1

Suicide Prevention and Screening Using the Columbia-Suicide Severity Rating Scale in an

Outpatient Clinic in Miami, Florida: An Educational Intervention among Primary Care

Providers.
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DNP PROJECT REPORT

Introduction

Suicide is defined as the voluntary and intentional act of taking one's life (Dowie, 2020).

Current data provided by Hedegaard et al. (2020), writing on behalf of the Centers for Disease

Control and Prevention (CDC), indicates that suicide is the 10th leading cause of death among all

age groups in the United States. Unfortunately, suicide rates have only increased over time. More

specifically, data indicate that suicide rates have increased 35% from 10.5 per 100,000

populations in 1999 to 14.2 per 100,000 populations in 2018 (Hedegaard et al., 2020). This

outcome represents a stark failure of the healthcare system as evidence does indicate that with

consistent screening for suicide risk many suicides can be prevented (Hofstra et al., 2020).

Screening can help providers identify those at risk for suicidal behavior, facilitating early

intervention to prevent this outcome (Hofstra et al., 2020). Over the last two decades several

valid and reliable suicide screening tools have been developed for use in clinical practice.

Among these tools is the Columbia-Suicide Severity Rating Scale (C-SSRS), which is noted to

have significant reliability for identifying patients who may be contemplating suicide (Thom et

al., 2020). In spite of readily accessible and reliable tools for suicide screening, many providers

do not regularly perform suicide screening as part of routine patient care (Bryan et al., 2021).

Further, this problem persists despite evidence-based practice recommendations from the United

States Preventive Services Task Force ([USPSTF], 2023) recommendations that all adults over

the age of 18 should be provided with suicide screening during clinical care encounters.

Suicide is a significant public health concern in the United States. According to the

Centers for Disease Control and Prevention (CDC), suicide was the 10th leading cause of death

in the United States in 2018 (Hedegaard et al., 2020). The suicide rate has been increasing over
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the past two decades, rising by 35% from 10.5 per 100,000 populations in 1999 to 14.2 per

100,000 populations in 2018 (Hedegaard et al., 2020). This alarming trend highlights the need

for effective suicide prevention strategies.

Various efforts have been undertaken to address the issue of suicide prevention in the

United States. These include the implementation of suicide hotlines, educational campaigns, and

the promotion of mental health awareness. Additionally, the development of evidence-based

screening tools, such as the Columbia-Suicide Severity Rating Scale (C-SSRS), has facilitated

the identification of individuals at risk for suicidal behavior (Thom et al., 2020). However,

despite these efforts, challenges remain in effectively implementing suicide prevention measures.

Despite the availability of reliable screening tools and evidence-based practice

recommendations from the United States Preventive Services Task Force (USPSTF, 2023) for

routine suicide screening, many primary care providers fail to consistently perform suicide risk

assessments during clinical encounters (Bryan et al., 2021). This gap in practice represents a

significant barrier to early intervention and prevention of suicidal behavior. Various factors,

including lack of training, time constraints, and discomfort discussing sensitive topics, may

contribute to this clinical gap.

The failure to effectively address suicide prevention not only has devastating human costs

but also significant economic implications for the healthcare system. Suicides and suicide

attempts often result in costly hospitalizations, emergency department visits, and long-term

treatment costs. By implementing comprehensive suicide prevention strategies, including routine

screening and early intervention, the healthcare system can potentially reduce these costs while

saving lives.
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The purpose of this research is to address the knowledge and clinical gaps among primary

care providers regarding suicide prevention. By identifying and addressing the barriers to routine

suicide screening, this study aims to improve the implementation of evidence-based practices

and enhance the overall effectiveness of suicide prevention efforts in the United States.

Problem Statement

Problem Statement

Universal suicide screening is recommended by the United States Preventive Services

Taskforce (USPSTF; 2023) among healthcare providers for all adults seeking healthcare

services. Most patients seek healthcare services in primary care clinics; therefore, the promotion

of suicide prevention and screening among primary care providers is critical in the attempt to

reduce suicide mortality rates in the United States (Bryan et al., 2021; Hofstra et al., 2020).

However, suicide rates have increased over time and in recent years, making suicide the tenth

leading cause of death among all age groups in the United States (Bryan et al., 2021; Hedegaard

et al., 2020). Despite readily accessible and reliable tools for suicide screening, such as the

Columbia-Suicide Severity Rating Scale (C-SSRS), healthcare providers do not regularly

perform suicide screening as part of routine patient care for undetermined reasons (Bryan et al.,

2021). Clinical and knowledge gaps surrounding suicide prevention, screening and management

could contribute to the problem (Bryan et al., 2021). Education on suicide prevention and the

significant role of suicide screening among primary care providers may reduce alarming suicide

rates and improve mental health outcomes (Bornheimer et al., 2023; Thom et al., 2020). The

purpose of this project is to improve the knowledge of primary care providers in an outpatient

clinic in Miami, Florida about the importance of suicide prevention and screening using the

Columbia-Suicide Severity Rating Scale. This project aims to increase suicide screening among
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primary care providers using the Columbia-Suicide Severity Rating Scale in patients at risk for

suicide.

