Suicide Prevention Best Practice Guideline: Enhancing Nursing Practice, Education and Organizational Policy to Address a Global Health Concern

Transcription

1 Suicide Prevention Best Practice Guideline: Enhancing Nursing Practice, Education and Organizational Policy to Address a Global Health Concern Elaine Santa Mina (Sta. Mina) RN, PhD 1 Josephine Muxlow, RN, MS 2 Victoria Smye RN, PhD 3 Beth Hamer RN, MS 4 Negin Shachi RN, BScN 1 1 Daphne Cockwell School of Nursing, Ryerson University 2 First Nations Inuit Health 3 UBC School of Nursing 4 PMental Health Centre Penatanguishine A Project of the RNAO, International Affairs and Best Practice Programs Funded by the Ontario Ministry of Health & Long Term Care SIGMA THETA TAU INTERNATIONAL RESEARCH CONFERENCE JULY 14, 2009

2 Guideline Development Process Topic Recommendations Panel Focus Areas Stakeholder Reviews Scope Literature Review Questions

3 Over the past 30 years, more than 100,000 Canadians have died by suicide, a leading cause of preventable death. 400,000 Canadians deliberately harm themselves every year (CASP, 2004). Many people have been affected by suicide at some point in their lives. The aftermath of a death by suicide is as painful and tragic as it is profound and far-reaching. The Context Suicide is a complex phenomenon that is influenced by physical, psychological, spiritual, social, economic, historical, political, cultural and environmental factors.

4 and Suicide Risk Reduction and Prevention Given their close proximity and relationships with those they interact with in their practice, nurses in all settings may find themselves in the position of identifying individuals who they think may be suicidal. Assessment and intervention for these individuals is fundamental to saving lives, but this can be difficult without the knowledge base and resources to support decision making.

5 Background January of 2007: a multidisciplinary panel with expertise in practice, education and research, from hospital, community and academic settings, was convened under the auspices of the Registered Nurses Association of Ontario (RNAO) Purpose: To design a Clinical Best Practice Guideline titled, Assessment and Care of Adults at Risk of Suicidal Ideation and Behaviour.

6 The Panel Samantha Mayo, RN, MN, Program Coordinator, RNAO Elaine Sta. Mina, RN, BA, BAAN, MSc, PhD Panel Team Leader & Associate Professor, Ryerson School of Nursing Shuan S. Boo, MA, Program Director, Crisis Response Service, CMHA, Thunder Bay Amy Brown, RN, Staff Nurse/Crisis Worker, Psychiatric Emergency Service, St Michael s, Toronto Lisa Clements, RN, Community Mental Health Nurse, ACT, North Bay Karin Doan, RN, MScN, CPMHN(C), Advanced Practice Nurse, CAMH Beth Hamer, RN, BA, BSN, MS, CPMHN(C), Nurse Educator/Practice Leader, Mental Health Centre, Penetanguishene Kristine Lorbergs, RN, BA, MN, PM-NP(C), CPMHN(C), Clinical Nurse Specialist, Mental Health, Trillium Health Center, Mississauga Josephine Muxlow, RN, MScN, Clinical Nurse Specialist, Adjunct Professor, Dalhousie University, Nova Scotia Jim Natis, BA, BSW, MSW, RSW, Social Worker, Mental Health, University Health Network, Toronto Elizabeth (Billie) Pryer, RN, MN, CPMH(C), Advanced Practice Nurse, Psych, Ottawa Hospital Victoria Smye, RN, BA, MHSc, PhD, Assistant Professor, UBC School of Nursing Kim M. Watson, RN, DPHN, MScN, Registered Nurse, Emergency Department, Windsor

7 Scope For adults over the age of 17: Recognition and assessment of risk for suicidal ideation and behaviour Nursing interventions towards the reduction of risk and prevention Strategies to promote ongoing wellness for the client and the nurse

8 Audience All RNs and RPNs who practice in Ontario in any setting and any specialty, across the continuum of care. Although the guideline is for mental health nurses as well, the goal was to produce a guideline for nurses who did not necessarily have mental health as an area of expertise.

9 A Guideline to Meet the Clinicians Needs in Practice The goal is to provide an evidence based guideline that is user friendly in any practice setting to: Reduce mental health jargon Provide easy access to critical information e.g., can take down off the shelf and use on a busy unit during a busy shift Produce more than an academic document!

10 Clinical Best Practice Guidelines Systematically developed statements to assist practitioners and patient decisions about appropriate health care for specific clinical (practice) circumstances. (Field and Lohr, 1990, p. 38) Best Practice Guidelines are developed using the best available evidence.

