For World Suicide Prevention Day, we reached out to Claudia Tindall and Kathy Ryan, two clinicians who were responsible for developing and implementing CAMH initiatives focused on suicide prevention.
Please describe your role at CAMH
Kathy: Claudia and I are Advanced Practice Clinicians at CAMH. Claudia is a master’s prepared social worker by training, and I am a master’s prepared registered nurse. We each provide clinical practice support for different client populations with mental health and addictions issues. As Advanced Practice Clinicians, we are involved in a variety of activities such as patient safety quality improvement initiatives, clinical program planning, developing and implementing evidence based practices, supervision of masters students, to name a few.
From 2012-2015 we led the working group that implemented the Registered Nurses Association of Ontario (RNAO) best practice guideline “The Assessment and Care of Adults at Risk for Suicidal Ideation and Behaviours.” This was one of several RNAO Best Practice Guidelines (BPG) that were implemented over 3 years and led to CAMH receiving the designation as a RNAO Best Practice Spotlight Organization in 2015.
Since 2011, CAMH has stepped up its strategy on suicide prevention. Can you explain your involvement in this initiative?
Claudia: In preparation for the CAMH Accreditation in 2011, I participated in a working group who developed a number of resources and educational materials for clinicians focusing on suicide prevention. These included a Suicide Prevention and Assessment Handbook, an e-learning for clinicians, and an educational toolkit. This information as well as education sessions and presentations were provided to all staff.
Kathy: Since then, the strategy on suicide prevention has been enriched by implementing the RNAO Best Practice Guidelines on Suicide Risk Assessment and Care of Adults at Risk, and creating a standardized form for the documentation of suicide risk assessments for our electronic heath record, I-CARE.
The BPG working group developed three education modules that addressed Suicide Awareness, Suicide Risk Assessment, and Care Planning and Intervention. These were delivered to clinical teams by 80 champions who were front-line clinicians from various disciplines.
In addition, we developed an educational tool kit for nurse educators that supplemented the modules, and a tent card that provides visual reminders for staff of key areas of assessment. There has been a large focus on education of clinicians both broadly in the organization and at the team level. A Suicide Risk Assessment documentation form was also developed as part of the BPG implementation. This assessment form captures the key components of a suicide risk assessment and is based on best practices described in the literature.
It is not always apparent when a person is at risk for suicide. What are you looking when assessing suicide risk?
Claudia: A suicide risk assessment needs to be carried out in a systematic manner, avoiding guesses and relying on intuition.
To begin with, it is very important to engage the person in an empathic and non-judgmental manner. A thorough suicide risk assessment includes asking directly about suicidal thoughts and behaviours, for example, the presence of a plan, and if so, the method and whether there is access to means, how lethal the plan is, whether any attempts have been made and the details of those.
It’s important to assess warning signs, risk factors and protective factors. Examples of warning signs are talking about ending one’s life, seeking access to means, expressing a plan, impulsivity, withdrawing from others and hopelessness. Risk factors can be psychosocial, such as previous attempts, psychiatric illness, history of trauma and few supports.
It is important to note that a previous attempt doubles the risk for suicide in the year following the attempt when compared with the general population.
Other risk factors can be a medical illness, chronic pain, ‘all or nothing’ thinking, or a history of suicide in the family.
We also know that certain populations may be at increased risk. Examples are adolescents, the elderly, aboriginal or LGBT. While all age groups can be at risk, it is important to highlight that in the Canadian context, the age group between 40 to 59 (mid-life) carries the highest rates.
Protective factors are all those that create meaning in a person’s life, such as a strong connection with family, responsibility for children and future orientation.
Other areas to think about when conducting a suicide risk assessment are related to the client’s psychiatric illness, history, strengths and vulnerabilities, psychosocial situation and current symptoms. Getting information from others such as family members, friends and other care providers is also critical to a thorough assessment.
People who are really determined to end their life may not share how they are feeling with health care professionals, however they may have given clues or spoken with others. All care providers and family members should also be aware that changes and transitions in care, such as discharge from hospital, are times when individuals at risk for suicide need to be monitored more closely. After carefully reviewing all information gathered we estimate the client’s level of risk and plan care accordingly. Planning care may include working with the client to develop a safety plan, develop coping strategies and selecting the care environment based on the client’s level of risk.
It is known that having a mental illness is an important risk factor for suicide. This makes your work all the more important in a setting such as CAMH. How do you ensure that clinicians are well equipped to recognize potential signs?
Claudia: A lot of effort has been put into educating clinicians so they know what to look for. With the implementation of the BPG on assessment and care of adults at risk for suicide, we created a solid foundation to enhance clinician skill in awareness, assessment and care planning. The education on assessment included warning signs and risk factors along with how to carry out a suicide inquiry.
