Content advisory—discussion on the topic of suicide.

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At Allegheny Health Network (AHN), we believe in creating a world where everyone embraces their health. When reading that statement, you may immediately think of your “medical” health. However, 1 in 5 U.S. adults experience a mental health condition every year, and 1 in 20 experience a serious mental health condition (National Alliance on Mental Illness, 2024). We sometimes forget that we need to care for the mental health of every single patient who walks into the hospital, regardless of their primary diagnosis or reason for visit, because mental health is an integral part of a person’s overall health. For this reason, AHN has prioritized several mental health optimization initiatives. This article discusses the roles of the nursing professional development (NPD) practitioner in two key programs that have benefited our patients, teams, and community.

Program 1: Suicide Prevention Program

In 2022, over 49,000 people in the U.S. died by suicide, making it the 11^th leading cause of death (Center for Disease Control and Prevention [CDC], 2024). Sadly, these deaths are just the tip of the iceberg, as 13.2 million people had serious suicidal ideation, 3.8 million people made a plan, and 1.6 million people attempted suicide (CDC, 2024). The Joint Commission (2022) established a National Patient Safety Goal to improve the quality and safety of care for people at risk of suicide in healthcare, including standards that must be met by accredited hospitals. At AHN, we recognized the need for a proactive suicide prevention approach, to better serve our patients and communities.

Building a Suicide Prevention Program

Members of leadership, nursing, psychiatry, emergency medicine, quality, patient safety, regulatory, information technology, informatics, and project management came together to form a team to address this issue. Together, we instituted universal screening for suicide risk for all adult patients entering the hospital (with certain exclusion criteria) utilizing an evidence-based screening tool, the Columbia-Suicide Severity Rating Scale (C-SSRS, Columbia Lighthouse Project, 2016). Utilizing a validated screening tool has many benefits, including preventing conscious and unconscious bias from impacting the screening process. Based on the answers given on the C-SSRS, the patient is risk stratified as no risk, low risk (indicating the patient is experiencing suicidal ideation), moderate risk (typically indicating the patient has suicidal ideation with a plan), or high risk (typically indicating the patient has some level of intent to act, which is considered a mental health emergency).

Addressing Suicide Risk

After identifying that a patient is at risk for suicide, nurse-driven protocols are implemented, such as notifying the provider, completing environmental safety precautions (such as removing ligature risks), and implementing a sitter for constant observation of high-risk patients. The provider also has a response protocol, including consulting a mental health professional (such as a nurse or social worker) to complete a more in-depth assessment and consulting a psychiatrist when needed. We developed education for nursing orientation and annual mandatory education to ensure our nursing staff was comfortable with the screening tool and the response protocols. Ongoing education is also provided based on identified learning needs, and includes webinars, seminars, eLearning, unit rounding, and competency assessments. As the NPD practitioner, I served in the role of change agent (helping our system adopt these new processes), learning facilitator (creating and managing our system-wide education), champion of inquiry (ensuring we were following the best practices in the evidence), and as a project leader in many of the smaller initiatives that helped to build this program.

Our Outcomes

We have been able to create a culture of universal screening for suicide at our hospitals. We are still working on project optimization initiatives, particularly around leveraging our electronic health record to simplify nursing tasks. We hope these optimizations will increase compliance in utilizing all the tools we have built, including our response protocols that are aimed at keeping our patients safe. This program has been essential for patient safety, and it ensures our hospitals meet compliance with the Joint Commission’s standards in suicide prevention (2022).

Program 2: Crisis Response Program

Workplace violence (WPV) is “… any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site” (Occupational Safety and Health Administration, 2015). The Joint Commission (2021) reports that violence-related injuries to healthcare workers have been steadily increasing for at least a decade. The consequences for WPV can be serious, including minor to severe injuries, emotional trauma, decreased job satisfaction, and higher turnover, even driving some away from the healthcare industry all together (Vento et al., 2020). WPV is also associated with an increase in adverse patient events and lower patient safety (Vento et al., 2020). AHN has prioritized creating a comprehensive WPV prevention program, with a major focus on crisis prevention and management.

