Research| Volume 44, ISSUE 5, P491-498, September 2018

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Assessing for Occult Suicidality at Triage: Experiences of Emergency Nurses

Published:March 01, 2018DOI:



      Screening for suicidality is a critical nursing function at the initial ED encounter. Suicide is the tenth leading cause of death in the United States, and a substantial percentage of people who die by suicide present for health care in the year before their deaths. The emergency department provides health care professionals with a critical opportunity to identify patients at risk for suicide and intervene appropriately.


      Qualitative exploratory study using focus-group data.


      Effective and accurate suicidality assessment occurs not by asking a single question but also with the assessment of patient behaviors and presentation (appearance, hygiene, etc). When emergency nurses suspected occult suicidality, additional actions (finding private space, keeping patients safe, and passing on information), took priority.


      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.


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        • Curten SA
        • Warner M
        • Hedegaard H
        Increase in suicide in the United States 1999–2014.
        Centers for Disease Control, 2016 ( Accessed November 16, 2017)
        • Berman AL
        • Silverman MM
        Suicide risk assessment and risk formulation, part II: suicide risk formulation and the determination of levels of risk.
        Suicide Life Threat Behav. 2014; 44: 432-443
        • Horowitz LM
        • Ballard ED
        Suicide screening in schools, primary care and emergency departments.
        Curr Opin Pediatr. 2009; 21: 620
      1. Detecting and treating suicide ideation in all settings. The Joint Commission. Issue 56. February 24, 2016
        • Allen MH
        • Abar BW
        • McCormick M
        • et al.
        Screening for suicidal ideation and attempts among emergency department medical patients: instrument and results from the Psychiatric Emergency Research Collaboration.
        Suicide Life Threat Behav. 2013; 43: 313-323
      2. Clinical Practice Guideline: Suicide screening in the ED. Emergency Nurses Association, 2017
        • Chung JYM
        An exploration of accident and emergency nurse experiences of triage decision making in Hong Kong.
        Accid Emerg Nurs. 2005; 13: 206-213
        • Gerdtz MF
        • Weiland TJ
        • Jelinek GA
        • Mackinlay C
        • Hill N
        Perspectives of emergency department staff on the triage of mental health-related presentations: implications for education, policy and practice.
        Emerg Med Australas. 2012; 245: 492-500
        • Wolf L
        Acuity assignation: an ethnographic exploration of clinical decision making by emergency nurses at initial patient presentation.
        Adv Emerg Nurs J. 2010; 32: 234-246
        • Wolf LA
        • Delao AM
        • Perhats C
        • Moon MD
        • Zavotsky KE
        Triaging the emergency department, not the patient: US emergency nurses’ experience of the triage process.
        J Emerg Nurs. 2018; 44: 258-266
        • Wolf L
        An integrated, ethically driven environmental model of clinical decision making in emergency settings.
        Int J Nurs Knowl. 2013; 24: 49-53
        • Wolf LA
        • Perhats C
        • Delao AM
        US emergency nurses’ perceptions of challenges and facilitators in the management of behavioural health patients in the emergency department: a mixed-methods study.
        Australas Emerg Nurs J. 2015; 18: 138-148
        • Betz ME
        • Sullivan AF
        • Manton AP
        • et al.
        Knowledge, attitudes, and practices of emergency department providers in the care of suicidal patients.
        Depress Anxiety. 2013; 30: 1005-1012
        • Orlando IJ
        The Discipline and Teaching of Nursing Process (An Evaluative Study).
        Putnam Publishing Group, New York, NY1972
        • Fawcett J
        Criteria for evaluation of theory.
        Nurs Sci Q. 2005; 18: 131-135
        • Saldana J
        An introduction to codes and coding.
        in: The Coding Manual for Qualitative Researchers. Sage Publications, Thousand Oaks, CA2009: 1-31
        • Rudd MD
        • Berman AL
        • Joiner Jr., TE
        • et al.
        Warning signs for suicide: theory, research, and clinical applications.
        Suicide Life Threat Behav. 2006; 36: 255-262
        • Hirschfeld R
        • Russell JM
        Assessment and treatment of suicidal patients.
        N Engl J Med. 1997; 337: 910-915
        • Fowler JC
        Suicide Risk Assessment in Clinical Practice: Pragmatic Guidelines for Imperfect Assessments.
        Psychother Theory Res Pract Train. 2012; 49: 81-90
        • Busch KA
        • Fawcett J
        • Jacobs DG
        Clinical correlates of inpatient suicide.
        J Clin Psychiatry. 2003; 64: 14-19
        • Denneson LM
        • Basham C
        • Dickinson KC
        • et al.
        Suicide risk assessment and content of VA health care contacts before suicide completion by veterans in Oregon.
        Psychiatr Serv. 2010; 61: 1192-1197


      Lisa A. Wolf, Member, Pioneer Valley Chapter, is Director, Institute for Emergency Nursing Research, Emergency Nurses Association, Des Plaines, IL


      Cydne Perhats is Senior Associate, Institute for Emergency Nursing Research, Emergency Nurses Association, Des Plaines, IL.


      Altair M. Delao is Senior Associate, Institute for Emergency Nursing Research, Emergency Nurses Association, Des Plaines, IL.


      Paul R. Clark, Member, Kentuckiana Chapter, is Assistant Professor, University of Louisville School of Nursing and System Educator, Norton Healthcare Institute for Nursing, Louisville, KY.


      Michael D. Moon, Member, San Antonio Chapter, is Associate Professor, University of the Incarnate Word, San Antonio, TX.


      Kathleen Evanovich Zavotsky is Assistant Vice President at the Center for Professional Development, Innovation and Research, Robert Wood Johnson University Hospital, New Brunswick, NJ.