Suicide Assessment by Psychiatric Mental Health Nurses: A Phenomenographic Study

Suicide is the eleventh leading cause of mortality in the United States. This study explored suicide assessment by psychiatric nurses. The primary aims of this study were to gain an understanding of nurses' conceptions regarding suicide and suicide assessment, describe the strategies of suicide assessment adopted by psychiatric nurses, and contrast these to contemporary standards and practice guidelines of suicide assessment. The research design was an inductive descriptive phenomenographic study. The nurse participants consisted of a snowball sample of six psychiatric nurses practicing in two psychiatric settings. The data were collected through participant observations of nurses' assessing patients and semi-structured in-depth interviews with nurses regarding their assessments of actual cases and vignettes. The participants in the study while performing suicide assessments relied on several different strategies among the common 10 categories that emerged as the core set of strategies. In most cases the nurses used between four to six different strategies in combination rather than relying solely on one specific strategy. However, the strategies used in suicide assessments by these nurses did not cover the areas identified in the standard guidelines in a comprehensive or all-inclusive manner, suggesting that the nurses were not systematic in their assessments. Out of the 10 categories , four have been linked to qualitative differences in suicide risk assessment. Namely, 1) reliance on exemplars, 2) reliance on intuition, 3) reliance on the assessments of other professionals, and 4) reliance on related stories. The characteristics of the 10 categories of description regarding suicide assessment could be classified into three dimensions: (a) the Knowledge Dimension, (b) the Method Dimension, and (c) the Reference Dimension. These Dimensions provide a "structure of suicide assessment" used in nursing practice by the participants of this study. The findings of this investigation are descriptive and were discovered in the nurses' practice. The results do not address correct or incorrect ways of practicing. However, the findings provide knowledge about actual nursing practice. This descriptive work can serve as a foundation for the development of a theory of nursing assessment. The findings have implications for nursing knowledge development, practice, education, administration, and research .


Abstract
Suicide is the eleventh leading cause of mortality in the United States.
This study explored suicide assessment by psychiatric nurses. The primary aims of this study were to gain an understanding of nurses' conceptions regarding suicide and suicide assessment, describe the strategies of suicide assessment adopted by psychiatric nurses, and contrast these to contemporary standards and practice guidelines of suicide assessment.
The research design was an inductive descriptive phenomenographic study. The nurse participants consisted of a snowball sample of six psychiatric nurses practicing in two psychiatric settings. The data were collected through participant observations of nurses' assessing patients and semi-structured in-depth interviews with nurses regarding their assessments of actual cases and vignettes .
The participants in the study while performing suicide assessments relied on several different strategies among the common 10 categories that emerged as the core set of strategies . In most cases the nurses used between four to six different strategies in combination rather than relying solely on one specific strategy. However, the strategies used in suicide assessments by these nurses did not cover the areas identified in the standard guidelines in a comprehensive or all-inclusive manner, suggesting that the nurses were not systematic in their assessments. Out of the 10 categories , four have been linked to qualitative differences in suicide risk assessment. Namely, 1) reliance on exemplars, 2) reliance on intuition, 3) reliance on the assessments of other professionals, and 4) reliance on related stories.
The characteristics of the 10 categories of description regarding suicide assessment could be classified into three dimensions: (a) the Knowledge Dimension, (b) the Method Dimension, and (c) the Reference Dimension.
These Dimensions provide a "structure of suicide assessment" used in nursing practice by the participants of this study.
The findings of this investigation are descriptive and were discovered in the nurses' practice. The results do not address correct or incorrect ways of practicing. However, the findings provide knowledge about actual nursing practice. This descriptive work can serve as a foundation for the development of a theory of nursing assessment. The findings have implications for nursing knowledge development, practice, education, administration, and research . x   Statistics, 1992). Suicide rates for adolescents have increased threefold since 1955, and individuals over 60 years have a higher rate than people between the ages of 25 and 55 years old (Clark & Fawcett, 1992). White older men (over 80 years old) are at the greatest suicide risk of all ages, gender, and racial groups. The increased suicide rate in older people is particularly noteworthy since they represent half the clientele for many clinicians (Whall & Colling, 2001 ). Statistical data regarding suicide are often underestimated. This may be related to the stigma associated with suicide, guilt of significant others, and concern for loss of insurance benefits.

List of Figures
Fifty to 65% of individuals who attempt suicide have contact with clinicians and generally communicate their suicide ideation to someone (including nurses) in the months preceding attempts (Fawcett, Clark, & Busch, 1993;Goh, Salmons, & Whittington, 1989;Morgan & Priest, 1999;Rich, Young , & Fowler, 1986). Brown, Jones, Betts, and Jingyang (2003) studied 3,500 mental health professionals and 43,000 patients finding clinicians missed early suicide signs in adults 57% of the time compared with patient self-reporting of suicidality via questionnaire. When practitioners were informed of the differences between their assessments and the client responses , the error rate dropped to 39% . This reduced "error rate" was similar for adolescents and resulted in a combined statistical improvement in risk assessment of 29%. Similarly, a root cause analyses of 17 attempted and completed suicides identified inadequate patient assessment, knowledge deficits, and poor communication as contributing factors (Dlugacz, Restifo, Scanlon, Nelson, Fried, Hirsh, Delman, Zenn, Selzer, & Greenwood, 2003).
Other studies (Somers-Flannagan & Somers-Flannagan , 1995;Miller, 1978) have shown that even when clients have expressed suicidal ideation (via a verbal or behavioral clue), clinicians have neglected to establish or prevent intent. Furthermore, some clinicians philosophically adhere to the belief that individuals have the right to suicide; still others feel suicide is unpreventable (Repper, 1999). Therefore, the conceptions regarding suicide and assessment strategies adopted by nurses may play a crucial role in the quality of individual nurses' suicide assessments and client outcomes.
Improved understanding of how nurses assess suicidality has significance to the public health problem of increasing suicide rates.
Theoretically, this study could contribute to knowledge development in nursing with a focus on practice (for example, in the area of deliberation and enactment phases in the nursing practice domain identified by Kim [1983Kim [ , 1987Kim [ , 2000). Pragmatically, there is value in gaining better insight into nurse's conceptions of suicide assessment with the goal of suicide prevention and early intervention.
The available statistics and findings make suicide a major national public health problem . As a result, for example , the U.S. Senate Special Committee on Aging held Congressional hearings entitled: "Suicide and the Elderly: A Population at Risk" ( 1996). The report given by the Director of the

National Center for Injury Prevention and Control of the Centers for Disease
Control and Prevention (CDC) identified suicide in older people as a vital public health preventable problem . The CDC's goal is to decrease the incidence of suicide in older people using the public health approach. This suicide prevention approach combines four primary activities: (a) surveillance to identify trends and epidemics and differential rates of suicide, (b) research to identify the sequence of causes in the chain of suicide, (c) design and evaluation of interventions to stop this chain and prevent suicides, and (d) program implementation encompassing demonstrated successful interventions. Other initiatives have developed to address other high-risk groups, such as children and adolescents (Horowitz, Fallon-Smith, Levin , & Klavon , 2002), older white males (Miller, 1978), and schizophrenics.
In 1999, Surgeon General David Satcher presented a blueprint to prevent suicide. The Surgeon General's Call To Action To Prevent Suicide (U.S. Public Health Service, 1999) outlines actions that can be implemented by individuals, communities, and policymakers. Other initiatives also highlight suicide as a priority national health problem (U.S. Department of Health and Human Services, 1998; U.S. Senate, 1997). For example, Healthy People 2000 has targeted older white males as a group most at risk for suicide and has set a goal for a 15% reduction in the rate of suicide for this group.
Similarly, in an attempt to attain the "Healthy People 2000" objective of decreasing "suicide deaths to no more than 10.5 per 100,000 residents" (Simmons, Peterson, & Hale, 1999, p. 337), community-based intervention strategies have emerged . Such federal initiatives address the implications of suicide on public health and impact on nursing practice.
Suicide is complex and multifaceted. This adds to the challenges of accurate suicide assessment. As Bongar (1992) states, "assessing the reliability of individuals reporting on suicidal inclinations is a matter of clinical judgment that goes beyond codified criteria" (p. 207). Furthermore, no one has been able to demonstrate "that any standardized suicide risk prediction scale can pick out persons who go on to die by suicide in samples beyond the sample that generated the scale" (Clark, Young, Scheftner, Fawcettt, & Fogg, 1987, p. 32). Bongar (1992) further states, "[t]he more commonly known suicide assessment instruments [appear] to be used infrequently and most of the traditional instruments are rated as having limited usefulness" (Bongar, 1992, p. 148).

5
Because there is a lack of specific precise measures and standardized procedures to unmistakably determine whether an individual is at risk for suicide, suicide assessment is especially problematic and challenging.
Although major advances have been made in the area of suicide assessment, there remains a lack of knowledge regarding suicide assessment. There is a need to continue with the efforts to understand and address the emerging trends in suicide and delineate better ways to assess and prevent suicide.

"Customary" Methods for Suicide Assessment
Jobes and colleagues found that psychiatrists, psychologists, and social workers (interestingly, nurses were not included in the study) "reply primarily on some form of clinical interview to assess suicide (specifically on certain valued questions and observations)" (Jobes, Eyman, & Yufit, 1990, p. 148).
" ... As Coombs et al. (1992) have shown , many clinicians fundamentally do not even ask about suicide and routinely fail to conduct and document basic assessment of suicide risk . Still other data suggest that some outpatient cl inics have explicit exclusion criteria for suicidal patients (Benstein , Feldberg , & Brown, 1991 ). It is striking to note that research examining empirical treatments for suicidality is so scant because most treatment research protocols routinely exclude high-risk suicidal patients (Linehan, 1998)" (Jobes, 2000, pp. 9-10).
Recent studies, have also found that, although the overwhelming majority of school counselors are familiar with adolescent suicide risk factors and believe that their role is to identify at risk students, only 1 in 3 reported feeling competent in identifying a student at risk (King , Price , Telljohann , & Wahl, 1999;Coder, Nelson , & Aylward , 1991). Only 74% of counselors studied felt knowledgeable about school district policy and procedures on suicide. Additionally, only 58% reported knowing how to negotiate a nosuicide contract and less (51 % ) reported understanding crisis theory and its re lationship to crisis intervention. Furthermore, myths, misinformation and/or misunderstanding of suicide continue to exist. For example, "between onehalf to two-thirds of respondents incorrectly believed that entering puberty at a late age, being financially disadvantaged, being obese, and having low grades were risk factors" (King & Smith, 2000, p. 404). Williams and Morgan (1994) describe negative attitudes and misconceptions surrounding the feasibility of suicide prevention (e.g. , some practitioners believe that individuals should be allowed to commit suicide if they desire and that suicide is often not preventable). However, Morgan and Evans (1995) found that providing education (on the incidence, assessment and management of suicide) significantly reduced such negative attitudes (Repper, 1999;Morgan & Evans, 1995).
Contemporary suicide assessment practice varies betwee_ n and among clinicians. Assessment can range from a comprehensive mental status assessment (including thorough qualitative data and/or use of quantitative instruments and consultation) to the use of intuition ("I know the patient.") or apparent absence of direct suicide assessment. Assessment of subjective data makes accurate suicide assessment another particularly challenging problem. In particular, we do not currently have a very good depiction of what really is happening in actual clinical practice with nurses in their assessment of suicidality.
Contemporary suicide assessment practice guidelines, although invaluable, are often complex, vary across settings and population and are not all inclusive. Such contemporary suicide assessments, depending on the clinician , could consist of a systematic comprehensive collection of the following data:

A. Determination of the presence of epidemiological and
sociodemographic risk factors . This would include, but is not limited to, high-risk populations , such as older people , single, white, male gender, those living alone , etc. If clinicians rely exclusively on risk factors as the basis of their suicide assessment, for example, erroneous clinical judgment could result (i.e., low risk does not mean no risk).

B. Determination of the presence of stressors. This would include,
but is not limited to, changes in personal , social, occupational , and/or academic life spheres .

C. Depression screening with associated agitation and/or anxiety.
Many clinicians use the SIG-E-CAPS acronym (Prescribe Energy Capsules) (Wise & Rundell , 1988) as a guide to assessing depression with anxiety/agitation . These areas include assessing (S) sleep disturbance, change in (I) interest (anhedonia), (G) guilt (excessive guilt, worthlessness, hopelessness, helplessness), (E) energy level (fatigue or loss of energy), (C) concentration difficulties or indecisiveness, (A) appetite change (>5% weigh loss or gain), (P) psychomotor agitation/anxiety or retardation , and (S) suicide (ideation , plan , or attempt). The extent of this assessment can vary in depth and breadth among and between clinicians. For example, some clinicians would incorporate additional in-depth questions regarding insight, judgment, impulsivity, intent and plan , and means and access (e.g ., having weapons or hoarding medication). E. More specific assessment for suicide. Other suicide assessment strategies may include the use of various quantifiable instruments and/or would entail directly asking the client a variety of questions including "Have you had thoughts of death or of killing yourself?" As a guide in specific suicide assessment, many clinicians also rely on the areas identified in the SADPERSONS SCALE (Patterson , Dohn , Bird , & Patterson , 1983) [Appendix A] and/or the areas within the "SLAP" acronym , wh ich stands for specificity, lethality, availability, and proximity (Sommers-Flanagan & Sommers-Flanagan , 1995).
There are many instruments that have been developed and are being used by practitioners both in nursing and in the psychiatric-mental health field for suicide assessment. These are reviewed briefly in the following section in order to provide a background of how suicide assessment is performed in practice.
Nursing Scales for Assessing Suicidality 9 A. "Suicide/self harm assessment" (Medical University of South Carolina, USA). Stuart (2001) provides a "Suicide/Self Harm Assessment" tool focusing on "key factors," including ability to contract for safety, suicide plan , lethality, elopement risk, suicidal ideation, attempt history, select symptoms, and current morbid thoughts. This nursing developed tool combines quantitative and qualitative components. The scoring is divided into high risk (a score of 10 or greater), moderate risk (a score of 4-9), and no precautions (a score of 0-3). Although reportedly used in select practice settings, there is no available documented evidence of the tools reliability and validity . . Furthermore, the "RN Subjective Appraisal of Risk" relies on the RN's ability to accurately appraise the client's trustworthiness, a task that can be challenging , particularly with clients who are guarded, withholding and paranoid.

B. "Guidelines for urgent mental health referrals" (North Solihull,
UK). , Tumney (2001 and a multidisciplinary team developed nurse led guidelines for urgent mental health referrals based on "good practice and collaboration in accordance with two of the standards identified in the National service Framework for Mental Health" (Tumney, 2001, p. 42). Unfortunately, to date, this writer has been unable to access these guidelines. However, in the currently available literature, it is unclear as to what "good practice" entails.
Furthermore , in addition to acknowledging that suicide prediction is difficult (Tanny, 1995), the urgent care team is only available during "traditional working hours" and caters to "the local population" (Tumney, 2001 ), thus, limiting its utility.

C. "Suicide prevention nursing protocol" (Bay Pines, FL). In 1997
Florida's Bay Pines Veteran Affairs Medical Center established a "researchbased suicide prevention nursing protocol." This protocol was developed by a team consisting of: a psychiatric nurse practitioner, a mental health nurse specialist, two mental health staff nurses, an education specialist, and a training specialist. The purpose was "to improve the quality of care while reducing the legal vulnerability of health care providers and the facility" (Robie, Edemon-Hill , Phelps, Schmitz, & Laughlin, 1999, p. 53). According to the authors, "this ensues that a standard is used to assess -and to intervene with -all patients at risk for suicide" (p.53).
Although this protocol and associated basic algorithm may have clinical usefulness, it is unclear as to whether it was developed with a theoretical framework , what "research-based" criteria was used, if the protocol has been tested , and whether utility extends beyond the stated population.
Furthermore , the authors provide a seemingly complex unsystematized list of behaviors and risks (including the SAD PERSONS scale) [Append ix A] which might be impossible to memorize or incorporate in clinical practice and do not provide a comprehensive mechanism for systematically assessing the suicidal client.
D. "Degree of suicidal risk" (Los Angeles, CA). In a noteworthy attempt to advance nursing suicide assessment, Hatton, Valente, and Rink (1977) and, later, Hatton and Valente (1984) proposed a "Degree of Suicidal Risk" assessment scale. This scale focuses on the assessment of specific behaviors or symptoms resulting in a rating from low to moderate to high intensity of risk. In addition to differentiating emergency versus long-term risk ratings (e.g. , "emergency risk rating ... defined as the potential of the person for killing himself or herself within the next 24 hours; and the long-term risk rating ... defined as the likelihood that a person will kill himself or herself within the next two years [p.57]), the authors identify the "three most significant assessment factors that identify for the caregiver the difference between these two ratings ... (1) the coping strategies, (2) the life style, and (3) the suicidal feelings of the client" (p. 56).
Although case examples are provided as illustrations, the behavior or symptoms and "three most significant assessment factors" are extensive areas to cover in a routine assessment and the scored ratings of low, moderate, and high intensity risk are subjective ratings and unclear. The authors, also, address the "intuitive" aspects in suicide assessment. Such intuition could yield fatal outcomes should clients be erroneously assessed.
E. "A scale for assessing suicidal potential" (Los Angeles, CA). In "Suicide Intervention by Nurses" (Miller, 1982), "A Scale for Assessing Suicidal Potential" is provided as a prototype assessment scale. As stated by the developers, the scale "is only useful in helping you to estimate suicidal potential , and therefore is not meant to be definitive" (p. 57). The scale is somewhat extensive, complex, and lengthy and questionably pragmatic.
Furthermore, the low, medium and high-risk ratings are the arithmetic mean which is "only meant to be suggestive, not conclusive" (p. 58).

