Attenuating Anxieties: Mental Health Nurses’ Responses to Suicidal

Behaviour: A Grounded Theory Study Jean Morrissey PhD & Professor Agnes Higgins

School of Nursing & MidwiferyTrinity College Dublin

This study was supported by

THE MARTHA McMENAMIN MEMORIAL SCHOLARSHIP

Suicide: Ireland Suicide: Ireland

Ireland has the eleventh lowest rate of Ireland has the eleventh lowest rate of suicide in Europe, with a reported rate of suicide in Europe, with a reported rate of 10.9 per 100,000 population (National Office 10.9 per 100,000 population (National Office Suicide Prevention Suicide Prevention (NOSP 2015). (NOSP 2015).

However, it ranks fourth highest in the EU However, it ranks fourth highest in the EU for deaths by suicide for 15-19 year olds – for deaths by suicide for 15-19 year olds – 10.5 per 100,000 population. 10.5 per 100,000 population.

Suicide: IrelandSuicide: Ireland

The highest rate of suicide in Ireland is The highest rate of suicide in Ireland is among young 45-54 year old males. Over among young 45-54 year old males. Over the last decade, this gender differentiation the last decade, this gender differentiation is a constant feature of the deaths by is a constant feature of the deaths by suicide. suicide.

In 2012 82.3% of all suicides were male In 2012 82.3% of all suicides were male (NOSP 2015(NOSP 2015).).

Suicide: IrelandSuicide: Ireland

The high rates of suicide and in particular The high rates of suicide and in particular among young males has propelled suicide among young males has propelled suicide and its reduction to the fore front of and its reduction to the fore front of health policy and research both nationally health policy and research both nationally and internationally.and internationally.

Self-Harm:Self-Harm: Ireland Ireland In 2014, there were 11,126 recorded In 2014, there were 11,126 recorded

presentations to hospital due to self-harm (SH), presentations to hospital due to self-harm (SH), with drug overdose being the commonest with drug overdose being the commonest method of self-harm involving over two-thirds method of self-harm involving over two-thirds 66% of individuals (National Suicide Research 66% of individuals (National Suicide Research Foundation (NSRF 2015). Foundation (NSRF 2015).

Cutting was the other common method of self-Cutting was the other common method of self-harm involved in all episodes. harm involved in all episodes.

Self-Harm:Self-Harm: Ireland Ireland

Although the female rate of SH is higher Although the female rate of SH is higher than the male rate, differences between than the male rate, differences between male and female rates have been narrowing male and female rates have been narrowing from 37% in 2004-2005 to 13% in 2009-from 37% in 2004-2005 to 13% in 2009-2014 2014 (NOSP 2006, 2010, 2011, 2012, 2015).(NOSP 2006, 2010, 2011, 2012, 2015).

Given the secretive nature of self-harm, Given the secretive nature of self-harm, many incidents are never reported and as many incidents are never reported and as such go unregistered.such go unregistered.

Determining death by suicide Determining death by suicide A distinct condition versus a symptom DSM-A distinct condition versus a symptom DSM-

5TR (APA 2013).5TR (APA 2013). Self-harm – Overt /Covert Secretive/HiddenSelf-harm – Overt /Covert Secretive/Hidden Gender paradox?Gender paradox? Youth phenomenon?Youth phenomenon? Decriminalization of suicide 1993Decriminalization of suicide 1993

Demographics & Epidemiology of Demographics & Epidemiology of Suicide & Self-harm: Challenges & ChangesSuicide & Self-harm: Challenges & Changes

Policy Policy

‘Reach out - National Strategy for Action on Suicide Prevention’ 2005-2014 (HSE et al 2005),

Suicidality: Mental Health Nursing Suicidality: Mental Health Nursing

Suicide risk is also a problem for people Suicide risk is also a problem for people experiencing mental health problems and experiencing mental health problems and accessing mental health facilities in Ireland.accessing mental health facilities in Ireland.

Mental health nurses are at the frontline of Mental health nurses are at the frontline of service provision to this client group and have service provision to this client group and have an important role to play in suicide prevention. an important role to play in suicide prevention.

