Development and Evaluation of a Guideline
for Nursing Care of Suicidal Patients
With Schizophrenia ppc_239
Esther L. Meerwijk, RN, MSc, Berno van Meijel, RN, PhD, Jan van den Bout, PhD, Ad Kerkhof, PhD,
Wim de Vogel, RN, and Mieke Grypdonck, RN, PhD
PURPOSE. The purpose of this study was to
develop and test an evidence-based guideline that
would support nursing care for suicidal patients
with schizophrenia.
DESIGN AND METHODS. Systematic review of the
literature and consultation of experts preceded
completion of the guideline. Twenty-one nurses
from two mental health institutions tested the
guideline for feasibility in nursing practice.
FINDINGS. The guideline was found to support
discussing suicidality with patients and
assessing suicide risk. Participants endorsed
implementation of the guideline in mental
health care.
PRACTICE IMPLICATIONS. Nurses who care for
patients with schizophrenia are advised to use
this guideline as a foundation for their care.
Search terms: Guideline, nursing assessment,
schizophrenia, suicide
* Previously, Junior Researcher, Julius Center for Health
Sciences and Primary Care, Department of Nursing
Science, University Medical Center Utrecht, Utrecht, The
Netherlands.
First Received February 13, 2009; Final Revision received July 7,
2009; Accepted for publication July 23, 2009.
Perspectives in Psychiatric Care Vol. 46, No. 1, January 2010
65..73
Esther L. Meerwijk,* RN, MSc, is a Doctoral Student at
the University of California San Francisco, School of
Nursing, San Francisco, CA, USA; Berno van Meijel,
RN, PhD, is a Professor of Mental Health Nursing and
Director of the Research Group Mental Health Nursing,
INHolland University for Applied Sciences, Amsterdam,
The Netherlands; Jan van den Bout, PhD, is a Professor of
Clinical Psychology, Department of Clinical and Health
Psychology, Utrecht University, Utrecht, The
Netherlands; Ad Kerkhof, PhD, is a Professor of Clinical
Psychology, Psychopathology and Suicide Prevention,
Department of Clinical Psychology, EMGO+ Institute,
Vrije University, Amsterdam, The Netherlands; Wim de
Vogel, RN, is Team Leader, Center of Expertise on
Psychotic Disorders, Dimence Mental Health Care Center,
Deventer, The Netherlands; Mieke Grypdonck, RN, PhD,
is a Professor of Nursing Science, Julius Center for Health
Sciences and Primary Care, Department of Nursing
Science, University Medical Center Utrecht, Utrecht, The
Netherlands.
D iscussing suicidality and assessing suicide risk
are challenges mental health nurses face in their
care of patients with schizophrenia. Evidence-based
guidelines are available that support the care for
patients with schizophrenia (American Psychiatric
Association, 2004; National Steering Committee on
Multidisciplinary Guideline Development in Mental
Health Care, 2005) and for suicidal patients in general
(American Psychiatric Association, 2003). However,
aspects of nursing care for suicidal patients with
schizophrenia are addressed only to a limited extent
in these guidelines.
Suicidality, which is defined here as any thought or
action that relates to a self-inflicted death, is a frequent
phenomenon among patients with schizophrenia.
According to the Practice Guideline for the Assessment
and Treatment of Patients with Suicidal Behaviors (Ameri-
can Psychiatric Association, 2003), 40–53% of patients
with schizophrenia think about suicide at some point
in their lives, and 23–55% actually engage in a suicide
65
Development and Evaluation of a Guideline for Nursing Care of Suicidal Patients With
Schizophrenia
attempt. The lifetime risk of suicide in schizophrenia
is estimated to be about 5% (Palmer, Pankratz, &
Bostwick, 2005). These figures indicate that mental
health nurses who take care of patients with schizo-
phrenia are likely to be confronted with patients who
are thinking about suicide and demonstrate suicidal
behavior.
