1-2 page paper on caring in nursing. I chose caring for suicidal patients and attached the article I used to start, as well as the draft of my paper I started.
Archives of Psychiatric Nursing 31 (2017) 31–37
Contents lists available at ScienceDirect
Archives of Psychiatric Nursing
journal homepage: www.elsevier.com/locate/apnu
Mental Health Nurses' Experiences of Caring for Suicidal Patients in
Psychiatric Wards: An Emotional Endeavor
Julia Hagen a,b,⁎, Birthe Loa Knizek a, Heidi Hjelmeland b a Department of Applied Social Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway b Department of Social Work and Health Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
a b s t r a c t
The purpose of the study is to investigate mental health nurses' experiences of recognizing and responding to sui- cidal behavior/self-harm and dealing with the emotional challenges in the care of potentially suicidal inpatients. Interview data of eight mental health nurses were analyzed by systematic text condensation. The participants re- ported alertness to patients' suicidal cues, relieving psychological pain and inspiring hope. Various emotions are evoked by suicidal behavior. Mental health nurses seem to regulate their emotions and emotional expressions, and balance involvement and distance to provide good care of patients and themselves. Mental health nurses have an important role and should receive sufficient formal support.
© 2016 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Caring for patients with suicidal behavior is one of the most chal- lenging tasks for mental health nurses in psychiatric wards, and preventing suicidal acts may be difficult. Suicide prevention in mental health services involves suicide risk assessments that should not only be based on standard risk factors (Cassells, Paterson, Dowding, & Morrison, 2005; Paterson et al., 2008), but warning signs; ‘what is my patient doing (observable signs) or saying (expressed symptoms) that elevates his or her risk to die by suicide …’(Rudd, 2008, p. 88). The latter requires more involvement with the patient, exploring aspects relevant to the individual's suicide risk at that particular moment. In Norway, it is the therapist (psychiatrist/psychologist) who has the main responsibil- ity for performing and documenting assessments of inpatients' suicide risk (National guidelines for Prevention of Suicide in Mental Health Care, Norwegian Directorate of Health and Social Affairs, 2008). Howev- er, nurses provide most of the direct care of the patients and have the opportunity to identify warning signs of suicide and prevent suicidal be- havior (Bolster, Holliday, Oneal, & Shaw, 2015; Cutcliffe & Barker, 2002). According to Sun, Long, Boore, and Tsao (2005); Sun, Long, Boore, and Tsao (2006), nurses assessed patients' suicide risk through vigilant ob- servation, recognizing warning signs, using their interviewing skills and gathering information about cues to suicide. Assessing the patients continuously throughout the hospital stay seems important to capture the patient's changing state of mind (Aflague & Ferszt, 2010; Sun et al., 2005). However, some nurses are not properly educated and trained in suicide assessments (Bolster et al., 2015).
⁎ Corresponding Author: Julia Hagen, Rn, MHSc, PhD candidate in Health Science, De- partment of Applied Social Science, Norwegian University of Science and Technology (NTNU), 7491, Trondheim, Norway.
E-mail address: [email protected] (J. Hagen).
http://dx.doi.org/10.1016/j.apnu.2016.07.018 0883-9417© 2016 The Authors. Published by Elsevier Inc. This is an open access article under
The recognition of patients' suicide risk should lead to meaningful in- terventions (Cutcliffe & Stevenson, 2007, 2008a). The literature has point- ed to the importance of nurses engaging in a close relationship with the suicidal patient (Cutcliffe & Barker, 2002; Cutcliffe & Stevenson, 2008b; Gilje & Talseth, 2014), where the patient feels confirmed as a significant human being (Samuelsson, Wiklander, Åsberg, & Saveman, 2000; Talseth, Lindseth, Jacobsson, & Norberg, 1999; Vatne & Nåden, 2014) and is moved from a ‘death-oriented’ position to a ‘life-oriented’ position through the process of ‘re-connecting with humanity’ (Cutcliffe & Stevenson, 2007; Cutcliffe, Stevenson, Jackson, & Smith, 2006). However, patients have reported that experiences of not being sufficiently cared for (e.g. lack of confirmation, not being seen) have led to increased suicidal behavior while hospitalized (Talseth et al., 1999; Samuelsson et al., 2000).
