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Research Literature
This section aims to analyze the existing literature and develop an evaluation of the material to respond to the main PICO question. In pediatric patients in an acute health care setting (P) does the use of suicide assessment tool (I) as compared to a standards pediatric assessment (C) reduce the risk of future suicide attempts (O)? Many medical practitioners observe children and adolescents at their risks of suicide because of different reasons. Some healthcare facilities provide strong assessment tools and techniques to identify possible mental health problems at their early stages. In many acute care settings, the reduction of the risk of future suicide attempts remains a problem. Suicide is defined as a leading cause of death among adolescents, and it is observed in about 16% of US cases (Bromber, Law, & Palermo, 2017). Therefore, multiple approaches to suicide prevention are developed regularly, and the creation of this evidence-based practice project requires a thorough analysis of past studies.
The identification of suicide risks is a common practice in pediatric emergency departments (EDs). For example, Ballard et al. (2016) identified a pediatric ED as a critical location where children and adolescents at risk for suicide may be identified. The researchers aimed to present a brief suicide screening as a standard of care, using the Ask Suicide-Screening Questions (ASQ) for 970 patients. This retrospective cohort study from the Johns Hopkins Hospital Pediatric ED proved that the choice of specially developed screening instruments might considerably increase the chances to identify future suicidal behavior even without direct reports and complaints (Ballard et al., 2016). The main limitation of this study was a single site of the record data. Still, it did not influence the benefits of this project such as the possibility to incorporate ASQs for pediatric ED patients.
The same setting was chosen for another important study on bullying victimization. Stanley et al. (2016) set the goal to describe the relationship between bullying and suicide risks of patients at the ED. In this perspective cross-sectional multisite project, 524 participants between 10 and 21 years were invited for interviews where they had to take the ASQ test and the Suicidal Ideation Questionnaire (SIQ) (Stanley et al., 2016). The results proved that a majority of people who reported bullying victimization had a positive attitude toward suicide risks. Despite the evident limitation of the impossibility to introduce causal inferences, the chosen study was a strong contribution to future studies due to its ability to gather collateral information from patients directly.
Suicidal ideation (SI) and concomitant signs turn out to be a serious issue for discussion in many healthcare settings. The role of Bromber et al. (2017) in this research cannot be ignored as they aimed to identify SI rates and characteristics regarding the presence and absence of chronic pain. With the help of self-reports completed by adolescents with and without chronic pain, a survey was developed with descriptive statistics being analyzed. The authors indicated adolescence as a developmental stage when increased risks for suicidal thoughts could be observed (Bromber et al., 2017). Though the relation between pain and suicide was not recognized, the study had several strengths. One of them was the attention to different mental health-related factors like anxiety, depression, and personal traumas. Although the possibility of biases in participant selection was defined as the limitation of the study, Bromber et al. (2017) explained why such issues as self-worth and hopelessness should be constantly monitored. Safety promotion among adolescents with suicidal behavior is a responsibility of the medical staff.
Several studies were developed to discuss the general aspects of suicide in adolescent populations. Montreuil, Butler, Stachura, and Pugnaire Gros (2015) developed a qualitative descriptive study to explore nursing care from the point of view of patients with suicidal thoughts and their parents. The data was gathered through observations, debriefing sessions with children, and interviews with parents. In the end, the need for a relational aspect in nursing care was proved because of social connectedness and cooperation with mental health practitioners. The study was limited because of the chosen themes that had to be common for parents and their children. No personalization was used in this project, but the participation of families made it possible to gather information about the intricate body-mind connection (Montreuil et al., 2015). Mental health care had to be offered to all families to reduce the risks of suicides later in life.
