Caring for Suicidal Patients; Mental Health Nurses

Caring for Suicidal Patients; Mental Health Nurses

NR103 TRANSITION TO THE NURSING PROFESSION

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.

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CO 2: Identify characteristics of professional behavior including emotional intelligence,

Communication, and conflict resolution. Caring for Suicidal Patients; Mental Health Nurses

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

 safety;

 delegation;

 prioritization; and

 caring.

After you find a scholarly nursing journal article using the Chamberlain library resources, you will

complete a one-two page summary and reflection on the article. The paper should be completed in

APA format and include the following. Caring for Suicidal Patients; Mental Health Nurses

 A cover page (not included in the page number requirement)

 A reference page (not included in the page number requirement)

 One direct quote from one of your references, appropriately cited in the body of your paper

 One indirect quote (or paraphrased reference) appropriately cited in the body of your paper

 Citations and references in APA format

NR103 TRANSITION TO THE NURSING PROFESSION

NR103 Transitions Paper 3.6.16 Revision 12-8-16 2 Caring for Suicidal Patients; Mental Health Nurses

TOTAL POINTS: 150 POINTS

Best Practices in Preparing the Paper Utilize resources available to you to assist with finding appropriate literature and articles from professional nursing journals relevant to your topic and preparing for and writing the paper (e.g., SmartThinking, located within the Tutor Source tab under Course Home, writing center, Turnitin, APA manual, and online resources). The grading rubric will help you understand how your faculty will be evaluating your paper. Use it as a checklist to make sure that you have included all the important elements. Caring for Suicidal Patients; Mental Health Nurses

Grading Criteria for Transitions Paper Assignment

Category Points % Description: See Rubric for Details

Introduction 20 13%

 Clearly states the purpose or focus of paper with conceptual key points to be discussed and engages the interest of the reader

Body of Paper 60 40%

 Complete, well-developed discussion of key points

 Logical development of ideas with information clear and accurate, supported by examples from personal and/or professional experiences

 Perception: Student provides own perspectives on the topic; reflective and insightful

Conclusion 30 20% Caring for Suicidal Patients; Mental Health Nurses

 Summarizes ideas presented in the body of paper in a clear and concise manner

 Provides reader with a thought, idea, or key message

NR103 TRANSITION TO THE NURSING PROFESSION

NR103 Transitions Paper 3.6.16 Revision 12-8-16 3

Writing Style, APA

Format, and

References

40 27% Caring for Suicidal Patients; Mental Health Nurses

 Proper grammar and mechanics

 Correct spelling

 APA Format: Margins, font style and size, spacing, citations, title page, and reference page

 One direct quote with in-text citation

 One indirect quote with in-text citation

 References from nursing journals (published within the last five years)

TOTAL 150 100 A quality assignment will meet or exceed all

of the above requirements.

NR103 TRANSITION TO THE NURSING PROFESSION

NR103 Transitions Paper 3.6.16 Revision 12-8-16 4 Caring for Suicidal Patients; Mental Health Nurses

Grading Rubric

Assignment

Criteria Outstanding or Highest

Level of Performance

A (92–100%)

Very Good or High Level of

Performance

B (84–91%)

Competent or Satisfactory

Level of Performance

C (76–83%) Caring for Suicidal Patients; Mental Health Nurses

Poor, Failing or

Unsatisfactory Level of

Performance

F (0–75%)

Introduction

20

 Introduction of the paper is clearly presented.

 Introduction clearly establishes the purpose of the paper and key points to be discussed.

 The introduction immediately captures the reader’s interest.

19–20 points

 Introduction of the paper is clearly presented.

 Introduction presents the general purpose of the paper and points to be discussed.

 Introduction is able to gain general interest of the reader. Caring for Suicidal Patients; Mental Health Nurses

17–18 points

 Introduction of the paper is present.

 Introduction presents the general purpose of the paper, but key points are not clearly presented.

 Introduction is able to gain general interest of the reader.

16 points

 Introduction of the paper is not clearly presented, irrelevant to the topic, or is absent.

