There are five instruments that you may find useful for initially assessing patients who present to the ED with suicidal thoughts.

As a nurse, you may interact with patients whom are suicidal. There are five instruments that you may find useful for initially assessing patients who present to the ED with suicidal thoughts. The instruments include the Mental Health Triage Scale (MHTS) (Happell, Summer, & Pinikahana, 2002; Smart, Pollard, & Walpole, 1999); the Behavioral Health Screening-Emergency Department (BHS-ED) (Fein et al., 2010); the ReACT Self-Harm Rule (Steeg et al., 2012); the Manchester Self-Harm Rule (Cooper, et al., 2006); and the P4 tool (Dube, Kroenke, Bair, Theobald, & Williams, 2010). Which of these tools has the least limitations in your view, and why?

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