Alan LeFollow

Date of Graduation

Fall 12-17-2021

Document Type


Degree Name

Doctor of Nursing Practice (DNP)


School of Nursing and Health Professions




Psychiatric Mental Health Nurse Practitioner

First Advisor

Dr. Trinette Radasa

Second Advisor

Dr. Alexa Curtis


Background: Patient suicide is a serious safety issue, especially in mental health settings since suicides disproportionately affect psychiatric patients. Environmental hazards are a primary contributing factor in patient suicide cases.

Problem: Mental health staff may lack tools and training to perform proper environmental risk assessments, which is the case at a psychiatric crisis residential center in northern California that utilized no environmental risk assessment tool.

Methods: An environmental risk assessment tool was implemented at the site for four months to increase staff confidence, ability to identify hazards and decrease risk of patient suicides.

Interventions: The Suicide and Self-Injury Patient Checklist (SSIPCL) was implemented, which is an evidence-based tool that has demonstrated efficacy in the standardized identification of hazards and reduction of patient suicide rates.

Measures: Primary outcome measures observed pre and post implementation include patient suicide attempt rate (indicated by 5150 DTS [danger to self] holds placed at the site per month or case of suicidal ideation [SI]). Staff confidence scores were measured in regards to perceived site patient safety and ability to identify environmental hazards.

Results: Patient suicide attempt rate (in holds per month) did not change after implementation, remaining the same at 0.25. For holds placed per case of SI, there was a decrease of 66% (1 to 0.33). There was a marked improvement in staff satisfaction scores.

Conclusions: The SSIPCL can be effective in reducing risk of patient suicide and increasing staff satisfaction in a residential setting, but more research is needed over a longer time span.

Key words: environment, suicide prevention, patient suicide, psychiatric, hazard