Literature Review

According to the Centers for Disease Control and Prevention ([CDC], 2023) suicide is the

ninth leading cause of death among all age groups in the U.S. This organization further notes that

the suicide rate in the United States has increased 36% between 2000 and 2021 and was

responsible for 48,183 deaths in 2021. As the suicide rate increases, public health agencies

including the United States Preventive Services Task Force ([USPSTF], 2023) have advocated

for routine suicide screening for all adults seeking healthcare services. At the selected practice

site, an outpatient clinic operating in Miami, Florida, routine suicide screening is currently not

conducted as part of standard care. Consequently, the purpose of this project is to improve the

knowledge of primary care providers in an outpatient clinic in Miami, Florida about the

importance of suicide prevention and screening using the Columbia-Suicide Severity Rating

Scale. This project aims to increase suicide screening among primary care providers using the

Columbia-Suicide Severity Rating Scale in patients at risk for suicide. This quality improvement

project could potentially reduce suicides in a primary care clinic in Miami, Florida. Support for

this project was established through a review of the literature on this topic, demonstrating both

the scope of the problem and the need for provider education regarding universal suicide

screening. The researcher searched for the studies using Cumulative Index to Nursing & Allied

Health (CINAHL), PsychINFO, and MEDLINE, and the following keywords: suicide, suicide

prevention, primary care providers, and suicide screening. Furthermore, only relevant full text

articles written in English and published from 2019 to present were selected. A total of 3 articles

were selected by the researcher. This review of the literature includes an in-depth review of three
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topics regarding the proposed project including, an examination of suicide in the United States in

recent years, knowledge deficits of suicide among primary care providers in the U.S., and lack of

suicide screening among primary care providers in the U.S. The articles will be discussed in their

respective content areas in the proceeding paragraphs.

Suicide in the U.S. in Recent Years

The first topic addressed in this literature review focuses on suicide in the U.S. in recent

years. Data reviewed in the introduction from the CDC (2023) provide some insight into the

scope and severity of suicide rates in the U.S. However, a closer look at the literature, primarily

through retrospective epidemiological studies provides additional insight into the problem and its

significance. For example, Martinez-Ales et al. (2021) conducted a retrospective age-period-

cohort study with the purpose of identifying the roles of gender, race, and method for committing

suicide among adults. More specifically, the death certificates of individuals who committed

suicide between 1999 and 2018 were reviewed utilizing ICD-10 codes. Data for this study was

obtained from the U.S. National Vital Statistics System and was analyzed using hexagonal grids

to construct aged-period-cohort models, designed to provide a more succinct epidemiological

model of suicide in the U.S.

The results of the study by Martinez-Ales et al. (2021) indicated that the primary method

of suicide involved the use of firearms, which account for 56.8% of all suicides in 1999 and

49.8% of all suicides in 2015. Other common methods of suicide included suffocation and

poisoning. With respect to age, the authors found that there were two peaks for suicide mortality

including youth under the age of 18 and older adults over the age of 65. Males were also found to

consistently have higher rates of suicide mortality along with individuals who were non-White.

The authors argue that understanding these trends in suicide mortality will be helpful for
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evaluating suicide risk and identifying which populations may be at greater risk for completing

this act.

In a similar vein of inquiry Conner et al. (2019) sought to estimate the overall and

specific methods of suicide fatality between 2007 and 2014. Using a retrospective cross-sectional

study, Conner and coauthors reviewed data from the National Vital Statistics System and the

Nationwide Emergency Department Sample to evaluate rates for suicide deaths and suicide

attempts as well as method of suicide and the distribution of age, gender, and region based on

methods of suicide. Descriptive statistics were used to evaluate the data and primarily included

frequency (percentage) calculations. The results indicated that of all suicide attempts made, 8.5%

were fatal and this rate was higher for males versus females, 14.7% and 3.3%, respectively.

Suicide rates were the highest for older adults (over the age of 65) and those aged 15 to 24 years

of age, 35.4% and 34.0%, respectively. Firearms were responsible for 88% of suicide deaths,

however only 8.8% of suicide acts involved a firearm. Drug poisoning accounted for 59.4% of

suicidal acts but only 13.5% of deaths. Suicide rates were noted to be highest among males of all

ages. Conner et al. (2019) note that these findings should provide insight into risk factors for

suicidal ideation and/or action and could be used to prevent suicide.

Further investigation into suicide lethality undertaken by Wang et al. (2020) facilitates

additional understanding of the problem. The purpose of this study was to examine trends and

incidence rates and lethality of suicide acts in individuals between the ages of 10 to 74 years. The

data was collected from the 2006 to 2015 Nationwide Inpatient Sample and Nationwide

Emergency Department Sample databases. The data was analyzed using descriptive statistics as

well as regression modeling to evaluate suicide trends among variables including age and gender.