 Introduction does not present the purpose of the paper or key points to be discussed.

 Introduction does not capture the reader’s interest. Caring for Suicidal Patients; Mental Health Nurses

0–15 points

Body of Paper

60

 Complete, well-developed discussion of key points strongly supports the purpose or main idea of the paper.

 There is logical development of ideas with clear and accurate information

 Ideas and statements are supported by three or more examples from personal and/or professional experiences.

 Perception: Student provides own perspectives on the topic: reflective, insightful, and original.

56–60 points

 Complete discussion of key points generally supports the purpose or main idea of the paper.

 There is logical development of ideas with clear and accurate information. Caring for Suicidal Patients; Mental Health Nurses

 Ideas and statements are supported by two examples from personal and/or professional experiences.

 Perception: Student provides own perspectives on the topic: reflective and insightful.

51–55 points

 General discussion of key points somewhat supports the purpose or main idea of the paper.

 There is some logical development of ideas, somewhat clear information; some information is inaccurate.

 Ideas and statements are supported by one example from personal and/or professional experiences.

 Perception: Student generally provides own perspectives on the topic; somewhat reflective and insightful.

46–50 points

 There is vague or minimal discussion of key points, which does not support the purpose or main idea of the paper.

 There is poor development of ideas; information is unclear and/or inaccurate. Caring for Suicidal Patients; Mental Health Nurses

 Ideas or statements are not supported by examples from personal and/or professional experiences.

 Perception: Student does not provide own perspectives on the topic: lacks reflection and insight.

0–45 points

NR103 TRANSITION TO THE NURSING PROFESSION

NR103 Transitions Paper 3.6.16 Revision 12-8-16 5

Conclusion

30

 Conclusion of the paper is clearly and concisely presented.

 Conclusion clearly establishes key points discussed in the paper.

 The conclusion leaves a strong impression on the reader (important thought, idea, or key message).

28–30 points

 Conclusion of the paper is clearly and concisely presented. Caring for Suicidal Patients; Mental Health Nurses

 Conclusion generally states key points discussed in the paper.

 The conclusion leaves a general impression on the reader (important thought, idea, or key message).

25–27 points

 Conclusion of the paper is present.

 Conclusion vaguely states key points discussed in the paper.

 The conclusion leaves a vague impression on the reader (important thought, idea, or key message).

23–24 points

 Conclusion of the paper is not clearly presented. Caring for Suicidal Patients; Mental Health Nurses

 Conclusion does not present key points discussed in the paper.

 The conclusion does not leave an impression on the reader (important thought, idea, or key message).

0–22 points

NR103 TRANSITION TO THE NURSING PROFESSION

NR103 Transitions Paper 3.6.16 Revision 12-8-16 6

Writing Style,

APA Format,

and References

40 Caring for Suicidal Patients; Mental Health Nurses

Writing Style

 Paper has correct use of Standard English grammar, paragraph, and sentence structure.

 There are no spelling or typographical errors.

 Paper is clearly organized around required components.

 Information flows in a logical sequence that is easy for the audience to follow.

APA Format and References

 There is correct and appropriate use of margins, spacing, font, and headers.

 Document setup includes title and reference pages in correct APA format. Caring for Suicidal Patients; Mental Health Nurses

 Citation of sources included in the body of the paper uses correct APA format for direct and indirect quotes.

 Sources are cited correctly on the Reference page. All elements of each reference are included in the correct order.

 All information taken from the source, even if summarized, must be cited and listed on the Reference page.

 All sources used are nursing journals published within the last five years.

37–40 points

Writing Style

 There are one to three minor errors in use of Standard English grammar, paragraph, and sentence structure.

 There are one to two spelling or typographical errors. Caring for Suicidal Patients; Mental Health Nurses

 Paper is organized and generally easy to read and follow.

APA Format and References

 There is incorrect format for any one of the items: margins, spacing, font, and headers.

 Document setup includes title and reference pages, with one to two errors in APA format.

 Citation of sources is included in the body of the paper for direct and indirect quotes, with one to two errors in APA format.

