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Patient summary
The patient is illustrative. Mr. T., 45, is admitted to an inpatient psychiatric unit with major depression after his partner found him researching ways to end his life. He lost his job 3 months ago, is drinking more, and says, "Everyone would be better off without me." He has no previous attempts.
Assessment
On admission the nurse uses the Columbia–Suicide Severity Rating Scale (C-SSRS), which rates both the severity and intensity of suicidal ideation and any suicidal behavior. In three multisite studies with adolescents and adults, the C-SSRS showed good convergent and divergent validity and high sensitivity and specificity for classifying suicidal behavior, and its ideation and behavior subscales were sensitive to change over time (Posner et al., 2011). Because it can be repeated, the nurse uses it again each shift and before any change in observation level or discharge.
Mr. T.'s answers show active suicidal ideation with a method in mind but no specific plan or intent today. Protective factors are his two children and his partner's support.
Nursing diagnosis
Risk for suicidal behavior, with risk factors of major depression, recent job loss, increased alcohol use and hopelessness (Herdman et al., 2024).
Goals
- Short term: Mr. T. will remain free of self-harm during hospitalization and will tell staff when suicidal thoughts increase.
- Before discharge: Mr. T. will complete a written safety plan with at least two coping strategies and three people or services he can contact, and will state how his home will be made safer.
Interventions and rationales
| Intervention | Rationale |
|---|---|
| Observe at the level ordered (for example, every 15 minutes or one-to-one) and keep the environment free of ligature points and sharp items | Reduces access to means while risk is high |
| Reassess with the C-SSRS every shift and with any change in mood or behavior | Ideation fluctuates, and the scale is sensitive to change (Posner et al., 2011) |
| Build a therapeutic relationship: ask directly about suicidal thoughts, listen without judgment | Asking directly does not plant the idea and lets the patient share how he really feels |
| Work with Mr. T. on a written safety plan before discharge | Gives him concrete steps to follow when a crisis starts (Stanley & Brown, 2012) |
| Talk with Mr. T. and, with consent, his partner about locking up or removing firearms, medications and alcohol | Restricting access to lethal means is one of the safety plan's steps |
| Coordinate referrals for outpatient therapy and alcohol use treatment, with an appointment booked before discharge | The days after discharge are a period of high risk |
The safety plan
Stanley and Brown (2012) describe a safety plan as a prioritized written list of coping strategies and sources of support, developed collaboratively with the patient. It has six steps: recognizing warning signs, using internal coping strategies, contacting people and social settings that provide distraction, contacting people who can help, contacting professionals or agencies, and making the environment safe. Mr. T.'s plan names his warning sign ("lying in bed all afternoon"), coping strategies (a walk with his dog, calling his brother), the 988 Suicide & Crisis Lifeline, his outpatient therapist and his partner's agreement to keep his medications.
Evaluation
Mr. T. reports suicidal thoughts to staff twice during his stay and uses his coping strategies. At discharge his C-SSRS shows no active ideation, he can explain each step of his safety plan, and his first outpatient appointment is scheduled for 3 days after discharge.
References
Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2024). NANDA International nursing diagnoses: Definitions and classification, 2024–2026 (13th ed.). Thieme.
Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., Currier, G. W., Melvin, G. A., Greenhill, L., Shen, S., & Mann, J. J. (2011). The Columbia–Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168(12), 1266–1277. https://doi.org/10.1176/appi.ajp.2011.10111704
Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256–264. https://doi.org/10.1016/j.cbpra.2011.01.001