During the time period analyzed, suicidal acts increased by 10%, with males being 1.6 times
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more likely to attempt suicide than females. While suicide rates were found to be highest in older

adults over the age of 65, Wang et al. also found that among those aged 20 to 44 and 45 to 64

years, methods of suicide increased in lethality, with firearms being identified as a significant

contributor to suicide mortality. The authors of this study argue that the results should be used to

understand the complexity of suicide and to identify individuals who may be at highest risk for

successfully committing suicide.

Additional epidemiological research conducted by Baldessarini (2019) provides further

insight into the complexity of suicidal behavior and mortality. Specifically, this author completed

a retrospective review of suicide data between 2003 and 2016 to identify critical factors

contributing to suicide risk. Data analysis was performed through various inferential methods

including linear regression and regression modeling. Several different data sets including

mortality statistics, mental health data, and demographic data were used to provide a descriptive

analysis of groups who were more likely to commit suicide. Over the time period investigated,

Baldessarini (2019) found that while suicide rates were once most common in rural areas, in the

2010s that data consistently demonstrated increased suicide rates in all geographic locations

including urban, rural, and suburban areas.

In addition, Baldessarini (2019) found that Native Americans had a higher rate of suicide

among all races and socioeconomic factors were implicated in a large number of suicides. In

particular, the data showed that under-employment, including socioeconomic stress, as well as a

lack of access to mental healthcare were prominent issues contributing to suicide mortality.

Serious mental illnesses, including bipolar disorder, and substance use disorders, including

opioid use disorder, were consistent factors contributing to increased suicide mortality.

Individuals with underlying cardiovascular and pulmonary conditions were also more likely to
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commit suicide. As noted by Baldessarini (2019), identification of these factors can promote

greater awareness of suicide risk for providers to consider these issues when delivering care.

Reducing suicide mortality would have benefit for patients, families, and public health

(Baldessarini, 2019).

Synthesis of this data indicates that while suicide risk has increased consistently over the

last two decades, the topic is one that is notably complex. In particular, three of the studies

reviewed demonstrated the lethality of firearms in committing suicide as well as the prevalence

of different methods of undertaking suicide (Conner et al., 2019; Martinez-Ales et al., 2021;

Wang et al., 2020). Further, the evidence demonstrates that older adults and persons between the

ages of 15 and 24 have the highest rates of suicide along with non-White individuals and males

(Conner et al., 2019; Martinez-Ales et al., 2021; Wang et al., 2020). Suicide occurs with similar

frequency across geographic regions and can be shaped by mental health conditions (serious

mental illness or substance use disorders) as well as social determinants of health including

employment and socioeconomic status (Baldessarini, 2019). Additionally, those investigating the

topic agree that by identifying variables regarding suicide, it may be possible to provide early

intervention to target groups in order to prevent suicide (Baldessarini, 2019; Conner et al., 2019;

Martinez-Ales et al., 2021; Wang et al., 2020). Although the data would be useful in identifying

those at greatest risk for suicide, the data also shows how prevalent and widespread the problem

is among the general population. This would support the use of suicide screening in primary

care.

Knowledge Deficits of Suicide Among Primary Care Providers in U.S.

The next topic addressed through this literature review involves knowledge deficits

regarding suicide among primary care providers in the United States. An examination of this
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topic focused primarily on studies evaluating provider knowledge and attitudes as well as the use

of training or education programs to help increase knowledge of primary care providers when it

comes to suicide screening and prevention. In particular, Boukouvalas et al. (2020) completed a

systematic review of the knowledge of, attitudes toward, and confidence of primary care

providers in delivering care for patients at risk for suicide. Specifically, Boukouvalas et al.

reviewed 46 primary research studies to explore the aforementioned topics. A systematic search

of four electronic article databases—PubMed, Medline, Embase, and PsychINFO—was

undertaken to review articles published between 2006 and 2016. Data abstraction was completed

by two authors utilizing established inclusion and exclusion criteria.

The results from the systematic review completed by Boukouvalas et al. (2020) indicated

that the ability of healthcare providers to effectively care for and manage suicidal patients is

influenced by education and training as well as past experiences with suicidal patients.

Unfortunately, the authors found that across multiple studies, most primary care providers lack

training/education and/or experience for treating and managing suicidal patients. The authors

note that these gaps should prompt the expansion of programs to educate primary care providers.

Boukouvalas and coauthors (2020) argue that the knowledge gaps present for primary care

providers can have deleterious impacts on patients and lead to adverse patient outcomes. What

this indicates is that provider knowledge will play a significant role in shaping how patients

struggling with suicidal ideation are treated, potentially increasing patient risk of suicidal

behavior.

Similarly, Mann et al. (2021) completed a systematic review of the literature to identify

factors that could improve suicide prevention in primary care settings. In this review, the authors

searched for articles on the topic from PubMed and Google Scholar between the years of 2005
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and 2019. Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-

Analyses) standards for systematic reviews, randomized controlled trials and epidemiological

studies were reviewed from a total of 127 studies. Data for this study was abstracted by two of

the authors using established inclusion and exclusion criteria. A review of educational programs

to prevent suicide in primary care definitively indicated that primary care providers lacked

awareness and knowledge of suicidal behavior and risk factors, including self-harm. The authors

note that educational programs, especially those that provide annual training, were most effective

in increasing provider knowledge of the topic and reducing suicide rates among patients.

