https://www.infirmiere-canadienne.com/blogs/ic-contenu/2025/05/20/pratiques-exemplaires-pour-prevenir-le-suicide
All patients should feel safe disclosing suicidal thoughts and discussing treatment
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Effective integration of preventive suicide strategies requires that discussion of suicide cannot be relegated to specific mental health areas. Nurses need comprehensive training to assess suicide risk across all health-care settings, from primary care and emergency rooms to medical inpatient services and long-term care facilities.
Takeaway messages
- Suicide is a major cause of premature death, and involves the interaction of a wide range of risk factors such as age, gender identity, deteriorating health, major loss or lack of social support, and financial hardship.
- Research shows that suicide is not reliably predicted or prevented, making it especially important to follow the guiding principles of suicide risk assessment and management to provide the best care possible.
- Nurses are essential in transforming the approach to suicide by using evidence-based practices and patient-centred care to reduce stigma, drive improvement, and promote a strengths-based, collaborative approach that brings hope and leads to better outcomes.
Canadian nurses have the power to make meaningful shifts in the health-care system to ensure that all people feel safe disclosing thoughts about suicide and are open to talking about strategies to address their suicidality.
Courtesy of Michelle Danda
“As the biggest group of health-care providers in Canada, nurses have a key role in destigmatizing suicide, promoting social justice, and implementing evidence-informed standard tools, quality improvement, and research,” Michelle Danda says.
Nurses are also well positioned to address suicide prevention from a population health perspective in which socioeconomic factors and the social determinants of health are explored to ensure a social justice lens through which nurses can be advocates for change.
Suicide is one of the leading causes of death in Canada, claiming 12 people each day. It is the leading cause of death in young adults aged 15–34 years, highlighting the importance of addressing it as both a public health and a social issue (Government of Canada, 2021; Mental Health Commission of Canada, 2024; Public Health Agency of Canada, 2022).
The impacts of suicide cut across diverse groups in Canada, transcending age, ethnicity, and gender, disproportionately affecting certain marginalized groups, including Black, Indigenous, and/or persons of colour (BIPOC), 2SLGBTQ+, and seniors (Public Health Agency of Canada, 2023; Williams et al., 2022).
Canada has a national framework for suicide prevention in which nurses can play an integral role to ensure its success in addressing and reducing death by suicide. In 2019, the Canadian Nurses Association (CNA) endorsed the National Suicide Prevention Action Plan 2024-2027. The focus of these documents is to promote life and research evidence into suicide prevention. The structure of the framework, in particular, is intended to facilitate federal coordination across the continuum of suicide prevention and life promotion.
As the biggest group of health-care providers in Canada, nurses have a key role in destigmatizing suicide, promoting social justice, and implementing evidence-informed standard tools, quality improvement, and research.
De-stigmatization and social justice
Suicide risk assessment is a basic competency for nurses in all areas of care because suicide affects people in all walks of life, from the young to the old, and from urban to rural. The key to building competency and skill in suicide assessment and management is that nurses must be comfortable talking about suicide. This begins with nursing students learning that asking about suicide is an essential nursing skill.
The Canadian Association of Schools of Nursing (CASN) entry-to-practice mental health and addictions competencies for undergraduate nursing education include the ability to identify clients’ emotional, cognitive, and behavioural state, including the potential for suicide.
Effective integration of preventive suicide strategies requires that discussion of suicide cannot be relegated to specific mental health areas. Nurses need comprehensive training to assess suicide risk across all health-care settings, from primary care and emergency rooms to medical inpatient services and long-term care facilities.
Nursing students should also be educated about suicide in their mental health curriculum to ensure their preparedness. Normalizing conversations about suicide enables nurses to embrace their role in de-stigmatizing this often anxiety-provoking issue. The power of destigmatization can enhance access to and equity of care, providing optimal support for those who might otherwise suffer in silence.
Nurses work across the health-care continuum, from public health and community-based primary care settings to acute inpatient and tertiary hospitals. In nursing school, we begin to build skills in assessing and intervening with patients who experience mental health crises such as suicide; this often occurs in the context of a mental health clinical rotation. However, these skills are necessary for any care area in which we interact with patients who may experience suicidal thoughts, including primary care and areas in which patients may receive life-changing diagnoses, such as cancer care.
Mental health nurses who work in specialized services must have more advanced skills in suicide intervention because of the nuances of patients who are either voluntarily presenting to a service because of self-awareness of mental health issues or being admitted to hospital under their provincial or territorial mental health act. Such patients require significant attention because of the imminent risk of suicide, or because they have already attempted suicide.
