Running Head: PEDIATRIC SUICIDE RISK SCREENING 1

Pediatric Suicide Risk Screening Assessment Need

Nicky Reed

Ferris State University

PEDIATRIC SUICIDE RISK SCREENING 2

Abstract

Adolescent and teen suicide rates continue to rise across the nation. Early recognition is key to

prevention of such unnecessary deaths. Acute care hospitals play a monumental role in

identification of pediatric patients at high risk of suicide. Current suicide screening tools are not

ideal for pediatric patients and recognition and improvement is a foremost concern.

Development of age-specific suicide risk screening questions are a must to provide justice to

such a vulnerable population. Utilization of current national quality standards will provide

guidance and structure for providing high quality care within acute care hospitals across the

nation affording opportunities of high standards for pediatric suicide risk patients. Nurses play

an important role on maintaining ethical rights to patients and development of similar screenings

for patients to maintain quality health and wellness to our communities. Adolescent and teen

suicide is a preventable fatality. Nurturing nursing minds in quality and safety endeavors is

opportune in maintaining an environment that recognizes early and prevents injury.

PEDIATRIC SUICIDE RISK SCREENING 3

Need for Pediatric Suicide Risk Screening

Suicide rates have been increasing year after year. The pediatric population is quite

vulnerable when it comes to assessment and screening. Current pediatric practice provides a

similar series of questions that adults are afforded when being screened. According to previous

statistics, “suicide rates for females aged 10–14 had the largest percent increase (200%) between

1999 and 2014, tripling from 0.5 per 100,000 in 1999 to 1.5 in 2014” (Curtin, Warner, &

Hedegaard, 2016). The purpose of the paper is identifying the need for improvement in suicide

screening for the pediatric population, recognize high reliability standards, just culture, and how

improving screening methods for pediatric patients will aid in meeting Joint Commission

National Patient Safety Goals.

Needs Assessment

Suicide rates have increased over the last decade. National standards have been initiated

to recognize the need to screen all for risk of suicide. Within acute care hospital setting a series

of three questions are asked on admission to the Emergency Department and all hospital

admissions. The three questions are (1) Do you want to harm yourself or others? (2) Do you feel

safe at home? and (3) Have you had thoughts of hurting yourself? The three questions are

standard questions and age is not considered. It has been found that suicide in adolescent and

teen age groups across the nation rank as the second leading cause of fatality (Centers for

Disease Control and Prevention, 2015).

Per author Michael Bratsis (2015), “for adolescences to the age of 25 years, the growth of

the hippocampus and amygdala, which is the center that allows us to feel and store emotions and

aids in the ability to control impulsivity, tend to mature before the prefrontal cortex does”. The

slow progression of maturity within the prefrontal cortex delays the ability for adolescences and
PEDIATRIC SUICIDE RISK SCREENING 4

teens from making decisions and planning. This places pediatric populations at greater risk of

depression and suicide. As researched by King, Berona, Czyz, Hortwitz, & Gipson (2016),

“approximately one-third of all adolescents in the United States seek emergency services each

year”.

Moreover, adolescents and are the age group most likely to visit Emergency Departments

for self-harm-related visits has multiplied four times over the past two decades (King et al.,

2016). In a 2016 study,”46.5% of the adolescents stated that the purpose of their suicide attempt

was ‘to die’, 28.5% wanted to ‘obtain relief from thoughts’, and 18.5% wanted to ‘show how bad

they were feeling” (Lindgaard et al., 2016). Suicide is a preventable fatality if identified early.

It is important to see how high reliability organizations and changing healthcare culture can help

recognize and impact the adolescent and teen suicide potential.

High Reliability Standards and Just Culture

High reliability organizations (HRO) are always on alert for potential of risk or failure.

Being able to identify small differences among threats may make the difference between

recognizing early or late. Identifying a problem before it is out of control is the optimal scenario

for high reliability organizations (Chassin & Loeb, 2013). Pediatric suicide risk screening that is

age-specific is an early recognition system valuable to acute care hospitals when assessing risk.

Key HRO principles when thinking is, “what could go wrong, a reluctance to

oversimplify complex situations, sensitivity toward operations, a commitment to resilience, and

deference to expertise” (Graban, 2016). Within acute care hospitals especially the emergency

department, when applying the HRO principles to the potential for risk of failure for pediatric

suicide screening, it is clear that the screenings are not age specific. The current screening
PEDIATRIC SUICIDE RISK SCREENING 5

process allots for potential fatal injury. It is important for HRO’s to create a culture that

embraces identification of safety and reporting of identifiable risk.

