Elrefaay SH1, Shalaby MH2*
1Faculty of Nursing, School of Nursing, Tanta University, Egypt
2Professor of Psychiatric Mental Health Nursing, Tanta University, Egypt
*Corresponding author: Mervat Hosny Shalaby, Professor of Psychiatric Mental Health Nursing, Tanta University, Egypt. Tel: +201224402599; Email: Dr.firstname.lastname@example.org
Received Date: 17 August, 2019; Accepted Date: 21 August, 2019; Published Date: 28 August, 2019
Suicide behavior is usually divided into four categories of suicidal ideation, suicidal threats, suicidal attempt and a completed suicide. Suicide is a complex phenomenon and there is no single explanation for its complicated process. Some biological, psychological and sociological theories explain its causes. Nursing role in caring with suicidal attempt patient is vital and important role in nursing work. In health care setting nurses are in a unique position to prevent death by suicide. Nurse must be well trained in the assessment of suicidal potential, the factors that enhance suicide risk and know what to do when faced with a client who is actually suicide.
Suicide is derived from Latin word (suicidium, from sui caedere, "to kill oneself') is the act of intentionally causing one's own death. Suicide behavior is usually divided into four categories of suicidal ideation, suicidal threats, suicidal attempt and a completed suicide. suicidal ideation, refers to thought of engaging in behavior intended to end one's life . In addition, certain suicide attempt may be referred to as suicide gestures. The gestures are suicide attempt directed toward the goal of receiving attention rather than actual destruction of self and should be taken seriously [2-4].
Suicide and psychiatric disorders
The vast majority of people who die by suicide approximately 90%) suffer from mental disorders. Most of the studies show that psychiatric disorders like major depression, schizophrenia, mood disorder, substance abuse and other mental disorder are significantly associated with suicide .
Suicide and depression
Suicide is one of the outcomes of untreated depression. According to WHO statics in 2014, it is estimated globally that, from 15% to 20% of all patients diagnosed with major depression complete suicide. Additionally, patients with psychotic depression have a high risk for completing suicide [6,7]. Depressed patients suffering from hypochondrical delusion, delusion of self-guilt, or delusion of poverty have a five-fold higher suicide rate than those without such delusions .
Suicide and schizophrenia
World Health Organization study found the most common cause of death in those with schizophrenia was suicide. It is estimated in 2014 that 40% of schizophrenic report suicide thought, 20% to 40% make unsuccessful suicide attempts, and 10% to 15% end their lives by suicide. Suicide is more likely to occur earlier in the course of the illness . The occurrence of schizophrenia with depressive symptoms increases risk of suicide. In addition to severity of positive symptoms including command hallucinations (voices repeatedly ordering the individual to do something), paranoid delusions have been related to increased suicide rates and self-awareness of symptoms is related to increased suicide rate [10-11].
Suicide and bipolar disorder
Editorial (2012) mention variables associated with increased suicide in bipolar disorders. These variables included; early in the course of illness, within the first 5 years of the initial diagnosis, severity of the disorder, frequent hospitalizations and Inadequate treatment, whether due to non-adherence, unavailability, or lack of treatment response, inadequate levels of mood stabilizers are found in the majority of those who die by suicide [12-13].
Substance abuse and suicide
The majority of suicide occurs in persons with multiple substance abuse. National Institute of Mental Health stated that, mixed substance abuse was identified in 67% of complete suicide in youths and young adults. Persons who abuse substances often have several other risk factors for suicide. In addition to being depressed, they are also likely to have social and financial problems. In addition, people who are intoxicated may make suicide attempts impulsively and aggressively that they would not make if they were not intoxicated .
Suicide and personality disorders
Suicide risk is strongly associated with and determined by personality disorders. Having a personality disorder may be a determinant of suicidal behavior in several ways; by predisposing to major mental disorders like depressive disorders or alcohol dependence; by leading to difficulties in relationships and social adjustment; by precipitating undesirable life events; by impairing the ability to cope with mental or physical disorders and by drawing the patients into conflicts with those around them .
Suicide and anxiety disorders
Patients with anxiety disorders are at high risk for suicidal ideation, regardless of whether the suicidal ideation is due to anxiety disorders itself or to co-occurring conditions. The most common anxiety disorder related most with suicide attempt is panic disorder .
Suicide and eating disorders
Suicide attempt and suicide behavior in eating disorders associated with emotional instability, interpersonal problems, impulsive behaviors including drug abuse, cognitive rigidity and perfectionism, body dissatisfaction, low self-esteem and feeling of chronic emptiness . The purpose seems to be an escape and a cessation of an unbearable psychological pain, they may feel more depressed and/or increasingly overwhelmed which could lead to an increase in suicidal thinking .