Research/LiteratureResearch/Literature

• Small descriptive qualitative studiesSmall descriptive qualitative studies• Confined to nurses working in in-Confined to nurses working in in-

patient studiespatient studies• Little research on how nurses assist Little research on how nurses assist

people presenting with suicidal people presenting with suicidal behaviourbehaviour

Aim of Study Aim of Study

The aim of this study was to develop a The aim of this study was to develop a grounded theory that explained how grounded theory that explained how mental mental health nurses within a mental health service health nurses within a mental health service in the Republic of Ireland, respond to clients in the Republic of Ireland, respond to clients who present with suicidal behaviour. who present with suicidal behaviour.

MethodologyMethodology Study informed by a constructionist Study informed by a constructionist

epistemology and the principles of epistemology and the principles of Grounded Theory (Glaser 1978). Grounded Theory (Glaser 1978).

Ethical approval was granted by the Ethical approval was granted by the university ethics committee and the local university ethics committee and the local ethics committee of the hospital.ethics committee of the hospital.

MethodologyMethodology Data was collected through interviews Data was collected through interviews

with 33 mental health nurses who were with 33 mental health nurses who were working in a variety of in-patient and working in a variety of in-patient and community-based clinical settings. community-based clinical settings.

Analysis comprised the concurrent Analysis comprised the concurrent processes of constant comparative processes of constant comparative analysis, theoretical sampling, theoretical analysis, theoretical sampling, theoretical sensitivity and memo writing. sensitivity and memo writing.

Theory Main ConcernTheory Main Concern

The participants’ main concern about The participants’ main concern about caring for suicidal clients was related to caring for suicidal clients was related to their feelings of professional and personal their feelings of professional and personal vulnerability and the need to protect both vulnerability and the need to protect both clients and themselves. clients and themselves.

““There’s two types of fear, there’s your own fear about being a professional There’s two types of fear, there’s your own fear about being a professional ….. but there’s fear concerning …will I be …have I failed the client, I don’t ….. but there’s fear concerning …will I be …have I failed the client, I don’t want someone to die… but I will be accused of failing? It’s a double, two want someone to die… but I will be accused of failing? It’s a double, two prong thing” (M2). prong thing” (M2).

Core CategoryCore Category

The participants dealt with these concerns The participants dealt with these concerns through a process conceptualized as through a process conceptualized as ‘‘Attenuating Anxieties’, Attenuating Anxieties’, which had five which had five subcategories, subcategories, most of which contain a most of which contain a number of related subcategories and number of related subcategories and properties.properties.

Turning point:Pursuing further

education

Learning the discourse of anxiety•Learning anxiety from others

•Learning the script of mental health nursing

Learning the discourse of anxiety•Learning anxiety from others

•Learning the script of mental health nursing

Cultivating the anxiety discourse•Profiling believability

•Sharing responsibility

Cultivating the anxiety discourse•Profiling believability

•Sharing responsibility

Managing anxieties•Keeping watch•Making deals•Preaching hope

Managing anxieties•Keeping watch•Making deals•Preaching hope

Safeguarding against anxieties•Retracing their steps

•Defensive debriefing

•Seeking absolution

•Searching for explanations

•Soothing self

Safeguarding against anxieties•Retracing their steps

•Defensive debriefing

•Seeking absolution

•Searching for explanations

•Soothing self

Containing anxieties•Hanging fear on theory

•Making sense of nurses’ responses

•Taking therapeutic risks

Attenuating AnxietiesAttenuating Anxieties

Learning anxiety from othersLearning anxiety from others ““its over twenty years ago that my brother died. He left a note. Over the its over twenty years ago that my brother died. He left a note. Over the

years I have tried to talk to my parents but they won’t accept it was suicide. years I have tried to talk to my parents but they won’t accept it was suicide. They tell everyone his overdose was an accident” (M17).They tell everyone his overdose was an accident” (M17).

““Speaking to a friend of mine whose father was a guard, he said that in the Speaking to a friend of mine whose father was a guard, he said that in the guards when someone committed suicide years ago and whenever they guards when someone committed suicide years ago and whenever they could, the guards would go out and they would maybe cut him down and put could, the guards would go out and they would maybe cut him down and put him into the bed and he would say he die in his sleep” (M3).him into the bed and he would say he die in his sleep” (M3).

““I think to talk about suicide there’s whole stigma attached to it. My friend I think to talk about suicide there’s whole stigma attached to it. My friend was around the same age as myself we were brought up in an era where was around the same age as myself we were brought up in an era where mental illness was not talked about” (M2).mental illness was not talked about” (M2).