Although Mann et al. (2021) did investigate other methods of suicide prevention through

their systematic review, the evidence provided regarding the knowledge of primary care

providers about the topic, and subsequent use of educational programs, does indicate that

provider knowledge of the topic represents a significant gap in current practice. According to

Mann et al. (2021) this gap may adversely impact patient outcomes as 45% of all suicidal

patients were found to seek care services from their primary care provider in the 30 days before

their suicide attempt. Further, Mann et al. (2021) note that 77% of patients who attempt suicide

visit their primary care providers in the 12 months leading to this event. Consequently,

identifying prevention issues, such as a lack of provider knowledge, awareness, and training, will

be critical for improving outcomes for patients.

Experimental studies including quasi-experimental pre-/post-intervention frameworks

also demonstrate the paucity of provider knowledge and its implications for suicide screening

and prevention in primary care (Cross et al., 2020; Solin et al., 2021). For instance, Cross et al.

(2020) completed a single-group pre-/post-intervention study to compare suicide screening

knowledge and behavior following the use of didactic training. Using a 17-item multiple-choice
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assessment of suicide prevention knowledge and observations of providers, Cross et al. collected

data on 127 residents and nurse practitioners before and three weeks following a didactic

educational intervention, provided in weekly one-hour online courses. The results indicated that

following education, knowledge scores of providers increased by 50%, suggesting that education

was needed to enhance the ability of providers to effectively screen patients for suicidal

behavior. Based on these results, Cross et al. note that educating healthcare providers about

suicide screening and prevention is critical to enhance patient care in the clinical setting.

Similarly, Solin et al. (2021) tested a three-hour training program for community care

providers in assessing, preventing, and managing suicidal patients. This pre-/post-intervention

design included 2,027 community providers of which 37% were primary care providers. Other

professionals enrolled in the study included social workers, public health providers, and nurses.

In this study, the primary outcome measure included was perceived self-competence in

managing various aspects of suicidality in patients. This was measured through a survey created

by the authors and scored on a Likert scale ranging from 1 (very bad) to 5 (very good). The

educational program covered four topics including risk and protective factors for suicide,

screening and evaluation of suicide risk, ability to confront the suicidal patient, and ability to

treat the suicidal patients. Descriptive statistics were used to evaluate the results with the data

indicating that on all four measures, self-competence increased from an average of 3.16 to 4.0

following education. The results indicate that providers have lower rates of self-competence for

the detection, prevention, and treatment of suicidality before education indicating the presence of

a knowledge gap. The authors maintain that education for providers is needed to fill critical gaps

in knowledge and self-efficacy for preventing suicide in community healthcare settings.

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Integration of the knowledge gained from the studies reviewed under this content area

indicates that knowledge levels for providers regarding the identification (screening), prevention,

and treatment of patients who are suicidal may be suboptimal (Boukouvalas et al., 2020; Cross et

al., 2020; Mann et al., 2021; Solin et al., 2021). This can have a deleterious impact on patients as

care for those experiencing suicidal ideation may be suboptimal (Cross et al., 2020; Mann et al.,

2021). The results also clearly indicate that education and training of primary care providers can

help to ameliorate gaps in knowledge (Cross et al., 2020; Solin et al., 2021). While the specific

outcomes for patients in terms of reductions in suicide are not included with the data reviewed,

the evidence suggests that by increasing primary care provider knowledge this should result in a

change in practice that will benefit patients through better care and the prevention of suicide

(Cross et al., 2020; Mann et al., 2021; Solin et al., 2021). In terms of the proposed quality

improvement project, this evidence not only indicates that the knowledge of primary care

providers regarding suicide screening and prevention are low, but this research also supports the

use of education to improve provider knowledge and, potentially, outcomes for patients.

Lack of Suicide Screening Among Primary Care Providers in the U.S.

The final topic evaluated for this literature review focuses on the lack of suicide

screening among primary care providers in the United States. Studies examining this topic

included those which evaluated the efficacy of suicide screening in primary care as well as the

feasibility of suicide screening with a review of the current challenges and barriers to

implementing suicide screening/prevention in primary care. The first study examined was a

systematic review of the literature conducted by Stene-Larson and Reneflot (2019) in which the

authors sought to evaluate the number of patients completing suicide attempts following visits

with primary care providers. Using studies obtained from five different electronic article
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databases—Medline, Embase, PsychInfo, Web of Science and Cochrane—between the years of

2000 and 2017, the authors established inclusion and exclusion criteria for data collection. Two

researchers abstracted the data and a total of 44 records were included.

