By Joeri Vandewalle
It is clear that nurses play a crucial and advantaged role in suicide prevention and in promoting the recovery of patients who experience suicidal ideation. Nurses make up a large proportion of multidisciplinary teams and have 24-hour contact with patients. Moreover, nursing has always been thought to be synonymous with providing care, conveying support, and developing helpful nurse–patient relationships [1, 2]. To deepen the understanding of how nurses interact with patients who experience suicidal ideation, we conducted a qualitative study [3], interviewing 19 nurses on psychiatric wards across Flanders, the Dutch‐speaking part of Belgium.
‘Creating conditions for open and genuine communication’
Nurses often expressed that patients may be ambivalent to seek their help, may isolate themselves, and may feel that it is not safe, or that they are not ready to disclose their (suicidal) thoughts and feelings (e.g. as a result of feeling shame). Based on these experiences, nurses try to enable patients to communicate in an open and genuine way. They do this by presenting themselves as accessible and approachable, reaching out to patients, and encouraging patients to come and talk to them. While most nurses indicated that they should ‘dare to discuss’ suicidal ideation to support the patient’s communication, they also felt that they must not ‘force the conversation’. Simultaneously, nurses highlighted the need to develop a trusting relationship, respect the emotions of patients, and reassure patients that they can disclose suicidal ideation.
We must have a certain relationship to discuss suicidality. It is true that we ask about suicidal thoughts and plans at admission, but I wonder whether people are honest at that moment. I think it must be difficult to talk about this when you meet someone for the first time.
‘Developing an accurate and meaningful picture of patients’
By analysing the interviews, we found that when patients can communicate in an open and genuine way, nurses are able to get to know patients, can assess suicidal ideation and also identify risk and protective factors. The stories of nurses show that suicide risk assessment is a crucial nursing task [4]. Nurses use several strategies to characterise the presence and severity of suicidal ideation, including listening to and observing patients, asking patients about the presence of suicidal thoughts and plans, and checking with colleagues. They also highlighted their alertness for expressions that might be indicative of suicidal ideation (e.g., self‐harm and social isolation). Interestingly, nurses expressed that they work a lot with their intuitive senses, and that their own emotional responses, including “feeling anxious about the potential of a suicidal attempt”, provide cues to emerging suicidal ideation. However, such emotional responses may also make them more likely to assess suicide risk as higher than it actually is.
Sometimes as a nurse you can do too much out of the fearful feeling: ‘We cannot lose another patient!’ And then you act too restrictive.
‘Experiencing “counter‐reactions” when using clinical procedures’
Nurses clearly spend a lot of time to performing assessment and observation procedures. One of their key concerns was that the (overly formal) application of these clinical procedures can trigger agitation and undermine patients’ sense of trust in the nurse. Moreover, in line with other studies, nurses perceived that patients sometimes conceal or deny suicidal ideation during assessments to avoid restrictive and controlling interventions [5, 6].
I sometimes hear people saying ‘we did not dare to talk openly about those thoughts because we were afraid of being locked up or being not allowed to leave on the weekend’.
To prevent this from happening, nurses stressed the importance of taking assessment as part of an open conversation, informing patients about procedures, and explaining them how procedures contribute to good and safe care. These insights clearly strengthen the need for nurses to involve in a multifaceted approach to suicide risk assessment; an approach that is underpinned by compassionate and considerate contact with patients rather than solely reliant on risk assessment tools that are limited in their ability to predict suicidal ideation [7].
‘Check and manage suicide risk or connect with the person?’
By analysing the interviews, we found that some nurses primarily use a ‘checking approach’ with a hyperfocus on gathering and documenting information to asses and manage potential suicide risk. They maintain this focus by posing standardized questions, listening selectively, and by ‘closely watching’ patients during observations. Other nurses moved beyond such ‘checking approach’ and instead made efforts to acknowledge and connect with patients as a person, even during standardized procedures. These nurses were more concerned with addressing the needs of patients and trying to enter their life world. They highlighted the need to express genuine interest and concern, listen attentively and non‐judgementally to the patient’s story, explore ‘sparkles of hope’, and try to understand the meanings of suicidal expressions. These ways of making contact enable them to establish a connection with patients; a connection that supports patients in discussing painful thoughts and feelings and provides them with a sense of security they can hold onto.
When I express my concern, I think patients feel the connection we have. That you bring in something personal rather than merely inventorying the things you see or hear. I believe then you really do make contact from human to human and that this can help them a step further in communicating their thoughts and feelings.
‘The vital importance of interpersonal nursing practice’
To conclude, nurses should (be supported to) represent the crux of their practice, which is providing care to patients, initiating human to human contact, and developing relationships with preventative and therapeutic potential [1,2,5,8]. Therefore, they must use and improve their interpersonal qualities and skills, especially those who -all too often- maintain distant relationships with patients and avoid to talk about suicide [4,8]. Indeed, patients repeatedly express their need to have the opportunity to connect and build trust with compassionate and competent professionals, have time and space to express suicidal thoughts and feelings, and gain the insight to address personal difficulties. These needs are unlikely to be met by nurses who are afraid to talk about suicide or merely check and control suicide risk [3, 4, 5, 8].
If nurses want to honour their crucial and advantaged role in suicide prevention, then they must (start to) talk about suicide with patients, and acknowledge and connect with patients as a person.
References
- Peplau, H.E. (1997). Peplau’s theory of interpersonal relations. Nursing Science Quarterly, 10, 162–167. https://doi.org/10.1177/0894318497 01000407
- Watson, J. (1979). Nursing: The philosophy and science of caring. Boston: Little Brown.
- Vandewalle, J., Beeckman, D., Van Hecke, A., Debyser, B., Deproost, E., & Verhaeghe, S. (2019). Contact and communication with patients experiencing suicidal ideation: a qualitative study of nurses’ perspectives. Journal of Advanced Nursing. https://doi.org/10.1111/jan.14113
- Bolster, C., Holliday, C., Oneal, G., & Shaw, M. (2015). Suicide assessment and nurses: What does the evidence show? The Online Journal of Issues in Nursing, 20(2). https://doi.org/10.3912/OJIN.Vol20No01M an02
- Lees, D., Procter, N., & Fassett, D. (2014). Therapeutic engagement between consumers in suicidal crisis and mental health nurses. International Journal of Mental Health Nursing, 23, 306–315. https:// doi.org/10.1111/inm.12061
- Richards, J. E., Whiteside, U., Ludman, E. J., Pabiniak, C., Kirlin, B., Hidalgo, R., & Simon, G. (2019). Understanding why patients may not report suicidal ideation at a health care visit prior to a suicide attempt: A qualitative study. Psychiatric Services, 70, 40-45. https:// doi.org/10.1176/appi.ps.201800342
- Bolton, J. M., Gunnell, D., & Turecki, G. (2015). Suicide risk assessment and intervention in people with mental illness. British Medical Journal, 351, h4978. https://doi.org/10.1136/bmj.h4978
- Cutcliffe, J. R., Stevenson, C., Jackson, S., & Smith, P. (2006). A modified grounded theory study of how psychiatric nurses work with suicidal people. International Journal of Nursing Studies, 43, 791–802. https:// doi.org/10.1016/j.ijnurstu.2005.09.001
Joeri Vandewalle (@Joeri_Vdwalle) is a PhD student at the Research Foundation-Flanders (FWO) and the University Centre for Nursing and Midwifery of Ghent University, Belgium (Joeri.Vandewalle@UGent.be).
*Featuring photo by Marcelo Leal on Unsplash
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