Caring for suicidal patients is emotionally demanding (Cutcliffe & Barker, 2002; Cutcliffe & Stevenson, 2008a, 2008b), and suicide/suicide attempt/self-harm evoke painful feelings in the professionals (Bohan & Doyle et al., 2008; Castelli-Dransart et al., 2014; Joyce & Wallbridge, 2003; Séguin, Bordeleau, Drouin, Castelli-Dransart, & Giasson, 2014; Takahashi et al., 2011; Valente & Saunders, 2002; Wilstrand, Lindgren, Gilje, & Olofsson, 2007; Wurst et al., 2010). It has been suggested that nurses may distance themselves in meetings with suicidal patients to protect themselves from emotional discomfort (Carlén & Bengtsson, 2007; Talseth, Lindseth, Jacobsson, & Norberg, 1997). To cope with the challenges involved in the care of potentially suicidal patients the literature has emphasized sufficient education, training, supervision and support (Bohan & Doyle, 2008; Cutcliffe & Barker, 2002; Cutcliffe & Stevenson, 2008a; Gilje & Talseth, 2014; Takahashi et al., 2011; Talseth & Gilje, 2011; Wilstrand et al., 2007).
The aim of this study is to extend the existing literature and develop further the knowledge of how mental health nurses deal with the vari- ety of demands in the care of potentially suicidal patients in psychiatric
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
32 J. Hagen et al. / Archives of Psychiatric Nursing 31 (2017) 31–37
wards: How do they experience their skills with regard to recognizing and responding to suicidal behavior/self-harm among patients? How do they react to suicide and suicidal acts, and deal with the emotional challenges in the care of patients at risk of suicide? We use the term ‘sui- cidal patient’ with an awareness of the diversity and complexity of each person's suicidality and related problems.
MATERIALS AND METHODS
A purposive sample of eight mental health nurses (seven women, one man) aged 43–60 years working in two different hospitals and five different psychiatric wards in Norway participated in the study. The lack of gender difference largely reflects the situation in many psy- chiatric wards where the majority of mental health nurses are female. In addition, the units' management assisted in recruiting mental health nurses with experience of caring for suicidal patients in psychiatric wards, thus, clinical experience and willingness to participate was em- phasized regardless of gender. Thereby, the strategy for selecting the study subjects (purposefully) was influenced by homogenous sampling (in terms of professional background and clinical experience) and con- venience sampling (Patton, 1990). Their professional experience in psy- chiatric hospital ranged from 5–25 years. Seven nurses had 15 years of experience or more. Five of the nurses worked in an acute ward, one in an acute/crisis unit, one in a specialized ward and one worked in a re- habilitation ward.
The first author conducted the interviews. Seven of the nurses were interviewed at their respective working places (available office/meeting room in or outside the ward, one interview was conducted in a vacant patient room), and one of the participants was interviewed in a meeting room not located at the hospital. The interviews lasted from 48 minutes to 1 hour and 22 minutes. A semi-structured interview guide was used as a tool to obtain detailed descriptions of the nurses' caring experi- ences, including both good interactions with suicidal patients and chal- lenging experiences involving suicidal acts and suicide among patients. Main questions were: How do you experience working in a psychiatric ward? How do you experience meetings with suicidal patients? Can you describe a situation where you did/did not achieve a good relation- ship with a suicidal patient? Have you experienced that a patient have attempted suicide or taken his/her life? Can you describe your experi- ences with regard to that? All interviews were recorded and transcribed verbatim.
The data were analyzed by means of systematic text condensation (Malterud, 2011, 2012). The approach is inspired by Giorgi's phenome- nological analysis (Giorgi, 1985, cited in Malterud, 2011), and is de- scribed as a four-step procedure: (1) reading the transcripts to get an
Table 1 Examples of the Analytic Approach.
Excerpt of meaning unit Codes
Experience over many years, signals emitted that are a bit difficult to explain. But – but many patients we know (…) Signals that the other sends out that – that tells me a little bit about plans.. of self-harm that could lead to something more, that is.
