Practice Tip of the Week | National Suicide Prevention Awareness Month

By Cornelius Metili, BSN, RN, PMH-BC; Jennifer Gonzales, BSN, RN; Jen Bowles, BSN, BA Ed, RN; and Thanh Nguyen, PA-C

September is National Suicide Prevention Awareness Month. Most practice tips written for this month are addressed to psychiatric nurses. This one is not. Suicide risk does not confine itself to behavioral health units, and the nurse who first hears a patient say something is rarely the nurse who was trained for it. This tip is about what to do in that moment.

Who Is Actually in the Room

In a study of 5,894 people who died by suicide across eight health systems, 83 percent had received health care in the year before their death, and half had no mental health diagnosis.1 Read that a second way. The majority of these patients were seen in medical clinics, emergency departments, and inpatient units, by nurses who had no reason to think they were caring for someone at risk. Risk was present. The setting was not psychiatric.

A Texas Story Worth Knowing

About a decade ago, Parkland Health decided to screen every patient for suicide risk, across inpatient, outpatient, and emergency settings, rather than only those who arrived with a psychiatric concern. The implementation was published in The Joint Commission Journal on Quality and Patient Safety, and an editorial in the same issue, led by researchers at the National Institute of Mental Health, called the program exemplary and described the team as trailblazers in suicide prevention in medical settings.^2,3

The fear going in was that screening everyone would surface more risk than the system could absorb. It did not. About 96 percent of patients screened negative, with positive rates near 1 percent on inpatient units, 2 percent in outpatient clinics, and 6 percent in the emergency department.3 Six percent reads as small until you attach it to the volume. Parkland operates what has repeatedly been the busiest emergency department in the country, reporting 228,759 visits in 2025, within a system handling more than a million patient encounters a year.^3,4 These were patients who came in for something else. Screening based on suspicion was never going to find them.

Texas nurses did that work, and Texas nurses now practice inside its result.

Ask Plainly

The most common reason nurses hesitate is the belief that asking about suicide plants the idea. It does not. A meta-analysis of thirteen prospective studies examining exactly this question found no significant iatrogenic effect of assessing suicidality, and the authors observed that the belief persists despite prior evidence against it.⁵

What this means at the bedside is that the question can be asked directly, in plain words, without softening it into something the patient has to decode. “Are you having thoughts of killing yourself?” is a clearer question than “You’re not thinking of doing anything, are you?” The second question tells the patient which answer you want. Some patients will give it to you.

Stay for the Answer

Asking is the smaller half of the skill. The harder half is what happens in the four or five seconds after the patient says yes.

Most of us have an impulse to move immediately, to reassure, to reach for the phone, to start the protocol. The impulse is not wrong, but it is early. A patient who has just disclosed something they may never have said out loud is watching your face to learn what it costs to have said it. If the first thing that happens is that you leave the room, they have their answer.

Stay long enough to say something ordinary and true. That you are glad they told you. That you are going to make sure they get help with this, and that you are not going to hand them off and disappear. Then start the protocol. The order matters more than the wording.

When the Patient Is a Child

Parkland extended the same screening to pediatric patients and published results from 91,580 encounters with patients aged 10 to 17, across the emergency department, inpatient medical units, and primary care clinics. Across settings, 2.9 percent produced a positive screen.⁶ Three of the eight authors were nurses.

One procedural detail matters more here than anywhere else in this article. The ASQ toolkit, the instrument the Joint Commission and the American Academy of Pediatrics point to, recommends screening youth with the parent or guardian out of the room, and it supplies a script for asking.7 A child sitting beside a parent is answering a different question than a child sitting alone.

Two conditions come with that. If the parent refuses to leave, or the child wants them to stay, screen with the parent present rather than forcing it. And the request is not an offer of secrecy. The toolkit’s parent flyer states that any concern about the child’s safety will be shared with the parent.8 The privacy is for the answer, not for the risk.

What Not to Reach For

The no-suicide contract, in which a patient agrees verbally or in writing not to harm themselves, still appears in some settings. There is no empirical evidence that it prevents suicidal behavior, and no randomized controlled trials of its efficacy.⁹

The more serious problem is what it does to disclosure. Clinical guidelines caution that using a contract to secure a promise may obscure the patient’s actual risk, because a patient may withhold what they are thinking rather than disappoint the clinician by breaking the agreement.⁹ A tool meant to keep the patient safe can end up costing you the information you needed. The reason the practice survives is worth saying plainly: contracts appear to lower clinician anxiety. That is a real benefit, and it centers the wrong person.

Safety planning is the evidence-supported alternative. In a cohort comparison of patients presenting to Veterans Affairs emergency departments for suicide-related concerns, those who received the Safety Planning Intervention with structured follow-up telephone contact were half as likely to show suicidal behavior over six months, and more than twice as likely to attend outpatient treatment, compared with usual care.¹⁰ This was a cohort comparison rather than a randomized trial, and the sample was predominantly male veterans, so the finding is an association in a specific population rather than a general causal claim.