 Sources are cited on the Reference page. There are one to two errors in elements of each reference.

 All information taken from source, even if summarized, must be cited and listed on the Reference page.

 All sources used are nursing journals published within the last five years. Caring for Suicidal Patients; Mental Health Nurses

34–36 points

Writing Style

 There is one major error or there are more than four minor errors in use of Standard English grammar, paragraph, and sentence structure.

 There are three to four spelling or typographical errors.

 Paper is organized and generally easy to read and follow. Caring for Suicidal Patients; Mental Health Nurses

APA Format and References

 Incorrect format is used for any two of the items: margins, spacing, font, and headers.

 Document setup includes title and reference pages, with three errors in APA format.

 Citation of sources is included in the body of the paper for direct and indirect quotes, with three errors in APA format.

 Sources are cited on the Reference page. There are three errors in elements of each reference.

 Some information taken from sources (even if summarized) is not cited and/or listed on the Reference page.

 Not all sources used are from nursing journals published within the last five years. Caring for Suicidal Patients; Mental Health Nurses

31–33 points

Writing Style

 Language needs development.

 There are more than four spelling and/or grammar errors.

 Paper has poorly organized thoughts and concepts; it is difficult to follow logic.

APA Format and References

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 Incorrect format is used for three or more of the items: margins, spacing, font, and headers. Caring for Suicidal Patients; Mental Health Nurses

 Document setup includes title and reference pages, with four or more errors in APA format.

 Citation of sources is included in the body of the paper for direct and indirect quotes, with four or more errors in APA format.

 Sources are cited on the Reference page. There are four or more errors in elements of each reference.

 Some information taken from sources (even if summarized) is not cited and/or listed on the Reference page.

 Not all sources used are from nursing journals published within the last five years. Caring for Suicidal Patients; Mental Health Nurses

0–30 points

NR103 TRANSITION TO THE NURSING PROFESSION

NR103 Transitions Paper 3.6.16 Revision 12-8-16 7

FACULTY FEEDBACK FORM

Category Points Comments

Introduction 20

Body of Paper 60

Conclusion 30

Writing Style, APA Format,

and References 40 Caring for Suicidal Patients; Mental Health Nurses

TOTAL 150

  • Purpose
  • Course Outcomes
  • Requirements and Guidelines
  • Faculty Feedback form

Caring for Suicidal Patients

Introduction

There are many factors that contribute into caring for suicidal patients. From controlling your emotions to inspiring hope to balancing emotional involvement and professional distance, it is said to be one of the most challenging jobs in nursing. In an article about mental health nurses it tells the about the challenging obstacles of taking care of mental health patients, and the stress of suicidal patients. Caring for Suicidal Patients; Mental Health Nurses

Not only do these nurses try to help the patient, they can also grow close to them. So if a patient does go through with it, there are many things the nurses feel. Sadness for the lost life of this patient they had to get to know to understand, as well as guilt. They wondered if they didn’t do enough, or give the patient enough attention.Caring for Suicidal Patients; Mental Health Nurses

Being close to the patient and knowing the signs is a really important aspect of caring for suicidal patients. You need to be closer to a patient, more observant to noticed expressed symptoms and see the observable signs. You also may help the patient get away from the need to inflict self-harm or even the want to end their own life. In doing so, mental health nurses have to be involved with the patients while at the same time not getting too involved. Caring for these patients can drain you mentally. They have to protect themselves from getting too close so if something were to happen it isn’t as hard on them.Caring for Suicidal Patients; Mental Health Nurses

While they do use their observations to help, they also use their “gut-feeling”. They sensed their patients mental state and acted when they had a bad feeling. “Several of the participants believe they have saved patients by acting at the right time.” Even when wrong about your feeling, I believe it is always better to be safe than sorry.

