Assessing for Occult Suicidality at Triage: Experiences of Emergency Nurses

The Joint Commission recommends using clinical judgment tools for the final determination of safety for a patient at suspected risk of suicide, as research findings suggest that a screening tool can identify persons at risk for suicide more reliably than a clinician's personal judgment. Our participants report that when they assessed suicide risk at triage, it was usually by asking a single question such as “Do you have thoughts or plans to harm yourself?” and they expressed concern about the effectiveness of doing so. Participants described their efforts to improve suicide screening across the duration of the patient's ED stay through an iterative process of assessment that included further probing and eliciting, evaluating, and reacting to the patient's response.Contribution to Emergency Nursing Practice
- Screening for suicidality is a critical function of triage nursing.
- Screening is a process that involves recognition and interpretation of verbal and nonverbal cues.
- Future efforts to improve triage assessment of suicide risk should include screening tools that are deployed continuously through the ED visit.