Learning the script of mental health nursingLearning the script of mental health nursing ““Looking back when I was training, anybody who would have expressed Looking back when I was training, anybody who would have expressed

suicidal thoughts was met with huge anxiety and you then got this sudden suicidal thoughts was met with huge anxiety and you then got this sudden surveillance the key thing is keep the client safe; it’s not much different now” surveillance the key thing is keep the client safe; it’s not much different now” (F6). (F6).

If a client kills themselves, as the nurse you have to live with that for the rest If a client kills themselves, as the nurse you have to live with that for the rest of your career” of your career” (M2)(M2)

““I know self-harm is different it’s not as high a risk than someone who is I know self-harm is different it’s not as high a risk than someone who is depressed and genuine, but you can never be sure, we had clients here who depressed and genuine, but you can never be sure, we had clients here who nearly died, they took tablets as well as cut their wrists. So you have to nearly died, they took tablets as well as cut their wrists. So you have to remember that at times…” (M3).remember that at times…” (M3).

““Those questions about their mood and if they still feel suicidal would be Those questions about their mood and if they still feel suicidal would be asked but sometimes I would doubt myself and when somebody you know is asked but sometimes I would doubt myself and when somebody you know is not expressing suicide as much as use to , you’re less likely to be asking them not expressing suicide as much as use to , you’re less likely to be asking them about – you’d say oh God am I putting into their heads” (F2)about – you’d say oh God am I putting into their heads” (F2)

Profiling believability Profiling believability

““We get a lot referrals to our Day Services from GPs about clients’ with low We get a lot referrals to our Day Services from GPs about clients’ with low mood; suicidal ideation, so we would do a suicide risk assessment as part of mood; suicidal ideation, so we would do a suicide risk assessment as part of their overall clinical assessment” (M2).their overall clinical assessment” (M2).

““There are definitely the two kinds of categories. I personally view self-There are definitely the two kinds of categories. I personally view self-harming behaviour as something that doesn’t have real suicidal intent, harming behaviour as something that doesn’t have real suicidal intent, whereas real suicidal behaviour would tick more boxes in term of, you know, whereas real suicidal behaviour would tick more boxes in term of, you know, plan, rescue efforts, you know, um, previous attempts” (F11).plan, rescue efforts, you know, um, previous attempts” (F11).

““More people who are suicidal are now looked after at home on homecare. A More people who are suicidal are now looked after at home on homecare. A number of clients that I looked after suffered from depression and sometimes number of clients that I looked after suffered from depression and sometimes were suicidal; I would assess clients during the daily visits” (M9).were suicidal; I would assess clients during the daily visits” (M9).

Sharing ResponsibilitySharing Responsibility

““It can be uncomfortable sometimes, If you haven’t made the It can be uncomfortable sometimes, If you haven’t made the right decision or not, it’s somebody’s life that you might effect. If right decision or not, it’s somebody’s life that you might effect. If you make the wrong call, it’s something that you live with for you make the wrong call, it’s something that you live with for the rest of your life” (M2).the rest of your life” (M2).

““You phone your colleagues and bounce it off them and they You phone your colleagues and bounce it off them and they might have given you another question to ask - have you done might have given you another question to ask - have you done this, or do you feel happy” (F11).this, or do you feel happy” (F11).

Keeping watchKeeping watch ““Well it’s an open ward so basically we have a check list that is due at 9, 1 Well it’s an open ward so basically we have a check list that is due at 9, 1

and 5 o clock so if somebody is noted not to be around at that time well and 5 o clock so if somebody is noted not to be around at that time well that’s when we go and do a search.”(F1). that’s when we go and do a search.”(F1).

““If I am not on at the weekend and somebody else is following them If I am not on at the weekend and somebody else is following them up, I’d ring to ask how is the person is, are they OK, have you been out up, I’d ring to ask how is the person is, are they OK, have you been out to see them? (F8). to see them? (F8).

   ““I feel this guy is very spontaneous when he leaves my room, he has to I feel this guy is very spontaneous when he leaves my room, he has to

walk cross a river, that thought crosses my head. Is he going to get to walk cross a river, that thought crosses my head. Is he going to get to the other side of the bridge? So I usually ring him when he gets home? the other side of the bridge? So I usually ring him when he gets home? Just to say I’ll see you tomorrow or whatever. That’s for my Just to say I’ll see you tomorrow or whatever. That’s for my reassurance as well” (M2). reassurance as well” (M2).