Mental health nurses often do not actively discuss
suicidal thoughts with their patients. In a study by
Talseth, Lindseth, Jacobsson, and Norberg (1999),
nurses at a psychiatric inpatient unit often avoided the
subject, although their suicidal patients expressed a
need for them to be present and listen. Another study
reported that psychiatric nurses need more training in
verbal communication skills with respect to discussing
suicidality (McLaughlin, 1999). Sun, Long, Boore, and
Tsao (2005) reported a need for advanced communica-
tion qualities to effectively assess suicidal patients and
maintain a therapeutic relationship. A need for training
with respect to risk assessment leading to evidence-
based interventions and meaningful responses to
people who are suicidal was also expressed by
Cutcliffe and Stevenson (2008).
During personal communication of one of the
authors with nurses from the field, nurses mentioned
emotional unrest caused by the lack of a standard of
care for the suicidal patient. This appeared to be
especially true shortly after a patient committed or
attempted suicide. Suicidality is a subject that neither
nurses nor patients bring up easily. However, by avoid-
ing the subject, patients are left with tormenting
thoughts. This adds to feelings of isolation, which is a
major problem in patients with schizophrenia (Ameri-
can Psychiatric Association, 2004).
Because no evidence-based guideline existed to
support nurses in their care for suicidal patients with
schizophrenia, a guideline was developed and tested.
The general purpose of this guideline was to enhance
mental health nurses’ competence to provide care
to suicidal patients with schizophrenia or related
psychotic disorders. More specifically, the aim of
the guideline was to support registered nurses and
66
licensed practical nurses with respect to: (a) discussing
suicidality with the patient, (b) assessing suicide risk,
and (c) selecting and performing appropriate nursing
interventions. Through enhancing nursing compe-
tence, it is expected that the guideline will contribute
to filling the patients’ needs to discuss suicidality,
and to improved assessment of suicide risk. It is also
expected that the guideline will contribute to work
satisfaction of nurses because of enhanced competence
in caring for suicidal patients.
This article describes the development of the guide-
line and provides a brief overview of the guide-
line itself. In addition, the results of a pilot study
are presented. The purpose of this pilot study was to
evaluate the guideline for clinical usability in nursing
practice.
Guideline Development
The objective was to develop a nursing practice
guideline based on existing evidence and best prac-
tice. Therefore, a literature review was conducted
using suicide, risk factor, risk assessment, and schizophre-
nia as search terms. Literature databases that were
accessed included: Medline, EMBASE, CINAHL, Psy-
cINFO, and Cochrane. English literature concerning
reviews and intervention studies published between
1990 and June 2007 was included. Exclusion criteria
were medication studies, articles about biological
psychiatric topics, and articles concerning child and
adolescent populations. Literature that remained after
application of these criteria provided the basis for an
initial draft of the guideline. The most important
sources of literature used to develop the guideline
were the Practice Guideline for the Assessment and
Treatment of Patients with Suicidal Behaviors (American
Psychiatric Association, 2003) and a systematic review
of risk factors for suicide and schizophrenia by
Hawton, Sutton, Haw, Sinclair, and Deeks (2005).
Dutch literature was used as well for the initial draft,
in particular the Dutch Multidisciplinary Guideline
Schizophrenia (National Steering Committee on
Perspectives in Psychiatric Care Vol. 46, No. 1, January 2010
Multidisciplinary Guideline Development in Mental
Health Care, 2005).
The guideline, Nursing Care of Suicidal Patients with
Schizophrenia or Related Psychotic Disorders, consists of:
(a) part A: theoretical background and recommenda-
tions, (b) part B: data collection and interventions, (c)
basic suicidality assessment (SA), and (d) advanced
SA. Parts A and B provide background information
and instructions for usage. The basic SA and advanced
SA are working documents that nurses can use in clini-
cal practice. In order to meet current standards, the
guideline was set up to comply with the AGREE instru-
ment for the appraisal of guidelines (The AGREE
Collaboration, 2001).
