Degree Name
Nursing Practice, DNP
Publication Date
9-29-2026
First Advisor
Lisa Drake
Second Advisor
Jason Weger
Abstract
Suicide prevention in outpatient mental health settings requires prompt recognition of and an appropriate response to suicide-related concerns, including those initially communicated to administrative staff. Frontline administrative phone staff may first encounter patients expressing suicidal thoughts; however, evidence supports education and standardized processes to facilitate effective recognition and response. At the project site, a practice gap existed in administrative staff preparation and confidence in responding to suicide-related concerns. The quality improvement project addressed this gap through structured, standardized Columbia-Suicide Severity Rating Scale (C-SSRS) education paired with a standardized suicide-risk stratification and escalation protocol. The project aimed to improve administrative staff confidence, measured using the Confidence Scale (C-Scale). Guided by Roy’s Adaptation Model, Lewin’s Change Theory, and the Plan-Do-Study-Act implementation framework, this one-group pretest-posttest quality improvement design was implemented over 10 weeks with administrative staff at an outpatient mental health practice. The pretest survey was completed by 12 participants, and the posttest survey was completed by 11; six pretest-posttest response pairs were matched and included in the paired analysis. Mean C-Scale scores increased from 13.50 (SD = 7.09) at pretest to 19.50 (SD = 5.39) at posttest. A paired-samples t test demonstrated a significant improvement in staff confidence, t(5) = −4.24, p = .008, with a large effect size (Cohen’s d = 1.73). Findings indicate that structured, standardized C-SSRS education paired with a standardized suicide-risk stratification and escalation protocol can improve administrative staff confidence in responding to suicide-related concerns.
Rights Management
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License
Recommended Citation
Oxley, Pamela, "Quality Improvement Project: Enhancing Suicide Recognition Protocols with the Use of Columbia-Suicide Severity Rating Scale in an Outpatient Mental Health Practice" (2026). Doctor of Nursing Practice Projects. 406.
https://arch.astate.edu/dnp-projects/406