Select Non-Nurse Developed Quantitative Instruments
Although numerous quantitative suicide assessment instruments have demonstrated "robust" reliability and validity (e.g., Beck Scale for Suicidal Ideation, Beck's Suicide Intent Scale, and Beck Depression Scale), quantitative scores interpreted alone can be dangerously misinterpreted and inaccurate as can qualitative assessment or a combination of inaccurate quantitative and qualitative assessment.
As Bongar (1991) (Maris, 1988, p. xii). Shneidman (1988 noted that "study of suicide is multidisciplinary -a never-completed circle, containing many legitimate sectors or fields or approaches" (p. 5). Pfeffer (1988) agrees , stating that "suicidal behavior is a complex, multidimensional phenomenon that can be understood from a variety of key vantage points: psychosocial , sociocultural, constitutional-biological, any many others" (p.21 ). Thus, there is no one ideal standard nor is there a static constellation of standards that can be applied in all areas of suicide. Similarly, as Bongar (1992) states, "No suicide scale is an ideal screening instrument.
One must use a scale that has the best normative data for the population in question and that is oriented toward the particular information most needed (e.g., degree of hopelessness, severity of suicidal ideation, and suicide intent)" (p. 128).
In sum , although such "scales" are potentially useful, they are not allinclusive and could provide the clinician with a potentially "deadly" false sense of security. The following selected quantitative instruments are illustrative of the more familiar and frequently used.
A. Suicide intent scale. The Suicide Intent Scale (Beck,Schuyler,& Herman,197 4) is a semi-structured interview administered by a trained clin ician that assesses suicidal intent from data collected reflecting the intensity of the attempter's desire to die at the time of the attempt. The scale, divided into two sections, contains 15 items rated in intensity from 0 to 2. The first section , "objective circumstances related to the suicide attempt," describes the person's behavior and events surrounding the attempt. The second section details the person's thoughts and feelings at the time of the attempt. Each item is rated on a 3-point scale of severity and a total score is the sum of the scores from the 15 questions. The Suicide Intent Scale has been shown to have an inter-item reliability ranging from .91 (Beck, Morris, & Beck, 1974) to .95 (Beck, Schuyler, & Herman , 1974).
B. Scale for suicide ideation. Beck and colleagues (1979) developed the "Scale for Suicide Ideation" to quantify the intensity of current conscious suicidal thoughts and plans . This 19-item scale is scored by a trained interviewer based on a semi-structured interview. Three alternative statements are scored (from 0-2), and the total score is the sum of the scores for each item. The Scale for Suicide Ideation covers 5 domains: (1) attitude toward dying and living; (2) suicide wish or ideation; (3) actualization of contemplated attempt; (4) nature of contemplated attempt; and (5) background factors . "Internal consistency was found to be .89 and interrater reliability .83" (Bongar, 1992, p. 130). This scale discriminates among groups varying in degree of suicidal ideation . The Scale for Suicide Ideation has been modified (Miller, Norman, Bishop, & Dow, 1986) for paraprofessional administration.
Unlike the Hopelessness Scale, the Scale for Suicide Ideation is only recommended for use with adults because there lacks research on its utility with adolescent populations.
C. Suicidal ideation questionnaire. Reynolds (1988) developed the Su icidal Ideation Questionnaire (SIQ) to assess an adolescent's severity and recent frequency of suicidal ideation. Forms for middle, junior, and high school students were designed primarily as screening instruments to identify adolescents at risk of suicidal behavior. The junior high school version includes 15 items and the high school version 30 items.

15
The items consist of statements relating to ideas of self-injury, death, and suicide. The student is asked to answer each question according to how often a statement was "on my mind" during the past month, using a 7-point scale ranging from "I never had this thought" to "almost every day." Interpretation is based on a total score for degree (severity) of suicidal ideation that is a sum of the item scores, critical items regarding specific thoughts and plans, and individual patterns. Reynolds (1988) suggests further suicidal risk evaluation for scores above a cutoff score or endorsement of 2 critical items on the junior high school version and 3 critical items on the high school version .
Although carefully constructed and one of the best suicide screening instruments for an adolescent population, the SIQ cannot be recommended for clinical use independently (Lewinsohn , Garrison, Langhinrichsen , & Marsteller, 1989). The instrument was developed with a sample of junior and senior high school students, thus, the scores from this general population are likely inappropriate for adolescent psychiatric inpatients (Bongar, 1992). Cull and Gill (1986) designed the Suicide Probability Scale to assess suicide risk in adolescents and adults.

D. Suicide probability scale.
Th is 36-item questionnaire asks respondents to rate the frequency of occurrence for every item of a 4-point Likert Scale. However, instructions are unclear about whether the respondent is to base the rating on current or past experiences.
"Hand-tabulated responses provide a total weighted score, a normalized total T-score, and a suicide probability score, which is the statistical likelihood an individual might belong to a population of lethal suicide attempters .. .. Golding (1985) indicated that a factor analysis showed the scale items to be scattered among various factors and highly correlated so the subscales are not statistically sound or independent; hence they should be used with caution" (Bongar, 1992, p. 131).

E. Other Select Assessment Tools. The United Kingdom's NHS
Health Advisory Service has developed a "thematic assessment process" (Williams & Morgan, 1994) that is meant to be suggestive, not conclusive and is only an estimate of suicide potential. Also, Gliatto and Rai (1999) provide a "management algorithm" for the evaluation and treatment of patients with suicidal ideation. Although addressing certain aspects of suicide assessment, this algorithm is not uniformly used in practice nor appears well known.

Commentary on Quantitative Instruments
Although standardized suicide risk assessment tools are readily available, Rice and Donnelly (1991 ) found that most clinicians do not utilize them . The authors provide several potential explanations for this trend: (a) some instruments are intended for research rather than practice; (b) extensive training is often involved to ensure competent administration of such instruments; and (c) most instruments are time consuming to accurately administer. However, given that many individuals who ultimately commit suicide have had recent contact with clinicians shortly before their death, this finding emphasizes the challenges of suicide assessment in routine practice.
Furthermore, although many of the quantifiable suicide assessment instruments have documented "reliability" and "validity, " it is unclear whether some of these instruments have been developed with a theoretical foundation (cogency), which raises doubts as to the reported levels of reliability and validity. Still , while some instruments may have been developed based on theoretical frameworks and tested for reliability and validity, many have not been appropriately and rigorously tested and some instruments have been developed without well established theoretical foundations (i.e., atheoretical).
Therefore, the quality of such instruments cannot be accurately evaluated and limitations in their application exist.
Additionally, some argue that quantitative instruments are reductionistic and negate the human aspect of suicide assessment (Jobes, 2000). Still, many of the available instruments are more appropriate in research or have been evaluated in non-clinical settings (Rice & Donnelly, 1991 ). That is, many quantitative instruments have been tested in controlled settings not equivalent to that of actual clinical practice.

State of the Art in Suicide Assessment
The abundance of assessment methods that have been developed to date indicates that there is no uniform standard of practice applied across various practitioners and settings. Although quantitative tools are available,  (Hirshfeld & Russell, 1997). Thus, there lacks clear understanding of suicide assessment in actual nursing practice (both with novice and expert/advanced practice nurses).

Select Clinical Practice Guidelines
Since the concept of suicide and the process of suicide assessment are exceptionally complex, no existing "practice guideline" can serve as the   [Appendix B] will be used as the primary practice guidelines for addressing research question #3 (How do the strategies of suicide assessment used by psychiatric-mental health nurses compare with current practice guidelines on suicide assessment?). As with Bongar's (1992) comprehensive practice guidelines, the guiding principle for the development of these guidelines is to provide a foundation of basic and critically essential clinical knowledge drawn from accumulated clinical wisdom , review of contemporary empirical findings, and extensive experience in managing the suicidal patient. Bongar (1991) also emphasizes that the opinion of a respected colleague can be the best immediate 'cross-validity check' on the standard of care. Similarly, Shneidman's (1981) dictum is that "Suicide prevention is not best done as a solo practice" (p. 344 ), thus, emphasizing the critical nature of ongoing consultation in assessing and managing the suicidal client. Although appropriate professional consultation is vital, the introduction of possible human error remains.

Purpose of the Study
Research links suicide to misdiagnosis, under-diagnosis (under/misassessment) or undertreatment of depression, and clinicians continue to miss and/or insufficiently manage suicidal intent (Whall & Colling, 2001 ). Although a large body of knowledge has accumulated in the field of suicidology, the strategies adopted by nurses in suicide assessment in actual clinical practice remains unstudied. This problem is particularly relevant to nursing practice, given that nurses are often the only or initial contact for clients (patients) and it is also nurses who assume around-the-clock accountability for patients.
Furthermore, research has shown that nurses often have low comfort levels and limited knowledge in managing suicidal clients (Horowitz, Smith, Levin, & Klavon , 2002). Improved understanding of how nurses assess suicide has significance to the public health problem of increasing suicide rates.
The major aim of this research is to gain knowledge about the conceptualizations and nature and characteristics of suicide assessment by psychiatric-mental health nurses. This study employs phenomenography as the principle method to identify similarities and qualitative differences in the strategies used by nurses in suicide assessment. The specific aim of this research is to identify and describe categories of description used by nurses in suicide assessment. Enhanced understanding of how nurses conceptualize and assess suicide will provide a foundation for improving nursing practice and education.

Research Design and Research Questions
This research applied a descriptive qualitative inductive design using phenomenography as its orientation . The study design (Appendix C) adopted two key assumptions of phenomenography: (a) there are a finite number of qualitative different ways that individuals conceptualize phenomena, and (b) an individual may not express all aspects of a conception (and conceptions can vary within the same individual at various times) [Marton, 1997;Sandberg, 1995]. Over 20 years of various phenomenographic studies support the first assumption (Marton, 1986;. Regarding the second assumption, Sandberg (1995, p. 158) notes that, in some circumstances, a specific conception cannot be perceived in its entirety in data obtained from one individual , but only within data obtained from several individuals. Thus, phenomenographic researchers synthesize data from many individuals in order to better understand the different qualitative ways of conceptualizing the phenomena. Under these assumptions, the present study sought to discover different ways suicidality was conceptualized and assessed in clients by psychiatric-mental health nurses.
The following research questions were advanced as the guide for this research : "Suicide," a noun, implies a set of diverse behavioral actions and experiences. There are additional issues that add to this unclarity, for example , the definitions of "assisted suicide" and other types of suicide .
Another problem is related to the lack of knowledge about suicide psychodynam ics.

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Numerous classifications of suicide , suicidal behavior (suicidality), and risk have been developed, contributing to inconsistencies in the definitions and complicating suicide research. Many typologies are impractical (e.g. , Durkheim , 1950;Shneidman, 1985). Other taxonomies rely largely on inferential assessment of risk factors and identify suicide types that are not exhaustive.
Historically, suicide is a relatively new term. According to "The Oxford English Dictionary," Walter Charleton used the word, suicide, in 1651 . Yet, Edward Philips , in his 1662 dictionary, "A New World of Words, " asserts to have coined the term . Before this, other words were used to describe suicide (Leenaars, 1988).
Many suicidologists have attempted to define suicide (e.g. , Beauchamp, 1978, Graber, 1981, Windt, 1980) yet, according to Shneidman (1985, these definitions suffer from "intellectual overkill" (p. 16). Shneidman himself is not satisfied with the incompleteness of his relatively succinct definition of suicide as a self-intentioned , self-inflicted cessation. Suicide may also be defined according to its purpose (e.g., medical or legal). In countries reporting to the World Health Organization , for example, suicide is defined by a medical examiner. Shneidman's (1985) text "Definition of Suicide" was an essential step in more effectively defining suicide. He asserts that clarification of the definition of suicide is sorely needed. As Shneidman states , "Currently in the Western world, suicide is a conscious act of self-induced annihilation, best understood as a multidimensional malaise in a needful individual who defines an issue for which suicide is perceived as the best solution " (p . 203). Thus, unlike some , Shneidman does not view suicide as a disease, immorality, neurological dysfunction, or biological anomaly.
The definition of suicide and related concepts in the literature (e.g ., suicide, suicidality, suicidal ideation, parasuicidal behavior, and suicide risk) are generally poorly defined. They are often inconsistent, unclear, underdeveloped , overlapping , and evolving . It is critical for nursing science to further refine and define these concepts. Such knowledge development could , for example, provide a firmer foundation for suicide assessment, prevention , and intervention.

Selected Specific Definitions
According to the World Health Organization (1977) According to Miller, Segal, and Coolidge (2000), suicidal ideation is defined as "the thoughts one has about killing oneself' (p. 358) and is a critical risk factor for serious suicidal behavior (Reynolds, 1991 ). Similarly, the National Institutes of Mental Health (NIMH , 2001) states, "Suicidal ideation refers to any self-reported (italics added for emphasis) thoughts of engaging in suicide-related behavior. Some investigators also consider thoughts that are less explicit wanting to take one's life (wanting to be dead, not wanting to awaken) as indications of 'passive' suicide ideation," (Pearson , Stanley, King , & Fisher, 2000, p. 2). This approach offers a broader definition of suicide.
Although the NIMH's definition is more encompassing than others, it seems its reference to suicidal ideation as being "self-reported" is problematic because of the potential for inaccuracy and unaccountability of self-reporting. Since clients often do not voluntarily self-disclose such personal ideation, grave outcomes cou ld result from literal reliance on this definition . In addition , this definition also lacks a referent to an accurate measurement. Thus, the definition by Miller, Segal , and Coolidge is believed to be the most accurate, conceptually clear, and practical. However, since this definition also seems to lack precise measurement, it is also incomplete.

Spectrum of Suicidality
Suicidal behaviors range from ideas (ideation , thoughts) that are never acted on , suicide attempts of varying degrees, and completed suicide.
Suicidal behavior can be characterized as a spectrum ranging from fleeting suicidal thoughts (ideation) to completed suicide (Gliatto & Rai, 1999).
Suicidality is a global term and is used to describe behaviors related to suicide. According to Shneidman (1973Shneidman ( , 1979, lethality is a synonym for suicidality, meaning the probability that a specific individual will commit suicide within a specified period of time. Suicidality can be conceptualized on a continuum , ranging from suicidal ideation, parasuicidal behaviors, and completed suicide. Suicidality represents a spectrum of risk (likelihood) with an implicit progression in the seriousness of risk from thoughts (ideation) to specific plans, gestures or minor self-injurious acts to attempts with a range of potential lethality, and completed suicide (O'Carroll, Berman , Maris, Moscicki, Tanney, & Silverman , 1996). Many possible social and environmental explanations for regional and national variations in suicidal rates have been considered including social or political systems, population density, climate, latitude or annual light/dark cycles. Given such complexities and numerous variables, it is understandable that suicide is often viewed to be impossible to predict just as meteorologists' forecast (prediction) is not a 100% accurate prediction . Although some risks aren't modifiable, the accurate assessment of suicidality is critical since intervention could save lives.

Operational Criteria for Classification of Suicide
The "Operational Criteria for Classification of Suicide" (Jobes, Berman, & Josselson, 1987, p. 323) is provided below. Intentionality is the most difficult criterion to assess.
I. "Self-Inflicted: There is evidence that death was self-inflicted. This may be determined by pathological (autopsy), toxicological, investigatory, and psychological evidence, and statements of the decedent or witnesses.