The population that is missing from this is all those patients who are accessing non-mental health or emergency services, for example, general medicine or oncology. While there is evidence to support an increase in awareness of the mental health impacts on patients diagnosed with life-altering illnesses such as cancer, or on those who are at risk for post-partum depression, the capacity to build the comfort level of nurses in asking difficult questions is not yet there (McInnes et al., 2022).
Implementation of evidence-informed practice: standard tools, assessment, and care planning
Nurses are the most numerous clinicians in the health-care system and spend the most contact time with patients; thus, they are an excellent resource to ask questions about suicidal ideation. Indeed, nurses are obligated to integrate evidence related to suicide into their day-to-day practice.
Suicide risk assessment is helpful at all levels of health-care contact for patients throughout the system, although one tool is no more effective than another (Ryan & Oquendo, 2020; Saab et al., 2022). Integration of standard tools and clear clinician expectations written into hospital and health-care authority policy and guidelines can be useful in normalizing the use of such tools across the care continuum.
Suicide risk assessment can invoke anxiety and discomfort within the clinician, resulting in the avoidance of asking in-depth questions about suicidal thoughts and behaviours (Hawton et al., 2022). This indicates the need to build clinician comfort levels and understanding of how to integrate risk assessment into their practice.
Standard tools may be helpful in structuring assessments and support clear documentation and communication with the health-care team. Structured assessments can also help in collaborative care planning.
In applying standard tools, nurses must understand the range of risk magnitude and communicate this to the health-care team. Factors that trigger suicidal ideation are complex and dynamic because they include broader concepts, such as the social determinants of health (Pirkis et al., 2023).
The answer is not a one-size-fits-all application of tools or assessments; rather, it requires a nuanced approach that builds on the foundational, relational, and caring approach of nursing. Clear communication with patients and across health-care teams is essential to normalizing and effectively integrating a standard approach across all levels of health care.
Nurses bring an important component of building therapeutic, trusting relationships with patients and their families to foster an approach that differs from a traditional medical focus on attempting to predict risk and control factors to mitigate it.
Quality improvement and research: shifting to a relational approach
Nurses approach health-care delivery from a place of compassion, care, commitment, confidence, and competence. Traditionally, suicide prevention in psychiatric practice is based on efforts to predict and manage risk in patients (Hawton et al., 2022; Kessler et al., 2020; Woodford et al., 2019).
Recently updated national guidelines in Norway have been criticized because of an emphasis on standardized risk assessment rather than taking a relational, strengths-based, and culturally responsive, justice-oriented approach (Espeland et al., 2021). Increasing evidence demonstrates the limitations in relying on predication of suicide risk, indicating the need to focus on therapeutic approaches to assessment and risk management (Hawton et al., 2022; Saab et al., 2022).
Nurses have the expertise to embrace this nuanced approach to suicide intervention and treatment because of the nursing perspective. To integrate this approach effectively, nurses can build strong therapeutic relationships, conduct comprehensive assessments, educate patients and families, collaborate with interprofessional teams, advocate for systemic improvements, and incorporate evidence-informed practices.
The main factor in driving risk assessment is to document it in the patient health record, including the stratification of risk as low, medium, or high as a means of preventing legal action in the event of adverse outcomes (Hawton et al., 2022). Examination of evidence shows that many people who die by suicide had recent contact with their health-care provider, and many denied suicidal thoughts when asked by clinicians before their death (Hawton et al., 2022). This finding underscores the need to improve the quality of clinician–patient interactions, because relying solely on discrete risk ratings fails to capture the dynamic, individualized nature of patients and the variability in clinician expertise and health-care setting constraints (Barzilay et al., 2020; Hawton et al., 2022).
However, the little research focused on the patient experience of suicide risk assessment shows that patients do not mind being asked about suicide, but do find formulaic and scripted questions unhelpful and inauthentic, demonstrating that alternative strategies and practices may be beneficial (Hawton et al., 2022). Nurses spend the most time with patients across the care continuum, and thus are well positioned to be leaders in engaging patients and their families in quality improvement projects and collaborative research to learn more about effective prevention strategies and interventions for patients.
Nurses leading change in suicide prevention and intervention
Nurses are considered the first line in suicide prevention because of their position in all levels of health-care services across Canada. As the largest group of health-care providers in Canada, nurses have an integral role in destigmatizing suicide and raising awareness of suicide prevention and treatment as a social justice issue, successful implementation of evidence-informed standard tools, and meaningfully engaging health-care providers and patients in ongoing quality improvement and research to improve the provision of care.