Part A of the guideline is predominantly derived
from the Practice Guideline for the Assessment and Treat-
ment of Patients with Suicidal Behaviors (American Psy-
chiatric Association, 2003) and provides information on
risk factors for suicide in the general population, risk
factors for suicide in patients with schizophrenia, and
on psychiatric management of patients who suffer
from suicidality. Part A concludes with general recom-
mendations for clinical practice. In part B, these recom-
mendations are translated into a guideline specifically
for nursing practice. Part B describes the underlying
principles and conditions in order to use the basic SA
and the advanced SA effectively. Furthermore, part B of
the guideline describes how suicide risk is evaluated
from the information collected and how nurses can
intervene to reduce the risk for suicide and improve
the patient’s quality of life.
The basic SA and advanced SA are constructed
around the evidence-based risk factors and protective
factors for suicide as described in part A of the guide-
line. Nurses are encouraged to discuss suicidality
openly, with an accepting and empathic attitude
(American Psychiatric Association, 2003; Talseth et al.,
1999), and patients must feel that speaking about sui-
cidality is acceptable and can be done without fear of
judgment. From the notion that nurses should be non-
judgmental follows that suicide should not be com-
pletely rejected as an option to the patient. The
Perspectives in Psychiatric Care Vol. 46, No. 1, January 2010
guideline promotes to assess suicidality in a naturally
flowing conversation rather than by asking items from
a standard instrument. These important underlying
principles for the SAs were supported by a multidisci-
plinary panel of experts selected on the basis of indi-
vidual experience with suicidality and schizophrenia.
This panel comprised four mental health nurse special-
ists, four patients from a patient support organization,
a psychiatrist, and a psychologist.
In order to support nurses in their communication
with patients, the basic SA and advanced SA contain
examples of questions and phrases that can be used
when discussing suicidality with patients. It is essen-
tial that nurses adapt these examples to their personal
communication style, the actual situation of the patient,
and their specific relationship with the patient. Further-
more, both assessments provide the opportunity to
score risk factors on an ordinal scale ranging from 0 to
2, with 0 indicating the absence of a risk factor, and 2
indicating the presence of a risk factor.
The basic SA uses several items from the Scale for
Suicide Ideation (Beck, Kovacs, & Weissman, 1979) and
provides a means to establish suicidality relatively
quickly. Topics include: quality of life; reasons for
living; reasons for not wanting to live; and suicidal
thoughts, behavior, and intent. The following example,
taken from the basic SA, illustrates the kind of ques-
tions and the principle of scoring the risk factors.
Have you ever felt the desire to harm yourself, for
instance by taking a lot of drugs or dangerous
behavior in traffic?’
Has the patient recently felt the desire to attempt
suicide (either active or passive)?
0. no
1. yes, weakly
2. yes, strongly
The advanced SA is used only when a nurse actu-
ally knows a patient suffers from suicidality, or when
the basic SA leads to the conclusion that this might be
the case. Contrary to the basic SA, the advanced SA is
67
Development and Evaluation of a Guideline for Nursing Care of Suicidal Patients With
Schizophrenia
geared toward schizophrenia and explores suicidality
and schizophrenia-related issues in more detail. The
advanced SA covers the following domains: (a)
suicidal thoughts and behaviors, (b) consequences of
schizophrenia, (c) psychosocial factors, (d) psycho-
logical and cognitive factors, (e) substance abuse, and
(f) physical disorders. The objective of the advanced
SA is to enable a more accurate assessment of suicid-
ality and suicide risk, and to obtain patient informa-
tion that will enable development of a patient-tailored
suicide intervention plan. This intervention plan
aims to support the patient in coping with his or her
suicidal thoughts and to improve the patient’s quality
of life.