Per the ANA, “A Just Culture promotes a process where mistakes or errors do not result

in automatic punishment, but rather a process to uncover the source of the error” (ANA, 2010).

The key to a successful, “Just Culture”, is to influence staff expectations and behaviors by

identifying risk in their environment, allowing mistakes to be reported without fear of reprimand,

making safe choices, recognizing the importance of following procedures and policy,

understanding and aligning organizational values, and being honest about actions refraining from

documenting fraudulently (ANA, 2010). Also it is important to have a culture free of threatening

punishment that allows nurses to critically think through and report more potential risk.

Joint Commission National Patient Safety Goal

The Joint Commission standards are “the basis of an objective evaluation process that can

help health care organizations measure, assess and improve performance” (Joint Commission,

2016). A recent standard, National Patient Safety Goal (2017), “Identifying Patient Safety Risk -

find out which patients are most likely to try to commit suicide”, is an initiative that would meet

the goal of identifying pediatric suicide screening and make it more age-appropriate (Joint

Commission, 2016). The standard is an attainable standard that can be measured, reviewed, and

provide an effective outcome to accomplish the standard of care that each patient deserves.

The pediatric population is overlooked when it comes to behavior health concerns within

acute care settings. Many organizations do not provide age-specific education when it comes to

the care of pediatric patients. The risk of suicide is a concern for every patient but the ability to

communicate is key to the success of suicide screening.

PEDIATRIC SUICIDE RISK SCREENING 6

Proposal for Change

The need for an age specific suicide screening is a relevant safety concern for acute care

hospitals. A proposal plan of creation of age specific questions identifying high risk factors

placing pediatrics at risk of committing suicide is ideal. The setting will be two rural hospitals

with 25-30 inpatient beds. The creation of the questions would be reflective of previous studies

with peer review identifying vulnerability of the pediatric population. Because of the varying

acute care settings and the flow of the emergency department setting, it would be ideal for a

minimum of three questions and no greater than five questions to be developed to capture the

pediatric at risk population. A team would be designed of social workers, pediatric emergency

room physicians, pediatric psychiatrists, staff nurses, and community outreach coordinators. The

team would review previous studies and formulate questions according to defined age groups.

The questions would then be trialed within the emergency departments of the two-acute care

hospital to evaluate the potential of success. The measurements that would be collected and

analyzed every three months and follow-up intervention disposition will be evaluated for

success. Many care processes are guided by nursing sensitive indicators.

Nursing-sensitive indicators organize care and stipulate appropriate treatments of care

influence the outcome of patient care (Montalvo, 2007). Pediatric and psychiatric indicators

were not on the list originally but were more recently added. Current National Database of

Nursing Quality Indicators (NDNQI®) do not identify any measurements pertaining to pediatric

suicide rate measurements. A specific measurement that would be beneficial is to identify how

many pediatric patients are screened for suicidal risk. A prediction is that recognition of need

will be identified around the pediatric mental health population and within schools. Growing
PEDIATRIC SUICIDE RISK SCREENING 7

environmental stimulus is feeding the need for evaluation within acute care settings and within

communities.

Ethical Implications

Nurses have an ethical obligation to be a patient advocate. Pediatric nursing has seen its

share of ethical concerns when it comes to parental control. Does the pediatric patient have a

voice and are nurses hearing it?

Suicide is always a sensitive topic but when it comes to the pediatric population it

becomes even more sensitive. Many nurses are concerned with the parent’s response when

asking pediatric patients questions in regards to wanting to harm themselves. Some parents

become extremely upset when you ask children questions that are very point blank when wanting

to end one’s life. Concerns of influencing thoughts to invoke children to take one’s life is the

ultimate concern that faces a parent. Previous studies have debunked this myth but is still a

concern for many nurses. One study conducted found that the participants who were asked a

series of questions that directly asked thoughts of harm, were neither more distressed nor more

suicidal than those who were not. In fact, a study conducted by Friedman found that, “among

high-risk students with a known history of depression or suicide attempts, those who had been

asked about suicidal thoughts and feelings actually felt less depressed and suicidal after the

survey than those who had not been asked such questions” (Friedman, 2006). Nurses have an

ethical right to protect the “little” voices and ask questions that are for the safety and wellness of

the child.