Showing their fear and uneasiness can also project onto a patient and instill them with the same emotions they’re showing. Being the calm and confident person in the presence of an unstable person can help them calm down. Caring for Suicidal Patients; Mental Health Nurses

Conclusion

Being a mental health nurse, you’re not only caring for this patient, you could also be preventing suicide. Experienced mental health nurses are trained, and learn from experience, to be there. Not only in a health care capacity, but in an emotionally supportive way as well. No matter the amount of training, there are somethings that can’t be taught. Caring for Suicidal Patients; Mental Health Nurses

References

Hagen, J., Knizek, B. L., & Hjelmeland, H. (2017). Mental Health Nurses Experiences of Caring for Suicidal Patients in Psychiatric Wards: An Emotional Endeavor. Archives of Psychiatric Nursing,31(1), 31-37. doi:10.1016/j.apnu.2016.07.018

Mental Health Nurses' Experiences of Caring for Suicidal Patients in

Psychiatric Wards: An Emotional EndeavorJulia 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 investigatemental 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. Interviewdata of eightmental health nurseswere 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.

Caring for Suicidal Patients; Mental Health Nurses

© 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).

Caring for Suicidal Patients; Mental Health Nurses

.

The latter requires more involvement with the patient, exploring aspects relevant to the individual's suicide risk at that particularmoment. InNorway, 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 identifywarning 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).

Caring for Suicidal Patients; Mental Health Nurses

⁎ 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: julia.hagen@ntnu.no (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 ismoved 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; Mental Health Nurses

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).

Caring for Suicidal Patients; Mental Health Nurses

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/).

Caring for Suicidal Patients; Mental Health Nurses

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?Weuse the term ‘sui- cidal patient’with an awareness of the diversity and complexity of each person's suicidality and related problems.

Caring for Suicidal Patients; Mental Health Nurses

MATERIALS AND METHODS

Participants

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- chiatricwardswhere themajority ofmental 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 specializedward and oneworked in a re- habilitation ward.

Caring for Suicidal Patients; Mental Health Nurses

Interview Procedure

The first author conducted the interviews. Seven of the nurses were interviewed at their respectiveworking places (available office/meeting room in or outside the ward, one interview was conducted in a vacant patient room), and one of the participantswas interviewed in ameeting room not located at the hospital. The interviews lasted from 48minutes 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- enceswith regard to that? All interviewswere recorded and transcribed verbatim.

Caring for Suicidal Patients; Mental Health Nurses

Data Analysis

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.

Caring for Suicidal Patients; Mental Health Nurses

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 themeaning within each code group; (4) summarizing the content into meaningful descriptions (Malterud, 2011, 2012).

Caring for Suicidal Patients; Mental Health Nurses

.

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 transcriptswere read repeatedly during this hermeneutical process (moving back and forth between data and the literature) to ensure that the constructed descriptionswere ground- ed in the empirical data (Malterud, 2011, 2012).

Caring for Suicidal Patients; Mental Health Nurses

Ethical Considerations

The Regional Committee for Medical and Health Research Ethics ap- proved the study. Themental 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.

Caring for Suicidal Patients; Mental Health Nurses

FINDINGS

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.

Caring for Suicidal Patients; Mental Health Nurses

Alertness to Suicidal Cues

Seven of themental health nurses' accounts indicate that they are sen- sitive andalert to the patients' emotional state andpick 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 verymuch rely on intuitive knowledge, although they acknowl- edge that they sometimesmaybewrong. 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

Caring for Suicidal Patients; Mental Health Nurses

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 “.

Caring for Suicidal Patients; Mental Health Nurses

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.

Caring for Suicidal Patients; Mental Health Nurses

“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, ormake 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“.

Caring for Suicidal Patients; Mental Health Nurses

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.

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Caring for Suicidal Patients; Mental Health Nurses

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.

Caring for Suicidal Patients; Mental Health Nurses

Relieving Psychological Pain and Inspiring Hope

Several of themental health nurses' descriptions of interactionswith 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 andmaking thepatientmore receptive to positive input seem to be part of this process.

Caring for Suicidal Patients; Mental Health Nurses

“…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 revolvingaround the sad, terrible, and…then I thinkweare like tapingblack 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.

