Date of Graduation
Doctor of Nursing Practice (DNP)
School of Nursing and Health Professions
Psychiatric Mental Health Nurse Practitioner
Dr. Trinette Radasa
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
Le, Alan, "Implementation of a Mental Health Environmental Risk Assessment Tool" (2021). Doctor of Nursing Practice (DNP) Projects. 272.