II.
Intent: There is evidence (explicit, implicit, or both) that at the time of injury the decedent intended to kill himself or herself or wished to die, and the decedent understood the probable consequences of his or her actions. A. Explicit verbal or nonverbal expression of intent to kill self.
• Implicit or indirect evidence of intent to die, such as the following: a. Preparations for death inappropriate to or unexpected in the context of the decedent's life. b. Expression of farewell or the desire to die or an acknowledgment of impending death. c. Expression of hopelessness. d. Expression of great emotional or physical pain or distress. e. Effort to procure or learn about means of death or to rehearse fatal behavior. f. Precautions to avoid rescue. g. Evidence that decedent recognized high potential lethality of means of death . h. Previous suicide attempt. i. Previous suicide threat. • Stressful events or significant losses (actual or threatened). • Serious depression or mental disorder" (Jobes , Berman , & Josselson, 1987, p. 323).

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Given the complexities and inherent problems in suicidality and risk as concepts , suicide assessment cannot assure a high degree of predictability.
Suicide assessment is problematic in terms of prediction in several respects.
For example , it may be impossible to obtain complete data when patients intentionally or unintentionally do not reveal important information to clinicians or due to changes in client's psychological states . A challenge for accurate suicide assessment is in obtaining critical information associated with suicidal behavior (Neuringer,197 4 ).

Suicide Risk
Suicide is multifaceted and has been associated with numerous risk factors , antecedents, and correlates. Risk factors seldom act independently to increase risk . Certainly, many individuals may have one or more risk factor(s) and not be suicidal (Moscicki , 1999). Similarly, an individual may be without "identifiable" risk factors and be suicidal (i.e. , no indication/identification of currently known risk factors does not mean no risk for suicidality/suicide.  Tuckman and Youngman (1963 , 1 968). These authors reported two follow-up studies after suicide attempts and enumerated 11 risk factors indicating the likelihood of subsequent suicide" (Bongar, 1992, p. 208 having left a suicide note k. history of suicide attempts "Those individuals, for example , who scored on 10 or 11 of these factors were found to have a tenfold increase in suicide compared to all other suicide attempters" (Bongar, 1992, p. 208) . Although the risk factors identified by Youngman (1963, 1968)  The statistical identification of risk factors juxtaposed with the low suicide base rate has commonly measured a risk period (the time during which the factor has demonstrated to be associated with suicide) of 2 years or more (Addy, 1992;Neu ringer, 197 4 ). However, in practice the focus is on a significantly shorter risk period , as the practitioner is primarily concerned about the probability of suicide occurring during the days succeeding the assessment (Mayo, 1998). As defined by Hirshfeld (1998), imminent risk of suicide is defined as within 48 hours.

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According to Repper (1999), "The process of assessing the risk of suicide involves matching the individual with a set of risk factors which have been shown to correlate positively with increased suicide . .. " (p. 4 ). "Briefly, an emergency risk rating may be defined as the potential of the person for killing himself or herself within the next 24 hours; the long-term risk rating may be defined as the likelihood that a person will kill himself or herself within the next two years" (Hatton, Valente, & Rink, 1977, p. 57

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Risk assessment is a prediction of the likelihood of a particular adverse outcome under specific circumstances happening within a specified time. Risk formulation is a process of organizing risk data, summarizing, and identifying risk factors. Risk formulation serves as the information foundation for risk management. The goal of risk management is to minimize the likelihood of particular adverse outcomes within the context of the overall management of a client, accomplish the ideal possible outcome, and deliver safe, effective, appropriate, timely care. Risk is not a static state and fluctuates. This necessitates ongoing assessment, especially during critical periods.
Assessment prediction is most precise in the short-term and is never perfect.
Risk assessment is an essential component of every clinical observation or assessment and should be incorporated in routine practice (Wilson, 1998).
Limits to risk assessment do occur and it is impossible to entirely eradicate risk. Even under the most ideal circumstances (using optimal assessment strategies and management modalities), adversity occurs. For example, epidemiological and actuarial measures are devised to identify high-risk groups and caution is needed when applying probabilities from these procedures to individuals. Furthermore, the history of the nurseagent/assessor and the context of the situation (e.g ., conceptions, attitudes, culture, age, gender, and/or religious convictions) will impact the assessment process and outcome.
There is no definitive method of predicting suicidal behavior. While risk factors are comparatively common , suicide is uncommon (e.g ., U.S. base rate of 0.011 %) [Moscicki, 1997]. However, there are individual past and present patterns of risk factors that are highly suggestive and should alert a practitioner to possible suicide risk. The low incidence of suicide, additionally, contributes to the challenges of developing precise tools to accurately identify those at risk. As Neuringer (1974) notes, as one gravitates away from specificity and towards generality of prediction , accuracy increases yet utility decreases (i. e., endeavors to improve the sensitivity of risk-prediction measures yields more false positives). "The aim of science is to be able to make constant valid specific predictions. Any adequate assessment of suicidal risk technique should aim at the development of highly probable specific predictions. One might posit that the capacity to deliver such accurate specific and particular predictions is the hallmark of a truly useful assessment technique" (Neuringer,197 4,p. 6).
Arguing against a pure reductionistic risk perspective, Jobes (2000) states , "If we only consider risk factors we may fail to appreciate the utility of directly accessing and listening to the patient's own intrasubjective experience of being suicidal. Generally speaking , clinical assessments of suicidality often over emphasize a top-down (quantitative) risk-factor approach rather than eliciting a bottom-up (qualitative) description of what it is like for a patient to be suicidal , in their own words" (p. 1 ).
In summary, nursing assessment of suicide risk and challenges to accurate ri sk assessment were addressed . A number of conceptual gaps were identified including the need for concept, knowledge , and theory development on suicide (including related terms), risks, and assessment.
Implications for nursing are infinite (e.g. , concept development, phenomenographic, and other research with clients, nurse-clients, and practice).

Select Theories of Suicide
The earliest theories of suicide were largely demonologic ("evil spirit") and theologic (religious) (Jackson , 1957). The major breakthroughs in the understanding of suicide were Freud's (1917) psychoanalytic conceptualization of suicide and Durkheim's (1950) sociological classification of suicide. In brief, Freud postulated the existence of 2 basic instincts, death instinct "thanatos" and life instinct "eros." Later, Durkheim classified all suicides into 4 kinds: altruistic, egoistic, anomic, and fatalistic.  (Shneidman , 1993). Shneidman develops the concept of psychache to explain the phenomenon of suicide. In his theory, one of the necessary elements of suicide is extreme psychache that the suicidal individual cannot endure. The source of psychache is frustrated psychological needs. Shneidman (1991) proposed a "cubic model" of suicide ( Figure 1 ).

Shneidman's Theory of Suicide
Included in th is cubic model are three critical "P" factors ("3 P's"). These are (a) press, (b) pain, and (c) perturbation. These three factors are closely interconnected . Press ("pressure") represents those aspects of the actual and imaginary world , or environment that impinge on or affect the individual. Pain refers to psychological pain resulting from thwarted psychological needs.
Perturbation is a general term meaning the state of being perturbed or upset.
With respect to suicide, perturbation includes: (a) constriction , i.e. , the reduction of the individual's perceptual and cognitive fields; and (b) "penchant for action ," (p. 171) also referred to as "pull" which is best understood as the lack of will power. The central assertion of Shneidman's theory is that although various areas in his three-dimensional cube may correspond to various psychological conditions, suicide occurs only within the depicted dark shaded area . Thus, if the intensity on at least one of the three dimensions is reduced to a level outside this area, the person will live. Conative :

Perturbation
a.
The common purpose of suicide is to seek a solution.
b. The common goal is cessation of consciousness. Situational: c. The common stimulus in suicide is intolerable psychological pain ("psychache"). d.
The common stressor in suicide is frustrated psychological needs. Affective: e. The common emotion in suicide is hopelessness-helplessness.
f. The common cognitive state in suicide is ambivalence. Cognitive: g.
The common perceptual state in suicide is constriction .
h. The common action in suicide is egression .
Relational : i. and perturbation can be assessed via objective external manifestations, the problem of assessing psychological pain is more elusive . Only recently Shneidman (1999) proposed the Psychological Pain Assessment Scale (PPAS). Shneidman acknowledges that the validity of the PPAS has not yet been empirically supported, but this instrument was found to be "useful." This scale is not used in routine nursing practice.
In short, Shneidman's theory primarily emphasizes defining suicide and suicide risks (i.e ., commonalities) unlike Beck's theories (below) that are causal theories of depression and suicide.

Beck's Cognitive Theory of Depression/Suicide
Psychiatrist Aaron Beck, born in Providence, Rhode Island, is a selfproclaimed "pragmatist" (DiMarco, 2001;Weinrach, 1988). He is a graduate of Brown and Yale Universities. The historical roots of Beck's theory of cognitive therapy date back to 1956 when he experimentally found that in response to success experiences with graded task assignments, depressed clients seemed to improve rather than resist these experiences (Beck, 1964;Loeb, Beck & Diggory, 1971 ). These findings were inconsistent with Freud's psychoanalytic conceptualization of depression (Freud, 1917(Freud, /1950 Beck and colleagues (1999) has become a leading model for comprehending human cognition (including suicidal ideation) having been supported in more than 120 empirical tests (Alford & Beck, 1997).
This raises questions about the reliability and validity of the latter instrument.
Additionally, Beck's theory of suicide does not account for all suicides (e.g. , Durkheim's altruistic).

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The central tenet of the cognitive theory is that human information processing (cognition , or "meaning construction") influences all emotional and behavioral experiences. The following are the theoretical axioms of this theory.
a. The central pathway to psychological functioning or adaptation consists of the meaning-making structures of cognition , termed schemas.
"Meaning" refers to the person's interpretation of a given context and of that context's relationship to the self. components are interpreted negatively in depression. In anxiety, the self is seen as inadequate (because of deficient resources), the context is thought to be dangerous, and the future appears uncertain. In anger and paranoid disorders, the self is interpreted as mistreated or abused by others , and the world is seen as unfair and opposing one's interests.
Cognitive content specificity is related in this manner to the cognitive triad.
h. There are two levels of meaning: (a) the objective or public meaning of an event, which may have few significant implications for an individual; and (b) the personal or private meaning. The personal meaning, unlike the public one , includes implications, significance, or generalizations drawn from the occurrence of the event.

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· There are three levels of cognition: (a) the preconscious, unintentional, I.
automatic level ("automatic thoughts"); (b) the conscious level; and (c) the metacognitive level, which includes "realistic" or "rational" (adaptive) responses . These serve useful functions, but the conscious levels are of primary interest for clinical improvement in psychotherapy.
j. Schemas evolve to facilitate adaptation of the person to the environment, and are in this sense teleonomic structures. Thus, a given psychological state (constituted by the activation of systems) is neither adaptive nor maladaptive in itself, but only in relation to or in the context of the larger social and physical environment in which the person resides (Alford & Beck, 1997, pp. 48-56).
In summary, based on the axioms of the cognitive theory, people are prone to suicidality as a function of cognitive vulnerabilities (faulty cognitive constructions). The crucial pathway for suicidality is cognition (the private meaning of the individual). Suicidality is secondary to maladaptive constructed meanings regarding the self, environment, and future (i.e., the cognitive triad and its related conditional assumptions and compensatory strategies, coined the suicidal belief system) . The suicidal belief system characterized by pervasive hopelessness often including, helplessness, poor distress tolerance, and unlovability varies among individuals depending on the context and content of the diverse psychological systems (i.e ., cognitive content specificity). The suicidal belief system exists at three discrete levels, the automatic or preconscious level, the conscious level, and the unconscious (i.e., metacognitive) level, with the conscious level predominantly amenable to psychotherapeutic change.

comparison of Shneidman's and Beck's Theories of Suicide
The main distinction between Shneidman's and Beck's conceptualizations on the phenomenon of suicide is that Shneidman provides a model representing the necessary conditions, i.e., identifying "risks" in which Shneidman's conceptualization is probably more useful for detecting at risk suicidal cl ients through judicious assessment of identified commonalities.
Yet it does not provide specific guidelines for reducing psychological pain .
Beck's theory is probably more useful for clinicians in providing guidelines for intervening with suicidal clients. Of course , given the ambiguities of the phenomenon of suicide , it would be erroneous to assume any single theory would account for all aspects of the phenomenon completely.
In short, Shneidman and Beck's conceptualizations of the phenomenon of suicide have been presented and contrasted. These theories, at minimum , provide a foundation for greater understanding of the phenomenon of suicide and management of at risk clients .

Assessment and Nursing
The result of a casual , nonrandom survey of nursing faculty, nursing students, and undergraduate and graduate psychiatric nursing texts suggests that there is no specific suicide theory that is uniformly emphasized by them .
More frequently, the focus is on integrated psy. chodynamic theories that may pertain to suicide assessment (e.g ., Freud's notion of internalized rage) .
Similarly, suicide assessment education varies and can include incorporation of various aspects of suicide assessment from qualitative mental status assessment to empirically tested and theoretically supported use of quantitative instruments.
The problem of accurate suicide assessment is of particular significance to nurses given that they are often the initial or only health professional in contact with diverse clients in a variety of settings.
Furthermore, nurses assume 24 hour accountability through clinical contact with clients for ongoing assessment as an integral aspect of nursing practice.
Surely, suicide assessment has monumental relevance to nursing science and practice .
As previously discussed , although some nurses have proposed quantitative suicide assessment instruments, they tend to lack quantitative rigor or clinical utility. For example, the "Evaluation of Suicidal Potential" is based on 13 yes/no questions, with every 'yes' considered to increase the probability of suicide (Miller, 1982). However, there is no indication as to how many yes responses that can range between one and 13 increase the possibility of suicide . Others have conceptualized such assessment in a more qualitative fashion , assessing the degree of suicidal risk on a continuum , for example in terms of low, moderate or high degree, and lethality (Hatton , Valente & Rink, 1977).
Most of the literature in nursing on suicide has focused on suicide-45 related intervention (Gournay & Bowers, 2000;Miller, 1982;Reid & Long, 1993;Repper, 1999;samuelsson , Wiklander, Asberg & Saveman , 2000). Recently, interdisciplinary collaborative and integrative approaches to suicide prevention have been advocated (Jones , 2000 ;, Sommers-Flanagan & Sommers-Flanagan , 1995, Upanne, 1999. Collaborative efforts (e.g ., a multidisciplinary approach utilizing professional consultation) in suicide research need to address the evolution of newer paradigms to replace outmoded existing assessment and treatment paradigms . Jobes (2000) addresses the impact of the clinical practice setting and views suicidality as essentially a relational phenomenon. "Fortunately, a new paradigm has begun to emerge in contemporary clinical suicidology, which objectifies suicidality and emphasizes the phenomenology of suicidal states. Moreover, from an increasingly empirical perspective, this approach is creating new and better ways to effectively assess and treat suicidal conditions" (p. 8).
As Jobes (2000) states, "Over the last decade a relatively small but determined band of clinician-researchers has set about trying to help us move beyond established but now outmoded assessment and treatment paradigms for suicidality. Indeed , we are now seeing within the subspecialization of 'clinical su icidology' an evolving , clinically informed and increasingly empirically oriented knowledge base that is beginning to create whole new ways of thinking about clinical work with suicidal patients. Therein, a new paradigm is beginning to emerge" (Jobes, 2000, p. 11 ). In short, Jobes (2000) advocates the integration of clinical suicidology which incorporates the relational phenomenon associated in suicide assessment with an emphasis on the phenomenology of the client's suicidality. Similarly,  advocates use of affective and action-based interventions in suicide prevention.

This Author's Experience-Problem of Prevention
The following briefly depicts this researcher's personal experience with suicide, its aftermath , and the problem faced by clinicians regarding suicide prevention. A patient, who had been admitted in an acute care, psychiatric, mental health care unit, was assessed as not suicidal and was given a 4 hour "therapeutic day pass" (unsupervised and outside the hospital confines). He was scheduled for an additional pass on the day of his suicide. Hence, his suicide was a complete surprise and unexpected by the clinicians. Neither the results of a complete battery of psychological (quantitative and projective) testing , nor the psychiatric multidisciplinary treatment team's assessment evaluated him to be suicidal. This misjudgment (or inaccuracy) in assessment led the nurses and other clinicians to not formally institute any special suicide preventive interventions on behalf of this patient. Furthermore, it was shocking to learn that the law authorities viewed this event as a potential homicide and considered staff negligent in their assessments or viewed the staff or other patients culpable. This drastically disturbing incident suggests many potential problems faced by psychiatric-mental health nurses and clinicians in relation to suicide assessment and illustrates many ramifications of suicide assessment. Kim (1983Kim ( , 1987Kim ( , 2000 provides a typology to explain and systematize According to Kim (2000), "Nursing practice in general is accepted as a  (Kim, 2000).

