Suicide Risk and Self-Harm Assessment Teaching activities and resources
This section supports educators with knowledge and skills to integrate suicide risk, self-harm assessment and developing a safety plan in mental health and addiction curricula.
At the end of this section, the educator will:
- Understand the prevalence, risk factors, and language of suicide and self-harm.
- Understand the purpose of and differences between suicidal ideation/behaviours and self-harm behaviours.
- Identify the components of the suicide risk/self-harm assessment.
- Perform and document a suicide risk assessment/self-harm assessment.
- Understand suicide risk in the context of Mental Health Act and other legislation.
- Develop a safety plan in collaboration with the client (Appendix F).
Self-harm is the expression of inner pain, hopelessness and helplessness experienced by people. Self-harm can be due to suicidal thoughts, a coping mechanism to gain control over one’s body and to simply feel better and get relief from pain (Moore & Melrose, 2014 & CMHA, 2016). Acts of self-harm can include cutting skin, burning skin, hitting oneself to the point of injury and preventing wounds from healing (CMHA, 2016). Self-harm can affect anyone, and is experienced more frequently by adolescents and females (CMHA, 2016). Self-harm is also more likely to affect those who have experienced trauma, have issues with coping and among those with low self-esteem (CMHA, 2016). It is important for health-care professionals to recognize that self-harm behaviours pose a high risk for completed suicide. Health-care professionals must also recognize the stigma associated with self-harm and understand counter transference and trauma associated with it.
Suicide is an abrupt ending to life and is the most extreme way in which individuals respond to overwhelming situations and stress (RNAO, 2009c). Some literature indicates that suicide can be elevated among youth, elderly, indigenous peoples, LGBTQ populations and those who are incarcerated (RNAO, 2009c). Mood disorders, which includes depression, are the most common psychiatric condition associated with suicide (Jamison, 2000). According to the Centre for Addiction and Mental Health (2016), between 20 percent and 60 percent of death by suicide occurs in this community. Other high risk groups include:
- People with bipolar depression—suicide risk is 15 times that of the general population.
- People with schizophrenia—the lifetime risk of suicide is 4 to 7 percent (and a 40 percent risk of suicide attempts).
- People with concurrent addiction—experience higher suicide rates.
- Persons who use and misuse substances—they often have several other risk factors for suicide such as being depressed or having issues pertaining to social health determinants such as social or financial difficulties.
Source: Centre for Addiction and Mental Health, 2016
Suicide is a complex phenomena influenced by biological (i.e., genetics), physical, psychological, spiritual, social, economic, historical, political, cultural and environmental factors (RNAO, 2009c). Many individuals are affected by suicide in Canada. Given the pervasiveness of suicide among these communities, health-care practitioners’ ability to recognize and address suicidality can be a life-saving skill (CAMH, 2016). Specifically, nurses have a significant role in intervening when individuals express suicidal ideation and behaviour (RNAO, 2009). Understanding risk factors and warning signs may help nurses identifying clients at risk of suicide.
Assessment of risk
RNAO’s Best Practice Guideline Assessment and Care of Adults at Risk for Suicide Ideation and Behaviour states, “A comprehensive assessment of risk involves interviewing the client, reviewing the medical records and/or gathering information from family or significant others” (RNAO, 2009, p. 31). In addition to a mental status examination (MSE), a comprehensive assessment regarding suicidal ideation and plan, a clinical interview and use of valid and reliable assessment tools may be used to gather information specific to:
- Presence of risk factors.
- Lack or presence of protective factors (e.g., spirituality, hope, future orientation, cultural and/ or spiritual factors).
- Suicidal intent.
- Access to means.
- Time frame.
- Previous suicide attempts.
Source: RNAO, 2009
When the risk of suicide is identified, nurses should also work to develop a therapeutic relationship with the client and their family, as appropriate (RNAO, 2009c). Furthermore, nurses need to develop safety plans in collaboration with clients.
A safety plan indicates how clients should respond to their suicidal urge by outlining coping and problem-solving skills and abilities (Centre for Applied Research in Mental Health and Addiction [CARMHA], 1996). For a template of a safety plan see Appendix F.
For more information, see Resources in this section.
Teaching and Learning Activities
The following are teaching and learning activities that can be employed in the classroom to further support nurses in the integration of theory, principles and best practices related to suicide risk/ assessment and self-harm.
- Safety Plan Template—Appendix F
- Case study examples:
- Physical exam where you find different layers of scarring on arms/legs.
- Person who on leaving states, “You may not see me again.”
- Simulation—Section 7.2
- Lived client experience/family experience—Appendix H
- Handout with reflective questions.
- Students might work independently first, and then in small groups, and/or come back to larger class.
- Arts-based approaches
- Vision boards
Learner Engagement Questions
The following are thought-provoking and engaging learner questions that can be used to further discussions with nursing students regarding suicide risk/assessment and self-harm. These questions can be used either to stimulate discussion, engage students in critical thinking or be tied to class assignments and/or reflection exercises.
- How would you explore the client’s spiritual and beliefs about death?