Depression is one of the most common mental health problems in people of any age. Kodish et al. (2016) evaluated the risks of suicide focusing on different bullying experiences and depression impact. The Behavioral Health Screen (BHS) tool was used to assess the problems and behaviors of more than 5,000 young participants (Kodish et al., 2016). The data was gathered from the screeners that participants agreed to complete electronically. The results showed that any type of bullying could lead to suicidal thoughts. However, a verbal type had a unique impact on people causing depression and several negative thoughts. Though self-data reports could be defined as the studys limitation, this information helps to understand the severity of suicidal risks in patients.
An understanding of suicidal thoughts in pediatric and adolescent patients can be reached through different assessment tools. Desjardins, Cats-Baril, Maruti, Freeman, and Althoff (2016) aimed at developing one of such assessments at the ED to predict risks within 72 hours, to define an intervention, and to identify the level of patient satisfaction. A randomized cross-sectional study was conducted at the university-affiliated academic medical center and consisted of three phases, including development, sampling, and replication (Desjardins et al., 2016). 174 participants from the ED and surgical units were invited to validate the developed model. It is one of the main strengths of the study that all the participants shared their positive attitudes towards the tool due to its simplicity and convenience, proving the correctness of the decisions made by the researchers. However, the participation rate and exclusion criteria were defined as the limitations of the project.
Screening for suicide risks in hospitals is a common topic for many projects. Ross et al. (2016) focused on the description of opinions about screening. Diamond et al. (2017) developed a comprehensive screening of suicidal patients to identify risk behaviors and associated stress. Patel et al. (2018) intended to clarify the risks of suicide and described the process of screening in a pediatric unit. In these three studies, different research approaches were chosen. Patel et al. (2018) implemented intervention and screened more than 4,500 patients between 12 and 19 years. Screening questions were posed to participants and reviewed retrospectively with the help of content analyses. Despite a small sample size, the results proved that many adolescents had mental health concerns that led to suicidal risks. The recognition of patients perceptions toward suicide screening was an important aspect of this work.
Almost the same research method was used in another study. Diamond et al. (2017) used the data from about 2,500 patients using a web-based comprehensive tool known BHS. Patients profiles helped to identify the risks and focus on such factors as psychiatric syndromes, behaviors, family problems, and violence exposure. The authors concluded that the influence of sexual assault, unsafe sex, and substance use determined suicidal risks (Diamond et al., 2017). The sample is a limitation in the study, and the introduced BHS became a promising tool in suicide rate evaluation.
One of the screenings helped to recognize new suicide themes, including prevention, responsibilities of providers, and emotional benefits. Ross et al. (2016) invited 200 pediatric patients to respond to several questions about suicidal thoughts and the role of nurses in care as a part of qualitative research. Quantitative information included descriptive statistics about the various demographic characteristics of patients. A small clinical sample did not influence the benefit of the study that was several revealing comments on suicidal risks given by ill youth.
Finally, the necessity to prevent suicides in youth cannot be neglected. However, many hospitals fail to succeed in suicide prevention, and Leavey et al. (2017) set the goal to examine the challenges from the point of view of family members. Qualitative in-depth interviews with the families whose members made attempts to commit suicide and the general practitioners who experienced the patients death because of suicide were developed to gather enough information for analysis. It was discovered that relatives could not detect suicide symptoms and changes in behaviors properly, and practitioners were not able to understand the needs of patients because of their social contexts (Leavey et al., 2017). As well as other studies, this article is limited in its sample size. Still, the possibility to investigate the same topic from two different perspectives and define the attitudes of two groups of people is a strength that cannot be observed in past projects. All the chosen qualitative and quantitative articles help create a solid background for discussing and investigating the main research question about the importance of assessment tools for preventing suicides in pediatric and adolescent patients.
Research Design
This EBP project is planned to use a qualitative research approach to identify the worth of suicide assessment tools compared to standard pediatric assessments in pediatric patients. A quasi-experimental intervention for 200 patients between 12 and 16 years will be employed at one of the local hospitals. A similar approach was developed by Desjardins et al. (2016) who used a cross-sectional study to analyze the value of assessment tools in the EDs with the only difference was the established period. This research design should help clarify a cause-effect relationship between several variables.