Studies and Theory on Conceptualization of Nursing Assessment
Enactment is analytically separated from deliberation and involves actions and behaviors in a contextual practice situation. Kim's (2000) conceptualization of nursing practice was influenced by action science of Argyris, Putnam , and Smith (1985) and reflective practice of Schon (1983).
"Variability in professional actions related to the professional's use of knowledge and cognitive processes that are used for translating 'what one knows' to 'what one does' is specifically at the core of questioning about the concept of practice" (Kim , 2000, p.130). Such variability is appropriate for phenomenographic and other studies.
Deliberation and enactment can be further viewed as holistic and particularistic levels of concept description. Of note, Kim (2000) includes assessment in both the deliberation and (particularistic) enactment dimensions. Assessment as a phenomenon consists of overlapping and iterative processes of deliberation (e.g., thinking, evaluating a plethora of complex data) and enactment (e.g., acting/action, "doing"). For example, assessment (i.e., obtaining information/data and critically analyzing the data to make clinical decisions) involves deliberating about what sorts of information to elicit and deciding which information is vitally important. Assessment, also, involves directly evaluating the client (e.g., enactment using quantitative instruments). Thus, assessment as a component of nursing practice consists of a combination of deliberation and enactment.
Dilemmas challenge researchers investigating concepts in the practice domain . For example, concepts are embedded in practice, indivisible, and difficult to isolate from the complexities of practice (e.g., "knowing the patient," differentiating some deliberation and enactment activities, cognitive processes, the impact of the practice setting, and suicide risk assessment). Additionally, practitioners do not function in isolation and practice is influenced by a multitude of factors (e.g., contextual, institutional, and transferential phenomenon). These factors influence practice (including assessment) and can impact scientific exploration.
Nursing assessment is a key component of the practice domain. It involves a process of systematic collection and analysis of data about a client for the purpose of making a judgment or nursing diagnosis (Gordon, 1994).
Assessment serves as a foundation for nursing care. As such, nursing assessment can be conceptualized and framed as a primarily deliberative (cognitive) process in nursing practice . Most, if not all , nurse scholars would concur that nursing assessment is ongoing and is an integral aspect of the enactment phase, as well as the deliberation phase of nursing practice.

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As an essential element of practice, assessment is generally conceptualized as involving cognitive and behavioral actions that are interwoven with the agent of practice. The most fundamental example of such actions is called , "nursing process,'' a problem-solving framework which incorporates assessment, diagnoses, planning, implementation, and evaluation.
The nursing process (which is taught in nursing education) requires a deductive reasoning process which is not the inductive, problem-solving process (which originates from the nurse activating a hypothesis) in use during decision-making activities. Furthermore, the conceptualization of practice within the nursing process framework is linear and fails to account for the complexities inherent in the circular or iterative processes of nursing practice.
Actual nursing practice involves higher functioning competencies such as critical analytical thinking and a repertoire of other complex behaviors, often subject to multiple interpretations (e .g., caring, advocacy, and "knowing" the client). Since nursing assessment is a critical component of the fundamental nursing process, nursing theorists incorporate assessment in their conceptualizations. Mental health nurse theorists, although not specifically focusing on suicide risk assessment, include mental/physical assessment in their nursing process conceptualizations (Orlando, 1990;Peplau, 1952Peplau, , 1997. Kim (2000) notes that most theorists regard the nursing process model as an accepted "principle" or "theory" and consider practice domain phenomena unsystematically and "tangentially, rather than as the primary foci for description and explanation" (p. 147). As Kim (2000) explicates, "The attitude that nursing action follows naturally from nursing assessment is particularly prominent in models which nursing action is viewed in a prescriptive manner" (p. 144) [e .g., Neuman, 1995;Roy & Roberts, 1981).
Other theorists, however, emphasize nursing assessment as a process involving more sophisticated diagnostic/clinical reasoning (e .g., Aspinall & Tanner, 1981 ;Carnevali & Thomas, 1993;Gordon, 1994). Carnevali and Thomas (1993), for example, address the complexities of nursing assessment as a process involving an integrative overlapping of data collection and analysis, informational processing , meaning assignment, and diagnostic labeling for use in actual clinical situations . Nursing process and related assessment involve numerous loops back through previous components and, hence, are not linear in actual practice. In this conceptualization , higher-level cognitive processes such as diagnostic reasoning are emphasized. Gordon (1994) also emphasizes the diagnostician's cognitive and perceptual assessment abilities and addresses the centrality of knowledge utilization in clinical practice . Tanner, Benner, Chesla, and Gordon (1993) advocate holistic assessment and have studied complex related practice constructs such as tailoring ("knowing the patient") and intuition.

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Assessment requires the cognitive processes of critical thinking and diagnostic reasoning in order to make nursing judgments. Clinical judgment involves data analysis and is the outcome of an inferential process. One cannot focus on all the data simultaneously. Thus, one learns to discriminate between patterns of stimuli to identify pertinent information and assign meanings to situations (Gordon, 1994;Carnevali & Thomas, 1993). To identify a problem, collect data on the problem, distinguish underlying premises, formulate hypotheses, and draw conclusions are all components of critical thinking, diagnostic reasoning, and assessment. As a precursor to recognizing and interpreting data that is significant to a client's situation, formulating judgments or decisions (critical thinking, for example), is related to accurate assessment. Thus, the greater the nurse's capacity to critically think, the more accurate the assessment should be (Wilson, 1998). This illustrates assessment from the rational approach that may not be what is occurring in actual practice.
Variability in nursing practice, along with individual nurses' philosophies , might account for qualitative differences in how nurses practice in relation to suicide assessment. For example, a nurse might accurately assess a client as acutely "suicidal" and, thus, diagnose the client as "high risk for suicide" undertaking all reasonable and customary precautionary standards of practice (including one on one continuous observation) while another nurse might inaccurately assess the same client (under exact circumstances) as "provocative" and "acting-out" and, thus, neglect to take appropriate suicide precautions (an erroneous judgment with potential lethal consequences).
Furthermore , although nursing diagnoses are routinely used in practice, Kim (1987) notes, nursing diagnoses are atheoretical, descriptive "averages," (p. 101) and seem to have a very little utility beyond the purposes of interprofessional communication and documentation.

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Nurses must frequently function instantaneously and adopt varied assessmenUdecision making strategies such as information processing, diagnostic reasoning, critical thinking/processing, heuristics, optimization , intuition, cost-benefit analyses, and decision under conditions of uncertainty.
Research has noted differences in novice and expert decision-making and practice (e .g. , Benner, 1982Benner, , 2000Benner, Tanner, & Chesla, 1987;Lauri et al., 2001) and investigated nurses' use of intuition in clinical practice (Benner & Tanner, 1987). Such variables could influence the assessment process and outcome since the problem here is how to accurately assess an often purely subjective/intersubjective phenomenon such as suicide.
In short, nursing assessment can be conceptualized as an ongoing process within the enactment and deliberation dimensions of the practice domain. Conceptualization of nursing practice including contemporary methods or standards of suicide assessment is continually evolving.

Conclusions
The aforementioned studies and approaches have been used to examine the phenomenon of suicide and suicide assessment. However, there is a lack of knowledge regarding what nurses do in their assessment of suicide in actual practice . Additionally, given that individual's perceive and conceptualize phenomena differently, variability in suicide assessment is likely to be a reality. This phenomenographic study was undertaken with the assumptions that nurses may not rely strictly on a rational process in assessing suicidality as in assessment in general, and that it is necessary to examine the processes as they occur in actual practice. It is hoped that research findings would add to the developing knowledge regarding the understanding of suicide assessment by nurses.
Furthermore, since it is unclear whether the rational approach to suicide assessment is used uniformly in practice, phenomenography is a useful method and theory which could provide (a) improved knowledge regarding the characteristics of nursing assessment of suicidality, (b) identification of differences in the assessment strategies for suicidality used by psychiatricmental health nurses, (c) better knowledge regarding the understanding of suicide held by nurses in relation to suicide assessment, and (d) knowledge regarding how nurses perceive their education and/or experiences influencing (shaping) their suicide assessments.

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The purpose of this study was to identify and describe categories of descriptions regarding strategies used by psychiatric-mental health nurses in suicide assessment applying phenomenography as a method focusing on the following research questions: The primary aims of this study were to gain an understanding of nurses' conceptions regarding suicide and suicide assessment, to describe the strategies of suicide assessment adopted by psychiatric-mental health nurses, contrast these to the contemporary standards and practice guidelines of suicide assessment, and explore participant perceptions regarding how education and/or experience influence their suicide assessments.

Design
The phenomenographic approach was applied in this research by putting the focus on discovering the nature and characteristics of suicide assessment and strategies used by psychiatric-mental health nurses, including similarities and qualitative differences. The focus was on the participants' thinking in the assessment of client's suicidality. The study attempted to discover-without any preconceived notions-the complexities involved in suicide assessment in the context of different ways (e.g. , strategies) nurses approach the problem . Greater understanding of nurses' conceptions of suicide and strategies used in suicide assessment is important in advancing nursing practice, enhancing professional education, and improving client outcomes. A phenomenographic approach was appropriate in exploring these questions.
The research design was an inductive qualitative descriptive study with phenomenography as its orientation. The data were collected through participant observations of nurses assessing patients and .semi-structured indepth interviews with nurses regarding their assessments of actual cases and vignettes. The analytic processes suggested for a phenomenographic study were applied for data analysis. The nurse participants in a convenience/snowball sample were six psychiatric-mental health nurses practicing in two psychiatric settings in New England states : a) a psychiatric hospital's emergency assessment service and b) a locked inpatient psychiatric unit of a general hospital.

Relationship Between Phenomenography and Phenomenology
There often is a misunderstanding of phenomenography, as it is 57 confused with phenomenology because of the similarity in the terms.
Phenomenology and phenomenography are related but distinct theoretical approaches relevant to the human and social sciences. Phenomenology evolved as a theoretical approach in psychology, whereas phenomenography was relatively recently proposed as a methodological approach in pedagogical research, specifically in educational psychology. As is evident from their names, both approaches relate to phenomena. Phenomenology and phenomenography may interface with each other inasmuch as learning is a process of human cognition.
The epistemological foundations are identical in both research traditions; i.e., there is no objective, real world out there. Rather, human knowledge is founded in their conceptions of reality (Sandberg, 1995). Both research traditions seek to reveal the nature of human experience and awareness in order to understand these conceptions of reality (Marton, 1997).
Also, in both research traditions, the goal is to describe the conceptions, not explain the cause or function of these conceptions (Larsson, 1986). However, there are some basic differences within these two research traditions.

Historic Origins and Definitions
Phenomenology is a philosophical movement that began in the Philosophical tradition of Edmund Husserl in Germany during the mid-1890s.
Early followers of Husserl's work described phenomenology as the study of essences of human phenomena, such as the essence of emotions. As was later formulated by Husserl, phenomenology is the study of the structures of consciousness that enable consciousness to refer to various objects existing outside itself. This type of study requires reflection on the content of the mind to the exclusion of everything else, such as: theory, deduction, or assumptions from other disciplines (e.g., natural sciences). Husserl referred to this type of reflection as phenomenological reduction or "pure description." Structures of consciousness that Husserl discovered were such acts as remembering, desiring, and perceiving and the abstract content of these acts, which he termed "meanings." Later, in "Cartesian Meditations" (1960), he defined phenomenology as the study of how these meanings are constructed in the course of experience.
The first scholar to have used the term phenomenography, instead of "phenomenology" was Ulrich , who distinguished between Heidegger's and Jaspers' schools of psychopathological research.
Sonnemann believed that Jaspers' phenomenology should be called phenomenography since it was "a descriptive recording of immediate subjective experience as reported" (p. 344 ).
Phenomenography is a qualitative inductive research approach that was advanced in the 1970's in the Department of Education of the University of Goteburg in Sweden (Marton, 1988a;1988b;1970). Marton emphasized that phenomenography is not an offspring of phenomenology. The term "phenomenography" has its etymological roots in Greek "phainomenon" (appearance) and "graphein" (description) making the literal meaning of the  Marton ( 1981) describes this as the "second order" perspective . For example, instead of asking, "Why do some children succeed in school better than others?" (first order approach), the phenomenographer's inquiry would be "Why do people think that some children succeed in school better than others?" Or, instead of asking "Why are some people at risk for suicide?" the phenomenographer may ask "How do nurses determine that some people are at risk for suicide?"

Strengths and Weaknesses
The major advances in phenomenography have been in pedagogical research , and , to a limited extent, other disciplines. The approach is still relatively new (25-30 years). It has been primarily developed in Sweden and has not yet received wide recognition.
The most important question with regard to the empirical data of any scientific inquiry is its validity and reliability. In quantitative studies, validity and reliability are often reflective of instrument accuracy and reproducibility of results. In qualitative research, where instrument accuracy is often absent or difficult to assess, it is commonly looked at from the perspective of credibility.
Since the phenomenographic approach addressed the "second-order perspective" (i.e. , the object of the study is the subjective thinking of the participant), what the participants' say and how they say it are givens. The "truth" is what the participants say and how they say it. Marton (1988) claims that replicability in phenomenography is not possible or even desirable. "The original finding of the categories of description is in a form of discovery, and discoveries do not have to be replicable. On the other hand, once the categories have been found, it must be possible to reach a high degree of intersubjective agreement concerning their presence or absence if other researchers are to be able to use them" (Marton, 1988, p.148). Thus, reproducibility is substituted by intersubjective agreement among researchers, which is deemed to be "sufficient" when 65 to 100% of researchers agree.
Another issue is rooted in the fact that the data are collected through interviews. This fact necessarily limits the numbers of participants and raises the question whether results obtained from a small number of participants are representative of a larger group. This may limit generalizability (transferability) of obtained results.
Phenomenography does not provide an exact algorithm for identifying the categories of description, nor does it provide a formal method for verifying validity of descriptions once they have been identified. Some might also argue that phenomenographic findings do not have significant value because phenomenographic research is concerned with answering questions of what and how and not why.
One way of looking at various research methodologies is to align them with the nature of the research problem for which a particular methodology is the most appropriate. As described above, the object of a phenomenographic study is not the phenomenon itself, but the content of human conceptions about that phenomenon. Consequently, the results extracted from the data collected in a phenomenographic study "do not necessarily contribute to an increase in the knowledge about the phenomenon [itself]" (Marton, 1981, p. 243 or how such pain can be best reduced or managed. In this case, the phenomenographic approach would not be very useful. If on the other hand, the researcher is interested in how pain is experienced and communicated by clients or how various medical professionals assess clients' pain, a phenomenographic approach could be utilized. To generalize, the phenomenographic approach is applicable when the researcher conducts a "second order" versus "first order" inquiry (Marton, 1981;Marton & Booth, 1997). What this means is that the research explores the ways in which individuals experience the phenomena and not the phenomena itself. Thus, it is unimportant if the participants' conceptions are "correct" or "incorrect," rather the research is aimed at identifying categories of description that provide the types and range of these conceptions .
This type of research is not uncommon in education or other kinds of systematic communication research (e.g., social psychology, advertising and marketing, etc.-although such research may not be labeled as phenomenographic) and is aimed at understanding people's ways of thinking and, ultimately, influencing these ways of thinking (and consequently, ways of acting). Such findings could have important implications to nursing education and practice.
Qualitative research focuses on the intensity, distribution of, and interdependence between qualities that cannot be quantitatively measured .
This type of research seeks to discover whether a particular quality is simply present or absent, and if it is present, to provide a descriptive and explanatory analysis of this quality. Accordingly, the aim of qualitative research is to provide categories of description that facilitate explanation of certain qualities (Dahlgren & Fallsberg, 1991 ). In contrast, quantitative research uses predefined (i.e. , a prion} categories and seeks to discover quantifiable differences among variables . The ultimate goal of phenomenographic research is to describe and categorize existing conceptions and, more generally, "to discover the structural framework with which various categories of understanding exist" (Morton, 1988, p.14 7). This implies that the basic assumption in any phenomenographic research is that "people vary with regard to what meanings they ascribe to phenomena in the world around them. Without such an assumption there would not be a need for any phenomenographic research whatsoever" (Dahlgren & Fallsberg, 1991, p. 151 ). According to Marton (1988), the most important research finding of phenomenographic research is categories of description themselves. In other words, the product of a phenomenographic study is the description of categories of description.
Marton compares phenomenography to a botanic study of previously unknown flora and fauna on a remote island . "In such a study, existing categories (species) are of limited usefulness. The botanists find new species and, therefore, must construct new categories. Only then can the botanist determine how these new categories fit into the whole system of species classification ... . Just as the botanist finds and classifies previously undiscovered species of plants, the phenomenographer must discover and classify previously unspecified ways in which people think about certain aspects of reality" (Marton, 1988, pp. 147-148 Dahlgren and Fallsberg (1991) in a social pharmacy study used phenomenography to investigate medication compliance. Because a major source of non-compliance was found to be experienced or anticipated side effects, through a phenomenographic inquiry the researchers addressed how clients conceived the concept of side effects . Sjostrom (1998)

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The distribution of these categories was then compared between nurses and physicians and analyzed with regard to the quality of assessment data. Because pain assessment is a routine nursing task, the author hypothesized that the quality of assessment is influenced by experience. In order to analyze the influence of experience , both groups were subdivided according to the length of experience (expert and novice). This study illustrates how a phenomenographic inquiry may provide a basis for description and/or explanation of observed differences. Dahlgren and Fallsberg (1991) provide the following metaphor and procedure for the process of data analysis in a phenomenographic study.