Experience, signals of self-harm
…if there are too many admissions in here, then I am little afraid that we quickly may become both mom, sister, aunt, friend, etc. And what is then left of the motivation to go out in the world and find it, I think. So to be warm and empathetic on the one hand, but do not become everything for the patient on the other hand, that is an art as I see it.
Many admissions, d sister, friend warm not become everyth
overall impression and identifying preliminary themes (e.g. emotional burdens, colleague support); (2) extracting meaning units from the transcripts and sorting them into codes (e.g. being calm and steady), and code groups (e.g. managing emotion); (3) condensing the meaning within each code group; (4) summarizing the content into meaningful descriptions (Malterud, 2011, 2012). Two simplified examples of the analytic approach are illustrated in Table 1. All authors read the tran- scripts, and the first author conducted all steps of the analysis and discussed the interpretations with the second and third author during the process. The first author's background as mental health nurse with knowledge and experience within the field has influenced the process of collecting and interpreting data. The final descriptions were devel- oped and refined over time, and transcripts were read repeatedly during this hermeneutical process (moving back and forth between data and the literature) to ensure that the constructed descriptions were ground- ed in the empirical data (Malterud, 2011, 2012).
The Regional Committee for Medical and Health Research Ethics ap- proved the study. The mental health nurses signed an informed consent to participate. They were informed that they at any time could with- draw from the study (until publication) without giving any reason. Data were treated confidentially and information about the nurses and their interactions with suicidal patients is presented in such a way that they are not identifiable. All nurses and described patients are re- ferred to as “she” to protect their anonymity.
We found that the mental health nurses' experiences involve being alert to suicidal cues, relieving the patients' psychological pain and in- spiring hope. Further, experiences of suicide and suicidal acts evoke var- ious emotions. The nurses seem to regulate their emotions and emotional expressions and balance their emotional involvement and professional distance in the relationships with the patients in order to provide good care of the patients as well as themselves. These findings are elaborated below.
Alertness to Suicidal Cues
Seven of the mental health nurses' accounts indicate that they are sen- sitive and alert to the patients' emotional state and pick up suicidal cues or warning signs, which they act upon to prevent self-harm/suicidal acts. Three of the nurses use the phrase “gut feeling” to describe their feelings or sensations of the patient's mental state and the situation. It appears that they very much rely on intuitive knowledge, although they acknowl- edge that they sometimes may be wrong. Several participants believe that they have saved patients by acting at the right time.
We have saved many people, we managed to, so in the moment we should be there, we were there. We managed to save them. (…)… gut-feeling is very important then. And then, so it has happened that,
Code group ⁎condensed unit Description
emitted, capture signals Responding to suicidality ⁎ The informant seems sensitive, and picks up signs of self-harm/suicidal acts
Alertness to suicidal cues
anger of becoming mom, and empathetic, but do ing, an art
Managing emotion ⁎It seems important to be close, but prevent being too emotional close to the patients
Balancing emotional involvement and professional distance
33J. Hagen et al. / Archives of Psychiatric Nursing 31 (2017) 31–37
you have supervision of a patient every 15 minutes, but that does not mean that 15 minutes is 15 minutes, you can die within 15 minutes, right? (…) But you check on the patient once, and then your gut- feeling tells you that, oh, no, you [the patient] are lying calm and smiling. But, then the gut-feeling tells you to come back in one minute and sur- prise her.(…) And then, then you're right, that has happened, that I have experienced. You come, you go out and close the door and then look back, oh, what is she doing (…) is about to strangle herself or hang herself “.
The nurse seemed to respond to subtle non-verbal signs communi- cated by the patient. Several statements from the participants show that, in addition to the assessments and decisions made by the thera- pist/psychiatrist, they make their own judgment regarding suicide risk and implementation of safety measures based on their intuitive sense of the patient's mental state. Although the nurses talk about differences between caring for patients who self-harm and patients who attempt suicide, or patients who are ‘acute’ or ‘chronic’1 suicidal, they seem to think that the outcome (suicide) can be the same regardless if they do not act to rescue them in time.