Caring for Suicidal Patients; Mental Health Nurses

This metaphorical description illustrates the importance of drawing attention to life and possibilities for change and improvement in the sit- uation, andnot only focusing on the suicidality and related problems, al- though exploring the person's psychological pain and the backgroundof the suicidality seems to be part of the process. However, although all participants are specialized inmental 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.

Caring for Suicidal Patients; Mental Health Nurses

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 beenmore 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.

Caring for Suicidal Patients; Mental Health Nurses

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 shewas puttingme in the situationwhere 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.

Caring for Suicidal Patients; Mental Health Nurses

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.

Caring for Suicidal Patients; Mental Health Nurses

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

Caring for Suicidal Patients; Mental Health Nurses

“Yes, it is about being the calm and confident one. (…) We represent, or inmy 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. (…) Youmust be aware of it so that the patient's crisis does not color [affect] you somuch 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’“.

Caring for Suicidal Patients; Mental Health Nurses

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 thepatient to share personal experiences on sensitive issues.

Caring for Suicidal Patients; Mental Health Nurses

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 andprofes- 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 therebymaking it eas- ier to act in a caring and professional manner.

Caring for Suicidal Patients; Mental Health Nurses

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.

Caring for Suicidal Patients; Mental Health Nurses

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 whowere at the same age as her children, whereas another nursemen- tioned it with regard to avoiding a too close connectionwith 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.

Caring for Suicidal Patients; Mental Health Nurses

Another nursewas challenged bywhat she perceived as too intimate care provided by someof 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.

Caring for Suicidal Patients; Mental Health Nurses

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 theway 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'

Caring for Suicidal Patients; Mental Health Nurses

feelings seems to help the nurses to clarify for themselveswhat 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.

Caring for Suicidal Patients; Mental Health Nurses

DISCUSSION

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.

Caring for Suicidal Patients; Mental Health Nurses

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), wheremental 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 semiotic competence, in which one learns to interpret communicative signs (Andersen, 2009). Further research should investigate the characteristics of (more or less subtle) suicidal cues communicated by patients and how a competence in recognizing such cues may be developed. Emotional and experience- based competence may be undervalued in current emphasis on evidence-based practice, and more focus on such knowledge in educa- tion and training of nurses could promote their skills in caring for suicid- al patients.

Caring for Suicidal Patients; Mental Health Nurses

Some of the participants point to the lack of competence among temporary and/or inexperienced staff, leading to higher demands on ex- perienced nurses and poorer care, which may contribute to increased (self) destructive behavior among the patients. Thus, adequate staffing and sufficient training of all staff members is important. In addition, po- tentially suicidal patients should be cared for by the most experienced professionals, as these persons need specific and sophisticated forms of care (Cutcliffe & Barker, 2002).

Caring for Suicidal Patients; Mental Health Nurses

Suicide and suicide attempt/self-harm amongpatients evoke various strong feelings in the participants, such as sadness, guilt, anger,

35J. Hagen et al. / Archives of Psychiatric Nursing 31 (2017) 31–37

Caring for Suicidal Patients; Mental Health Nurses

frustration, fear, helplessness, and feelings of having failed. These pain- ful emotions are common following a patient's suicidal behavior (Bohan & Doyle, 2008; Joyce & Wallbridge, 2003; Valente & Saunders, 2002; Wilstrand et al., 2007). In addition, one nurse's sadness was accompa- nied with relief after a patient suicide, which is less reported (Castelli- Dransart, 2014; Wurst et al., 2010). However, people bereaved by sui- cide have described relief as part of the reaction when the suicide is the end of a long period of suffering and difficulties (Sveen & Walby, 2008). Several participants reported that caring for potentially suicidal patients was emotionally straining, particularly when the patient re- peatedly self-harmed, and that they sometimes needed to share the burden or take a break. This is consistent with previous findings where caring for patients who harm themselves repeatedly have been challenging and frustrating (O'Donovan & Gijbels, 2006; Tofthagen, Talseth, & Fagerström, 2014; Wilstrand et al., 2007).