Evidence for effective nursing interventions is
lacking for suicidal patients with schizophrenia. There-
fore, the interventions in the guideline are based on
what is described in other guidelines (American Psy-
chiatric Association, 2003; National Steering Commit-
tee on Multidisciplinary Guideline Development in
Mental Health Care, 2005) and what was considered
good clinical practice according to members of the
expert panel. Interventions with respect to safety of
patients include: keep contact regularly, make clear
when you will see or contact the patient again, limit
access to lethal means, set up a crisis response plan
(Rudd, Mandrusiak, & Joiner Jr., 2006), and consider
admission to an inpatient unit. Other interventions
include: provide psycho-education, assist in activities
of daily living, mobilize social support system, support
in solving problems, and provide education about
rehabilitation programs and buddy programs. Because
of the severe nature of suicidality, it is of paramount
importance that co-workers in nursing and other dis-
ciplines are consulted to discuss appropriate interven-
tions in order to guarantee that the best possible care is
given.
The initial draft of the guideline was reviewed for
validity and completeness by the panel of experts.
Semistructured interviews were conducted with the
professional experts on an individual basis. The
patients who took part in the expert panel were inter-
68
viewed as a group. Topics for these interviews were:
the specific content of the guideline, potential of the
guideline to achieve the intended goals, clinical usabil-
ity of the guideline, and clarity and readability of the
guideline. The interviews were audiotaped and tran-
scribed for analysis.
A qualitative analysis of the interview transcrip-
tions was performed. Suggestions for modification of
the guideline were assigned a level indicating the
necessity for modification (level 1: compulsory; level
2: will improve the guideline; level 3: suggested but
not required). Members of the expert panel could
review suggestions made by all other panel members
and provide feedback on the modifications as pro-
posed by the authors. Based on feedback of the expert
panel, a revised version of the guideline was pre-
pared for the pilot study. The same panel of experts
reviewed the final version of the guideline, which
included modifications based on results from the
pilot study.
Pilot Study Method
The pilot study involved 21 mental health nurses
and community mental health nurses from two purpo-
sively selected mental health institutions in The Neth-
erlands: one located in a large city, and the other in
a rural area of the country. After approval from the
institutions’ medical and ethical review boards was
obtained, nurses from eight inpatient and outpatient
units self-selected to participate in the pilot study. The
average experience of the nurses with suicidal patients
was 11.2 years (SD = 7.2 years).
During two half-day sessions, participating nurses
from both institutions were trained to use the guide-
line. Subsequently, they used the guideline to conduct
SAs and develop suicide intervention plans for
patients from their caseloads, during a period of 5
months. The completed SAs and intervention plans
were collected. Group interviews with the nurses were
conducted twice at both locations: halfway and at the
end of the 5-month period. These interviews were
Perspectives in Psychiatric Care Vol. 46, No. 1, January 2010
Table 1. Nurses’ (n = 17) Responses to the Pilot Test Questionnaire

M
(range 1–5)* SD

Discussing suicidality with patients

The guideline supports discussing suicidality. 4.00 1.06
The example questions and phrases in the basic suicidality assessment (SA) 3.82 1.02
are useful.
The example questions and phrases in the advanced SA are useful. 3.59 1.00
Because of the guideline, I am more active in discussing suicidality. 3.06 0.90
Assessment of suicide risk
The guideline supports assessment of suicide risk. 3.94 0.56
The guideline enables assessment of suicide risk 3.35 0.79
Selecting and performing interventions
The guideline supports in selecting interventions. 3.53 0.80
The guideline supports in performing interventions. 3.12 0.70
Using the guideline results in appropriate interventions. 3.38 0.72
Using the guideline results in interventions that are realistic and attainable. 3.41 0.71
Usability of the guideline
I would recommend this guideline for nursing practice. 3.76 0.97
The basic SA is usable at my institution. 3.76 1.03
The advanced SA is usable at my institution. 3.41 0.94
Part A contains useful background information. 3.88 0.86
The guideline improved my caring for suicidal patients. 3.00 0.87
Secondary outcomes of the guideline
The guideline improved my caring for family and friends of suicidal patients. 2.69 0.60
Because of the guideline, the communication between nurses and patients has 2.76 0.66
improved.
Because of the guideline, interdisciplinary communication about suicidality 2.65 0.61
has improved.

*1, do not agree at all; 2, do not agree; 3, do not agree/agree; 4, agree; 5, fully agree.