- Do people have the right to kill themselves when it is related to mental illness (including addiction)?
- Does age, gender, or additional health concerns make a difference in terms of attitude regarding suicide?
- How might our beliefs about the individual’s right to suicide play out in our interactions with patients/clients?
- How do our professional standards help to guide us in working with individuals presenting with suicidal ideation/behaviour?
- How do our professional standards fit with the current move to legalize assisted death/suicide?
- Do some people deserve to die?
- Can talking about suicide cause suicide?
- What’s the difference between suicidal ideation/behaviour and self-harm behaviour?
- What might it mean if a person is engaging in “cutting behaviours” to deal with stress?
Evaluation and Self-reflection
The following tools can be used to evaluate students in their understanding and application of suicide and self-harm risk/assessment:
- Return demonstration
Self-reflection question: What are my own beliefs about suicide, death and choice? Also, reflect on lived client experience of someone who has lost a friend/family/colleague to suicide
- Suicide Prevention (MHCC)
- Applied Suicide Intervention Skills Training (ASIST) Suicide Prevention Courses—including Safe Talk
- Suicide Prevention Courses – including Safe Talk and ASSIST
GUIDES AND HANDBOOKS
- Centre for Addiction and Mental Health (CAMH). (2011). CAMH suicide prevention and assessment handbook. Toronto, ON: Centre for Addiction and Mental Health.
- Canadian Coalition for Senior’s Mental Health. (2010). Suicide assessment and prevention for older adults.
- Registered Nurses’ Association of Ontario. (2009c). Assessment and care of adults at risk for suicidal ideation and behaviour. Toronto, ON: Registered Nurses’ Association of Ontario.
- De Silva, Stefanie; Parker, Alexandra; Purcell, Rosemary; Callahan, Patrick; Liu, Ping; Hetrick, Sarah (2013). Mapping the evidence of prevention and intervention studies for suicidal and self-harming behaviors in young people. Crisis: The Journal of Crisis Intervention & Suicide Prevention, 34(1),223-232.
- Einfeld SL; Beard J; Tobin M; Buss R; Dudley M; Clarke AR; Knowles M; Hamilton B (2002). Evidence-based practice for young people who self harm: can it be sustained and does it improve outcomes? Australian Health Review, 25(4): 178-188.
- Gros, C.P., Jarvis, S., Mulvogue, T., Wright, D., (2012), Les interventions infirmières estimées bénéfiques parles adolescents à risque de suicide, Santé mentale au Québec, (37) 2, 193-207.
- Jacobs, D. G. (2007). A resource guide for implementing the Joint Commission 2007 patient safety goals on suicide. Wellesley Hills, MA: Screening for Mental Health, Inc.
- Mental Health Commission of Canada. (2012). Changing directions, changing lives: The mental health strategy for Canada. Calgary, AB: Author.
- Moore, S. & Melrose, S. (2014). Suicide. In M. J. Halter, Varcaroli (Eds.). Canadian psychiatric mental health nursing: A clinical approach (1st ed.) (pp. 509- 525). Toronto, ON: Elsevier Canada.
- Montreuil, M., Butler, K., Stachura, M., & Gros, C. (2015). Exploring helpful nursing care in pediatric mental health settings: The perceptions of children with suicide risk factors and their parents. Issues in Mental Health Nursing, 36(11), 849-859.
- Murray, B. L., & Austin, W. (2015). Self-harm and suicidal behaviour. In W. Austin & M. A. Boyd (Eds.), Psychiatric & mental health nursing for Canadian practice (3rd ed., Chapter 19, pp. 340–363). Philadelphia, PA: Wolters Kluwer.
- Patrick L. Kerr, PhD, Jennifer J. Muehlenkamp, PhD, and James M. Turner, DO (2010). Nonsuicidal Self-Injury: A Review of Current Research for Family Medicine and Primary Care Physicians. Journal of American Board of Family Medicine, 23 (2), 240-259.
- Perlman, C. M., Neufeld, E., Martin, L., Goy, M., & Hirdes, J. P. (2011). Suicide Risk Assessment Inventory: A Resource Guide for Canadian Health Care Organizations. Toronto: Ontario Hospital Association and Canadian Patient Safety Institute.
- Randy A. Sansone, MD, and Lori A. Sansone, MD (2010). Measuring Self-Harm Behavior with the Self-Harm Inventory. Psychiatry (Edgemont), 7(4):16–20.
- Registered Nurses’ Association of Ontario. (2009). Assessment and Care of Adults at Risk for Suicidal Ideation and Behaviour. Toronto: ON, Registered Nurses’ Association of Ontario.
- Sakinofsky, I. (2005). Suicide and suicidality. In D. S. Goldbloom (Ed.), Psychiatric Clinical Skills (pp. 167–185). Philadelphia, PA: Elsevier Mosby.
- Wright, D., & Gros, C.P. (2012). Theory inspired practice for end-of-life cancer care: an exploration of the McGill Model of Nursing. Canadian Oncology Nursing Journal. 182-189. Summer 2012.