“It is like balancing just barely. She [the patient] knows exactly the mg of paracetamol, for example, (…) And knows exactly when to make themselves known, or make sure to be found. It can be strangulation just enough to allow passage of some oxygen and a little circulation. (…) If we then do not find the person in time, the person will then die, so in that respect he is suicidal, right. So that is – that is another group of pa- tients really, it is. But the outcome can be the same“.
The statement suggests that it might not always be useful to distin- guish between suicide attempts and self-harm, (or ‘acute’ vs. ‘chronic’ suicidal), and to claim that only the former action is suicidal and the lat- ter is not. The nurses' alertness to suicidal cues seems to relate to all pa- tients engaging in suicidal acts.
One important challenge is that staff members lacking competence and/or clinical experience (e.g. temporary staff working in the summer and occasionally in the afternoons/weekends), seem to lack the skill to pick up suicidal cues or other signs indicating exacerbation in patients' mental state. “…if the patient does not take his own life, we have – we do have more self-harm when we have a lot of temporary staff in the ward in the summer. We do. We also have more like acting out, we notice that too. (…) they do not pick up the signals before the turmoil starts, right”. It appears to be difficult to provide good care if several of the staff members on duty lack competence, which may lead to failure in the follow-up of suicidal patients and/or increased self-destructive behavior.
Relieving Psychological Pain and Inspiring Hope
Several of the mental health nurses' descriptions of interactions with suicidal patients were about relieving their psychological pain and in- spiring hope. This process seems to involve gaining a joint understand- ing of the patient's life situation and suicidality, and then, helping the patient to be more oriented toward life and the future. Broadening the patient's perspectives and making the patient more receptive to positive input seem to be part of this process.
“…to try to open some hatches to let in some light, so to speak, I am very engaged in then, when it comes to conversations. Because, if everything is revolving around the sad, terrible, and…then Ithink wearelike taping black bags on the windows, making it even more black. I am a little concerned about trying to open some hatches and then getting in some more light“.
1 ‘Chronic’ suicidal is a term we do not usually use because we think it is stigmatizing and disempowering. However, it is the term used by the participants and it is frequently used in clinical practice.
This metaphorical description illustrates the importance of drawing attention to life and possibilities for change and improvement in the sit- uation, and not only focusing on the suicidality and related problems, al- though exploring the person's psychological pain and the background of the suicidality seems to be part of the process. However, although all participants are specialized in mental health nursing, one of them stated that she does not feel educated or confident enough to talk with pa- tients about suicide, and another informant stated that there should be much more focus on caring for suicidal persons in the education.
Emotions Evoked by Suicide and Suicidal Acts
All nurses expressed sadness related to patient suicides, and one of them said that suicide was the worst part of the job. Several of the par- ticipants' statements express guilt after suicide/suicidal acts. “And the bad thing is when they actually do it [suicide]. You feel a bit like guilty, and guilty conscience and … That you actually didn't see the person enough, or did enough or…“. The suicide becomes a sign of failure, and the informant feels she should have been more attentive. Another infor- mant felt she had failed in her attempt to establish a good relationship with a patient who tried to kill herself while they were together. In ad- dition, after a patient suicide one of the nurses had wondered whether some of the patient's activities that day (e.g. doing the laundry) could be a sign of her suicide, as if she could have prevented the suicide if she had only been more alert. It appears like a patient's suicide or sui- cide attempt may lead to self-judging among the nurses, who may not feel good or competent enough. This reflects a strong sense of responsi- bility for the patient's safety.
However, being put in a helpless position seemed to reduce the sense of responsibility. One of the nurses was contacted by a patient (on leave) who was about to attempt suicide. There was nothing the nurse could do, and she felt helpless, yet angry to be put in this position. “So I felt a little discomfort, and then I felt that I was a little angry – I became very annoyed and angry, because she was putting me in the situation where I felt that discomfort». The nurse's growing discomfort and anger in the statement may reflect the intensity in her experience as she recalls and describes the situation. It seems as though the nurse feels that the patient put her life in her hands, but the nurse will not accept the re- sponsibility, yet she is left with uncertainty, anxiety and fear. Three other participants also shared experiences of feeling anger and frustra- tion, particularly when a patient repeatedly engaged in suicidal acts.
