparison between the current questionnaire

and a proposed revised comprehensive screening instrument measuring patterns of adolescent

suicide risk patients arriving to emergency department. Disadvantages of design may have

denoted issues with self-reporting during triage and it will not indicate causation.

Sampling

The sampling of the target population for the proposed study are adolescents. The

population discussed are adolescents ages twelve through nine-teen presenting to emergency

departments; for this study the sampling method is non-probability. The project will consist of

consecutive sampling with the use of dichotomous questioning. The selection of the age group

specifically presenting to the emergency department would categorize the use of probability

sampling technique; as all adolescents within given age group will be screening for suicidal

risks. The exclusion criteria for the study will be developmental disability or cognitive

impairments. The proposal will be presented to local emergency departments including free-

standing emergency departments. The questionnaires are conducted in the local emergency

departments and analyzed retrospectively by assessing medical records. The participants and

guardians will grant informed consent to medical evaluation and treatments as they normally do

in any emergency visit. Confidentiality will be maintained throughout the study and medical

chart reviews by ensuring that identifiable information is protected. Information will be

confidential and only utilize to collect data for the study.

SUICIDE SCREENING TOOLS IN ADOLESCENTS 10

Theoretical Framework

The evidence-based theoretical framework model chosen to support this proposal is the

Stetler Model. The Stetler Model emphasizes an individual nurse or organizational level

involvement to pursue change by evaluating current practices and potentially making impact in

decision making process. With the use of Stetler’s model an individual nurse or research team

may collaborate with respective institution in the identification, research, and development of

evidence based practice to improve current standards. Stetler’s model is comprised of a five-

phase model. Preparation is the first stage, in which the potential issue is identified. At this point,

further information is gathered to evaluate current issues with suicide risk screening tools in

place in the emergency department which a focus on adolescents and statistical data. The second

component of this model is to validate the data collected: current 2-question suicide risk

screening tool performed in triage, suicide attempts, and repeat suicide attempts following

emergency department discharge. In the comparative evaluation phase the research team in

collaborative with interdisciplinary team and the emergency department will compare current

screening tool and decide in the best revised suicide screening triage tool to be utilized for the

project. Translation/application phase-identify the practice implication as the need to incorporate

revised tool to improve suicide risk identification in the adolescent population presenting to

emergency departments. The propose suicide risk screening triage tool would be directed at

institutional level to be implemented in emergency department settings by triage nurses. The

information would be disseminated to institution and subsequently to staff for further education

regarding the new instrument. The last step in Stetler’s model include the evaluation component.

During the phase, the suicide screening risk tool at triage will be monitored for its effectiveness

completion compliance and evaluate suicide risks identified during the study. Staff and
SUICIDE SCREENING TOOLS IN ADOLESCENTS 11

interdisciplinary team will be consulted during evaluation phase; any suggestions will be

evaluated and make revision to tools as necessary to improve effectiveness and feasibility to all

parties.

Data Collection Methodology

As the advents of primary healthcare are evolving the emergency department is being a

primary healthcare provider. As such the emergency department is instrumental in the

identification and evaluation of the increasing suicide risk population in adolescents. The current

practice recommended to emergency departments by accreditation institutions such as Joint

Commission merely stipulate the requirement to screen for self-harm or suicide risks behavior

upon arrival to the emergency department. There are many current screening tools available to

achieve this task. It is important to understand that a suicide risk screening tool is typically

performed as part of a triage process in the emergency department. This is not to be confused

with a suicide risk assessment which is an incorporated comprehensiveincorporated

comprehensive detailed questionnaire including past attempts, social supports, etc. The proposal

is to revise the current practice suicide risks screening tools performed by triage nurses in

emergency departments. This tool must be standardized throughout to maximize effectiveness

and optimize suicide risk identification especially in vulnerable population such as adolescents.

The goal of the proposal for the project is to evaluate the current 2-question self-

harm/suicide screening tool being performed as a standard practice in adolescent population:

revise the screening instrument to increase identification of suicide risk and decrease suicide

attempt recurrence and suicide deaths in adolescents.