Data Analysis in Phenomenography
"Imagine that somebody is given an ordinary pack of playing cards and asked to sort them . Most probably the result would be four different groups of cards according to the four suits. A possibility is of course thirteen groups according to denomination . ... but the important difference with card sorting task is that the resea rcher does not previously know the categories according to which the task can be solved" (p . 152). Methodologically, the research most commonly proceeds in the following sequence: familiarization~ condensation~ comparison ~grouping~ articulating~ labeling~ contrasting. Each of these stages is explained below.
a. Familiarization. The researcher, although in most cases also the interviewer, must read through the protocols carefully, to get acquainted with them in detail. This stage is also necessary for making required completions and corrections.
b. Condensation. The most significant statements made by the participant are selected to give a short but representative version of the entire dialogue concerning a certain phenomenon .
c. Comparison. The selected significant dialogue excerpts are compared in order to find sources of variation or agreement. d. Grouping. Answers, which appear to be similar, are put together. e. Articulating. A preliminary attempt is made to describe the essence of the similarity within each group of answers . Stages four and five may be repeated several times.
f . Labeling. The various categories are denoted by constructing a suitable linguistic expression.
g. Contrasting. The obtained categories are compared with regard to similarities and differences (Dalhgren , 1991 , p. 152).
In summary, phenomenography is an appropriate methodological approach to study suicide assessment by nurses.

Study Participants
The recruitment of psychiatric-mental health nurse participants was accomplished using a convenience/snowball sampling. The nurse participants in this sample were six psychiatric-mental health nurses (conversational partners) practicing in two psychiatric settings in two different states in northeast New England: a) a psychiatric hospital's emergency assessment service and b) a locked inpatient psychiatric unit of a general hospital. Since there was only one male participant, all participants have been given a female pseudonym in order to protect individual identity. Five of the participants had more than fifteen years of experience as psychiatric-mental health nurses, while only one had less than one year experience as a psychiatric-mental health nurse yet this participant worked as a mental health worker for five years prior to becoming a registered nurse.

Human Subjects
Approval from the Institutional Review Boards on Human Subjects at the University and two participating hospitals were obtained in July 1, 2002, July 15 2002 , and January 6, 2003. The consent forms for this research approved by these Boards were used prior to the data collection phase.
As part of the informed consent procedure , participants were informed that the information they provided would be used for research purposes and communicated in oral and written reports . Participation in this study was voluntary. Due to the sensitive nature of the study, consent forms and identifying face sheets have been kept separate from the rest of the data for the study and secured in locked boxes at the researcher's office as outlined in the consent forms . The listing of the names and assigned code numbers were recorded on a separate sheet filed in a locked drawer to which only the investigator has access. All records , including notes and transcribed interviews, do not identify participants by name and are kept locked in a file cabinet. A code number identifies the interview. Audiotapes have been kept in a separate locked file cabinet. Participant's names do not appear on the audiotape label. A number, assigned by the researcher, which appears on the tape label , identifies participants . Because the audiotapes have intrinsic value as an audit trail and for future research , they will be kept in a locked cabinet for three years then permanently destroyed by this researcher.
Adult patients who were being assessed by the study participants for suicidality were approached for their consent for this researchers observation during the assessment sessions . Inclusion criteria for consenting adult patients were that they were 18 years of age or older, could speak English , and were competent to provide informed consent for observations (i.e., individuals with guardians or who were court mandated were excluded).
Patient consent forms do not identify the patient as seeking psychiatric services . These forms have been kept locked in a separate file cabinet in another location and will remain so for three years then destroyed by this researcher.
The study records have been shared with only a small number of professional colleagues (specifically, this researcher's Major Professor and second reader on the Dissertation Committee). At the end of the research, all written notes and cassettes will remain secured in locked cabinets and destroyed after three years.

Data Collection
The data were collected through participant observations and audio taped in-depth semi-structured interviews. Each participant was observed by the researcher performing a suicide assessment. After the assessment of an actual case was completed, a semi structured audio taped interview was conducted. Each participant was later asked to read three vignettes of cases depicting different degrees of suicidality. The vignettes were administered in a standardized manner. In-depth semi structured interviews were conducted using the same format as with the actual (observed) case. Additionally, each participant was asked to rate the three vignettes according to level of suicide risk (low, moderate, or high).
The data collection was conducted in four phases over approximately ten months (July 2, 2002-August 16, 2003. Prior to initiating Phase I of this study, three vignettes depicting three different levels of suicidal risk were obtained for use in suicide assessment (Appendix D). The use of vignettes in addition to an assessment of an actual client was determined because of the difficulty anticipated in obtaining clients with potential suicidal risks in practice situations.
The focus in Phase I was gaining entry and obtaining informed consent (Appendix E) and demographic data (Appendix F) from nurse participants.
snowballing technique was used to identify nurse participants. Once identified, this researcher contacted potential participants at a convenient time.
The researcher reviewed the four phases of the study and guaranteed confidentiality. Once all questions were satisfactorily and fully answered, the researcher obtained signed and dated informed consent. A copy of the consent was promptly given to the nurse participant.
In Phase II , prior to observations, the consenting nurse participants asked potential appropriate adult patients' permission for this researcher to observe the assigned nurse interview them . Each eligible patient was informed that the researcher was a nurse studying nurses in practice by observing them interview patients. Patients were informed that their decision (to participate or not) would not affect their care. The assigned nurse or this researcher obtained written consent (Appendix E). Opportunities for any questions to be fully answered by this researcher were provided . If there was any disruption in agency routine (at any time), the plan was that this researcher would remove himself; This did not occur. Pending patient informed consent, the researcher began with the first nurse-participant by observing the nurse perform a suicide assessment on a consenting adult patient. This process was repeated with subsequent nurse participants.
During the observational periods, the researcher was located on the periphery, observing the nurse-participant as she or he assessed the patient.
As immed iately as possible following each observation session , the researcher arranged a formal interview with each participant using a post-assessment guide that conta ined specific questions (Appendix G). The formal interviews were conducted in a private area away from others to maintain confidentiality, freedom of speech , and provide a conducive environment. The focus was to gain each nurse's description of their assessments. The goal was to have Phases II and Ill lasted approximately ten months (July 2, 2002-April 16, 2003. Ongoing iterative data analysis using phenomenographic procedures occurred and concluded with the final analysis phase (Phase IV) and write up of the study.
In Phase IV, ongoing transcription , final data analysis and write up 73 continued. To validate the data analysis findings, two doctorally prepared nurse researcher/experts/academicians provided 100% inter-rater agreement (i.e., agreement of identified phenomenographic categories of description).
Phase IV was completed with the write up of the report (February 7, 2004).

Diversity in Research
The researcher attempted to invite nurses representing diverse ethnicity, race , or gender who met the inclusion criteria. It was not feasible to obtain this representation because of the sample size.
As with the nurse participants, consenting adult clients of any ethnicity, race, or gender who met the inclusion criteria (as stated in the informed consent form) were invited to participate. An attempt to obtain a diverse patient population was reasonably made, however, given the design and sample size, it was not feasible to represent an array of minority patients.

Data Analysis
Responses from each participant were transcribed verbatim by this researcher. Each participant's verbatim transcription was analyzed using the seven steps in the phenomenographic research tradition . The data analysis sequence occurred as follows : familiarization ~ condensation ~ comparison ~grouping~ articulating~ labeling~ contrasting (Dalhgren & Fallsberg,199 1,p. 152). The detailed results obtained following this process are presented in Chapter IV.
The final write up was completed after terminating the data collection phase and final analysis of the data.

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After exiting the research setting, the ongoing transcription process and final data analysis continued. To validate the data analysis findings, two doctorally prepared nurse researcher/experts/academicians provided 100 % inter-rater agreement (i.e., agreement of identified categories of description [Marton, 1988]). A variety of checks and balances were used such as communicating with appropriate colleagues and iterative dialogue with them to obtain critical feedback and ensure rigorous adherence to the methodological process of phenomenography and credibility of the findings.
Inter-rater reliability of the three vignettes was obtained by unanimous consensus of five advanced practice psychiatric nurses (master's and doctorally prepared). Further assurance of quality in using the phenomenographic method was accomplished by making the research process visible and allowing for systematic reviews by members of the dissertation committee. Additionally, diligently adhering to the interview guide across participant interviews, administering the vignettes in a standardized manner, obtaining descriptive detail (fittingness), and strict adherence to the Phenomenographic sequential steps of data collection and analyses (auditability) further validated trustworthiness (Bowden & Walsh, 2000).

Identified Categories of Description
The following section provides the results of the analysis in relation to the research questions.
A. Familiarization. This researcher transcribed the audio taped responses of participants within 8-12 hours of each conversational interview.
Once the audiotapes were transcribed , familiarization of the data was accomplished by rereading of the transcripts several times and repeatedly listening to the audio tapes. The complete transcripts of the interviews were reviewed by two members of the dissertation committee in their entirety, and are being kept for future audits.

B. Condensation.
Following the familiarization process, the most significant statements made by the participant(s) were selected to give a short representative version of the complete dialogue concerning the phenomenon of suicide assessment (e.g., "I assess for depression."). The researcher kept detailed notes of his experiences in collecting and analyzing the data, and the feedback and responses received from the major professor and a member of the dissertation committee regarding the research process, data analysis, and write-up of the dissertation. Based on this essential feedback, appropriate adjustments were made and preliminary categories were more clearly and logically identified. An initial identification of 16 preliminary (P) categories (Appendix H) was made and shared with this researcher's major professor and second reader for their analytic and clinical expertise and to ensure methodological rigor and validity. With the expert guidance of the major professor and second reader, it was discovered that several of the preliminary (P) categories were overlapping and more appropriately and logically subsumed under another category (e .g., FEASIBILITY OF A PLAN [P06] was included in ASK ABOUT A PLAN [P05]). These categories were then further collapsed . As a result of this process, the initial 16 preliminary categories were condensed to ten categories (Appendix I). These ten categories of description were : • Reliance on risk factors which are well-established in the literature (C01) (e .g. , relying on the evidence of depression and substance abuse).
• Looking for the presence of states commonly associated with suicidality (C02) (e.g. , investigating to see whether the client exhibited psychosis and increased agitation followed by calmness).
• Presence and availability of resources (C03) (e.g. , looking into the presence or absence of responsible family, significant other(s), other social support( s ), and out-patient provider( s) ).
• Listen to client (C04) (e .g. , listening to the client as he/she talked about past and/or present status, problems, or issues of concern). • • Ask about a suicide plan and/or the feasibility of carrying out a plan (C05) (e.g., directly asking the client as to whether he/she has any suicidal intention, plan , and access to a plan).
Reliance on exemplars (C06) (e.g., relying on past experiences with clients who represent exemplary cases or on "classic, textbook" examples).

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• Perceptions of significant others (C08) (e.g., meeting with a friend or family to assess their perceptions on the client's current situation and validate data obtained from clients who are often distracted and inaccurate).
• Reliance on other professionals (C09) (e.g., using assessments done by other professionals through consultation and communication with them).
• Related stories of suicide risk (C10) (e .g., relying on the presence of relevant personal stories such as interpersonal loss, loss of health status, or loss of employment).
C. Comparison. Following the condensation phase, significant dialogue excerpts were compared, in order to identify sources of variation or agreement. The audiotapes and transcriptions were repeatedly reviewed again to identify verbatim excerpts from the participants.
For organization, a grid was made listing each of the ten categories in a column with the actual case and three vignettes in corresponding rows. This process led to the identification of those participants that used or did not use each of the ten categories for the actual case and the three vignettes (Appendix J).
Next, significant dialogue excerpts were compared to identify potential sources of variation or agreement. Verbatim examples provided evidence as to whether participants used or did not use the categories and the initial grid was further developed (Appendix K) .
o. Grouping. Following the comparison phase, participants' answers (responses) that appeared to be similar were grouped together.
E. Articulating. Following the grouping phase, a preliminary attempt was made to describe the essence of the similarity within each group of verbatim answers. Stages four and five were repeated several times to confirm the logic and accuracy of the analysis.

Participants' Perceived Conceptualizations of Suicide Assessment (Research Question #1)
For research question #1 (i.e ., What are the understandings (conceptualizations) of suicide held by nurses in relation to suicide assessment?), the conceptualizations of suicide discovered in the interviews with the participants are as follows:

First Participant-Amy
Amy is a masters-prepared, certified psychiatric clinical nurse specialist, with 25 years of psychiatric nursing experience, 17 years in acute inpatient units and eight years in psychiatric assessment service at the same urban psychiatric teaching hospital. Her current role is in the psychiatric hospital's emergency assessment service involving emergency assessment of acutely ill diverse psychiatric clientele.
Amy conceptualized suicide as a risk for wanting to kill oneself because of feelings of hopelessness (negative outlook on life), inadequacy, and worthlessness, and having nothing to live for. She identified depression as the "trigger" (precipitant) and emphasized the vital role of the presence of (viable) resources to the distraught individual as critical components of suicide assessment.

Second Participant-Beth
Beth is a masters-prepared (non-nursing), certified psychiatric nurse generalist enrolled in an MSN program with 26 years psychiatric nursing experience, five years on a psychiatric inpatient unit, 10 years in psychiatric emergency services, and 11 years in psychiatric community/psychiatric day hospital at the same urban psychiatric teaching hospital. Her current role is in the psychiatric hospital's day program involving emergency assessment of acutely ill diverse psychiatric clientele.
Beth conceptualized suicide as self-inflicted death because the individual felt there was nothing to live for. She focused on the thought (ideation) accompanying the (suicidal) condition. Beth also identified depression as a precipitant and emphasized the vital role of investigating the individual's attempts and plan as critical components of suicide assessment.

Third Participant-Carol
Carol is a bachelor's prepared psychiatric nurse with 15 years 81 psychiatric nursing experience , five years in psychiatric inpatient units and 10 years in a psychiatric assessment service in the same urban psychiatric teaching hospital. Her current role is in the psychiatric hospital's psychiatric assessment service involving emergency assessment of acutely ill diverse psychiatric clientele .

Carol conceptualized suicide as an individual's perception that
there is no alternative but to end life with accompanying feelings of rejection , worthlessness , and sadness coexisting with depression.
Beth identified these factors as essential components of suicide assessment.

Fourth Participant-Denise
Denise is an associate degree-prepared psychiatric nurse with a previously earned Bachelor of Arts degree in psychology who worked for five years as a mental health worker at another facility, a small rural psychiatric teaching hospital. Denise currently has nine months of psychiatric nursing experience following general visiting nurse experience . All of her psychiatric nursing experience has been as a staff nurse on a psychiatric inpatient unit in a suburban general community hospital.
Denise conceptualized suicide as self-induced death. She attributes suicidality to feelings of helplessness, hopelessness, impulsivity, anxiety, and anger accompanied by depression and selfdestructive behaviors. Denise identified loss as a precipitant, and substance abuse, a history of past attempts, family history of suicide, and male gender as risk factors. She emphasized the vital role of social support (e.g ., family and friends). Denise also focused on withdrawal, isolation, having a specific plan with access, and the energy required to commit suicide. She identified these as essential components of suicide assessment.

Fifth Participant-Eve
Eve is a three year diploma nurse who later earned a bachelor's degree in nursing and is certified as a psychiatric nurse generalist. She has had 25 years of nursing experience with 19 years as a psychiatric nurse. She was a staff nurse on an inpatient unit in a suburban psychiatric hospital for 18 years and a psychiatric nurse in a partial day hospital for one year. Currently she works as a staff nurse on a psychiatric inpatient unit in a suburban general community hospital.
Eve conceptualized suicide as a desperate act to end one's life due to the individual's perception that there is no other way of eliminating their pain and suffering . She attributed suicidality to the inability of an individual to look forward to his/her life. Eve also looked for anger, desperation , and depression in the patient's presentation .
Eve identified these as essential components of suicide assessment.