Suicide prevention and nursing role toward suicidal patient
Nurses are 'front line' in the prevention of suicide, suicide prevention is influenced by nurses' ability to accurately screen, assess, and manage a patient's suicide risk. The goal of suicide prevention is to, treat and provide adequate nursing care to suicidal patients, decrease the likelihood of a suicide attempt in the high-risk patients and prevent complication of this behavior. The continuum of suicidal behavior ranges from ideas to gestures, to risky lifestyles, suicide plans, suicide attempts, and, finally, suicide completion. It occurs through hospitalization [18-20].
The decision to hospitalize patient depend on diagnosis, severity of mental disorders and suicidal ideation, presence of risk factor of suicide, the patient's and family coping abilities, the patient living situation, availability of social support. When patients are admitted to hospital, the primary goal is to prevent suicide by making the environment safe and by restricting the patient’s access to dangerous equipment and materials, which are readily available in hospital . Knowing where the patient is at all times is essential. It has been recommended that inpatient facilities should remove any structural obstacles that prevent nurses from observing patients and fixtures that can be used in hanging. Thus, hospitals should have an adequate number of nursing staff to carry out special observation of patients who had attempted suicide .
Patients receive therapeutic measures depend on patient underlying diagnosis. Patient receive antidepressant or antipsychotic medication as indicate according the underlying causes, individual therapy, group therapy, family therapy and patient receive the hospital's social support to provide sense of security. Electroconvulsive therapy may be necessary for some severely depressed patient who may require several treatment courses. Supporting psychotherapy also by psychiatrist shows concern and may alleviate some of patient intense suffering .
Nursing role in caring with suicidal attempt patient is vital and important role in nursing work. In health care setting nurses are in a unique position to prevent death by suicide . Nurse must be well trained in the assessment of suicidal potential, the factors that enhance suicide risk and know what to do when faced with a client who is actually suicide. The nurses must use their knowledge about epidemiology, causes and dynamics of suicidal behavior when they provide care to the suicidal attempt patients. This knowledge has an impact on the effectiveness of the nursing process .
Since work with suicidal clients can be both professionally and emotionally challenging. Nurses should pay attention to their own reactions to the patient, which may be conveyed verbally, or through non-verbal behavior. Without a conscious effort to communicate on the part of the nurse, the patient may be left feeling isolated because these reactions may interfere with their care of the suicidal client . In this context, informal and formal conversations with colleagues may provide important opportunities to obtain both advice and support. These conversations may help to reduce the isolation and stress that is often a component of work with suicidal patients [27-30].
The nurses must be aware of and monitor their own beliefs and values about suicide. It is crucial because these can impact one’s verbal and nonverbal communications with a patient in suicidal crisis. Usually, when patient’s life is depending on nurses, that make nurses uncomfortable with that amount of responsibility. Psychiatric nurses would have great difficulty travelling with patients who have depth of their emotional pain, if they have not first looked honestly at themselves [1,5,31].
Nursing intervention for hospitalized suicidal patient mandates stress response and symptoms reduction and enhancement of psychological and social resources. During early part of hospitalization, the most important ways of reducing stress is to help the client fell more secure and hopeful. Nursing role for suicidal patients focus on; assessment of suicide, maintaining safe environment, use effective communication skills, apply different therapeutic techniques to dealing with suicidal patients and help suicidal patients for rehabilitation .
Assessment of suicide
Pre-assessment competencies are followed by management competencies necessary for someone at risk for suicide. Horowitz (2013) found that lack of proper ‘assessment’ was the leading root cause for 80% of all hospital suicides. The most common method to assess suicide risk is simply to ask, but nurses must use therapeutic verbal and nonverbal communication when intervening with persons at risk for suicide .
The goal of the suicide risk assessment is to identify factors that may increase or decrease a patient’s level of suicide, and to develop a care plan that addresses patient safety and modifiable contributors to suicide risk. Assessment always include physical and mental status examination, identify risk factors, clues or cries for help, inquiring about suicide idea and plan, accurate lethality assessment and assess past suicide attempt .
A physical examination should be included, and could reveal signs and symptoms of substance abuse (impaired attention, irritability, euphoria, slurred speech, unsteady gait, flushed face, psychomotor agitation, needle tracks), previous suicide attempts (e.g. scars on wrists), and/or debilitating medical conditions, including chronic pain. A mental status examination should could reveal a disturbance in concentration, orientation, and memory, which may suggest a possible organic brain syndrome or a severe major depressive disorder . The examination may show impairment in the patient’s impulse control which increases the potential for suicide. A disturbance in thought processing, evidenced by delusions, and/or a disturbance in perception, evidenced by hallucinations that place the patient at greater risk for suicide .
