POLICIES AND PROCEDURES All inpatient units must have
written and regularly updated policies and procedures for the care of suicidal
patients. These policies and procedures may be understood as addressing four principal
areas of concern: o Environmental precautions o Patient-specific interventions o
Privilege system o Pass system
Environmental Precautions
An inpatient service that can appropriately accept and contain patients judged
to be acutely suicidal must be architecturally equipped for safety (Benensohn
& Resnik, 1973; Kroll, 1978; Schoonover, 1982). Windows must have stops to
keep them from providing an opening through which a person could escape. Safety
screens must be in a place that prevent exit and resist tampering or destruction.
Obviously, all doors and other exits from the unit must be locked, equipped with
an alarm, or staffed by someone who can prevent egress.
Toxic
substances, including detergents and cleaning substances, must be kept in locked
boxes, dispersed in limited quantities, and carefully overseen by the cleaning
staff who bring these substances by cart onto the unit. Bathroom curtain rods
must be designed to break if subject to any significant weight. Closet rods must
also meet this specification. Wooden rods harden with age and can bear more weight,
making J-hooks a desirable alternative (Libby, 1992). Finally, exposed pipes in
low-security areas should be covered or rendered inaccessible.
Units
should consider instituting "environmental rounds," in which clinicians
and members of the plant and operations department inspect the unit. Established
parameters for inspection, including those just mentioned, would be examined and
new problems addressed as they arise.
Patient-Specific
Interventions The most intensive level of intervention is seclusion,
with or without restraint, with either an open or closed door. Highly specific
regulations exist for seclusion and restraint on a state-by-state basis. These
regulations serve as the basis of unit procedural requirements.
An
important unit procedure is the search of the patient's belongings. Sharps (pointed
or bladed instruments) and flames (matches, lighters, and cigarettes) must be
confiscated from the suicidal patient. All patients must surrender prescriptions
and over-the-counter medications. Suicidal patients must surrender any substances
that could be put to deleterious use (e.g., art supplies, detergents, dyes, etc.).
Belts, shoelaces, and other articles of apparel represent dangerous devices for
suicidal patients. However, staff must weigh the danger of these objects against
the dehumanization of stripping patients of everyday elements of attire and convenience.
The
use of the body search should be restricted to patients at high risk for suicide.
A body search is intrusive and potentially humiliating or stimulating to vulnerable
patients. Room searches, on the other hand, may be done with less concern and
are one way the staff can demonstrate their rigor and commitment to safety.
Observation
of the patient is fundamental to all inpatient units and is typically a dimension
of nursing policy and procedure. Increments of observation should be specified
and procedures articulated. One-to-one observation (constant observation) should
be defined as either "at arm's length" (i.e., immediately next to the
patient) or under the continuous eye of the staff. Typical increments of observation
then proceed from 5- to 15- to 30-mm checks. Checks may be recorded either by
staff or by the patient (self-checks), depending on clinical goals. Orders for
intensive observation probably would last no longer than 24 hr and, optimally,
require daily physician examination of the patient.
Supervision
of the patient is different from observation and may warrant its own policy and
procedure. Certain patients may require, for safety, supervision of their use
of sharps and flames. Other patients may not be safe in the kitchen area because
of the many materials and instruments that can be used for self-destruction. Bathroom
use will need to be supervised for all patients who are on one-to-one status and
for some patients who cannot safely be allowed access to pipes, rods, and pools
of water. Finally, some patients may have "open areas" supervision,
which indicates that they are safe in public areas where people are present, but
they cannot be trusted to not secrete themselves away when alone. Staff supervision
can be effective only for limited periods of time (i.e., hours to days) because
of the limited capacity to control anyone, and in fact it should be in place for
only a limited period of time, because prolonged supervision can invite regression.
Privilege
System A privilege system exists on all inpatient units and varies
among hospitals and staffs. Privileges should be clearly defined and require a
physician's order. A typical privilege system spans degrees of freedom from restriction
to the unit, to permission to go off unit if accompanied (by staff or by family/friend),
to permission to go off unit unaccompanied. Some units will differentiate ongrounds
from off-grounds privileges.