Publicly available, evidence-informed resources that may be of value to nurses include:
References
Barzilay, S., Schuck, A., Bloch‐Elkouby, S., Yaseen, Z.S., Hawes, M., Rosenfield, P., Foster, A., & Galynker, I. (2020). Associations between clinicians’ emotional responses, therapeutic alliance, and patient suicidal ideation. Depression and Anxiety, 37(3), 214–223. https://doi.org/10.1002/da.22973
Espeland, K., Hjelmeland, H., & Loa Knizek, B. (2021). A call for change from impersonal risk assessment to a relational approach: Professionals’ reflections on the national guidelines for suicide prevention in mental health care in Norway. International Journal of Qualitative Studies on Health and Well-Being, 16(1), 1868737. https://doi.org/10.1080/17482631.2020.1868737
Government of Canada. (2021, April 13). Leading causes of death, total population, by age group. Statistics Canada. https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310039401
Government of Canada. (2022). Working Together to Prevent Suicide In Canada—The Federal Framework for Suicide Prevention 2022 Progress Report. Minister of Health. https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/diseases-conditions/2022-progress-report-federal-framework-suicide-prevention/2022-progress-report-federal-framework-suicide-prevention.pdf
Hawton, K., Lascelles, K., Pitman, A., Gilbert, S., & Silverman, M. (2022). Assessment of suicide risk in mental health practice: Shifting from prediction to therapeutic assessment, formulation, and risk management. The Lancet Psychiatry, 9(11), 922–928. https://doi.org/10.1016/S2215-0366(22)00232-2
Kessler, R.C., Bossarte, R.M., Luedtke, A., Zaslavsky, A.M., & Zubizarreta, J.R. (2020). Suicide prediction models: A critical review of recent research with recommendations for the way forward. Molecular Psychiatry, 25(1), 168–179. https://doi.org/10.1038/s41380-019-0531-0
McInnes, S., Halcomb, E., Ashley, C., Kean, A., Moxham, L., & Patterson, C. (2022). An integrative review of primary health care nurses’ mental health knowledge gaps and learning needs. Collegian, 29(4), 540–548. https://doi.org/10.1016/j.colegn.2021.12.005
Mental Health Commission of Canada. (2024, March 1). Public Health and Suicide Fact Sheet. https://mentalhealthcommission.ca/resource/public-health-and-suicide/
Pirkis, J., Gunnell, D., Hawton, K., Hetrick, S., Niederkrotenthaler, T., Sinyor, M., Yip, P.S.F., & Robinson, J. (2023). A Public Health, Whole-of-Government Approach to National Suicide Prevention Strategies. Crisis, 44(2), 85–92. https://doi.org/10.1027/0227-5910/a000902
Public Health Agency of Canada. (2022, December 22). Suicide in Canada: Key statistics (infographic). https://www.canada.ca/en/public-health/services/publications/healthy-living/suicide-canada-key-statistics-infographic.html
Public Health Agency of Canada. (2023, November 14). Suicide, self-harm, and suicide-related behaviours in Canada: Suicide mortality [Datasets; statistics; education and awareness]. Government of Canada. https://health-infobase.canada.ca/mental-health/suicide-self-harm/suicide-mortality.html#sm_trends
Ryan, E.P., & Oquendo, M.A. (2020). Suicide risk assessment and prevention: Challenges and opportunities. Focus, 18(2), 88–99. https://doi.org/10.1176/appi.focus.20200011
Saab, M.M., Murphy, M., Meehan, E., Dillon, C.B., O’Connell, S., Hegarty, J., Heffernan, S., Greaney, S., Kilty, C., Goodwin, J., Hartigan, I., O’Brien, M., Chambers, D., Twomey, U., & O’Donovan, A. (2022). Suicide and self-harm risk assessment: A systematic review of prospective research. Archives of Suicide Research, 26(4), 1645–1665. https://doi.org/10.1080/13811118.2021.1938321
Williams, M.T., Khanna Roy, A., MacIntyre, M.-P., & Faber, S. (2022). The traumatizing impact of racism in Canadians of colour. Current Trauma Reports, 8(2), 17–34. https://doi.org/10.1007/s40719-022-00225-5
Woodford, R., Spittal, M.J., Milner, A., McGill, K., Kapur, N., Pirkis, J., Mitchell, A., & Carter, G. (2019). Accuracy of clinician predictions of future self‐harm: A systematic review and meta‐analysis of predictive studies. Suicide and Life-Threatening Behavior, 49(1), 23–40. https://doi.org/10.1111/sltb.12395
Michelle Danda, RN, PhD, CPMHN(C), graduated from the bachelor of nursing accelerated track program at the University of Calgary in 2008 and recently completed her PhD in doctoral nursing program at the University of Alberta. She is a professional practice initiatives lead in Vancouver, B.C., and practised mental health and substance use nursing through the Lower Mainland, B.C.
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