Publication Date




Embargo Period


Degree Type


Degree Name

Doctor of Philosophy (PHD)


Nursing (Nursing)

Date of Defense


First Committee Member

Anne E. Norris

Second Committee Member

Joseph De Santis

Third Committee Member

Brian E. McCabe

Fourth Committee Member

Tara Strine


Suicide is the 10th leading cause of death in the U.S., and suicide rates in Monroe County, Florida are among some of the highest in the state. The purpose of this dissertation was threefold: (1) analyze the concept of suicide lethality to clarify the concept through the identification of antecedents, attributes and consequences; (2) identify suicide risk factors to target for prevention in Monroe County, Florida; and (3) identify the sociodemographic characteristics associated with selective nonresponse to suicide risk questions. The two methods used in this dissertation were six stages of the Walker and Avant concept analysis method to literature search findings that included articles published in the English language between 1970 and 2016 using MEDLINE, the Cochrane Library, Pubmed, Psychlit, Ovid, PsychInfo and Proqest, and secondary analysis of the 2016 Monroe County Behavioral Risk Factor Surveillance Survey (BRFSS) of adult residents (n = 528). Univariate analyses, Chi Square tests and multivariate logistic regression using weights and strata to account for the complex survey design were conducted to generate prevalence estimates, standard errors, 95% confidence intervals and hierarchical regression models. Variables of interest included suicidal behavior questions, self-reported demographics, mental illness, physical illness, access to health care, and socio-economic status (SES) and suicide risk question nonresponse. Findings of the secondary analysis were, of those who responded, 7.34% (n = 49, CI = 4.27-10.41) were at risk for suicide in Monroe County, FL. Notably, persons at risk for suicide were more likely to be renters (63.5%, n = 19, CI = 43.53-80.52) than persons not at risk (36.9%, n = 86, CI = 28.53-43.29). 32% (n = 109, CI = 26.5-38.4) of the population did not respond to suicide risk questions. Sociodemographic characteristics of suicide risk question nonresponse were comparable to the characteristics of individuals identified as being at risk for suicide. Hispanics were more likely to not respond to suicide risk questions than any other race or ethnicity (AOR = 2.2, CI = 1.14-4.39). The concept analysis differentiated between suicide, lethality, suicidal behavior, and suicide lethality. Presence of a suicide plan or a written suicide note was not found to be associated with the majority of completed suicides with suicide lethality. Implications of this dissertation for suicide prevention clinical practice, research and policy include the need for practice to be guided by the clearer definition of the concept of suicide lethality. The findings of this dissertation support the development and testing of preventative nursing screening interventions to help reduce the incidence of suicide. Future studies investigating population-based suicide risk should also assess housing status as a possible indicator of SES. Advocating for more affordable housing could possibly help decrease suicide behavior in high risk areas.


BRFSS; Suicide Risk; Suicide Prevention; Suicide Lethality; Completed Suicide

Available for download on Friday, April 24, 2020