Caring for Suicidal Patients; Mental Health Nurses

Nurses might be burdened with feelings (Wilstrand et al., 2007), or feel traumatized after a suicide/suicide attempt (Bohan&Doyle, 2008). Someof the emo- tional burdenmay be related to the projection of painful emotions from the patient, which might evoke negative feelings in the mental health nurse that can, at worst, trigger self-harm in a patient (Tofthagen et al., 2014). Richards (2000) maintained that suicidal patients might find it difficult to share their distressing feelings, and thus project (un- consciously) those feelings onto the professional and then possibly evoke countertransference reactions. Recognizing transference– countertransference processes and managing one's own emotions in a professional way is important to avoid acting out negative counter- transference reactions (Cureton & Clemens, 2015; Richards, 2000).

Caring for Suicidal Patients; Mental Health Nurses

Mental health nurses' care of potentially suicidal patients seems to involve a great deal of ‘emotional labor’, a concept developed by the so- ciologist Arlie Hochschild (1983/2003). Hochschild (1983/2003) argued that jobs with face-to-face or voice contact with the public imply ‘emo- tional labor’with the purpose to affect the emotional state in others in a desirable way and to act in an appropriate and socially accepted man- ner. The author suggested that the emotional work is influenced by ‘feeling rules’ (expectations of what we should feel), and ‘display rules’ (corresponding outer display).

Caring for Suicidal Patients; Mental Health Nurses

Furthermore, the emotional labor may be performed through either ‘deep acting’ (attempting to experi- ence the feeling that one wishes or is expected to display), or ‘surface acting’ (working on appearance but concealing/suppressing feelings) (Hochschild, 1983/2003). In our study, both techniques seem to be in- volved when the mental health nurses attempt to feel and appear calm, confident and caring (deep acting), or to just appear as such (surface act- ing), when they encounter distressed and suicidal patients. Being calm, attempting to not being overwhelmed by the patient's strong emotions and suppressing/concealing one's own feelings (of for instance fear, sad- ness, anger) may protect the professionals from being too involved and weakening their clinical judgment (Mann, 2005).

Caring for Suicidal Patients; Mental Health Nurses

However, the participants in our study also seem to spontaneously experience and express care of the patients, and although Ashforth and Humphrey (1993), p.94) stated that the genuine experience and expression of expected emotion meant that there was no need to ‘act’ (thus arguing for a third way of accomplishing emotional labor), some emotional effort is required to ensure that expressed emotions match patient or social expectation (display rules) (Mann, 2005). Two of the participants shared examples of expressing genuinely felt negative emo- tions (e.g. anger) in encounterswithpatients engaging in suicidal acts, sug- gesting that it is not always easy or desirable to comply with the common display rules inprofessional care. This raises thequestions ofwhat itmeans to be professional and of which display rules apply to mental health care, particularly with regard to the expression of felt negative emotions.

Caring for Suicidal Patients; Mental Health Nurses

Although the purpose of emotional labor is positive outcomes for both professional and patient it may have a negative impact on the health and well-being of the caregiver (Mann, 2005), including higher levels of stress (Mann & Cowburn, 2005). In our study, there are exam- ples of experiences in which a mismatch between feelings and appear- ance (surface acting) seems to be emotionally straining.

Caring for Suicidal Patients; Mental Health Nurses

It has been

suggested that experiencing emotional dissonance over time may con- tribute to emotional exhaustion and depersonalization (Brotheridge & Grandey, 2002; Hochschild, 1983/2003); signs of burnout (Maslach & Jackson, 1981). Our study suggests that some mental health nurses make a lot of efforts in managing emotions to maintain a professional appearance in the care of patients who engage in suicidal acts repeated- ly and over time, as these patients seem to evoke more anger, fear and frustration. This is consistent with Wilstrand et al.' (2007) findings, where nurses reported that caring for patients who self-harm sometimes involved being so overwhelmed by fear and frustration that they strug- gledwith their professional demands. This aspect ofmental health nurses' emotional labor should be further explored in future research.