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Fran is an associate's degree psychiatric nurse with 28 years of nursing experience including 23 years in psychiatric nursing, 14 years on an inpatient psychiatric units and eight years in psychiatric assessment service, all in the same urban psychiatric teaching hospital. Previously, Fran also worked four months as a psychiatric visiting (community) nurse. Her current role is as a staff nurse in the hospital's psychiatric assessment service involving emergency assessment of acutely ill diverse psychiatric clientele.
Fran conceptualized suicide as an act to end one's life because the individual feels totally hopeless and helpless; is not able to change life's circumstances; is unable to live with the intense and overwhelming emotional suffering ; and believes that he/she is better off dead . Fran conceptualized suicide assessment as a "judgment call. " She identified specific precipitants and risk factors as past attempts, no future orientation , decreased level of functioning , and the presence of (recent) losses. Fran identified these as essential components of suicide assessment.
Interestingly, yet not surprisingly, given the psychiatric practice settings of participants, all participants' conceptualizations of suicidality related exclusively to the taking of one's own life during emotional distress (i.e., there was no mention of other modes of suicide such as euthanasia, terrorist suicide, group/suicide packs, etc.).

summary
Overall , based on participants' conceptualizations of suicide , one may conclude that these psychiatric nurse participants conceptualized suicide as an attempt to end one's life when pain is intolerable. This is consistent with Shneidman's theory. Additionally, these participants believed that suicide is associated with hopelessness, helplessness and is primarily linked to depression. This also is consistent with Shneidman's and Beck's theories.
These nurses did not conceptualize suicide as an impulsive act that could come without warning . Instead, they viewed suicide as a possible act that results from clients' persistent conditions of life and psychological states of hopelessness.

Participants' Strategies for Suicide Assessment (Research Question #2)
For research questions #2 (i.e., What are the strategies of a suicide assessment used by psychiatric nurses?), the following provides a description of the strategies used by participants in suicide assessments.    Although Denise had never directly worked with this client, she was struck (as was this researcher) with the extent of the client's past self mutilation. There were deep lacerations throughout her forearms. Denise described the client as, "Sicker than she appears superficially .. . quite high functioning ... a good patient ... and doing well from an outside perspective. But when you delve into her closer, she's really quite ill."

Assessment of an Actual
During the assessment session Denise sat opposite the client and did not use any hospital assessment forms nor did she take any notes. On the inpatient unit, the nurses performed "brief check-ins" which is often routine practice in settings where some client history is already known to staff (e.g ., time limited, symptom focused assessment periodically done throughout a client's inpatient treatment and when a client is scheduled for a "therapeutic pass" off the unit to assess the client's ability to adhere to the purpose of the "pass" and accompanying viable expectations). Denise spent about 15 minutes performing a "brief check in" versus a comprehensive mental status assessment, asking questions regarding (a) suicidal ideation, (b) the client's "ability to contract for safety, " (c) the client's ability to approach staff if she experienced recurrent suicidal ideation, and (d) the client's self rating of her depression.

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During the post assessment questioning, Denise emphasized if she had more time to assess the client (other than her current "brief check-in") or if the client was a new admission (versus a client who had been on the inpatient unit for a considerable period of time), she would have reviewed the client's chart regarding background information, substance abuse issues, and family history of suicide . Denise stated that the unit had "developed" a "Suicide Lethality Scale" as part of the nursing assessment form but she did not use it during "brief check-ins" with clients nor felt it was especially useful as this scale was used on initial assessment and all clients were, generally, "over rated" by admitting nurses. Furthermore , this scale has not been tested for its reliability or validity. However, if Denise were to have used this scale, it would have captured the additional information that Denise would have assigned her client: anxiety, impulsivity, destructive coping, degree of withdrawal and isolation, and vague fleeting suicidal thoughts (Although the client denied suicidal ideation during the assessment, Denise added she would assign this to the client "erring on the side of safety").
At the post assessment interview Denise indicated that she relied on the following strategies: (a) directly asking the client about suicidality relying on "her words" (e.g., "I believed her."), (b) observing the client's "presentation"/behaviors, and (c) considering the client's self-report of her depression.

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Denise rated this client's risk for suicide as "considerable ... moderate" yet "dangerous" for future suicide attempts and/or self-mutilative Denise rated the suicide risk of the three vignettes as follows: vignette #1: very high risk; vignette #2 : pretty high risk; and vignette #3: mild to moderate risk. Denise stated she did not feel confident in her level of certainty regarding her suicide assessment ratings.

Fifth Participant-Eve
Assessment of an Actual Case. The client Eve assessed was a single Caucasian female in her early 30's with an extensive history of polysubstance abuse and recent suicide attempt necessitating locked inpatient psychiatric treatment. The client was approaching discharge from her inpatient stay on a locked psychiatric unit and awaiting a visit from her mother who was to take her for a "therapeutic day pass." Although the client had been on the unit for an extended period, Eve had not been assigned to her prior to this time.
During the assessment session Eve sat facing the client and did not use any hospital assessment forms nor did she take any notes. She spent about 1 O minutes asking the client questions about her suicide attempt. Eve's assessment was guided towards finding "ways that would help her not get to that point [suicidal] again (because there's probably still a risk)," future orientation, "how she had -been doing," and "what her problems were." Eve stated, "I don't just focus on suicidality but I try and get a sense on ... every level where the person is at and that's when I feel the most comfortable . ... I will ask about that (suicidality) and I think they expect those .. . questions so they're going to tell me what they think I want to hear but if I ask them about some other things, maybe they'll give me more of a genuine picture of how they're (actually) doing." Eve, also, made the assessment that the client was "quite intelligent," had "a lot of insight," and "[i]t almost seemed that it gave her a sense of relief to talk about it (suicide attempt) some more." At the post assessment interview Eve indicated that she relied on the following strategies: (a) viewing the client holistically as an individual, (b) not focusing on suicidality rather trying to "get a sense on every level where the person is (presently) at (biopsychosocially)," (c) hearing her story, (d) evaluating the client's future orientation , (e) the assessment of other professionals (team members) regarding the client's "readiness" for discharge, (f) assessing the cl ient's "insightfulness,'' (g) directly asking about suicidality, (h) assessing the client's reported ability to "contract for safety, '' and (i) believing the client's statement, "I want to be alive (

Sixth Participant-Fran
Assessment of an Actual Case. The client Fran assessed was an 18 year old single Caucasian male who came from a residential facility for an emergency evaluation following suicidal threats and gestures; self-injurious risk taking behaviors (carving his wrist, pouring lighter fluid on himself and igniting it then quickly extinguishing the flames) ; punching his wrist through a wall following a "disagreement" with a residential employee for restricting a parental visit; and passive homicidal ideation toward this residential employee (" ... to get back at him"). During the assessment session , Fran sat at a desk facing the client who sat to her right. Using the hospital's psychiatric assessment form , Fran spent about 30 minutes asking questions regarding suicidal ideation, suicide attempts, psychiatric history, the client's affect ("I felt he's needy .. . hopeless .. . he felt sad ... strangeness"), family situation , his sentiments regarding his residential placement, and future plans.
Although Fran stated the "intake form" guided her assessment, she felt since the client had been in the psychiatric system for some time, he was likely to respond according to what he felt she wanted to hear. Therefore, Fran asked questions "from different angles" to more accurately assess the client.
During the question proceeding the observed interview, Fran articulated an extensive knowledge of suicide assessment including: (a) using risk factors

Summary
In summary, participants used a number of similar and different strategies with variability in their approaches to suicide assessment. However, it is essential to mention that assessment is a complex process. Furthermore , given the complexities of suicide assessment, it is understandable that accurate, precise assessment remains challenging and often problematic.
Undoubtedly, the nurse participants in this study were overall knowledgeable and skillful in performing this tremendously complex role. In any event, given risk under uncertainty, nurses need to be conservative in their suicide assessments to prevent lethal outcomes.

Participants' Assessment in Relation to Practice Guidelines (Research Question #3)
For research question #3 (i.e., How do the strategies of suicide assessment used by the psychiatric-mental health nurses compare with current practice guidelines on suicide assessment?), the participants' strategies of suicide assessment were compared to "The Harvard University Suicide Assessment Protocol Guidelines." This protocol provides a current and credible set of practice guidelines.

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The Harvard University Suicide Assessment Protocol Guidelines (Guidelines) were developed in 1999 and consists of five categories developed to provide suicide assessment practice guidelines for clinicians ) (Appendix 8). A comparison of the suicide assessment strategies used by the nurse participants in this study and these five categories is presented in this section. Of note, none of the participants responded affirmatively when asked if they used practice guidelines in their suicide risk assessments.

I. Consider Predisposing Factors: Axis I Diagnosis
The substance abuse yet only one participant assessed for bipolar illness.
Furthermore, one participant did not assess the adolescent (a particularly high suicide risk group) who had recently attempted suicide (Vignette #3), as being suicidal enough to require inpatient hospitalization.
All nurse participants demonstrated their understanding and application of comprehensively assessing particular at risk populations (e.g ., depressed and substance abusing clients). However, consideration of other specific disorders such as schizophrenia was not articulated. Furthermore, modifiable risk factors, such as panic, or anxiety, were not specifically identified by the majority of participants. Rather, specific symptoms and clinical features such as hallucinations, paranoia, and impulsivity were areas of focus skillfully assessed.
As a predisposing factor, interpersonal loss, an important precipitant to suicide, was identified by all participants and strategies were used to assess the impact of loss on the individual and relationship to suicide risk (e .g., vignette #2 in which the woman lost her children in a motor vehicle accident and, also, lost her previous functional capacity).
The nurses seemed to consider the meaning and weight of specific risk factors that were evident in the clients identified from their knowledge of the clients' backgrounds, rather than having a specific list of risk factors to be checked in assessment.

Detect Potentiating Factors
The Guidelines identify the following seven areas within the "Detect

Conduct a Specific Suicide Inquiry
Two areas are included in "Conduct a Specific Suicide Inquiry" in the Guidelines: (a) determination made of suicidal ideation and intent and (b) assessment of suicide plans and attempts. All participants used specific strategies to assess suicidal ideation, plans, and attempts. They were all knowledgeable and skilled in conducting a suicide inquiry. All participants asked clients directly about their past and current ideation, plans, and attempts . However, there was considerable variability between the nurses regarding the depth , breadth , and clarity of inquiry. For example, one participant relied on prior assessments made by other team members (i.e., other team member's prior assessment and communication that the client was no longer suicidal despite the recent suicide attempt by the client and capable of a "therapeutic day pass" out of the hospital); another participant specifically asked the client if she would be able to approach the staff, using the psychiatric term , "contracting for safety." Many clients are confused by this term or may not be able to, understandably, assess their own level of safety.
Therefore, this strategy to assessment may be unreliable.

IV. Determine the Level of Intervention
This category is identified with five specific areas of focus: a. More control taken by clinician when patient has disorder-based suicidality 101 b. More control given to patient who has personality-based suicidality c. Assessment made of patient's compliance Uudgment, level of compliance, ability to understand treatment) d. Assessment made of therapeutic alliance e. Reassessment of suicidality scheduled The participants working in psychiatric assessment service (where rapid data collection even amidst crisis, time, and other constraints is essential) spent more time with clients compared with participants practicing on the inpatient unit. In this setting nurses perform "brief check-ins" which is often routine practice in settings where staff are familiar with the client's history (e.g. , time limited, symptom focused assessment periodically done throughout a client's inpatient treatment and when a client is scheduled for a "therapeutic pass" off the unit to assess the client's ability to adhere to the purpose of the "pass" and accompanying viable expectations).
All participants working in the psychiatric assessment service used strategies to assess the "level of care" needed by the patients and focused on the nature of disposition. Specific areas of assessment included client's judgment, insight, level of compliance, and ability to participate in treatment.
The participants working in the locked psychiatric units demonstrated using strategies also focusing on patient's judgment, insight, and compliance.

102
The participants did not use different assessment strategies regarding their approach to intervention according to specific causal frames of suicide in the clients. That is, the participants did not differentiate their assessment strategies in relation to whether the client's suicidality was disorder-based or personality-based. In addition, the participants did not articulate seeking out information from their clients regarding the clients' alliances with psychiatric professionals for therapy in their past or the present therapeutic alliance.

V. Documentation
This category refers to the documentation of assessments as a requirement for assuring communication. Due to confidentiality, the researcher did not examine documentations completed by the participants in the client records. However, it was observed that extensive documentation via the psychiatric assessment service intake form was performed by every participant.

Summary
In summary, although none of the participants used suicide assessment clinical guidelines, all participants incorporated various suicide assessment strategies from the literature. However, without the use of structured practice guidelines, the participants did not perform a comprehensive suicide assessment as defined by the Guidelines. Additionally, none of the participants utilized any well established suicide assessment instruments.
Four of the participants expressed that quantitatively oriented instruments would be useful, while one felt it would detract from the nurse-client relationship .

Participants' Assessment in Relation to Education and Experience (Research Question #4)
For research question #4 (i.e., "How do nurses perceive education and/or experience influencing their suicide assessments?"), the following summarizes the nurse participants' perceptions regarding how their education and/or experience influenced their suicide assessment.

First Participant-Amy
At the completion of earning her baccalaureate education, Amy did not feel adequately prepared to perform suicide assessments. Amy reported her clinical practice as a psychiatric-mental health nurse combined with education at the master's level (MSN) and in-service education provided her with the knowledge and skills necessary to adequately prepare her to perform this type of assessment. Despite her educational and clinical preparation, Amy stated, "not a day goes by that I don't wonder if I made the correct assessment." Amy attributed this to the complexities of suicide assessment.

Second Participant-Beth
Upon completion of earning her baccalaureate degree in nursing, Beth did not feel adequately prepared to perform suicide assessments. Beth reportedly developed this knowledge and skill through her clinical psychiatric experience and in-service education.

Third Participant-Carol
Carol stated that her basic nursing education did not adequately prepare her to perform suicide assessments. Carol reportedly developed this knowledge and skill through her clinical experience and general continuing education (not necessarily specific to suicide assessment [e .g., thanantology]).
Of note , Carol was the only participant that alluded to the importance of assessing religious affiliation . She, also, spoke of her own past "history" and "therapeutic use of self' impacting her nursing practice.

Fourth Participant-Denise
Denise stated her basic nursing education did not adequately prepare her for suicide assessment. As with the previous participants, Beth reported her clinical experience in psychiatric-mental health as the source for her preparation in assessing clients for suicide. The foundation of her knowledge and skill in suicide assessment was from her role as a mental health worker, which involved direct client care. Although Denise only has an associate's degree in nursing and minimal experience as a psychiatric-mental health nurse (nine months), she was strikingly knowledgeable about suicide assessment. However, she did express the greatest uncertainty about the accuracy of her findings.

Fifth Participant-Eve
Although Eve felt her basic nursing education provided her with a "holistic" view of clients, she did not feel it adequately prepared her for suicide assessment. Reportedly, her clinical experience in psychiatric-mental health has prepared her in suicide assessment. In fact, Eve jokingly emphasized that she is a graduate of "The X Hospital School of Psychiatric Nursing" in which she attributes the experience and learning attained in this psychiatric teaching hospital (which she is not currently employed) as preparing her for suicide assessment. Eve, as did Amy, acknowledged the complexity of suicide assessment and repeatedly stated, "If I'm going to make a mistake, I'm going to make it on the side of safety."

Sixth Participant-Fran
Fran stated that she was not adequately prepared to perform suicide assessments in her associate degree program and as with the other five participants, Fran states that her clinical experience and/or in-service education were the sources of this preparation.

Summary
All participants were asked how they perceived their education influencing their suicide assessments. They all responded that they did not believe their basic nursing education adequately prepared them for suicide assessment. Rather, their experience, on-the-job training, in-service education , and/or continuing education best prepared them for this challenging role and responsibility. Four participants attended in-service education in suicide assessment. However, one participant admittedly stated it would be impossible to recall everything given the plethora of content covered.
A note regarding on-the-job training is in order. Peplau (1952), a nurse theorist, developed the anxiety continuum , in part, highlighting the impact of various levels of anxiety on learning . Thus , a nurse who may be experiencing higher levels of on-the-job anxiety in an already anxiety producing environment, may be incapable of adequately learning or incorporating critical suicide assessment via on the job preparation. Additionally, the quality of onthe-job training depends on adequate and available opportunities to assess diverse clients as well as the competency of those providing the experiential "learning" opportunities. Similarly, in-service and continuing educational programs vary in efficacy contingent on the content and context of presentation (e.g. , exclusively didactic or role playing/modeling) and the style of participant learning .