Data analysis for the study completed by Stene-Larson and Reneflot (2019) included

descriptive statistics to calculate both means and ranges for the data obtained. The results

indicated that approximately 80% of patients who attempted suicide (range 49%-86%) made

contact with their primary care provider 12 months before attempting suicide. Six months prior

to a suicide attempt, 54% of patients made contact with their primary care provider (range 27%-

69%) and one month prior to a suicide attempt 44% of patients made contact with their provider

(range 17%-73%). In these cases, suicide screening or prevention was not provided for patients,

suggesting that at any given point in time, providers are failing to identify a large portion of

patients who are at risk for suicide. Given these numbers, Stene-Larson and Reneflot (2019)

argue that the data supports the need for increased suicide screening in primary care.

Additional data provided by LeCloux et al. (2020) examined the feasibility of

implementing a suicide screening program in primary care using the Ask Suicide-Screening

Questions (ASQ) Toolkit. The purpose of this study was to evaluate changes in suicide risk

screening through a targeted program for patients. Using a quasi-experimental pre-/post-

intervention framework, suicide screening rates before and following program development and

implementation were measured along with suicide risk detection rates. Descriptive statistics and

chi-square tests were used to evaluate changes in outcomes from the pre-/post-intervention and

to assess if these changes were statistically significant. The results indicated that there was an

increase in suicide screening from 5.8% before the intervention to 61.0% following intervention.

The result was found to be statistically significant: X2 = 200.61, p < 0.001. Similarly, suicide
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risk detection rates increased from 0.7% before the intervention to 6.2% following intervention.

This outcome was also statistically significant: X2 = 12.58, p < 0.001.

The results of this study indicate that before the intervention suicide screening and

detection rates were notably low, suggesting that most patients were not screened for suicide

risk. Early detection of suicidality can help prevent suicide and save lives. Based on these results,

there is strong evidence to not only demonstrate low suicide screening rates in primary care but

also how implementing suicide screening in primary care practice can prevent suicide. In

reviewing the results of their study, LeCloux et al. (2020) argued that implementing suicide

screening programs in primary care represents a feasible undertaking that has the potential to

markedly improve care for patients and foster a reduction in the number of suicide attempts that

occur each year.

An additional study completed by Bryan et al. (2023) sought to determine if suicide risk

screening is needed for patients who are screened for depression. More specifically, this study

utilized an observational follow-up approach to assess suicidal behavior among 2,744 patients

who sought care at the Department of Defense primary care medical system. According to the

authors, the Patient Health Questionnaire-9 (PHQ-9) is routinely used to screen for depression at

patient medical visits. To assess the efficacy of the PHQ-9 in detecting suicidal behavior, 16

items from the Suicide Cognitions Scale (SCS) were added to patient assessment. Follow-up

phone calls with patients at 30 and 90 days was undertaken to evaluate PHQ-9 assessment scores

in conjunction with suicidal behavior and in light of SCS scores. Descriptive statistics were used

including frequencies (percentages) to assess outcomes. The results indicated that alone the

PHQ-9 was effective for identifying 65% of patients with suicidal behavior. Because suicide

screening is not routinely provided in primary care, the authors note the utility of screening for
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suicide as depression screening alone does not identify a large percentage of patients (35%) who

may be at risk for engaging in suicidal behavior.

Synthesis of the studies included on this topic clearly demonstrates that suicide screening

is needed in primary care, especially in light of the number of patients who seek care in this

setting in the month or year before their suicide attempt (Stene-Larson & Reneflot, 2019). The

evidence demonstrates that if structured programs for suicide prevention are not utilized in

primary care practice, only a small percentage of patients will receive suicide screening

(LeCloux et al., 2020). The need for specific suicide screening programs outside of routine

depression screening is needed as many patients (up to 35%) contemplating suicide may not be

identifiable (Bryan et al., 2023). The data also indicates that with consistent suicide screening in

primary care suicide detection rates do significantly increase, creating an opportunity for the

provider to intervene and prevent suicide (LeCloux et al., 2020).

The evidence included in this literature review does demonstrate the growing complexity

of suicide attempts and mortality in the U.S. While the data highlights the specific populations

that are impacted, the data also demonstrates that the problem is widespread and can impact most

population groups. Further, the evidence indicates that primary care providers lack considerable

knowledge about suicide detection and prevention, which can adversely impact patient care. This

is problematic in light of the fact that suicide screening rates are notably low despite the fact that

provider education and the incorporation of suicide screening programs in primary care can

improve suicide screening and detection. Based on this data, there is an impetus for changing

practice including educating providers to perform patient suicide screening as a standard part of

primary care. The purpose of this project is to improve the knowledge of primary care providers

in an outpatient clinic in Miami, Florida about the importance of suicide prevention and
 17

screening using the Columbia-Suicide Severity Rating Scale. This project aims to increase

suicide screening among primary care providers using the Columbia-Suicide Severity Rating

Scale in patients at risk for suicide. This quality improvement project could potentially reduce

suicides in a primary care clinic in Miami, Florida.

Purpose

The purpose of this project is to improve the knowledge of primary care providers in an

outpatient clinic in Miami, Florida about the importance of suicide prevention and screening

using the Columbia-Suicide Severity Rating Scale. This project aims to increase suicide

screening among primary care providers using the Columbia-Suicide Severity Rating Scale in

patients at risk for suicide. This quality improvement project could potentially reduce suicides in

a primary care clinic in Miami, Florida.

