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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
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- 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.
Interview Procedure
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.
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.
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 empat
hetic 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).
Ethical Considerations
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.
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.
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