Suicide Prevention: Warning Signs, the Safety Plan, and Lethal Means Safety

Who needs this teaching

Clients with suicidal ideation, a recent suicide attempt, or a positive suicide risk screening, and the family or support person. Teach before discharge from the emergency department or psychiatric unit. The first weeks after discharge are a period of high suicide risk. Risk factors include a previous attempt, depression, substance use, chronic pain, recent loss, social isolation, and access to firearms.

The priority teaching points

1. Warning signs. Verbal signs include talk of wanting to die, hopelessness, feeling trapped, and feeling like a burden. Behavioral signs include searching for a means, giving away possessions, saying goodbye, withdrawal from others, increased alcohol or drug use, and reckless behavior. A sudden calm after severe depression indicates a possible decision to act.
2. Ask directly. Teach the family to ask, "Are you thinking about suicide?" Asking directly does not increase suicide risk. Listen without judgment. Never promise to keep suicidal thoughts a secret.
3. The written safety plan. The nurse and client write the plan together, in the client's own words. It lists personal warning signs, internal coping strategies, people and places that provide distraction, people to ask for help, and professionals and crisis lines to contact. The client keeps a copy in the phone and wallet. A safety plan replaces a no-suicide contract; no-suicide contracts do not prevent suicide.
4. Lethal means safety. Firearms account for more than half of suicide deaths in the US. During the period of risk, store firearms outside the home with a trusted person. Otherwise store them unloaded and locked, with ammunition locked separately. Lock up medications, keep only small supplies, and dispose of unused drugs. Remove alcohol from the home.
5. Crisis contacts. Call or text 988, the Suicide and Crisis Lifeline in the US, 24 hours a day. Veterans press 1 after dialing. Call 911 for immediate danger. Never leave a person at immediate risk alone.
6. Treatment adherence. Keep the first follow-up appointment, ideally within 7 days of discharge. Take medications as prescribed. During early antidepressant treatment, energy returns before mood improves. Avoid alcohol and drugs; they increase impulsivity.

Red flags the client or family reports

Teach-back questions

• "What warning signs tell you a crisis is starting?"
• "Name two things you will do on your own to cope."
• "Who will you call first, and what is the crisis number?"
• "Where will the firearms and extra medicines be kept?"
• "What will you do if your son tells you he has a plan?"

Teaching tips

• Write the safety plan with the client; never hand over a blank form.
• Enter 988 and the support people's numbers into the client's phone before discharge.
• Ask about firearms in every home where the client stays, and include the family in lethal means counseling.
• Use the word "suicide" directly; it shows the client that the topic is safe to discuss.

Read more on NCLEXPace

• Suicide Risk: What the NCLEX Expects You to Do
• Therapeutic Communication: The Answer Patterns That Win

Sources

• Stanley B, Brown GK. Safety Planning Intervention: A Brief Intervention to Mitigate Suicide Risk. Cogn Behav Pract. 2012;19(2):256-264.
• Stone DM, Holland KM, Bartholow B, Crosby AE, Davis S, Wilkins N. Preventing Suicide: A Technical Package of Policy, Programs, and Practices. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2017.
• The Joint Commission. R3 Report Issue 18: National Patient Safety Goal for Suicide Prevention. The Joint Commission; 2018.
• Halter MJ. Varcarolis' Foundations of Psychiatric-Mental Health Nursing: A Clinical Approach. 9th ed. Elsevier; 2022.