PICO Question

Is there a significant difference between pretest and posttest knowledge and competency

scores among primary care providers in an outpatient clinic in Miami, Florida after an

educational intervention on suicide risk assessment and prevention utilizing the Columbia-

Suicide Severity Rating Scale (C-SSRS)?

Ha: There is a significant difference between pretest and posttest knowledge and

competency scores among primary care providers at an outpatient clinic in Miami, Florida after

an educational intervention on suicide risk assessment and prevention utilizing the C-SSRS.

Definitions of Terms

The variables of this project were knowledge and competency, age, gender, ethnicity,

level of education, provider role, years of experience, and prior suicide prevention training; they

are described in the following paragraphs.

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Knowledge and Competency

This variable referred to healthcare providers' knowledge and self-rated competency in suicide

risk assessment and prevention. To quantify this variable, the researcher will administer the

modified Suicide Intervention Response Inventory-2 (SIRI-2) scale before and after an

educational training session. Five additional items will be included to measure knowledge of

evidence-based tools like the Columbia Suicide Severity Rating Scale (C-SSRS) and comfort

with core competencies.

Age This ratio variable refers to the age of healthcare providers. This demographic

variable will be grouped as follows: (a) 18 to 30 years; (b) 31 to 44 years; and (c) 45 years and

older.

Gender This nominal variable refers to the gender of healthcare providers. This

demographic variable will be categorized as follows: (a) female; (b) male; and (c)

non-binary/other.

Ethnicity This categorical variable refers to the ethnicity of healthcare providers. This

demographic variable will be labeled as follows: (a) White; (b) Black or African American; (c)

Hispanic or Latino; (d) Asian; and (e) Other.

Level of Education This nominal variable refers to the highest degree attained by

healthcare providers. This demographic variable will be classified as follows: (a) Bachelor's

degree; (b) Master's degree; and (c) Doctoral degree.

Provider Role This categorical variable refers to the primary role of healthcare

providers. This demographic variable will be catalogued as follows: (a) Physician; (b) Nurse

Practitioner; and (c) Physician Assistant.

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Years of Experience This nominal variable refers to the years of clinical experience of

healthcare providers. This demographic variable is grouped as follows: (a) 0 to 5 years; (b) 6 to

10 years; and (c) 11 years or more.

Prior Suicide Prevention Training This categorical variable refers to healthcare

providers' prior training or education related to suicide prevention. This demographic variable is

labeled as follows: (a) None; (b) Some; and (c) Extensive.

Suicide Risk Assessment Knowledge This variable measured healthcare providers'

knowledge related to assessing suicide risk in patients. It will be evaluated using a series of

true/false and multiple-choice questions covering topics such as risk factors, warning signs,

screening tools like the C-SSRS, and appropriate interventions based on risk level.

Confidence in Suicide Risk Assessment

This variable assessed providers' self-rated confidence in their ability to effectively identify and

respond to patients at risk for suicide. It is measured through Likert scale questions asking about

comfort levels in areas like directly asking about suicidal thoughts, utilizing suicide screening

tools, and developing safety plans.

Attitudes Towards Suicide Prevention This variable examined providers' attitudes and

perceptions related to suicide prevention in healthcare settings. Questions aimed to identify

stigmatizing beliefs, perceived roles and responsibilities, and opinions on the importance and

feasibility of routine suicide risk screening.

Perceived Barriers to Suicide Screening An open-ended question will allow providers

to describe any perceived barriers or challenges to implementing routine suicide risk screening

and prevention efforts in their clinical practice. Common themes from responses were analyzed

qualitatively.
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Training Needs for Suicide Prevention

Participants will be asked what additional training or resources would be helpful to increase their

competency in suicide risk assessment and prevention. Responses provided guidance on desired

training content and modalities.

Conceptual Underpinning and Theoretical Framework

The DNP project will be guided by Malcom Shepherd Knowles' Andragogy, an adult

learning theory that recognizes that interactive and participatory educational strategies are more

likely to result in meaningful knowledge acquisition and retention among healthcare

professionals. In 1980, Knowles made four assumptions about the characteristics of adult

learners (andragogy), in 1984, Knowles added the fifth assumption. According to El-Amin

(2020), Knowles' Andragogy theory is based on a set of assumptions, including the need for self-

direction, prior experiences influencing learning, a readiness to learn when there is a perceived

need and a problem-centered approach to learning. Knowles contends that adults are assumed to

be internally motivated, drawing on their life experiences to enhance learning (Loeng, 2020).

Therefore, this theory highlights the importance of creating a learner-centric environment that

respects the autonomy and unique needs of adult learners. The theory can guide the development

of and implementation of the educational seminar for nurses and physicians in the outpatient

setting, leveraging their experiences to create a collaborative and interactive learning

environment.