11 1. What are the contributing factors/predictors of suicidal ideation and behavior? 2. What are the screening/assessment tools? 3. What are the attributes of clinical assessment? 4. What are effective interventions and post interventions? 5. What are the standards for clinical practice for assessment and management of suicidal ideation and behaviour?

12 Philosophical/Theoretical Position Excellence in relational practice considering cultural safety, cultural awareness and cultural competence Social Justice Lens with attention to the social determinants of health Client as individual, family and/or community Collaboration is essential to ensure safety Asking a person about suicide is necessary and will NOT lead the person to suicide (APA, 2003)

13 Multidisciplinary Practice Guidelines Quantitative and qualitative investigations Emic perspectives of culture Promising practices Grey literature Client knowledge Multiple Ways of Knowing Expert opinion/consensus

14 Promising Practices interventions that have not been systematically developed and tested. (Walker and Bruns, 2007)

15 Recommendations 14 Practice Recommendations 2 Education Recommendations 10 Organization and Policy Recommendations

16 Major Areas of Focus Safety/ Observation Meeting Client s Needs Mobilizing Supportive Resources Hope Cultural Safety Reducing Anxiety Impulsivity Treatment Modalities Post Intervention Promoting Wellness Supporting the Clinician

17 Key Concepts Clients must always be taken seriously! Safety is a priority A complete and documented assessment is essential Mobilizing resources and collaboration between the client, team, family and community in key Promotion of protective factors and well-being starts with relational practice that takes into account cultural safety and minimizes stigma Interventions involve fostering hope and problemsolving The well-being of the nurse is also important

18 Facilitating Implementation Vignettes Scenario Nurses Reflection (critical thinking) Nurses Response Practice Boxes: Experiential Learning Application Strategies: on-the-job Stop Signs Suggested Models Tools for Practice Lightbulbs

19 Recommendation #1: The nurse will take seriously all statements made by the client that indicate, directly or indirectly, a wish to die by suicide, and/or all available information that indicates a risk for suicide. (Type III evidence)

20 VERBAL CUES On the evening shift, the RN gives Mr. Smith, a 60 year old retired widower with cancer, his bedtime medications. He sighs and says, There is no point to any of this. It is not worth living like this. I should just get my affairs in order now. Assess Taking Seriously Listen Warning Signs Psychiatric Assessment Protective Factors Needs Assessment Mobilize Resources Problem Solving Intervene

21 LISTEN/OBSERVE Client s status should be considered a potential emergency until assessed otherwise by clinicians All verbal and non-verbal behaviours that may convey an expression of dying are taken seriously Self-harm intentions and behaviours without the expressed desire to die should also be taken seriously

22 PROBLEM SOLVING APPROACH TO SOLUTIONS (Muxlow & Hamer, personal communication, October 22, 2007) IDENTIFY PROBLEM Client s understanding of the problem, what is important, and contributing factors EXPLORE PAST ATTEMPTS TO ADDRESS ISSUE EXPLORE ALTERNATIVES/ CHALLENGES OR BARRIERS CHOOSE SOLUTION/S Explore with the client what has worked in the past Identify the client as the expert in determining solutions Support client s selected decision IMPLEMENT PROCESS EVALUATE OUTCOME By nurse, for example: Provide information, teaching, counseling, and support the client Effectiveness/deficiencies and whether problem was resolved or unresolved Problem-Solving Approach

23 Dissemination and Implementation Begin with current beliefs, comfort and competence and provide evidence-based education Develop institution-specific strategies to remove barriers e.g., spotlight hospitals, journals, conference and on-site presentations Reassess beliefs, comfort and competence

24 Conclusions Development of the BPG is step One! The next step is to develop innovative education strategies one recommendation at a time and choose specific criteria to measure effectiveness of implementation (and the recommendations).

25 References American Psychiatric Association (APA). (2003). Canadian Association for Suicide Prevention (CASP). (2004) Field, M. J. & Lohr, K. N. (Eds) (1990). Clinical practice guidelines: Directions for a new program. Institute of Medicine, Washington, DC: National Academy Press. Santa Mina E., Mayo, S., Shalchi, N., Muxlow, J., & Hamer, B. (2009). Suicidal Ideation and Behaviour: A Best Practice Guideline for the Assessment and Care of Adults at Risk- Part I. The Registered Practical Nursing Journal, Winter Santa Mina E., Mayo, S., Shalchi, N., Muxlow, J., & Hamer, B. (2009). Suicidal Ideation and Behaviour: A Best Practice Guideline for the Assessment and Care of Adults at Risk- Part II The Registered Practical Nursing Journal, Spring 14-16

26 Walker, J. S. & Bruns, E. J. (2006). Building on Practice-Based Evidence: Using Expert Perspectives to Define the Wraparound Process. Psychiatric Services, 57 (Nov.), References continued

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