One of the nurses revealed that although she felt sadness after a patient had taken her own life, she also felt relief. “But when she takes her life then… It is sad, but at the same time also sort of a – it is bad to say it, but…a little relief, because you may have been so tired and so angry at times too, right“. She seemed slightly ashamed, yet exhausted of experiencing emotional turmoil over time. The partici- pant had shared experiences about collaborative problems in the staff group. Thus, the strain seemed not only evoked by the patient's emotional pain, but by the challenging working conditions. The sui- cide put an end to some of her burdens, and the feeling of sadness was accompanied with relief.
Regulation of Emotions and Emotional Expressions
The mental health nurses seem to try to control their emotions and be confident and calm, or at least to appear as such, in acute and difficult situations (e.g. facing distressed and suicidal patients, verbal/physical aggression). A calm and controlled appearance sometimes involved suppressing or concealing negative feelings such as fear, anger and sad- ness. Several participants used words such as “being steady”, and talked about how they had to withstand threats of suicide/self-harm, and en- dure the pain communicated by suicidal patients in order to provide good care.
34 J. Hagen et al. / Archives of Psychiatric Nursing 31 (2017) 31–37
“Yes, it is about being the calm and confident one. (…) We represent, or in my opinion should represent, when someone in a deep crisis is admit- ted, and then someone in the surroundings has to stay calm and steady. And appear like confident then. (…) You must be aware of it so that the patient's crisis does not color [affect] you so much that you are at a loss, but that you're able to be there and endure hearing that someone says ‘yes, I want to die. I don't want to live’“.
It seems as though it may be difficult to actually feel and be calm and confident. Further, it seems important not being too much affected by the patient's state of mind to prevent being overwhelmed or paralyzed by the patients' strong emotions. Another nurse thought that if she did not show any emotions and spoke with a calm and neutral voice, it could be easier for the patient to share personal experiences on sensitive issues.
Even though a calm appearance seems to be important, some of the participants' descriptions reveal that this is not always easy and may have some costs. One of the nurses, while striving to be calm and profes- sional to a patient, felt anger toward the person who for a long period repeatedly tried to strangle herself. “…you manage to be professional to the patient, but you struggle a lot, you know, you have to – as a professional on the outside, and then you're being torn inside“. The nurse experienced a mismatch between her feelings and her appearance, which seemed to be emotionally straining. Sharing thoughts and feelings with colleagues (e.g. in the staff room as challenges occur) is important and seems to be a way of regulating themselves emotionally, and thereby making it eas- ier to act in a caring and professional manner.
Although it seems common to suppress/conceal negative feelings, two participants describe situations where they expressed irritation or anger to a patient who had engaged in suicidal acts. One of the nurses thought she perhaps was unprofessional in the situation, whereas the other nurse (who knew the patient well) seemed to express her anger because she wanted to contribute to change in the patient's self- destructive behavior.
Balancing Emotional Involvement and Professional Distance
To balance emotional involvement and professional distance seems to involve being empathic and caring, yet maintaining a distance to the patient. Several participants related their care to motherhood; one felt that it could help her to achieve a connection with suicidal patients who were at the same age as her children, whereas another nurse men- tioned it with regard to avoiding a too close connection with the patient. “… I am little afraid that we quickly may become both mom, sister, aunt, friend, etc.“. The nurse seems to add other intimate family/friend rela- tionships to emphasize the importance of not establishing a too strong emotional bond to the patient, and thus attempting to avoid becoming a substitute for significant others and increase the patient's dependency.
Another nurse was challenged by what she perceived as too intimate care provided by some of her colleagues to a traumatized and (occasion- ally) suicidal patient. “But we are not mother – if they miss a mother in their lives, there are many who do – a father too perhaps, but missing a mother, no one can replace that“. The participant seems to assume that some patients may seek a mother figure in the nurse, and that some nurses respond to this need. And although the nurse appears to think it is important not to be emotionally involved like a mother, she refers to some of the patients as children in need of clear boundaries.
