Suicide risk does not stay on the psychiatric unit. Patients arrive on medical, surgical, oncology, and outpatient floors carrying the same despair that brings others to a crisis line, and the nurse at the bedside is often the first and only clinician positioned to notice it. Recognizing warning signs in general care is a core safety skill, not a specialty add-on.
Why general care nurses are the front line
Many people who die by suicide had contact with a non-psychiatric health setting in the weeks before, often for an unrelated medical complaint. That makes universal, structured screening more reliable than waiting for a patient to volunteer how they feel. The Ask Suicide-Screening Questions (ASQ) toolkit from NIMH was built specifically for medical settings, including emergency departments, inpatient medical and surgical units, and outpatient clinics, for patients ages 8 and above. It uses four brief yes/no questions that take roughly 20 seconds to administer.
A real-world implementation at the NIH Clinical Center, published in the Joint Commission Journal on Quality and Patient Safety, folded the ASQ into the routine nursing admission assessment on medical and surgical units. Nurses delivered it with standardized training, scripts, and EMR integration, screening took about two minutes per patient, and nurse compliance reached well over 90 percent across the first year. The takeaway for staff nurses is practical. Screening works best when it is a normal, scripted part of intake rather than an awkward special conversation.
What warning signs actually look like at the bedside
A validated screen catches what a busy assessment may miss, but nurses should also know the signs that warrant a closer look. NIMH groups warning signs of suicide into what a person says, feels, and does.
- Talk: wanting to die, feeling like a burden to others, having no reason to live, or expressing great guilt or shame.
- Mood and feeling: emptiness, hopelessness, feeling trapped, or extreme emotional distress.
- Behavior change: withdrawing from people, making a plan, giving things away, dangerous risk-taking, mood swings, changes in sleep or appetite, or increased substance use.
Pay particular attention when a behavior is new, has increased, or appears tied to a painful loss or change, such as a terminal diagnosis, disfiguring surgery, chronic uncontrolled pain, or sudden loss of independence. The CDC notes that suicide is rarely caused by a single event and instead emerges from combinations of factors. Serious illness and chronic pain are themselves listed individual-level risk factors, alongside a previous attempt, depression, hopelessness, substance use, and social isolation. Patients on medical floors frequently carry several of these at once.
Asking, escalating, and keeping the patient safe
Asking directly about suicide does not plant the idea. A structured tool gives you defensible language. If a screen is positive, the next step is not to interrogate or to leave the patient alone, but to follow your facility's pathway.
A positive screen identifies a patient who needs further assessment. It is the start of a process, not a diagnosis.
Under the ASQ workflow, a positive result triggers a brief suicide safety assessment by a trained clinician, who determines whether a fuller mental health evaluation is needed. The NIH implementation distinguished two paths. An acute positive, meaning current or imminent thoughts, prompted an immediate psychiatry page, one-to-one observation, and full safety precautions. A non-acute positive prompted a brief safety assessment within 24 hours and a disposition decision. The overwhelming majority were non-acute, which is reassuring evidence that universal screening does not flood units with crises.
While escalation is underway, basic environmental and observation measures protect the patient. Consistent with Joint Commission expectations for non-psychiatric units, these may include initiating the ordered level of monitoring, removing accessible means of self-harm when doing so does not compromise medical care, checking items brought in by visitors, and using safe transport procedures off the unit. Always work within your facility's policy and your charge nurse and provider rather than improvising the level of observation on your own.
Documentation, handoff, and patient connection
What you document and hand off matters as much as what you ask. Record the screening tool used, the patient's actual responses, your direct observations, the time, who was notified, and the precautions in place. Carry the same detail into handoff so the next shift does not start from zero. If precautions are active, the receiving nurse needs to know the level of observation and what means have been removed.
Closing the loop with the patient is part of safe care. Patients who screen positive should leave with crisis resources regardless of disposition. The simplest is the 988 Suicide and Crisis Lifeline, reachable by call or text to 988 or chat at 988lifeline.org, available around the clock. Offering it plainly, without judgment, models that help is normal and accessible. The nurse who screens routinely, recognizes the signs, escalates by policy, and documents clearly turns a quiet risk into a managed one.