Comparison of the Findings Across Participants
The details of the number of the various categories that emerged in this study used by different participants are given in Table 1. Overall, all participants demonstrated knowledge of some RISK FACTORS in their suicide assessments. However, the major risk factor identified consistently across the participants was depression. Other risk factors were not systematically identified by the participants. The participants did not use tools such as the SADPERSONS scale in order to assess risk factors. All participants demonstrated knowledge of psychological states commonly associated with suicidality yet not all participants acknowledged some commonly known ASSOCIATED STATES (e.g., agitation followed by calmness in the case of vignette #2).
Throughout the assessments of the observed cases and the vignettes, Amy did not rely on EXEMPLARS, Carol did not rely on INTUITION, Denise did not rely on the SIGNIFICANT OTHERS or RELATED STORIES, and both Beth and Fran did not rely on OTHER PROFESSIONALS. Similarly, Amy and Denise (with the exception of the assessments of the observed cases) did not rely on OTHER PROFESSIONALS. It may suggest, in part, that these nurses (Amy, Beth , and Denise) function rather independently in their autonomous roles and because of their clinical experiences spanning decades. All partici pants , with the exception of Denise, felt their general understanding (conceptualization) of suicide influenced their practice in suicide assessment.
The suicide assessments by all participants were notably more extensive for the observed cases compared to the vignettes (in which many felt the vignettes provided "scanty" data). None of the participants used an established suicide assessment instrument. All participants demonstrated and/or articulated their holistic nursing practice approach and the development of therapeutic nurse-client relationships and "therapeutic use of self." All participants either directly asked their clients if they were suicidal and/or used individualized strategies (e.g., future orientation , insight, judgment, impulsivity) in their suicide assessments.
Analysis of the ratings of the three vignettes by each of the nurse participants , although evidencing variability, did not show any discernable differences in relation to academic or experiential preparation . Table 2 shows the variations in the ratings of the vignettes by the nurse participants, indicating that the variation is most evident in the case of Andrew (Vignette #1) ranging from moderate to very high . Similarly, variation in rating the adolescent in vignette #3 ranged from low to high. It is noteworthy that four participants rated the adolescent's suicide risk as low when suicide rates for adolescents have increased threefold since 1955 and suicide is the third leading cause of death (National Center for Health Statistics, 1992) for this vulnerable population. The participants in the study, in performing suicide assessments, relied on several different strategies among the common 10 categories that emerged as the core set of strategies. In most cases the nurses used between four and six different strategies in combination rather than relying solely on one specific strategy. This may be due to the complex nature of suicide as a phenomenon and the nurses tendency to be conservative in regard to this diagnostic responsibility as misdiagnosing has a "serious" consequence . In addition, the nurses were neither comprehensive nor systematic in seeking information from clients regarding risk factors and potentiating factors for suicide risk. This may be due to gaps in knowledge regarding suicidality or the tendency to focus more on common risk factors rather than using a comprehensive list of possible ones. This may be due to the processing of information adopting cognitive short-cuts such as cognitive heuristics of representativeness, availability, and anchoring (Kahneman & Tversky, 1973).
The assessments of three vignettes by the nurses tended to be less elaborate and more conservative in their ratings of suicidal risk. That is, in general the nurses used fewer strategies in assessing these cases compared to the assessments of observed cases. This may be due to the inability to seek additional information besides that present in the vignettes. The "Reference Dimension" is oriented to strategies related to how one forms an idea -the process, in the sense of "I refer to my intuition" or "I refer to what the doctor said" or "I refer to what a typical case is like." This structure of 10 categories of descriptions shown in Figure 2 indicates that suicide assessment involves a multidimensional process within wh ich variations among the nurse participants were found. This insight into the structure of assessment has theoretical implications regarding our understanding of suicide assessment and nursing assessment in general.
This may mean that nurses are engaged in assessment of clients guided not only by their knowledge and conceptualizations of phenomena of interest but also by various methods of obtaining information and reliance on different sorts of referential bases for decision making. This is in line with Sjostrom's findings (1998)  Improved understanding of how nurses conceptualize and assess suicidality has critical significance in suicide prevention and intervention . The findings of this study could contribute to Kim's (1983Kim's ( , 1987Kim's ( , 2000 extensive work in knowledge development regarding nursing practice and add to theory development regarding nursing assessment as one of the critical phenomena in the practice domain. This study has led to the identification of other potential areas in need of knowledge development and inquiry. For example, this study did not investigate the quality of suicide assessment or the outcomes of specific suicide assessments on nursing actions (enactment). There is a need to develop theoretical understanding about the relationships between the specific strategies used by nurses and outcomes of the patterns of use both on nursing actions and clients. Furthermore, the theoretical structure that emerged from this investigation leads to questions such as how the bases for the Knowledge Dimension become established in nurses, and why certain nurses are more likely to rely on the strategies in the Method Dimension or the Reference Dimension than on those within the Knowledge Dimension while others tend to rely heavily on the strategies of the Knowledge Dimension. In addition , it is critical to discover whether or not this structure applies to various other types of nursing assessment. This can lead to a middle-range theory of nursing assessment.
Furthermore, the findings that the nurses rarely use any of the standard , pre-established guidelines in suicide assessment, suggest a need for further investigations on the reasons and consequences of this practice .

Methodological Implications
Phenomenography, the methodologic approach of this study provided a meaningful way to systematically study participants·· conceptualizations of suicide and strategies used for suicide assessment. The methodological rigor and the richness of the data collected through the use of observations and semi-structured interviews validated the utility of utilizing this method in the development of nursing knowledge . The process of data analysis, as applied in this investigation, had been specified in detail by the proponents of phenomenography and provided a framework for analytical rigor. One of the major requisites in data analysis is involving other researchers who are familiar with phenomenography in various phases of data analysis. It is critical to receive feedback and validation from credible researchers regarding emerging categories and condensations.
Vignettes were used in addition to actual cases for suicide assessment because of an anticipated difficulty in obtaining clients in suicide-prone states.
Although the use of vignettes was satisfactory in confirming various strategies of assessment used by the nurses, there were a few problems in its use. First, the nurses in general felt that the information provided in the vignettes was neither detailed nor comprehensive enough for the purposes of assessment.
Secondly, the inability of nurses to obtain data from clients in a progressive, on-going manner through dialogue and observation seems to have limited their processing of information. This, too, speaks to the need to study the effectiveness of the use of simulated case studies as a teaching method.
Methodologically, if vignettes are to be used in this type of research, it may be better to use interactively based vignettes (using computers) whereby participants could obtain additional data on request.
As a developing and pragmatic method, the use of phenomenography presented unique challenges. For example, since the members of the Institutional Review Boards (IRB's) were not familiar with this method, education of the members of the IRB's was necessary (Appendix M). As a result, beginning this study was significantly delayed .
Accessing informed consent from the patients being assessed by the nurses was often difficult. Flexibility, time, and patience were key to achieving the goals of the study. Repeated visits were required to obtain sufficient data, accommodate the nurses' schedules, and be sensitive to the needs of the system . At times the nurses were too busy to participate due to the high number of patients that needed assessments.

Implications for Nursing Practice
As a practice profession , it is essential that nurses build upon their knowledge of suicide assessment in order to further develop more effective client-focused deliberative and enactment interventions, thus, improving the quality and outcome of nursing care.
The findings of this study have led to the following implications for nursing practice . Given that all participants identified their clinical experience (practice) as the primary mechanism for developing suicide assessment skills, there is a crucial need for increased clinical experience, role modeling, mentoring, in-service, and adequate continuing education Similarly, given the great variability in performing a suicide assessment for the adolescent in vignette #3, particular attention to the various clinical presentations and required nursing strategies in assessing diverse clientele throughout the life span is warranted .
In addition , since some nurses relied on other nurses' or professionals' assessments as the bases for coming to assessment decisions, it is critical to assure the overall quality of assessment in practice situations. It may be necessary to develop organizational programs in which professionals involved in assessments dialogue about the strategies and processes of assessment specifically focusing on the quality of outcomes. If the tendency to rely on others continues , then the best way to assure assessments of a high quality is through creating a culture of excellence in the clinical practice arena .

Implications for Nursing Education
This study points to the necessity for educating nursing students in suicide assessment. It is recommended that nurse educators re-evaluate their course content and practicum experiences, placing greater emphasis on providing students with the opportunity to perform suicide assessments.
Continuing education programs for practicing psychiatric-mental health nurses need to focus on helping practitioners gain insights into their own practice in order to understand the strategies that are used by them and what potential consequences are in using them. It would be beneficial to educate psychiatric-mental health nurses on the method of Critical Reflective Inquiry suggested by Kim (2000) in order to have the nurses examine their own assessment practices thereby gaining self-understanding about the strategies used.
Nurse educators should also include more theoretically-based suicide assessment content and incorporate the work of nurse theorists as a theoretical foundation. Furthermore, given the nursing shortage and an increase in the appeal of non-traditional accelerated nursing degree programs (e .g., second degree, "fast track," "online," and BSN-PhD), it is critical that nurse educators include in courses dealing with suicide assessment normative theories, related skills of assessment, and the descriptive theories and findings about the nature of actual practice in order to show that disparities in practice exists .

Implications for Nursing Research
As a result of this study, it is recommended that additional research be conducted to investigate similarities and differences in the conceptualizations of suicide and strategies for suicide assessment by novice versus expert nurses and heterogeneity. Furthermore, research investigating diagnostic reasoning ; intuition and transference in suicide assessment; and/or errors in clinical decision making is sorely needed.
Additionally, it is recommended research be conducted to investigate the actual versus perceived needs by some nurses to incorporate quantitative suicide assessment instruments into routine practice and whether such quantitative instruments serve utility or detract from the nurse-client relationship. Research examining the use of standardized suicide protocols and/or suicide assessment instruments is critical. However, as the first step, there is a need to develop theoretically grounded, valid, and reliable instruments that can be incorporated into quantitative measurement protocols.
As suggested earlier, it is important to investigate further how extensive the strategies, discovered in this study, are used by psychiatric-mental health nurses in assessing clients for suicidality. Through various validation studies, it would be possible to develop a more insightful descriptive theory of suicide assessment.

Implications for Nursing Administration
Nurse administrators play a critical role in examining current standards of nursing practice in suicide assessment and determining the educational needs of nursing staff specific to suicide assessment. It is recommended that nursing administration allocate the necessary resources to provide in-service education , preceptorships, and/or mentoring of nursing staff. Additionally in view of "cut-backs" in the health care delivery system , the valuable contributions by psychiatric-mental health clinical nurse specialists requires reconsideration of the allocation of resources .

Concluding Remarks
The findings of this investigation are descriptive and were discovered in the nurses' practice. The emphasis one must make in such a study is that the results do not address what are correct or incorrect ways of practicing.
However, the insights regarding what actually occurs in practice provide an important starting point for developing knowledge about nursing practice .
Nursing assessment as one of the most important nursing responsibilities requires not only an in-depth understanding but also a normative theory. This study is the first step toward such a goal. Rating: A positive factor counts one point. Scoring: 0-2 = Little risk 3-4 =Follow closely 5-6 = Strongly, consider psychiatric hospitalization 7-10 =very high risk, hospitalize or commit Source: Patterson, Dohn, Bird, & Patterson, 1983 You have been asked to take part in a research project described below. The researcher, John M. Aflague, Ph.D.(c), M.S., RN, CS, will explain the project to you in detail. You should feel free to ask questions. If you have more questions later, John M. Aflague, the person mainly responsible for this study--------------, will discuss them with you .

Description of the Project
You have been asked to take part in a study which will explore the ways nurses perform suicide assessment.

What will be done
If you decide to take part in this study here is what will happen. Once your questions have been satisfactorily and fully answered, this researcher will obtain your signed and dated informed consent. A copy of the consent will be promptly given to you . Your confidentiality is guaranteed. You will complete and return a brief demographic data sheet. You will ask potential adult patients' permission for this researcher to observe you interview them. Inclusion criteria for consenting adult patients will be that they are 18 years of age or older, can speak English , and are competent to provide informed consent for observations (i.e., individuals with guardians or who are court mandated will be excluded). Each eligible patient will be informed that I am a nurse studying nurses in practice by observing them interview patients. Patients will be informed that their decision (to participate or not) will not effect their care. You will also obtain signed and dated consent from the patient. This consent will also be signed and dated by you and this researcher. Once patient consent is obtained, this researcher will observe you perform a suicide assessment on one appropriate consenting adult patient. If a patient does not formally consent or there is a disruption in agency routine (at any time), this researcher will remove himself. During the observational period, this researcher will be located on the periphery observing you interview the patient. As soon as possible following the observation session, this researcher will arrange a conversational interview with you . The conversational interview will be conducted in a private area in the clinical setting or mutually negotiated place away from others to maintain confidentiality, freedom of speech, and provide a conducive environment. During this time, this nurse researcher will ask you to share how you go about performing suicide assessment of patients. The interviews will take place "off duty." This interview (-1 hour) will be audio taped. At a convenient time (which could occur on the same day of the patient observation and conversational interview as outlined above and as follows:), you will also be asked to read 3 brief vignettes. Next (at a convenient time, ideally as soon as possible after reading the 3 vignettes), you will be asked to verbally respond to the 3 vignettes in a conversational interview with the researcher by providing your assessment of the factitious scenarios and answering questions related to the 3 vignettes in a conversational interview with this nurse researcher. This interview (-1 hour) will also be audio taped. The researcher may ask to call you for further questions and clarification. You may decline to answer any question or questions.

Risks or discomfort
In the process of the interview you may experience some distress in discussing suicide assessment or feel uncomfortable being observed by a nonjudgmental nurse researcher, otherwise, there are no other risks or discomforts known.

Benefits of this study
Although the results of this study may not be of direct or immediate benefit to you, the information obtained from the study has potential important implications for nursing practice and education . If nurses can better understand the process(es) by which nurses assess patients ,' educational opportunities can be designed to enhance this role. The results can improve care and patient outcomes.

Confidentiality
The information that you provide will be used for research purposes only, including teaching and publication. Your participation in this study is confidential . Due to the sensitive nature of the study, consent forms and identifying face sheets will be kept separate from the rest of the study and secured in locked boxes at the researcher's office as outlined. The listing of your name and assigned code number will be recorded on a separate sheet filed in a locked drawer to whom only the investigator has access. All records, including notes and transcribed interviews, will not identify you by name and will be kept locked in a file cabinet. A code number will identify the interview. Audiotapes will be kept in a separate locked file cabinet. Your name will not appear on the audiotape label. A number, assigned by this researcher, will appear on the audiotape label. Because the audiotapes have intrinsic value for future research , they will be kept in a locked cabinet for at least three years. Patient consent forms will not identify the patient as seeking psychiatric services. These forms will be kept locked in a separate locked file cabinet in another location for at least three years .

Decision to quit at any time
The decision to take part in this study is up to you. You do not have to participate . If you decide to take part in the study, you may quit at any time. Whatever you decide will in no way affect your job, status in nursing services or job evaluation. If you wish to quit, you simply inform John M. Aflague at--------------of your decision.

Rights and Complaints
If you are not satisfied with the way this study is performed , you may discuss your complaints with John M. Aflague or with his major professor, Dr. Hesook Suzie Kim , Ph.D ., RN. , College of Nursing, University of Rhode Island at (401)

Invitation to Participate and Description of Project
You are invited to participate in a study designed to investigate suicide assessment by psychiatric-mental health nurses. You have been invited to participate because you are a registered psychiatric-mental health nurse and have been identified by a colleague as being potentially interested in participation . Your participation in the study would last approximately one day to four weeks. It will require approximately two to four hours.
In order to decide whether or not you wish to be a part of this research study, you should know enough about its risks and benefits to make an informed judgment. This consent form gives you detailed information about the research study which a member of the research team will discuss with you . This discussion should go over all aspects of this research : its purpose, the procedures that will be performed, any risks of the procedures, possible benefits and possible alternative treatments. Once you understand the study, you will be asked if you wish to participate; if so, you will be asked to sign this form.

Description of Procedures
If you decide to participate in this study here is what will happen. Once your questions have been satisfactorily and fully answered, this rnsearcher will obtain your signed and dated informed consent. A copy of the consent will be promptly given to you. You will complete and return a brief demographic data sheet.
You will ask potential adult patients' permission for this researcher to observe you interview them. Inclusion criteria for consenting adult patients will be that they are 18 years of age or older, can speak English , and are competent to provide informed consent for observations (i.e., individuals with guardians or who are court mandated will be excluded). Each eligible patient will be informed that the researcher is a nurse studying nurses in practice by observing them for periods of time. Patients will be informed that their decision (to participate or not) will not effect their care. You will also obtain signed and dated consent from the patient. This consent will also be signed and dated by you and this researcher. Once patient consent is obtained, this researcher will observe you perform a suicide assessment on one appropriate consenting adult patient. If a patient does not formally consent or there is a disruption in agency routine (at any time), this researcher will remove himself.
During the observational period, this researcher will be located on the periphery observing you interview the patient. As soon as possible following the observation session, this researcher will arrange a conversational interview with you. The conversational interview will be conducted in a private area in the clinical setting or mutually negotiated place away from others to maintain confidentiality, freedom of speech , and provide a conducive environment. During this time, this nurse researcher will ask you to share how you go about performing suicide assessment of patients. The interviews will take place "off duty." This interview (-1 hour) will be audio taped. You understand that every effort will be made to not identify me on the recording(s) .
At a convenient time (which could occur on the same day of the patient observation and conversational interview as outlined above and as follows :), you will also be asked to read 3 brief vignettes. Next (at a convenient time, ideally as soon as possible after reading the 3 vignettes), you will be asked to verbally respond to the 3 vignettes by providing your assessment of the factitious scenarios and answering questions related to the 3 vignettes in a conversational interview with this nurse researcher. This interview (-1 hour) will also be audio taped.
The researcher may call you for further questions and clarification. You may decline to answer any question or questions.