audiotaped and summarized for analysis purposes. Pilot Study Results

The summaries focused on topics relevant to usability
of the guideline, observed patients’ responses, and
implementation issues with respect to current practice.
Content analysis of the interview summaries, SAs, and
intervention plans was performed.
In addition to these qualitative data, quantitative
data were collected by means of a questionnaire (see
Table 1) that the nurses filled in after the pilot study. A
symmetrical 5-point Likert scale was used ranging
from 1 (do not agree at all) to 5 (fully agree).
The number of SAs and intervention plans com-
pleted during the pilot study are shown in Table 2.
From this table, it can be seen that the basic and
advanced SA and intervention plans were not
completed by all nurses. The reasons nurses men-
tioned for not applying the guideline were positive
symptoms of schizophrenia and low verbal intelli-
gence of the patients, which hindered communica-
tion. Furthermore, the nurses thought it better to

Perspectives in Psychiatric Care Vol. 46, No. 1, January 2010 69

Development and Evaluation of a Guideline for Nursing Care of Suicidal Patients With
Schizophrenia
Table 2. Number of Suicidality Assessments (SAs)
and Intervention Plans That Were
Developed Based on the Guideline During
the Pilot Study
Done by
Total number
number of nurses
Basic SAs 37 15
Advanced SAs 14 9 Memorizing the items enabled the nurses to integrate
Intervention plans 4 4
refrain from assessing suicidality when patients were
focusing on rehabilitation (e.g., restoring independent
living, employment, study).
During the interviews, nurses indicated that the
patients’ responses to application of the guideline
were very positive. Although speaking about their
suicidality had not been easy for the patients (more
than once they reacted emotionally to the questions),
they expressed appreciation for having been given
the opportunity to talk about suicidality and related
issues. One patient responded that it was the first
time someone had asked about suicidal thoughts, and
that he had found it difficult to bring up the issue
himself.
Seventeen of the participating nurses filled in
the questionnaire after the pilot study. Table 1
shows their responses (average ratings and standard
deviation). The remainder of the results of the
pilot study are described in relation to the topic areas
that were covered by the questionnaire. Where appli-
cable, average questionnaire ratings are indicated in
the text.
Discussing Suicidality with a Patient
The interview data revealed that the guideline
made nurses more aware of the issue of suicidality.
Nurses mentioned that they were more alert to risk
70
factors for suicide and tended to respond more thor-
oughly to patient symptoms indicative of suicidality.
They scored slightly above neutral about whether
the guideline made them more active in discussing
suicidality (rating 3.06). The nature of the items in
both SAs enabled discussion with patients. The use-
fulness of the example questions and phrases in the
assessments was rated quite positively at 3.82 and
3.59 for the basic SA and advanced SA, respectively.
them into a natural conversation. The overall poten-
tial of the guideline to support nurses in discussing
suicidality with patients is reflected in a rating
of 4.0.
From the interviews, it became clear that some
nurses experienced difficulty in adapting the wording
of the example questions and phrases to their personal
communication style and the actual situation of the
patient. The interviews also made clear that many
nurses did not discuss suicidality with patients if there
were no apparent signs of suicidality. In fact, some
nurses mentioned that they found it difficult to ask a
patient about suicidal thoughts if there were no clear
signs of suicidality.
Assessing Suicide Risk
The ratings from the questionnaire with respect to
assessment of suicide risk were 3.94 for “the guideline
supports assessment of suicide risk” and 3.35 for “the
guideline enables assessment of suicide risk.” During
the interviews, the nurses did not mention any diffi-
culty assessing suicide risk.
Selecting and Performing Interventions
Because only four nurses developed an interven-
tion plan based on the guideline, interventions were
not discussed in detail during the interviews. Some
nurses mentioned that they did develop an interven-
tion plan, but that it was structured in accordance
with the format used within their organization. These
Perspectives in Psychiatric Care Vol. 46, No. 1, January 2010
intervention plans were not part of the data that were
collected for the pilot study.