Summary

In summary, it is identified that a need for improvement of pediatric suicide risk

screening and an emphasis on age-specific questions need to be developed to be used within

PEDIATRIC SUICIDE RISK SCREENING 8

acute care hospitals. High reliability organizations play a key role in the development and

surveillance of quality improvement standards. By creating a culture free of punishment it will

aid in improving reporting high risk safety concerns and aid in development of interventions like

the pediatric suicide risk screening. The pediatric suicide risk screening will provide a means to

meet the Joint Commission National Patient Safety Goal of identification of patient risks such as

those most likely to commit suicide. Furthermore, a proposed plan was identified and plan for

implementation. Measurement standards to evaluate success are considered and optimal for

accomplishment. Ethical considerations are clarified and reveal the sensitivity of suicidal

questioning with the understanding of nursing’s responsibility to the minor patient. Suicide is a

difficult topic which nurses have an obligation to be a voice for this vulnerable population.
PEDIATRIC SUICIDE RISK SCREENING 9

References

American Nurses Association (2010). Position statement: Just culture. Retrieved from

http://nursingworld.org/psjustculture

American Psychological Association (2016). Suicide is preventable. Retrieved from

http://www.apa.org/research/action/suicide.aspx

Bratsis, M. S. (2014). Preventing teen suicide. Science Teacher 81(6):14. Retrieved from

http://web.a.ebscohost.com.ezproxy.ferris.edu/ehost/detail/detail?sid=3409ea59-6d3d-

4f82-a22f-

8d0231193db8%40sessionmgr4009&vid=0&hid=4112&bdata=JnNpdGU9ZWhvc3QtbG

l2ZQ%3d%3d#AN=97649448&db=eft

Center for Disease Control and Prevention (2015). Suicide: Facts at a glance. Retrieved from

http://www.cdc.gov/ViolencePrevention/pdf/Suicide-DataSheet-a.pdf

Curtin, S. C., Warner, M., & Hertgaard, H. (2016). Increase in suicide in the United

States,1999-2014 (NCHS Data Brief No. 241). Retrieved from Centers for Disease

Control and Prevention, National Center for Health Statistics website:

http://www.cdc.gov/nchs/products/databriefs/db241.htm

Chassin, M. R. & Loeb, J. M. (2013). High-reliability health care: Getting there from here. The

Milbank Quarterly 91(3): 459-490. Retrieved from

https://fsulearn.ferris.edu/bbcswebdav/pid-1348024-dt-content-rid-

9417320_1/courses/83362.201608/10722.201601_ImportedContent_20151130013507/Hi

gh%20Reliability%20article%20from%20Joint%20Commision.pdf
PEDIATRIC SUICIDE RISK SCREENING
10
Friedman, R. A. (2006). Uncovering an epidemic: Screening for mental illness in teens. The

New England Journal of Medicine 355(26): 2717-2719. Retrieved from

http://www.nejm.org/doi/pdf/10.1056/NEJMp068262

Graban, M. (2016). Lean hospital: Improving quality, patient safety, and employee engagement.

Boca Raton, FL: CRC Press

Joint Commision (2016). Facts about joint commission standards. Retrieved from

https://www.jointcommission.org/facts_about_joint_commission_accreditation_standards

Joint Commission (2016). 2017 Hospital national patient safety goals. Retrieved from

https://www.jointcommission.org/assets/1/6/2017_NPSG_HAP_ER.pdf

King, C. A., Berona, J., Czyz, E., Horwitz, A. G., & Gipson, P. Y. (2015). Identifying

adolescents at highly elevated risk for suicidal behavior in the emergency department.

Journal of Child and Adolescent Psychopharmacology 25(2): 100-108. Retrieved from

http://search.proquest.com.ezproxy.ferris.edu/docview/1664533285?rfr_id=info%3Axri%

2Fsid%3Aprimo

Lindgarrd-Hedeland, R., Teilmann, G., Horby-Jorgensen, M., Rejkjaer-Thiesen, L., & Andersen,

J. (2016). Risk factors and characteristics of suicide attempts among 381 suicidal

adolescents. Acta Paediatrica: Nurturing the Child 105(10):1231-1238. doi:

10.1111/apa.13458

Montalvo, I. (2007). The national database of nursing quality indicators. Online Journal Issues

in Nursing 12(3):2. doi: 10.3912/OJIN.Vol12No03Man02