Two things about it are directly relevant to nurses. The intervention was designed to be delivered by clinicians across disciplines, nurses named among them, and it takes twenty to forty-five minutes. And it has to be built collaboratively, in the patient’s own words, because a list of coping strategies generated by the clinician is unlikely to help a patient who was never asked what actually works for them.⁹ A safety plan is a conversation that produces a document, not a document that produces a conversation.

What to Do With What You Heard

Escalation pathways are institution-specific, and yours is the one that governs. Know before your next shift who responds to a positive screen in your facility, how they are reached, and what your role is while you wait for them. That is a five-minute question to ask your charge nurse, and the answer is worth having before you need it. A patient who has just told you something hard should not have to watch you figure out what happens next.

It is worth knowing what a positive screen is and is not. At Parkland it did not automatically mean constant observation or detainment. A brief secondary assessment determined what the result actually meant.³ That distinction matters at the bedside, because a nurse who believes a yes triggers a room change and a sitter has a quiet reason to hope for a no.

The 988 Suicide and Crisis Lifeline is available by call or text, around the clock, and is appropriate to give directly to patients and families at discharge. It is also available to you.

A Note on What This Costs the Nurse

Sitting with a patient’s disclosure has a weight to it, and the weight does not disappear because the shift ended. If a disclosure stays with you, that is not a sign you handled it badly. It is a sign you were present for it. Tell someone. Most institutions have a debrief mechanism, an employee assistance program, or a peer support process, and all of them work better than carrying it alone.

Reflective Takeaways

Risk is not confined to psychiatric settings, and most patients who die by suicide were last seen somewhere else. Screening by suspicion misses them.

Asking directly does not create risk. The evidence on this is settled, and the hesitation most nurses feel is not supported by it.

The seconds after a disclosure are part of the intervention. What the patient learns about the cost of telling you shapes whether they tell anyone again.

REFERENCES

1. Ahmedani, B. K., Simon, G. E., Stewart, C., Beck, A., Waitzfelder, B. E., Rossom, R., Lynch, F., Owen-Smith, A., Hunkeler, E. M., Whiteside, U., Operskalski, B. H., Coffey, M. J., & Solberg, L. I. (2014). Health care contacts in the year before suicide death. Journal of General Internal Medicine, 29(6), 870–877. https://doi.org/10.1007/s11606-014-2767-3

2. Roaten, K., Johnson, C., Genzel, R., Khan, F., & North, C. S. (2018). Development and implementation of a universal suicide risk screening program in a safety-net hospital system. The Joint Commission Journal on Quality and Patient Safety, 44(1), 4–11. https://doi.org/10.1016/j.jcjq.2017.07.006

3. Horowitz, L. M., Boudreaux, E. D., Schoenbaum, M., Pao, M., & Bridge, J. A. (2018). Universal suicide risk screening in the hospital setting: Still a Pandora’s box? The Joint Commission Journal on Quality and Patient Safety, 44(1), 1–3. https://doi.org/10.1016/j.jcjq.2017.11.001

4. Falvey, A. (2026, February 27). 77 hospitals with the most ED visits in 2025. Becker’s Hospital Review. https://www.beckershospitalreview.com/rankings-and-ratings/hospitals-with-the-most-ed-visits-in-2025/

5. DeCou, C. R., & Schumann, M. E. (2018). On the iatrogenic risk of assessing suicidality: A meta-analysis. Suicide and Life-Threatening Behavior, 48(5), 531–543. https://doi.org/10.1111/sltb.12368

6. Roaten, K., Horowitz, L. M., Bridge, J. A., Goans, C. R. R., McKintosh, C., Genzel, R., Johnson, C., & North, C. S. (2021). Universal pediatric suicide risk screening in a health care system: 90,000 patient encounters. Journal of the Academy of Consultation-Liaison Psychiatry, 62(4), 421–429. https://doi.org/10.1016/j.jaclp.2020.12.002

7. National Institute of Mental Health. (n.d.). Ask Suicide-Screening Questions (ASQ) toolkit. https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials

8. National Institute of Mental Health. (2020). Parent/guardian flyer: Inpatient medical/surgical unit [ASQ suicide risk screening toolkit]. https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq-toolkit-materials/youth-inpatient/parent-flyer-inpatient-youth-asq-nimh-toolkit.pdf

9. 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

10. Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., Chaudhury, S. R., Bush, A. L., & Green, K. L. (2018). Comparison of the Safety Planning Intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry, 75(9), 894–900. https://doi.org/10.1001/jamapsychiatry.2018.1776