Caring for Suicidal Patients; Mental Health Nurses

Our findings indicate that it is important, yet difficult, to balance emotional involvement and professional distance in the relationships with the patients. Based on the participants' accounts, mental health nurses' caremay resemble amother's care of her child or other intimate family/friend relationships, although it appears important not being too motherly (or too close) to avoid compromising the patient's autonomy and the nurses' professional integrity. Acting as a mother figure is de- scribed by other nurses as well, for instance in research describing nurses experiences of preventing patient violence (Virrki, 2008), or car- ing for patients with eating disorders (Malson & Ryan, 2008). Hochschild (1983/2003) suggested that women's maternal role may at- tach to several professional roles, in which women may be and act motherly at work. This seems particularly relevant for nursing, a female-dominated profession that involves taking care of people.

Caring for Suicidal Patients; Mental Health Nurses

How- ever, Hochschild (1983/2003) argued that women are in danger of overdeveloping altruistic characteristics and lose track of its boundaries, which relates to one of the nurses' experiences in our study. Her expe- rience of some colleagues' providing a too intimate care might also re- flect transference–countertransference mechanisms between the colleagues and the patient. Becoming overinvolved and assuming too much responsibility for thepatient are common countertransference re- sponses (Ens, 1999; O'Kelly, 1998). Our findings add to previous re- search addressing challenges with regard to closeness and distance (Talseth et al., 1997; Tofthagen et al., 2014; Tzeng, Yang, Tzeng, Ma, & Chen, 2010) and balancing professional boundaries (Gilje, Talseth, & Norberg, 2005; Wilstrand et al., 2007) in the relationship between the nurse and the potentially suicidal patient.

Caring for Suicidal Patients; Mental Health Nurses

The present study shows that the nurses appreciate the informal support from their colleagues. Caring for suicidal patients is demanding (Cutcliffe & Barker, 2002; Cutcliffe & Stevenson, 2008b), and nurses need informal and formal support (Gilje & Talseth, 2014) of emotional and educational character (Talseth & Gilje, 2011). Castelli-Dransart et al., 2014 found that respondents that had received sufficient support re- ported low emotional response and traumatic impact after a patient sui- cide. However, our study indicates a need for more formal support, which is also reported by other nurses caring for potentially suicidal pa- tients (Bohan & Doyle, 2008; Takahashi et al., 2011; Wilstrand et al., 2007).

Caring for Suicidal Patients; Mental Health Nurses

Clinical supervision may lead to increased self-reflection and competence (Akerjordet & Severinsson, 2004), and enhanced emotional awareness related to transference and countertransference reactions (Cureton & Clemens, 2015; Rayner, Allen, & Johnson, 2005). Further- more, supervision might enable the nurses to continue caring for suicidal patients (Cutcliffe & Barker, 2002; Cutcliffe & Stevenson, 2008a), and con- tribute to lower levels of burnout (Edwards et al., 2006; Sherring & Knight, 2009). Considering the adverse effects burnout may have on pro- fessionals' mental health (Pompili et al., 2006) and on quality of care (Maslach & Jackson, 1981; Sherring & Knight, 2009), our study suggests that there should be more focus on formal support systems for mental health nurses.

Caring for Suicidal Patients; Mental Health Nurses

CONCLUSIONS

Although this is a small-scale qualitative study, it provides insights into mental health nurses' experiences of their clinical skills and

36 J. Hagen et al. / Archives of Psychiatric Nursing 31 (2017) 31–37

management of emotions in the care of suicidal inpatients. The findings indicate that experienced mental health nurses may have an important role in preventing suicidal acts/self-harm among patients. By providing close care and getting to know the patients they have opportunities to recognize and respond to their expressions of mental distress (verbal and non-verbal) that are possible warning signs of suicide or self- harm. However, caring for potentially suicidal patients involves a great deal of emotional work and may be emotionally straining, in which the theory of emotional labor (Hochschild, 1983/2003) has extended our understanding. Our study points to the importance of providing the mental health nurses with sufficient resources and support to en- able them to provide good care.

Caring for Suicidal Patients; Mental Health Nurses

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