In collaboration with institutions in the South Texas Region several institutions will be

participating in study. The study will collect data from two trauma centers and three free-
SUICIDE SCREENING TOOLS IN ADOLESCENTS 12

standing emergency departments to demonstrate an accurate representation for that area. The

areas selected represent all emergency departments providing emergency care with the

geographical area.

As all emergency departments already have existing policies governing self-harm/suicide

risks tools our goal will be to implement an addition to current screening. The non-experimental

design of study will be comprised of non-probability sampling using convenience sampling

methodology.

A revised suicide risk screening tool incorporating psychometric assessment will be

provided. It will be compromised of self-reporting in dichotomous questing format along with

observation methods to gauge behavioral inferences implicitly suggestive of duress in such given

cases. The revised suicide risk screening tools are to be performed by the triage nurse to all

adolescents arriving in the emergency department. The revision will be conducted alongside the

normal standard in a longitudinal retrospective study. The data will be collected for 24-hours a

days as normal operational hoursdays as normal operational hours forir an emergency

department during a six-month period. After the six months period the retrospective study will

collect all medical records.

Once all data is collected from all five emergency departments for the six-month period

the evaluation of all material will begin. The data will provide a standard 2-question suicide risk

screening tool injunction to a revised suicide screening risk tool for all adolescents presenting to

the emergency room. The tools will be conducted on all adolescents presenting to emergency

departments for any symptoms not specifically for behavioral or mental health related

complaints.
SUICIDE SCREENING TOOLS IN ADOLESCENTS 13

The collection of the data using the methodology aforementioned will provide a

consensus of all adolescents being treated in that area. It will demonstrate how many adolescents

are being identified through the use of current standard practice suicide risk screening tool and

allowed to compare the potential significance in rates of potential suicide risks utilizing the

revised suicide risk screening tool proposed. Evidence-based practice suggests in the pursue in

research and implementation of practices to optimize patient care delivery which in this case is

instrumental in maximizing the early identification of potential suicide risks in adolescents upon

initial presentation to any emergency department. I believe this section could be more succinct.

A lot of the information is repeated. Use the grading rubric to help organize your writing.

Analysis

The data are reported using statistical descriptive analysis to include frequency

distribution regarding the subset with the population of adolescents. With the information

collected from the study we can analyze the volume of adolescents presented in the emergency

departments and evaluate ages. In analyzing the total volume, specific ages of adolescents, and

median ages of emergency department patients. We can also infer by bivariate statistical analysis Commented [C1]: Incomplete sentence.
Commented [C2]: Which bivariate statistics??
the positive identification when utilizing the 2-question current standard versus the revised Crosstabulation? Correlation? Describing risk? ANOVA? T-
tests?

suicide risk screening tool. Having the ability to compare the both suicide screening tools side

when evaluating medical records should provide a clear understanding of what suicide risk

screening tools increases the potential identification of suicidal risks in adolescents presenting to

the emergency department.

The implementation of the proposed study is critical as through current research in

multifaceted and still required to come to a consensus as to what it ??????

Conclusion
SUICIDE SCREENING TOOLS IN ADOLESCENTS 14

As trends shift to more Americans using the emergency departments, in this case

adolescents seeking care in local emergency departments; especially adolescents, research must

be developed to create a standardization of current suicide screening instruments to improve the

identification of potential suicide risks. The goal in optimizing potential adolescents at risks with

the standardization of a new screening instrument is to decrease the recurrence of suicide

attempts and deaths amongst the adolescent population. As evidenced by research, a revised

suicide risk or self-harm/suicide risk `questionnaire may be instrumental for at risks adolescents

presenting to the emergency department. A comprehensive suicide risk instrument in the

emergency department presented by the initial triage nurse may increase suicide risk

identification. All patients will be screeneding upon arrival to the emergency department. The

instrument will be to improve current clinical guidelines in identification of a vulnerable

population. The revised instrument will incorporate factors such as affect and mood to provide a

brief systematic assessment in triage to decrease suicide rates and patients retuning with suicide

related complaints after being discharge from the emergency department.

SUICIDE SCREENING TOOLS IN ADOLESCENTS 15

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