The identification of risk factors for suicide in patient is important for nurse in planning the intensity and type of care the patient requires preventing a suicidal attempt. Nurse must identify high risk groups for suicide attempt, the level of suicidal intent at the time of self-harm, degree to which individuals wished to die  Inquiring about suicidal ideation is an essential component of the suicide assessment. Nursing staff may reluctant to ask direct questions about suicidal intent, fearing that it may introduce the idea to the patient. However, many patients are relieved when a direct enquiry is made. An understanding of the patient’s motivation and effective communication with the patient may not prevent further attempts in itself, but is likely to lead to a more thorough assessment and the patient is less likely to be alienated [38-40].
Nurses should start by asking whether the patient feels hopeless or has thoughts of death. They should then ask whether the patient has explicit thoughts of suicide. It is important for nurses to focus on the nature, frequency, depth, timing, and persistence of suicidal ideation . If suicidal ideation is present, the nurse will next probe for more detailed information about specific plans for suicide and any steps that have been taken toward performed those plans .
If the patient has developed a suicide plan, it is important to assess its lethality (the ability of suicidal plan to success in inducing death). There are three main elements to be considered when evaluating lethality of suicidal plan, the first step is specificity of details, the second is lethality of proposed method and the third is availability of means. The specificity of details involves at least several of the following elements: definite timing, definite place and actions made in furtherance of the plan (procuring a method, “scoping out” the setting, rehearsing the plan in any way). The more detailed and specific the suicide plan, the greater will be the level of suicide risk [43,44].
The lethality of method indicates the level of risk such as how quickly the person would die by that method. High risk method includes using of gun, jumping, hanging and carbon monoxide poisoning. Low risk method includes slashing one wrists, inhaling gas, ingesting of pills. When means are available, the situation are serious . Third component is the availability of means. When the proposed method is available, the situation is more serious. Thus, it is important to determine access to methods for any patient who is at risk for suicide or displays suicidal ideation .
The nurse must be alert and evaluate the suicidal clues to determine degree of suicide risk and can help to prevent a planned suicide attempt. These clues may be verbal, somatic, behavioral or psychodynamic. Verbal clues may involve covert statement as "It is of now, soon everything will be well" It’s okay now. Soon everything will be fine,” “Thing will never work out,” or overt statement as "I wish I were dead", “Life isn’t worth living anymore” .
Nurses should also be alert for nonverbal behavioral clues, including giving away possessions, or organizing their financial affairs. sudden change of behavior, isolated or withdrawal behavior, giving prized possession away. Somatic clues as physiological complaints, this can mask physiological pain and internalized stress such as unusual appetite, headache, muscle ache, sleep disturbances, weightless. Emotional clues can signal possible suicide ideation such as; irritability, hopelessness, helplessness, aggression or moodiness . A sudden brightening of mood with more energy may indicate that the patient has made the decision to suicide. Assessment of this change in mood and behavior is critical especially if the patient was recently prescribed an antidepressant medication [49-50].
It is important for the psychiatric nurses to inquire about past suicide attempts and self-destructive behaviors, including specific questioning about failed suicide attempts. For each attempt, the nurse should try to obtain details about the precipitants, timing, intent, and consequences as well as the attempt’s medical severity . The patient’s consumption of alcohol and drugs before the attempt should also be ascertained, since intoxication can facilitate impulsive suicide attempts but can also be a component of a more serious suicide plan .
Nurse must maintain safety precaution in psychiatric ward to protect suicidal patients from themselves. It is necessary for nurses to develop set of guidelines for observing and monitoring patient behavior which referred to suicidal precautions . The patients' own belongings being used in a suicide attempt and securing the patient’s belongings (since purses and backpacks may contain weapons, cigarette lighters or matches, and medications or other potentially toxic substances) should be carefully evaluated by creating and reviewing policies and procedures regarding the storage of clients’ belongings and restricting the patient’s access to dangerous equipment and materials, which are readily available in hospital . The nurse should keep patient safety during bathroom use, by observing patients before and after toilet use, remove any harmful objects from toilets like detergent, pesticides, chemical substances and make sure that toilet windows are closed .
Safeguards in other places outside patient room include: safety glass in all windows, remove sharp and hazardous objects, no window openings, stairwells secured and no access to the roof, elimination of articles or materials for hanging, including: shower curtain rods, clothes hooks (if used should not able to support the weight of a person), rails in bathrooms, exposed pipes, telephone cords. Monitoring items used within the daily functioning of the unit, in addition to protecting and storing these items appropriately when not in use. For example, a common linen hamper could be dismantled and used as a weapon [54-56].
The nurse must make close direct and indirect observation for suicidal patients at irregular interval. staff should be aware that individual with suicide risk are at particular risk for suicide at certain times in hospital ward, around change of shift time, over the week end period, during visit, at night or in early morning, also observe during medication administration and make sure that patient swallow it .
