Purpose: This study investigated evidence of nurses’ congruence with and patients’ experience of suicide risk assessment post implementation of evidence-based practice education.
Methods : This study used a cross sectional, mixed-method, post-intervention (guideline implementation and education) design in which the qualitative and quantitative methods were conceptualized, designed, and implemented within the pragmatist paradigm. This mixed-method design with a complementarity purpose sought elaboration, enhancement, illustration, and clarification of the results from one method with the results from the other approach. Interpretation and meaning was enhanced by via the inherent strengths of each method (quantitative: patient record / documentation audit and qualitative: focus group with RNs and RPNs plus individual interviews with patients), while counteracting the respective inherent methodological biases. Quantitative and qualitative methods were used to measure overlapping but also different facets of the phenomenon, yielding an enriched, elaborate understanding. The expansion purpose was used to measure different and distinct phenomena (i.e. nurses’ and patients’ perceptions of the nursing assessments of patient suicide risk versus documentation of assessment and response to suicidal ideation). This extended the breadth and range of inquiry through different methods for different inquiry components. The triangulation purpose was based on the logic of convergence. This logic required that the quantitative and qualitative methods be different from one another with respect to their inherent strengths and limitations (biases) and that both method types be used to assess the same phenomenon. Data was collected from one acute care and one long term care unit plus the outpatient department. Quantitative Methods: The researchers collected key nurse and patient demographic data to describe the sample. The Principal Investigator and the Co-Principal Investigators conducted patient record audits of nurses’ notes to measure nurses’ suicide risk assessment documentation. The researchers used the audit data from the patient record nurses’ notes instrument, created by the investigators for this study, to measure congruence with the guideline recommendations, via compliance indicators as measured on a 3-point likert scale. The quantitative data was analyzed with SPSS version 20. Qualitative Methods: The Investigators conducted three (3) – 30 minute nurse focus groups (5-7 persons per group) in order to provide adequate time for all participants to contribute and discuss their perceptions of their assessment and documentation of patients’ suicidal ideation and/or behavior. The investigators conducted nine (9) individual out-patient interviews to assess patients’ perceptions of nurses’ assessment of their suicidal feelings and behaviours. Each individual interview required approximately one-half (1/2) hour of each patient’s time. The qualitative data was analyzed using methods consistent with constructivism. Ethics approval was granted from the University and the Health Care Centre.
Results : Thirty-four patient records (long term care n = 15, acute care = 19) were audited for evidence of congruence and/or divergence of suicide risk assessment according to guideline recommendations. Fourteen nurses (female n = 10, male = 4) participated in three focus groups. Nine patients (female n = 6, male n = 3) participated in individual interviews. Data triangulation revealed practice congruence with and divergence from recommendations specific to suicide risk assessment constructs. Descriptive analyses demonstrated that all patient records had at least some dimension of suicide risk assessment documented by nurses. However, nurses more frequently documented patients’ future plans to attempt suicide (100 %) than the suicide plan that prompted admission to hospital (46%), or previous history of suicide attempts (57%). Documentation of suicidal ideation, suicidal behaviour, and suicide attempt method were also less frequent (66%, 78%, 44%, respectively). Documentation of other risk factors for suicide attempts and protective factors against suicide was also less frequently documented (85% and 76% respectively). Thematic analysis of narratives complemented the quantitative results and supported the quantitative evidence that suicide risk was assessed by nurses. However, both patients and nurses described ‘the dance-who will invite whom?’ between them that may facilitate or hinder assessment. This theme may indicate that nurses and patients may be reluctant to approach the other to engage in a conversation about suicidality and timing of that approach was described as similar to the timing involved in an invitation to ‘dance’.
Conclusion: Study findings demonstrate the richness of triangulation of nurse-patient data to evaluate implementation outcomes and understanding of the phenomenon: suicide risk assessment. Although there is substantive evidence from suicide risk assessment documentation as well as nurse and patient experience of such assessments, some crucial dimensions of assessment may not be as fully assessed and documented as appropriate to patient needs. If both patients and nurses experience a tentative approach to each other to discuss this risk dimensions, then critical intervention opportunities to provide safe care may be missed. Issues around this ‘dance’ may be grounded in the foundations of the nurse-patient therapeutic relationship. Therefore, the study highlights the limitations of a linear approach to application of recommendations from one guideline without integration with, reference to, and education of other related guidelines. It also highlights the limits of a purely positivist approach to understanding and applying evidence in practice; and that a more holistic, intuitive approach may be appropriate to complex nursing care (Welsh & Lyons, 2001). This presentation highlights the importance of including the patients’ voices in addition to the nurses’ perspectives to expand upon the traditional, objective metrics in evaluation of evidence-based practices to inform clinicians, educators, and researchers.
Implications: Findings provide direction for guideline education for nurses. Related guidelines, such as a guideline for the nurse-patient therapeutic relationship, need to be considered and included in nursing education of suicide risk assessment. Suicide risk assessment guidelines are not linear per se and need to be taught simultaneously, within the context of holistic patient care. Nursing education and practice need to focus on areas of risk that are less likely to be assessed and documented. Nursing research on evaluation of evidence-based practice needs to include the nurse and patient narratives to more fully understand dimensions of practice. Larger multi-site studies would be beneficial to explore potential, broader similarities and differences across practice settings and demonstrate a global reach to improve risk assessment and suicide prevention.
.