As Kathy mentioned, the introduction of CAMH’s Health Record system, I-CARE, offered a unique opportunity to create a documentation form based on best practices. This ensures that CAMH documentation standards are based on a thorough review of the existing literature in the field.
To optimize the introduction of the Suicide Risk Assessment form, practice guidelines and expectations were created. The guidelines outline the points in care when a suicide risk assessment must be conducted— for example a suicide risk assessment needs to be completed within 24 hours of an inpatient admission.
How does CAMH mitigate the risk of suicide in its client population, and what steps have been taken so far to decrease the potential for suicide?
Kathy: Education is an important part of it, as we’ve described. Clinical staff require knowledge and skills in assessing risk, so knowing how to do a suicide risk assessment is critical, so we can identify people at risk.
Sometimes hospitalization may be needed, or the client may receive care as an outpatient, depending on how high the level of risk. To guide clinicians, we have developed a standardized Suicide Risk Interdisciplinary Plan of Care based on best practices that includes interventions aimed at preventing suicide in both in-patient and out-patient settings.
Interventions specific to individual clients can also be added to their hospital record. Examples of interventions include developing a therapeutic relationship, monitoring level of risk, developing a Safety and Comfort Plan, addressing acute stressors, exploring the person’s reasons for living, and ensuring the environment is safe.
Not only is it important to understand why the client wishes to end their life or has made an attempt, it is important to explore their “reasons for living”. Most people who consider suicide experience ambivalence about it. So through the process of exploring and identifying reasons for living, we build on them and strengthening them. Equally important is treating symptoms of their illness. A worsening in symptoms of mental illness and/or addictions is a risk factor so often medications or other biological therapies are used together with counselling.
The Safety and Comfort Plan I mentioned is developed in collaboration with the client. This is the client’s safety plan. It captures the client’s perspective on how they experience distress, things that trigger distress for them, what helps them feel more in control, and ways in which they cope. There are prompts in the plan for the clinicians that suggest different strategies to explore with the client. There is a list of community resources and websites in the plan. This is an empowering process and can lead to new ways of coping that can be used when they are in distress or suicidal. This plan can be printed out so the client has a copy of it.
Effective teamwork and good communication is critical to ensuring client safety and helps mitigate risk. With transfers in care being vulnerable times for clients, ensuring we provide a thorough handover to the next care provider is crucial. Introducing an evidence-based framework helps clinicians focus on the most relevant information when transferring care to improve safety.
Another way in which we address risk is by building safety alerts or flags into the electronic health record. An example of one we’ve done is an automatic flag to the clinician to initiate the Suicide Risk Care Plan when moderate or high suicide risk is documented in the Assessment.
So there are many different ways in which we mitigate risk in our client population and ways in which we are reducing the potential for suicide —ongoing education of clinicians, thorough assessments, effective interventions, receiving feedback on how we are performing — and remembering that developing a therapeutic relationship with the client is central to all of our interventions. This is where healing begins.
Since embarking on this initiative, what are some of the accomplishments you are particularly proud of?
Claudia: We are particularly proud of the work of the interprofessional team members who participated in our working group. They were a very dedicated group of staff who were very passionate about the important work we were doing in this area. We are also extremely proud of the 80 champions who introduced the three education modules at the service level. This made it a real grass roots approach which was successful in creating awareness and decreasing stigma.
We also encouraged clinicians to be aware of the language they used to discuss issues related to suicide. Instead of the phrase to “commit suicide” we encouraged staff to use language such as “died by suicide” which is less stigmatizing and addresses the negative association between suicide and “crime”. The implementation of the best practice guideline created a foundation for ongoing discussion and dialogue which continues to this day.
One of the other things we are really proud of is that this work has really put the issue of suicide prevention on everyone’s radar, in all of the ways we’ve touched upon. And we’ve been able to continue our work, which is work that we are very passionate about. For example, by enhancing the Suicide Risk Assessment documentation form in I-CARE to make it more “user friendly” for clinicians, improving on the interdisciplinary plan of care for suicide risk and providing refresher education sessions for staff.
September 10 is Suicide Prevention Awareness Day. Can you share any tips for those who might know someone who is contemplating suicide, in order to prevent it?
Kathy: Reach out to that person, let them know you are there to help.
Understand that they are in pain and suffering to such an extent that they are considering suicide. Listen to them. Support them. Don’t judge. There’s still a lot of stigma attached to suicide and they may be afraid to talk about it. Ask them what has stopped them so far from hurting themselves or ending their life. Maybe it’s important people in their lives, children, spiritual beliefs and so on. Emphasize how important it is that they continue to live, that others would be devastated without them, including you.
There is always hope. Let them know you care and encourage them to get help. Offer to go with them to get help….
The theme of World Suicide Prevention Day essentially sums it up… Connect, Communicate and Care.