By definition, privileges must
be earned. The patient must demonstrate the clinical capacity to merit the lifting
of restriction. Inpatient units are the opposite of a democracy; freedom is not
inherent to life on an inpatient unit, especially for the involuntary or dangerous
patient. Instead, restriction is normative and freedom is granted as a privilege
when the patient has shown alliance, self-control, and responsibility for safety.
The
patient's privileges (and passes) should also be consistent with his or her legal
status. A patient committed to the unit by court order, for example, should have
privileges consistent with the court's action, or there should be documentation
as to why privileges do not conform to the court's order.
Pass
System Two types of passes generally are used: therapeutic and nontherapeutic.
Therapeutic passes are provided to patients so that diagnostic or treatment plans
may be pursued or to test patients' capacity to tolerate increasing degrees of
liberty. Nontherapeutic passes may be offered to allow the patient to care for
everyday needs (car, bank, or shopping) or for recreational purposes (exercise,
entertainment, or socializing). Patients with restricted privileges may receive
therapeutic passes; they should not receive passes for convenience or social purposes.
Passes
may also be accompanied or nonaccompanied. It is important to distinguish accompaniment
for support from accompaniment for safety. Many patients will benefit from pass
accompaniment but will not be unsafe without it. Patients who require accompaniment
for safety (those at risk of escaping or causing themselves harm) should be accompanied
by staff adequate in number and strength to maintain safety.
Summary
No standardized system of policies and procedures exists for the four areas of
concern discussed herein. Each hospital or inpatient unit has its own specific
resources and concerns, making a universal system undesirable. Nevertheless a
core set of policies and procedures is important, for clinical and risk management
purposes, for all facilities. The Harvard University hospitals and the Harvard
Risk-Management Program are in the process of developing such a set of guidelines
for the care of the suicidal patient.
- Leenaars, Antoon, Maltsberger, John
T., & Robert A. Neimeyer, Treatment of Suicidal People, Taylor & Francis:
London, 1994.
Update
Inpatient Suicide in Psychiatric Settings:
Evaluation of Current Prevention Measures
- Chammas, F., Januel, D., & Bouaziz, N. (2022). Inpatient suicide in psychiatric settings: Evaluation of current prevention measures. Frontiers in psychiatry, 13, 997974.
Personal Reflection Exercise Explanation The Goal of this Home
Study Course is to create a learning experience that enhances your clinical skills.
Thus, space has been provided for you to make personal notes as you apply Course
Concepts to your practice. Affix extra Journaling paper to the end of this Course
Content Manual. We encourage you to discuss the Personal Reflection Journaling
Activities, found at the end of each Section, with your colleagues. Thus, you
are provided with an opportunity for a Group Discussion experience. Case Study
examples might include: family background, socioeconomic status, education, occupation,
social/emotional issues, legal/financial issues, death/dying/health, home management,
parenting, etc. as you deem appropriate. A Case Study is to be approximately 150
words in length. However, since the content of these Personal Reflection
Journaling Exercises is intended for your future reference, they may contain confidential
information and are to be applied as a work in progress. You will
not be required to provide us with these Journaling Activities. Only the Test is to be returned to the Institute.
Personal
Reflection Exercise #4 The preceding section contained information
about differentiation of the characteristics of the suicidal crisis. Write three
case study examples regarding how you might use the content of this section in
your practice.
Reviewed 2023
Peer-Reviewed Journal Article References:
LaCroix, J. M., Perera, K. U., Neely, L. L., Grammer, G., Weaver, J., & Ghahramanlou-Holloway, M. (2018). Pilot trial of post-admission cognitive therapy: Inpatient program for suicide prevention. Psychological Services, 15(3), 279–288.
Rath, D., Teismann, T., Schmitz, F., Glaesmer, H., Hallensleben, N., Paashaus, L., Spangenberg, L., Schönfelder, A., Juckel, G., & Forkmann, T. (2021). Predicting suicidal behavior by implicit associations with death? Examination of the death IAT in two inpatient samples of differing suicide risk. Psychological Assessment, 33(4), 287–299.
Rufino, K. A., Daruwala, S. E., & Anestis, J. C. (2021). Predicting suicide attempt history in a psychiatric inpatient sample: A replication and extension. Psychological Assessment, 33(7), 685–690.
QUESTION
12 According to Leenaars, what is the most intensive level of intervention
in a suicidal crisis? Record the letter of the correct answer on the Test.