As soon as the intervention is identified and discussed, participants will be randomly divided into two groups. On the one hand, an experimental group of participants will take a specially developed suicide assessment tool. On the other hand, an ordinary pediatric assessment tool will be used with a control group. Two independent variables, a suicide assessment tool, and a standard assessment, cannot be manipulated. It is necessary to follow a post-test only design to compare the results in both groups and check where the reduction of future suicide attempts is possible. This study will help to analyze the effects of two different assessments on suicide rates in pediatric patients during a certain period.
The data will be gathered from a questionnaire that is offered to every participant. The chosen method and the number of patients create certain limitations and benefits to the project. The main advantage of the selected design is the possibility to evaluate the worth of two different assessment tools on pediatric patients using their reports and personal information. However, there is also a disadvantage in this sample size to be mentioned. Statistical analysis in this study may not be meaningful enough because of the lacked randomization and internal validity threats. Human errors cannot be neglected, but the decision to develop quasi-experimental research is rationalized by the absence of time constraints and true experimental concerns. There are several important reasons why this research design should be chosen to answer the already developed PICO question. First, one person can easily introduce an intervention, gather the material, and analyze the data in terms of this study. Second, validity threats can be identified at the initial stages of the project and be removed by a researcher. Finally, it does not take much time to get prepared for this kind of intervention.
Sampling
One of the most important steps in developing a quasi-experimental research project is the selection of participants, also known as sampling. The target population of the study includes pediatric patients who may have suicidal thoughts with time. The possibility to cooperate with local hospitals provides an opportunity to focus on random selection as a part of probability sampling. It means that all units in the chosen population have equal chances for participation. However, to strengthen the study, it is necessary to make sure that sufficient subjects are enrolled within the selected groups which are easy to administer (Patel et al., 2018). This type of sampling is called stratified random and combines people about their interests, physical conditions, or certain problems. In this case, a researcher is interested in pediatric patients who should be assessed for suicide attempts. The main inclusion criteria are:
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Patients between 12 and 16 years;
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English speaking people;
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Children who can read and write in English.
The exclusion criteria, in this case, will be:
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Children who have already made suicidal attempts before the intervention;
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Orphans
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Children who are younger than 12 years and older than 16 years.
It is expected to cooperate with about 200 children, and both groups (control and experimental) will include 100 participants each. All participants must stay unaware of what kind of tool is applied in their cases. The study should be approved by the appropriate research ethics committee. A nurse may be invited to provide participants with information about the intervention, its potential importance, and their roles in research. In addition, such information as the approximate time required, possible risks, and benefits have to be discussed. As a rule, informed consent has to be obtained from each participant in a written form so that participants can learn their duties and withdraw from an intervention anytime they want. It helps protect patients confidentiality, anonymity, and other rights with all possible harms being avoided.
Intervention
The PDSA change model is the core method to implement the offered intervention. It consists of four steps: planning, doing, studying, and acting. Its main goal is to promote improvements and ensure quality during working processes (Christoff, 2018). However, to succeed in this EBP project, it is not enough to set an aim and create a team. It is important to be prepared for a change and check each step and its possible effect on patients and the solution to a problem. To test a change in terms of the PDSA cycle means to develop a strong plan, take the first implementation steps, observe the results, and act by the results obtained. In this study, the main change includes the necessity to replace a standard pediatric assessment tool with a special suicide assessment tool for patients. The task of research is to monitor change and make sure that all new information can be rapidly transferred between all the participants of the intervention (Leavey et al., 2017). The PDSA cycle is an interactive model that tests interventions from multiple perspectives.
The choice of this model is explained by the necessity to introduce an intervention that has not yet been tested in pediatric care settings. It has a simple structure, and a researcher can be properly guided during the whole process. The change of tools can lead to unpredictable results in care and attitudes to care, and this project should not put participants, as well as other stakeholders, under threat.