Creating a Crisis Response Program

In 2018, a team from executive leadership, nursing, psychiatry, corporate security, quality, safety, regulatory, and more came together to form AHN’s crisis response program. It started with formulating a code of conduct for patients and visitors, to set expectations for behaviors that promote a safe and therapeutic environment for everyone. A tiered crisis response approach was then developed which identifies the person in crisis’ behavior and the recommended team response. The level 3 response evaluates that the person in crisis is physically violent or has the potential to become physically violent and activates the crisis response team in our hospitals, which is made up of nurses, security, hospital police officers, providers, mental health professionals, and more (depending on staff availability).

Crisis Response Educational Program

The Crisis Response in Healthcare (CRH) program was created to meet the needs for a comprehensive, evidence-based, educational program in crisis prevention and management to address WPV in healthcare. This educational program is tailored around AHN’s tiered crisis response model. The highlights of this education include: An overview of WPV, aligning to our mission/vision and policies/procedures, self-awareness and regulation, trauma-informed care, therapeutic communication, verbal de-escalation, situational awareness, environmental precautions, safety maneuvers and physical restraint principles/techniques, debriefing and reporting after an event, and self-care and resiliency tips. Simulation was also incorporated into the classes with scenarios depicting common causes of WPV in healthcare. Simulation in WPV education is shown to increase staff confidence in managing patient aggression, provide a safe and realistic environment to practice the techniques taught in the class, and enhance the partnership and collaboration between the interprofessional team members (Ming et al., 2019).

The CRH program went live at AHN hospitals in the summer of 2024, with NPD practitioners acting as the change agents introducing this new education program, and as learning facilitators for classes at their hospital. In 2024, more than 1,000 staff members completed the CRH training. Evaluation survey data shows that staff highly rate the classes in all domains, with an average in the mid-to-high 90 percent for “agree” to “strongly agree” on Likert scale questions. An average of 95 percent of staff agree “this class improved my ability to respond to crisis events” and 97 percent of staff agree that they “...can apply what I learned to my clinical and/or professional practice”.

Our Outcomes

Data from our annual clinician wellness survey in 2024 showed a decrease in the overall self-reported physical assaults to nurses at AHN hospitals. Physical assaults decreased on medical-surgical units, inpatient perioperative/surgical units, ambulatory primary care clinics, and ambulatory specialty clinics. However, rates of physical assaults increased in several high-risk units, including inpatient psychiatric units, emergency departments, and intensive care units. This underscores the need for our continued commitment and focus on improvement for WPV prevention.

The NPD Practitioner's Role in Mental Health Initiatives

We all have mental health that needs to be cared for at times - mental health is a vital part of our overall health! We are excited to also be piloting employee mental health and wellness initiatives, such as critical incident stress management teams and mental health first aid classes. Prioritizing mental health initiatives in our hospitals helps our frontline staff, patients, and communities. Moreover, you do not need to be an expert in psychiatry to support and work on these kinds of initiatives. As an NPD practitioner, you have expertise in many roles, such as being a champion for inquiry, change agent, learning facilitator, and leader, and can be an essential member of a project team to bring these types of mental health initiatives to your hospital or facility.

References

• Center for Disease Prevention and Control. (2024). Suicide data and statistics. https://www.cdc.gov/suicide/facts/data.html
• Columbia Lighthouse Project. (2016). About the protocol. https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale/
• Joint Commission. (2022). Suicide prevention. https://www.jointcommission.org/resources/patient-safety-topics/suicide-prevention/  
• Joint Commission. (2021). R3 report: Requirement, rationale, reference. https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/wpvp-r3_20210618.pdf
• Ming, J. L., Huang, H. M., Hung, S. P., Chang, C. I., Hsu, Y. S., Tzeng, Y. M., Huang, H. Y., & Hsu, T. F. (2019). Using simulation training to promote nurses’ effective handling of workplace violence: A quasi-experimental study. International Journal of Environmental Research and Public Health, 16(19), 1-10. https://doi.org/10.3390/ijerph16193648
• National Alliance on Mental Illness. (2024). Mental health by the numbers. https://www.nami.org/about-mental-illness/mental-health-by-the-numbers/
• Occupational Safety and Health Administration. (2015). Guidelines for preventing workplace violence for healthcare and social service workers. https://www.osha.gov/healthcare/workplace-violence#:~:text=Workplace%20violence%20(WPV)%20is%20a,%2C%20clients%2C%20customers%20and%20visitors
• Vento, S., Cainelli, F., & Vallone, A. (2020). Violence against healthcare workers: A worldwide phenomenon with serious consequences. Frontiers in Public Health, 8, 570459. https://doi.org/10.3389/fpubh.2020.57045