The quantitative data showed that the nurses were
positive about the interventions in the guideline and
the proposed procedure of selecting appropriate inter-
ventions (3.38–3.53), although they had not all had the
opportunity to actually develop an intervention plan.
The potential of the guideline to support in the actual
performance of the interventions was rated only
slightly less at 3.12.
Usability of the Guideline
Although there was considerable spread in opinions
about usability, the overall rating of the nurses who
expressed their opinions about implementing the
guideline in mental health nursing practice was posi-
tive (rating 3.76). From the interviews, it became clear
that the nurses were especially positive about the basic
SA. This appreciation can also be seen in the ratings
about the assessments’ usability within their institu-
tions, which were 3.76 and 3.41 for the basic and
advanced SA, respectively.
Another finding from the interviews was that many
nurses experienced difficulty to apply the guideline to
all patients with schizophrenia or related psychotic
disorders. They stated very strongly that the guideline
is better not used with patients with comorbid person-
ality disorders or mental retardation. Because suicidal-
ity is so explicitly the subject of the assessment, nurses
feared that this would trigger or increase suicidal
thoughts in these patients.
Some nurses questioned the necessity of the guide-
line. In their opinion, the guideline was not in any
respect new. They mentioned that they already dis-
cussed suicidality during regular contacts as a primary
caregiver of the patient. About half of the participating
nurses believed the guideline to be especially useful
for nurses with little experience in this area of psychi-
atric nursing. They were moderate about the effect of
the guideline on their personal ability to provide care
to suicidal patients (rating 3.00).
Perspectives in Psychiatric Care Vol. 46, No. 1, January 2010
Secondary Outcomes of the Guideline
The nurses were mostly positive about the primary
aims of the guideline, but they were moderate about its
perceived effect on their ability to provide care to
family and friends of suicidal patients (2.69). Quantita-
tive data did not show perception of improvement in
general communication between patients and nurses
(2.76), nor in interdisciplinary communication about
suicidality (2.65).
Discussion and Conclusion
A practice guideline for nursing care of suicidal
patients with schizophrenia or related psychotic disor-
ders was developed and tested. The guideline is
grounded in available evidence about risk manage-
ment and best practice interventions to reduce suicide
risk. Using the assessments included in the guideline
assures that all issues relevant to suicide risk are
covered when discussing suicidality with a patient. The
level of detail of these assessments exceeds standard
questions about suicidality. They allow for an open
discussion with the patient, with ample opportunity
for the patient to discuss personal experiences. The
guideline furthermore discusses interventions to
reduce suicide risk and improve the patient’s quality
of life.
The results of the pilot study show the potential of
the guideline to support nurses in discussing suicidal-
ity with patients and assessing suicide risk, and to a
lesser extent, the potential to support selection and
execution of interventions. The level of experience of
the nurses who participated in the pilot study was
quite high. This may explain why some of the partici-
pating nurses experienced the guideline as nothing
new. It is possible that the guideline makes explicit
what some nurses already do based on experience. The
guideline received less support for selection and
execution of interventions, which may be a result of
having had few opportunities to develop an interven-
tion plan based on the guideline. According to the
71
Development and Evaluation of a Guideline for Nursing Care of Suicidal Patients With
Schizophrenia
nurses, the main reason for these few opportunities
was the perceived absence of suicidality among
patients that were in care during the pilot study. In
addition, the majority of nurses in one institution had
to draw from the same pool of patients, which reduced
the number of candidates.
However, there may be another explanation for the
relatively few assessments and intervention plans.
Many nurses indicated that they normally do not
discuss suicidality with patients if there are no appar-
ent signs of suicidality. This raises the question of
which signs should be apparent to make them ask
about suicidality. Moreover, nurses sometimes feared
that discussing suicidality may actually trigger suicidal
thoughts and may increase suicidal intent and behav-
ior. Some nurses mentioned that their patients focused
on rehabilitation. This may have led these nurses to
assume that suicidality would not be an issue for these
patients, which is not necessarily a valid assumption
because suicide risk increases immediately after hospi-
tal discharge (Troister, Links, & Cutcliffe, 2008).