Risks and Inconveniences
In the process of the interview you may experience some distress in discussing suicide assessment or feel uncomfortable being observed by a nurse researcher, otherwise, there are no other known risks or discomforts.

Benefits
Although the results of this study may not be of direct or immediate benefit to you, the information obtained from the study has potential important implications for nursing practice and education. If nurses can better understand the process(es) by which nurses assess patients, educational opportunities can be designed to facilitate this role . The results can improve care and patient outcomes.

In Case of Injury
There are no known risks other than perhaps feeling uncomfortable while being observed and asked questions by the researcher and/or some distress in discussing suicide assessment. However, should injury result, there is no formal program for------Hospital or the researcher(s) to pay for treatment or injury resulting from this study, or to pay for such things as lost wages, disability, or discomfort due to injury. By signing this form you will not give up any of your rights concerning compensation for injury.
In the event that you need hospitalization for medical or psychiatric care, the study investigators, Hospital, and University of Rhode Island will not assume responsibility for treatment expenses . If your insurance will not pay for inpatient care, you may be at risk for personal financial responsibility for hospitalization.

Alternative Treatments
The decision to take part in this study is up to you. You do not have to participate . If you decide to take part in the study, you may quit at any time. Whatever you decide will in no way affect your job, status in nursing services or job evaluation. If you wish to quit, you simply inform John M. Aflague at--------------or ------------at --------------of your decision.

Confidentiality
You will not be personally identified in any reports or publications that may result from this study. The confidentiality of the information you provide to us will be maintained in accordance with the laws of the State of Rhode Island and Providence Plantations.
The information that you provide will be used for research purposes only, including teaching and publication .
Due to the sensitive nature ~f the study, consent forms and identifying face sheets will be kept separate from the rest of the study and secured in locked cabinets at the researcher's office as outlined. The listing of your name and assigned code number will be recorded on a separate sheet filed in a locked drawer to whom only the investigator has access. All records, including notes and transcribed interviews, will not identify you by name and will be kept locked in a file cabinet. A code number will identify the interview. Audiotapes will be kept in a separate locked file cabinet. Your name will not appear on the audiotape label. A number, assigned by this researcher, will appear on the audiotape label. Because the audiotapes have intrinsic value for future research, they will be kept in a locked cabinet for three years at which time the contents will be erased by the researcher.
Patient consent forms will not identify the patient as seeking psychiatric services. These forms will be kept locked in a separate locked file cabinet in another location for three years .

Voluntary Participation
You are free to decide whether or not to participate in this study and tree to withdraw from the study at any time. A decision not to participate or to withdraw from the study will not adversely affect future interactions with ------Hospital, -----University, or University of Rhode Island.

Financial Disclosure
Not applicable.

Questions
In preparation of this consent form it was necessary to use several technical words. Please ask for an explanation of any that you do not understand .

135
I understand that this recording will be used for the sole purposes of research, education, or treatment by properly qualified research personnel and will remain the property of the researcher.
I understand that this recording will be erased when it is no longer to be used for research, education, or treatment purposes (at the end of three years).
I understand that every effort will be made not to identify me by name on the recording . You are invited to participate in a study designed to investigate assessment by nurses. You have been invited to participate because you are a patient of your assigned nurse who has consented to participate in this study. Your participation in the study would last approximately 10 to 30 minutes.
In order to decide whether or not you wish to be a part of this research study, you should know enough about its risks and benefits to make an informed judgment. This consent form gives you detailed information about the research study which a member of the research team will discuss with you. This discussion should go over all aspects of this research: its purpose, the procedures that will be performed, any risks of the procedures, possible benefits and possible alternative treatments. Once you understand the study, you will be asked if you wish to participate; if so, you will be asked to sign this form.

Description of Procedures
If you decide to take part in this study here is what will happen. Once your questions have been satisfactorily and fully answered, your nurse will obtain your signed and dated informed consent. The nurse re. searcher will also sign this consent. A copy of the consent will be immediately given to you and a copy placed in your medical record. Your decision (to participate or not) will not effect your care.
Once consent is obtained, this researcher will observe your nurse perform an assessment on you . If you should decide to withdraw your consent or there is a disruption in agency routine (at any time), this researcher will remove himself.
During the observational period, this researcher will be located on the periphery observing your nurse interview you.

Risks and Inconveniences
During the interview by your nurse, you may experience distress or feel uncomfortable being observed, otherwise, there are no other known risks or discomforts.

Benefits
Although the results of this study may not be of direct or immediate benefit to you, the information obtained from the study has potential importance to nursing practice and education. This could improve nursing care.

In Case of Injury
There are no known risks other than perhaps experiencing distress or feeling uncomfortable while being observed . However, should injury result, there is no formal program for------Hospital, The University of Rhode Island , or the researcher(s) to pay for treatment or injury resulting from this study, or to pay for such things as lost wages, disability, or discomfort due to injury. By signing this form you will not give up any of your rights concerning compensation for injury.
In the event that you need hospitalization for medical or psychiatric care, the study investigators, ------Hospital, and The University of Rhode Island will not assume responsibility for treatment expenses. If your insurance will not pay for inpatient care, you may be at risk for personal financial responsibility fci hospitalization.

Alternative Treatments
The decision to take part in this study is up to you. You do not have to participate. If you decide to take part in the study, you may quit at any time. Whatever you decide will in no way affect your care or treatment. If you wish to quit, you simply tell John Aflague at --------------or ------------at --------------of your decision .

Confidentiality
You will not be personally identified in any reports or publications that may result from this study. The confidentiality of the information you provide to us will be maintained in accordance with the laws of the State of Rhode Island and Providence Plantations.
The information that you provide will be used for research purposes only, including teaching and publication .

138
The consent form will not identify your seeking mental health services . These forms will be kept in a separate locked file cabinet in the researcher's locked office for three years then destroyed.

Voluntary Participation
You are free to decide whether or not to participate in this study and free to withdraw from the study at any time. A decision not to participate or to withdraw from the study will not adversely affect future interactions with ------Hospital, -----University, or The University of Rhode Island.

Financial Disclosure
Not applicable.

Questions
In preparation of this consent form it was necessary to use several technical words . Please ask for an explanation of any that you do not understand.
I have read this form and decided t h a t -------------(name of subject) will participate in the project described above. Its general purposes, the nature of my involvement, and possible hazards and inconveniences have been explained to my satisfaction. My signature also indicates that I have received a copy of this consent form.

CONSENT FOR PARTICIPATION IN A RESEARCH PROJECT
---------------Hospital and University of Rhode Island College of Nursing (Acute Psychiatric Inpatient Unit in a General Community Hospital)

Invitation to Participate and Description of Project
You are invited to participate in a study designed to investigate suicide assessment by psychiatric-mental health nurses. You have been invited to participate because you are a registered psychiatric-mental health nurse and have been identified by a colleague as being potentially interested in participation. Your participation in the study would last approximately one day to four weeks. It will require approximately two to four hours.
In order to decide whether or not you wish to be a part of this research study, you should know enough about its risks and benefits to make an informed judgment. This consent form gives you detailed information about the research study which a member of the research team will discuss with you. This discussion should go over all aspects of this research: its purpose, the procedures that will be performed, any risks of the procedures, possible benefits and possible alternative treatments. Once you understand the study, you will be asked if you wish to participate; if so, you will be asked to sign this form .

Description of Procedures
If you decide to participate in this study here is what will happen. Once you r questions have baen satisfactorily and fully answered, this researcher will obtain your signed and dated informed consent. A copy of the consent will be promptly given to you. You will complete and return a brief demographic data sheet.
The Attending Psychiatrist will identify patients for recruitment. The Unit Manager or study sponsor will ask potential adult patients' permission for this researcher to observe you interview them . Inclusion criteria for consenting adult patients will be that they are 18 years of age or older, can speak English, and are competent to provide informed consent for observations (i.e., individuals with guardians or who are court mandated will be excluded). Each eligible patient will be informed that the researcher is a nurse studying nurses in practice by observing them for periods of time. Patients will be informed that their decision (to participate or not) will not effect their care or treatment. The Unit Manager, study sponsor, or researcher will also obtain potential patient's initialed and dated consent. This consent will also be signed and dated by the Unit Manager, study sponsor, or this researcher once the patient's question(s), if any, are fully answered by the researcher. Once patient consent is obtained, this researcher will observe you perform a suicide assessment on one appropriate consenting adult patient. If a patient does not formally consent or there is a disruption in agency routine (at any time), this researcher will remove himself.
During the observational period, this researcher will be located on the periphery observing you interview the patient. As soon as possible following the observation session, this researcher will arrange a conversational interview with you. The conversational interview will be conducted in a private area in the clinical setting or mutually negotiated place away from others to maintain confidentiality, freedom of speech, and provide a conducive environment. During this time, this nurse researcher will ask you to share how you go about performing suicide assessment of patients. The interviews will take place "off duty." This interview (-1 hour) will be audio taped. You understand that every effort will be made not to identify you on the recording(s).
At a convenient time (which could occur on the same day of the patient observation and conversational interview as outlined above and as follows:), you will also be asked to read 3 brief vignettes . Next (at a convenient time, ideally as soon as possible after reading the 3 vignettes), you will be asked to verbally respond to the 3 vignettes by providing your assessment of the factitious scenarios and answering questions related to the 3 vignettes in a conversational interview with this nurse researcher. This interview (-1 hour) will also be audio taped.
The researcher may call you for further questions and clarification. You may decline to answer any question or questions.

Risks and Inconveniences
In the process of the interview you may experience some distress in discussing suicide assessment or feel uncomfortable being obsented by a nurse researcher, otherwise, there are no other known risks or discomforts.

Benefits
Although the results of this study may not be of direct or immediate benefit to you, the information obtained from the study has potential important implications for nursing practice and education. If nurses can better understand the process(es) by which nurses assess patients,' educational opportunities can be designed to facilitate this role . The results can improve care and patient outcomes.

In Case of Injury
There are no known risks other than perhaps feeling uncomfortable while being observed and asked questions by the researcher and/or some distress in discussing suicide assessment. However, should injury result, there is no formal program for---------------Hospital, The University of Rhode Island , the researcher(s), or their agents to pay for treatment or injury resulting from this study, or to pay for such things as lost wages, disability, or discomfort due to injury. By signing this form you will not give up any of your rights concerning compensation for injury.
In the event that you need hospitalization for medical or psychiatric care , the study investigators, ---------------Hospital, The University of Rhode Island , the researcher(s), or their agents will not assume responsibility for treatment expenses. If your insurance will not pay for inpatient care, you may be at risk for personal financial responsibility for hospitalization .

Alternative Treatments
The decision to take part in this study is up to you. You do not have to participate . If you decide to take part in the study, you may quit at any time. Whatever you decide will in no way affect your job, status in nursing services or job evaluation. If you wish to quit, you simply inform John M. Aflague at··--------------or --------------------at -------------of your decision .

Confidentiality
You will not be personally identified in any reports or publications that may result from this study. The confidentiality of the information you pru tide to us will be maintained in accordance with the laws of Massachusetts and the State of Rhode Island and Providence Plantations.
The information that you provide will be used for research purposes only, including teaching and publication.
Due to the sensitive nature of the study, consent forms and identifying face sheets will be kept separate from the rest of the study and secured in locked cabinets at the researcher's office as outlined . The listing of your name and assigned code number will be recorded on a separate sheet filed in a locked drawer to whom only the investigator has access . All records , including notes and transcribed interviews, will not identify you by name and will be kept locked in a file cabinet. A code number will identify the interview. Audiotapes will be kept in a separate locked file cabinet. Your name will not appear on the audiotape label. A number, assigned by this researcher, will appear on the audiotape label. Because the audiotapes have intrinsic value for future research , they will be kept in a locked cabinet for three years at which time the contents will be erased by the researcher.
Patient consent forms will not identify the patient as seeking psychiatric services. These forms will be kept locked in a separate locked file cabinet in another location for three years than destroyed by this researcher.

Voluntary Participation
You are free to decide whether or not to participate in this study and free to withdraw from the study at any time. A decision not to participate or to withdraw from the study will not adversely affect future interactions with --------------Hospital or the University of Rhode Island .

Financial Disclosure
Not applicable.

Questions
In preparation of this consent form it was necessary to use several technical words. Please ask for an explanation of any that you do not understand . I understand that this recording will be used for the sole purposes of research , education, or treatment by properly qualified research personnel and will remain the property of the researcher.
I understand that this recording will be erased when it is no longer to be used for research , education , or treatment purposes (at the end of three years).
I understand that every effort will be made not to identify me by name on the recording .

Invitation to Participate and Description of Project
You are invited to participate in a study designed to investigate assessment by nurses. You have been invited to participate because you are a patient of your assigned nurse who has consented to participate in this study. Your participation in the study would last approximately 10 to 30 minutes.
In order to decide whether or not you wish to be a part of this research study, you should know enough about its risks and benefits to make an informed judgment. This consent form gives you detailed information about the research study which a member of the research team will discuss with you . This discussion should go over all aspects of this research: its purpose, the procedures that will be performed, any risks of the procedures, possible benefits and possible alternative treatments. Once you understand the study, you will be asked if you wish to participate; if so, you will be asked to initial this form.

Description of Procedures
If you decide to take part in this study here is what will happen. Once your questions have been satisfactorily and fully answered, a member of the research team will obtain your initialed and dated informed consent. The nurse researcher will also sign this consent. A copy of the consent will be immediately given to you and a copy placed in your medical record . Your decision (to participate or not) will not effect your care.
Once consent is obtained, this researcher will observe your nurse perform an assessment on you . If you should decide to withdraw your consent or there is a disruption in agency routine (at any time), this researcher will remove himself. This will not affect your care or treatment.
During the observational period , this researcher will be located on the periphery observing your nurse interview you.

Risks and Inconveniences
During the interview by your nurse, you may experience distress or feel uncomfortable being observed, otherwise, there are no other known risks or discomforts.

Benefits
Although the results of this study may not be of direct or immediate benefit to you , the information obtained from the study has potential importance to nursing practice and education . This could improve nursing care.

Economic Considerations
None

In Case of Injury
There are no known risks other than perhaps experiencing distress or feeling uncomfortable while being observed . However, should injury result, there is no formal program for---------------Hospital, The University of Rhode Island, the researcher(s) , or their agents to pay for treatment or injury resulting from this study, or to pay for such things as lost wages, disability, or discomfort due to injury. By signing this form you will not give up any of your rights concerning compensation for injury.
In the event that you need hospitalization for medical or psychiatric care, the study investigators, ---------------Hospital, The University of Rhode Island , the researcher(s) , or their agents will not assume responsibility for treatment expenses. If your insurance will not pay for inpatient care, you may be at risk for personal financial responsibility for hospitalization.

Alternative Treatments
The decision to take part in this study is up to you. You do not have to participate. If you decide to take part in the study, you may quit at any time. Whatever you decide will in no way affect your care or treatment. If you wish to quit, you simply tell John Aflague at --------------or -------------------·· at --------------of your decision.

Confidentiality
You will not be personally identified in any reports or publications that may result from this study. The confidentiality of the information you provide to us will be maintained in accordance with the laws of Massachusetts and the State of Rhode Island and Providence Plantations.
The information that you provide will be used for research purposes only, including teaching and publication .
The consent form will not identify you by name nor of your seeking mental health services. These forms will be kept in a separate locked file cabinet in the researcher's locked office for three years then destroyed .

Voluntary Participation
You are free to decide whether or not to participate in this study and tree to withdraw from the study at any time. A decision not to participate or to withdraw from the study will not adversely affect future interactions with ---------------Hospital or The University of Rhode Island.

Financial Disclosure
Not applicable.

Questions
In preparation of this consent form it was necessary to use several technical words. Please ask for an explanation of any that you do not understand. Authorization: I have read this form and decided t h a t ---------------(initials of subject) will participate in the project described above. Its general purposes , the nature of my involvement, and possible hazards and inconveniences have been explained to my satisfaction. My signature also indicates that I have received a copy of this consent form .        ...