There are four main steps in this model with the help of which a researcher can accomplish the goals set. First, a plan should be developed to identify the tasks. In this case, an intervention will be offered to the pediatric patients at the local hospital during their first visits. It is expected to inform all participants about the risks of suicide at early stages and check their emotional and behavioral concerns. The next step, doing, focuses on carrying out the intervention and reporting on all relevant data. At this stage, a researcher offers a special tool to an experimental group and a standard tool to a control group. Then, the study step is taken to evaluate all the observations and answers obtained. Participants attitudes toward the tools and the information about their emotional states have to be analyzed and presented in a table format. Finally, if the appropriateness and worth of the tool are proved, and the intervention is successfully introduced, it should be adopted to check if this change can reduce the number of suicidal attempts.
A serious barrier in the implementation of this intervention may occur because of the inability to establish trustful relationships with participants. To overcome this challenge, a researcher may cooperate with a nurse and learn how to introduce the information to people in healthcare settings. The development of communication skills and creative thinking may also facilitate the EBP results and simplify a working process. In addition, the environment that has to be developed to support EBP may considerably foster the future practice setting. A researcher will learn how to talk to patients, establish clear goals, and develop plans. The exchange of personal information and research objectives is a solid skill that may be applied in future projects.
References
Ballard, E. D., Cwik, M., Van Eck, K., Goldstein, M., Alfes, C., Wilson, M. E., & Wilcox, H. C. (2016). Identification of at-risk youth by suicide screening in a pediatric emergency department. Prevention Science, 18(2), 174182. Web.
Bromberg, M. H., Law, E. F., & Palermo, T. M. (2017). Suicidal ideation in adolescents with and without chronic pain. The Clinical Journal of Pain, 33(1), 21-27. Web.
Christoff, P. (2018). Running PDSA cycles. Current Problems in Pediatric and Adolescent Health Care. Web.
Desjardins, I., Cats-Baril, W., Maruti, S., Freeman, K., & Althoff, R. (2016). Suicide risk assessment in hospitals: An expert system-based triage tool. The Journal of clinical psychiatry, 77(7), 874-882. Web.
Diamond, G. S., Herres, J. L., Krauthamer Ewing, E. S., Atte, T. O., Scott, S. W., Wintersteen, M. B., & Gallop, R. J. (2017). Comprehensive screening for suicide risk in primary care. American Journal of Preventive Medicine, 53(1), 4854. Web.
Kodish, T., Herres, J., Shearer, A., Atte, T., Fein, J., & Diamond, G. (2016). Bullying, depression, and suicide risk in a pediatric primary care sample. Crisis, 37(3), 241-246. Web.
Leavey, G., Mallon, S., Rondon-Sulbaran, J., Galway, K., Rosato, M., & Hughes, L. (2017). The failure of suicide prevention in primary care: Family and GP perspectives A qualitative study. BMC Psychiatry, 17(1), 369-379. Web.
Montreuil, M., Butler, K. J. D., Stachura, M., & Pugnaire Gros, C. (2015). Exploring helpful nursing nare in pediatric mental health settings: The perceptions of children with suicide risk factors and their parents. Issues in Mental Health Nursing, 36(11), 849859. Web.
Patel, A., Watts, C., Shiddell, S., Couch, K., Smith, A. M., Moran, M. J., & Conners, G. P. (2018). Universal adolescent suicide screening in a pediatric urgent care center. Archives of Suicide Research, 22(1), 118-127. Web.
Ross, A. M., White, E., Powell, D., Nelson, S., Horowitz, L., & Wharff, E. (2016). To ask or not to ask? Opinions of pediatric medical inpatients about suicide risk screening in the hospital. The Journal of Pediatrics, 170, 295300. Web.
Stanley, I. H., Horowitz, L. M., Bridge, J. A., Wharff, E. A., & Teach, S. J. (2016). Bullying and suicide risk among pediatric emergency department patients. Pediatric Emergency Care, 32(6), 347-351. Web.
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