Patients should be monitored closely both before and during their transitions between care settings during emergency evaluations because of the potential for suicide. Moreover, patients should be located in a room close to the nurses’ station for closer monitoring with regular checking intervals. Thus, hospitals should have an adequate number of nursing staff to carry out special observation of patients who had attempted suicide [29,30].
Beginning with the initial encounter with suicidal patient, the psychiatric nurses should attempt to build trust, establish mutual respect, and develop a therapeutic relationship with the patient. Suicidal ideation and behaviors can be explored and addressed within the context of this cooperative nurse -patient relationship, with the ultimate goal of reducing suicide risk .
Effective communication skills are the axiom of the nurse–patient relationship, the manner in which psychiatric nurses communicate with suicidal patients could help patients to make sense of their lived experiences, perhaps resolve their difficulties, and hence preventing future suicidal behavior. The therapeutic alliance can be enhanced by paying careful attention to the concerns of patients and their family members as well as their wishes for treatment .
Psychiatric nurses must also be competent in the non-verbal skills of communication. In addition, they must be skilled in reading between the lines of the patients’ verbal communication. Other non-verbal qualities and skills inherent in non-verbal, psychotherapeutic communication include having the ability to demonstrate empathy with patients. characterized by a cognitive ability to perceive, interpret and reason as well as the verbal ability to communicate understanding of the other person’s feelings and their attached meanings. Hence, demonstrating empathy requires nurses to focus on and validate the patients’ feelings .
It is important for psychiatric nurses to listen actively through the lens of non-judgmental attitudes and respond compassionately. Sometimes, nonverbal physical contact is effective. A gentle touch on the forearm may have an important calming effect and signify human concern. The focus must be on the person’s feelings, and sufficient time allocated for the person in crisis. Knowledge and application of verbal and nonverbal therapeutic communication techniques is crucial .
Different therapeutic techniques in dealing with suicidal patients
The nurse may intervene by treating the patients as someone deserving attention and concern to promote self -esteem. Positive attribute of patient should be recognized with genuine praise. An attempt to make up reasons to praise the patient is usually recognized as artificial and lower patient self -esteem. The message is that the patient is so bad that one has to search for positive characteristics . When getting to know the patient, the nurse should be alert to strengths that can be built on to provide patient with positive experiences. It is important to reinforce reason for living and promote the patient's realistic expectations .
Nursing care should be directed toward helping patients become aware of their feeling label them and express them appropriately. Anger and anxiety is often difficult feeling for those patients. The angry patient must have helped to deal with anger constructively through learning and using anger and stress management skills .
Remain calm and neutral; treat patient’s suicide threats and gestures in matter-of-fact manner. Treat any physical injury without excessive emotion. Any self-destructive threat or gesture should be taken seriously and not ignored. Ask the patient to identify any disturbing thoughts or feelings that occurred just before the threat or action. Encourage him or her to put thoughts and feelings into words rather than acting them out impulsively and destructively. Encourage the patient to alert staff members if feeling out of control or when having thoughts of self-harm .
Nurse also try to elicit negative thoughts that influence how patient view the world, role playing may be use to assess different thoughts the patient experience throughout the interaction and help patient to pay attention relationship between these negative thoughts and their emotion [60-63]. Encourage patient to use positive self-talk, thought substitution techniques also helpful; by teaching patient to replace negative thoughts about the problem with positive thoughts and see the situation from different perspective’s not see negative part only. Nurses also try to help patient to explore reality of any situation without overestimation. Other techniques nurses can teach patient is thought stopping; by saying stop to negative thoughts .
It is important for nurses to inspiring hope for suicidal patients through; encourage patient to discuss recent events or stresses that have contributed to the hopeless view, offer alternative analysis viewing the event without arguing or minimizing patient’s concerns. Emphasize the patient’s strengths and problem-solving abilities and encourage him to describe past success [34-37]
Nurses play role in rehabilitation of suicidal
patients aimed at diminishing
the consequences of suicide attempts, reduce residual disability after an
illness and help patient to adapt with underlying stressors as well as referral
for other supportive services. It is important also to provide education to the
patient's family about treatment of underlying causes of suicide attempt ,reduce
stigma that a combined with suicidal attempt, identify the source of social
support and prepare the client environment at home must be safe as possible, the
family member must remove any object that the client may use it in committing
suicide and instruct family member to maintain medication regimen and close
observation for patient treated from major depressive disorder. Make sure that
patient and family have information on referrals for follow up counseling. They
should also have emergency numbers such as suicide hotlines [66,67].
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Citation: Elrefaay SH, Shalaby MH (2019) Suicide Among Psychiatric Patients and Nursing Role: A Literature Review. J Nurs Women’s Health 3: 156. DOI:10.29011/2577-1450.100156