Methodology

The purpose of this project is to improve the knowledge of primary care providers in an

outpatient clinic in Miami, Florida about the importance of suicide prevention and screening

using the Columbia-Suicide Severity Rating Scale. This project aims to increase suicide
 21

screening among primary care providers using the Columbia-Suicide Severity Rating Scale in

patients at risk for suicide. This quality improvement project could potentially reduce suicides in

a primary care clinic in Miami, Florida. The methodology for this DNP project encompasses a

pre-post intervention design within a primary care clinic. This design facilitates a direct

comparison of participants' knowledge levels before and after the educational seminar on suicide

screening using the Columbia-Suicide Severity Rating Scale (C-SSRS). Convenience sampling

method will be employed to collect data from five healthcare professionals, including nurses and

physicians, who are actively engaged in patient care within the clinic. Data collection will

involve administering pre- and post-intervention knowledge assessments supplemented by

demographic data forms. Statistical data analysis, adhering to ethical standards, will examine the

impact of the intervention on participants' knowledge of suicide risk assessment. The sequential

sections address the study design, setting, sample, inclusion criteria, exclusion criteria,

intervention, measures and instruments, data collection procedures, data analysis, as well as

protection of human subjects.

Study Design

The DNP project will use a pre-post intervention design, allowing for a direct and

systematic comparison of participants' knowledge levels before and after the educational seminar

on suicide prevention and screening using the C-SSRS. In the pre-intervention phase, baseline

data will be collected to establish the initial level of knowledge among nurses and physicians,

working in the primary care clinic. According to Cardoso et al. (2020), baseline measurement is

crucial for understanding the starting point and gauging the effectiveness of an intervention.

Following the baseline assessment, the educational intervention will be implemented in the form

of an in person seminar and have the participants complete the demographics/pre/posttests using
 22

Qualtrics (online using their phones or laptops) to facilitate data collection. It will be focused on

suicide prevention and screening using the C-SSRS. This interactive and participatory session

aims to enhance participants' understanding of the instrument's purpose and use in identifying

and managing suicide risk among patients. Post-intervention, participants will undergo a follow-

up assessment to measure the immediate impact of the educational seminar on their knowledge

levels. The comparison of pre-and post-intervention data will provide insights into the

effectiveness of the educational intervention in achieving its intended outcomes.

Setting

The project will be carried out in a primary care clinic. This clinical setting provides a

practical and realistic environment for the educational seminar, allowing participants to apply the

knowledge gained to their clinical responsibilities immediately. The real-world applicability

enhances the project's potential to influence clinical practice positively, fostering improved

suicide risk assessment and patient care outcomes within the outpatient context.

Sample

The sample population for this DNP project will comprise five healthcare professionals,

that is, nurses and physicians actively working in the primary care clinic. Convenience sampling

technique will be used to recruit and access data from participants who work in the primary care

clinic in Miami, Florida.

Inclusion Criteria

Eligible participants must hold positions as registered nurses, physicians, or psychologists

actively engaged in direct patient care. Their responsibilities should involve patient assessment

and interaction, specifically focusing on the potential identification of suicide risk. Furthermore,

participants must be currently employed full-time within the primary care clinic, ensuring that
 23

the intervention aligns with the practical realities of their day-to-day clinical activities. This

targeted approach aims to capture meaningful insights into the impact of educational intervention

on suicide risk assessment in the primary care clinic context.

Exclusion Criteria

Individuals who do not directly engage in patient care, such as administrative staff, will

be excluded. Additionally, participants with pre-existing knowledge levels that could potentially

bias the results will not be included in the study. Healthcare professionals who do not work in the

primary care clinic in Miami, Florida cannot participate in this project. The exclusion criteria

ensure that the impact of the educational intervention is accurately assessed among those who

genuinely benefit from increased knowledge in suicide risk assessment within the outpatient

clinic setting. This deliberate approach aims to refine the sample, optimizing the project's ability

to draw meaningful conclusions regarding the intervention's effectiveness.

Intervention

The intervention entails an educational seminar on suicide screening utilizing the

Columbia-Suicide Severity Rating Scale (C-SSRS). The seminar aims to enhance healthcare

Professionals’ understanding of suicide risk assessment, emphasizing the purpose and proper

utilization of the C-SSRS tool, and most importantly the prevention of suicide in the primary

care setting. Through interactive sessions, participants will learn to identify risk factors, assess

suicidal ideation, and implement appropriate interventions. Practical case studies and role-

playing exercises will reinforce learning and facilitate skill acquisition. By

equipping healthcare professionals with enhanced knowledge and competence in suicide risk

assessment, the intervention seeks to improve patient safety and outcomes within the outpatient

clinic setting.
 24

Measures and Instruments

The measures and instruments employed in this DNP project include pre- and post-

assessment questionnaires, along with administering a demographic data form to gather

participant information like: age, gender and ethnicity. The pre- and post-assessment

questionnaires will be designed using the Qualtrics online platform. These questionnaires aim to

evaluate participants' knowledge levels before and after an intervention such as the educational

seminar (Nardi et al., 2023). The questionnaires are designed to be comprehensive, covering

critical aspects of suicide risk assessment. The questions are structured to provide a quantitative

measure of participants' understanding, allowing for a systematic assessment of knowledge

enhancement. These pre- and post-test surveys will use a five-point Likert scale rating system,

where participants will be asked to specify their level of agreement with statements related to

their level of confidence in identifying and interacting with individuals at risk for suicide. There

will be a scale from 0-10, 10 being the highest. The surveys will also include questions about

mental health and treatment perceptions. Moreover, the pre-/posttest will measure participants'

knowledge about suicide through true or false questions. Finally, these surveys will contain a

five-point Likert scale rating system section that evaluates participants' understanding of the

proper utilization of the C-SSRS tool. To enhance instrument reliability and validity, several

strategies will be employed in the administration and development of the pre-and post-test

surveys for the DNP project.