Overall, it appears that nurses are reluctant to discuss
suicidality when patients do not bring up the issue
themselves. It seems they prefer to “let sleeping dogs
lie,” rather than consider the consequences of avoiding
the issue for a patient who is indeed suffering from
suicidality.
The nursing discipline is not the only discipline that
appears to avoid discussing suicidality with at-risk
patients. Similar results were reported among physi-
cians (Feldman et al., 2007; Stoppe, Sandholzer,
Huppertz, Duwe, & Staedt, 1999). Feldman et al. (2007)
also mentioned the idea that talking about suicidal
thoughts and behavior increases their severity.
However, there is no evidence to support this idea
(Williams, Noel, Cordes, Ramirez, & Pignone, 2002).
The little evidence that does exist points to the opposite
(Gould et al., 2005). Moreover, the Practice Guideline for
the Assessment and Treatment of Patients with Suicidal
Behaviors states that discussing suicidality does not
“plant the issue in the patient’s mind” (American Psy-
chiatric Association, 2003, p. 19). Raising the topic
72
provides patients with an opportunity to express their
feelings about suicidal thoughts and behaviors, which
may in fact be a relief to them and make them feel
understood and recognized. It would be worthwhile to
investigate the motives of nurses who are reluctant to
discuss suicidality with patients who do not bring up
this issue themselves.
The only international data-based publication on the
nurse’s role in assessing suicide risk to compare our
guideline with is the Nurses’ Global Assessment of
Suicide Risk (Cutcliffe & Barker, 2004), which is a scale
that enables quick assessment of suicide risk. Like our
guideline, it is evidence based, but it does not discuss
how information about the patient is best obtained, nor
does it provide interventions that can be performed.
There are some limitations that should be taken into
consideration when interpreting the results of this
study. First, the instances in which nurses were able
to apply the complete guideline, that is, basic SA,
advanced SA, and intervention plan, were few. As a
result, not every nurse who participated in the pilot
study had been able to evaluate the complete guideline
in clinical practice. Some nurses who filled in the ques-
tionnaire had not had the opportunity to use (all parts
of) the guideline.
Second, the group interviews did not allow for con-
clusions based on consensus among the nurses. Some-
times, it was clear that the majority of the nurses
agreed with a particular statement, but other issues
clearly applied to the specific situation of an individual
nurse. Another aspect of the group interviews that may
have affected the results is that one group consisted
almost entirely of a single team of nurses working at
the same unit. Their team culture may have had a dis-
proportionately large effect on the data, masking the
opinion of individual nurses.
We conclude that the pilot study shows the potential
of the guideline to support nurses in discussing suicid-
ality with patients and in assessing suicide risk. Nurses
who participated in the pilot study were positive in
their advice to implement this guideline in mental
health care.
Perspectives in Psychiatric Care Vol. 46, No. 1, January 2010
 Implications for Nursing Practice
Although the guideline may be very useful for
nurses with little experience in caring for suicidal
patients, it is our perception that experienced nurses
who care for patients with schizophrenia can also
benefit from the guideline. Using the guideline as a
standard of care asserts that issues relevant to suicide
risk are covered, and it prevents nurses from becoming
overconfident about a phenomenon that is complex in
nature and can have as far-reaching consequences as
suicidality. Training in using the guideline should
dedicate ample time to adapting the example phrases
and questions of the SAs to one’s personal communi-
cation style in order to enable integration in a naturally
flowing conversation. Furthermore, during training, it
must be communicated that there is no scientific evi-
dence to support the idea that discussing suicidality
triggers or increases suicidal thoughts, intent, or
behavior. Coaching and intervision/supervision may
be required to further enhance successful implementa-
tion of the guideline.
Acknowledgement. This research was supported
by grant number 54010004 from ZonMw, The
Netherlands.
Author contact: esther.meerwijk@ucsf.edu, with a copy to the
Editor: gpearson@uchc.edu
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