Self-delineation seems to be important in order to balance emotional involvement and professional distance, which appears to involve reflecting upon challenging interactions (e.g. with colleagues or alone in the car on the way home), processing the experiences and attempting to separate their own feelings from the patients'. “One has to have oneself – one must be…clarified oneself, one must know what – what feelings are mine and what feelings are the patient's now, in this. And what am I going to carry now for the patient, and what is it that the patient should get back to carry himself“. Separating their feelings from the patients'
feelings seems to help the nurses to clarify for themselves what their re- sponsibilities are.
A more practical way of self-delineation is reducing the emotional involvement by sharing the burden with other staff members and/or taking a break. “…if one has been in that kind of pressure with several pa- tients [engaging in suicidal acts/self-harm] over several weeks, and that- that one somehow feels that now I need a break, if it could be possible that I work with another kind of issue now, then I prefer that for a few days to kind of collect myself a little again“. The statement reflects the emotional intensity and strain in caring for patients who engage in suicidal acts and the need to occasionally distance oneself and recover.
Several participants state that they receive debriefing or supportive conversations from their managers after challenging situations such as a patient suicide. Only one nurse mentioned that clinical supervision (in groups) is offered and that she recently has considered attending.
The findings indicate that mental health nurses experience having specialized skills in detecting and responding to suicidality among psy- chiatric inpatients. In addition, caring for potentially suicidal patients in- volves managing emotions, emotional expressions and balancing emotional involvement and professional distance, which may be a way of providing good care of patients and oneself.
Mental health nurses' ability to pick up suicidal cues seems to be an emotional and experience-based competence that may prevent self- harm and suicidal acts among patients. Our finding is similar to what was found in Tofthagen et al.' study (2014), where mental health nurses were able to observe signs of self-harm and sometimes experienced a sense of intuition regarding a patient's impending self-harm. Further- more, our findings are in keeping with Sun et al. (2005, 2006) who found that nurses observed overt and covert suicidal cues (verbal and behavioral) displayed by the patients. Observing non-verbal communi- cation is important (McLaughlin, 1999; Vråle & Steen, 2005), and nurses continue to assess suicide risk through observations and conversations with the patients (Larsson, Nilsson, Runeson, & Gustafsson, 2007), and implement safety measures if necessary (Vråle & Steen, 2005). Accord- ing to Benner, Tanner, and Chesla (2009), ‘expert nurses’ are able to read a patient/situation and respond instantaneously, claiming that there are intuitive links between noticing significant aspects and ways of responding to them. It has been suggested that intuition is involved in experienced mental health nurses' suicide assessments (Aflague & Ferszt, 2010), and that the intuition is linked to formal and tacit knowl- edge (Welsh & Lyons, 2001). Whereas Akerjordet and Severinsson (2004) stated that intuition is a part of mental health nurses' emotional intelligence, Klein (2003) described it as a skill built up through repeat- ed experiences in which one learns to recognize a set of cues. This may relate to semiotics (the study of signs), and …
NR103 TRANSITION TO THE NURSING PROFESSION
NR103 Transitions Paper 3.6.16 Revision 12-8-16 1
Transitions Paper Assignment Guidelines
PURPOSE The purpose of this assignment is to explore a critical concept in nursing. The student will be able
to demonstrate application of information literacy and ability to utilize resources (library, writing
center, SmartThinking, located within the Tutor Source tab under Course Home, APA resources,
Turnitin, and others) through literature search and writing the paper.
COURSE OUTCOMES This assignment enables the student to meet the following course outcomes.
CO 2: Identify characteristics of professional behavior including emotional intelligence,
Communication, and conflict resolution.
CO 3: Demonstrate information literacy and the ability to utilize resources.
DUE DATES Please refer to the Course Calendar for exact due dates of the draft for peer feedback exercise
and for the final paper.
REQUIREMENTS AND GUIDELINES Pick one of the following topics and find a scholarly nursing journal article (published within the last
five years) that discusses this nursing topic. The topics are
After you find a scholarly nursi
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