Demographic data is gathered online using a researcher-developed instrument via

Qualtrics. The following data is collected from research participants: (a) age (a. 18 to 30 years; b.

31 to 44 years; and c. 45 years and older); (b) gender (a. female; b. male; and c.

non-binary/other); (c) ethnicity (a. White; b. Black or African American; c. Hispanic or Latino;
 25

d. Asian; and e. Other); (d) level of education (a. Bachelor's degree; b. Master's degree; and c.

Doctoral degree); (e) provider role (a. Physician; b. Nurse Practitioner; c. Physician Assistant);

(f) years of experience (a. 0 to 5 years; b. 6 to 10 years; and c. 11 years or more); and (g) prior

suicide prevention training (a. None; b. Some; and c. Extensive).

Knowledge and competency related to suicide risk assessment and prevention is

quantified and measured, before and after an educational intervention, by use of a modified

Suicide Intervention Response Inventory-2 (SIRI-2) scale, originally developed by Newell et al.

(2010). The original SIRI-2 had high internal consistency with a Cronbach's alpha of 0.92. The

scale is modified to include five additional items to more precisely measure healthcare providers'

knowledge and competency in identifying and responding to suicide risk: (1) "I am confident in

my ability to use the Columbia Suicide Severity Rating Scale (C-SSRS)"; (2) "I understand the

importance of directly asking about suicidal thoughts"; (3) "I can effectively develop a safety

plan for patients at risk of suicide"; (4) "I am comfortable discussing sensitive topics like suicide

with patients"; and (5) "I know the appropriate steps to take if a patient expresses active suicidal

ideation". The modified SIRI-2 scale encompasses a total of 29 items and uses a 5-point Likert

scale to record responses: 5 = Strongly Agree, 4 = Agree, 3 = Neutral, 2 = Disagree, 1 = Strongly

Disagree. Consistent with the original scale, 12 items are reverse coded. Higher scores indicate

greater knowledge, more favorable attitudes, and higher self-rated competency related to suicide

prevention. The highest obtainable score is 145, while the lowest possible score is 29.

Data Collection Procedures

Data collection procedures will commence with obtaining FIU IRB approval, then

informed consent from eligible participants, ensuring ethical considerations. The pre-intervention

phase will involve administering a demographic data form to gather participant information. A
 26

pre-intervention knowledge assessment will then be conducted through a structured

questionnaire. Subsequently, the educational seminar will be conducted, employing interactive

methods to enhance participant understanding of suicide risk assessment using the Columbia-

Suicide Severity Rating Scale (C-SSRS). Post-intervention, participants will undergo a

knowledge assessment mirroring the pre-intervention questionnaire. The collected data,

including demographic details and pre/post-intervention knowledge scores, this will take

approximately 40 min to complete it. Collecting data for a period of three weeks. will be

meticulously recorded and securely stored to maintain confidentiality.

Data Analysis

Data analysis for this DNP project will follow a systematic approach, ensuring a rigorous

evaluation of the intervention's impact on healthcare professionals' knowledge of suicide risk

assessment. Collected data, comprising demographic information and pre-post-intervention

knowledge scores, will be stored securely and will be accessible only to authorized personnel,

safeguarding participant privacy. The demographic data will be summarized using descriptive

statistics, providing insights into the characteristics of the participant sample. Continuous

variables will be presented as means with standard deviations, while categorical variables will be

summarized using frequencies and percentages. The focus will then shift to analyzing the

pre/post-intervention knowledge scores. Paired t-tests will be employed to assess the statistical

significance of changes in knowledge levels before and after the educational seminar. The level

of significance will be set at p < 0.05.

Protection of Human Subjects

Following FIU IRB approval and the completion of the CITI ethics certification, the

researcher will preserve the rights and privacy of participants. Prior to participation, potential
 27

subjects will receive detailed information about the project's purpose, procedures, and potential

risks and benefits. Informed consent will be obtained from each participant, emphasizing

voluntariness and the right to withdraw at any point without consequence. Participants will

benefit from the educational seminar by gaining enhanced knowledge in suicide risk assessment.

Moreover, data safety measures will include secure storage of collected information,

anonymizing participant identities through Qualtrics, and restricting access to authorized

personnel only. Confidentiality will also be strictly maintained throughout the project, ensuring

the privacy and rights of all participants.

 28

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