Making deals Making deals ““Another approach is a contract; they make a promise between you. I‘d say Another approach is a contract; they make a promise between you. I‘d say

to the client - if you have anyto the client - if you have any worries you promise me you’d come to me” worries you promise me you’d come to me” (F1).(F1).

““I never get into written contracts – it’s not something that I am keen on. I I never get into written contracts – it’s not something that I am keen on. I

don’t use the word contracts with clients but by me asking the question can don’t use the word contracts with clients but by me asking the question can you assure me….not even promise………..I’ve often used the word assure”? you assure me….not even promise………..I’ve often used the word assure”? (F7).(F7).

““When you’re dealing with a suicidal patient, it’s all about, well certainly I When you’re dealing with a suicidal patient, it’s all about, well certainly I

would say ….can you promise me that you will stay safe until….,” (F12).would say ….can you promise me that you will stay safe until….,” (F12).

“In my experience I would operate very much on a contract. I believe that when people put their name to it – when they sign something 99% of the time they will adhere to it … my word is my bond” (M10).

Preaching hopePreaching hope ““You try to find what it is for that person that you can latch onto for that You try to find what it is for that person that you can latch onto for that

person, whether it is they might have children, their partner, their mother, person, whether it is they might have children, their partner, their mother, brother or whatever it might be. With a view to trying to get them to see brother or whatever it might be. With a view to trying to get them to see that’s why you should want to live, that’s what you have to look to when that’s why you should want to live, that’s what you have to look to when you’re feeling so low at night and you’re thinking there is nothing - I want to you’re feeling so low at night and you’re thinking there is nothing - I want to kill myself”(F4).kill myself”(F4).

““It’s draining because we all like to mix with happy people, sociable It’s draining because we all like to mix with happy people, sociable

people. And I think people who are suicidal tend to be a lot more people. And I think people who are suicidal tend to be a lot more depressive, probably a lot harder to engage with as well” (M6). depressive, probably a lot harder to engage with as well” (M6).

   ““You pull out all the positives you can because I think if someone is in You pull out all the positives you can because I think if someone is in

that frame of mind, feeling that low, feeling that depressed where they that frame of mind, feeling that low, feeling that depressed where they are contemplating suicide then from an internal view they don’t see any are contemplating suicide then from an internal view they don’t see any positive way out. You start to try and get positives for them. So you positive way out. You start to try and get positives for them. So you have to try and find a way where they can see the positives” (M5).have to try and find a way where they can see the positives” (M5).

Retracing their stepsRetracing their steps ““I had to do a report of my work I had to do a report of my work

and what interventions I did. and what interventions I did. And even that was a bit And even that was a bit worrisome because it was worrisome because it was something that I had never had something that I had never had to do before. And I remember at to do before. And I remember at the time I was just flummoxed the time I was just flummoxed and the first thing that was said and the first thing that was said to me was - are your notes up to to me was - are your notes up to date? And I have to say I felt date? And I have to say I felt like saying fuck off..,” (F7). like saying fuck off..,” (F7).

““I did my notes reflected on I did my notes reflected on what I did accurately and then what I did accurately and then will they think I am covering up will they think I am covering up what you didn’t do as opposed what you didn’t do as opposed to explaining exactly what you to explaining exactly what you did do” (F8).did do” (F8).

Defensive Debriefing Defensive Debriefing

So called debriefing, it wasn’t a So called debriefing, it wasn’t a debriefing at all it was like a fact debriefing at all it was like a fact finding, cover your ass kind of finding, cover your ass kind of exercise, that’s what I and a few exercise, that’s what I and a few others felt it was like. It wasn’t a others felt it was like. It wasn’t a debriefing, a debriefing isn’t about debriefing, a debriefing isn’t about fault finding - it’s talking about fault finding - it’s talking about what happened. The consultant what happened. The consultant setting the scene (M13). setting the scene (M13).

Seeking absolutionSeeking absolution

It was the whole thing do I get in It was the whole thing do I get in contact with her. I just felt I had to, contact with her. I just felt I had to, so I got in touch with his wife and so I got in touch with his wife and said if she would like to come in” said if she would like to come in” (F7).(F7).

““Everything in her conversation Everything in her conversation was directed at me. It wasn’t in was directed at me. It wasn’t in a bad way, it was like that I was a bad way, it was like that I was the one that was going in every the one that was going in every day and there was no blame at day and there was no blame at all on me. She was so nice all on me. She was so nice about it. I felt so relieved” (M7). about it. I felt so relieved” (M7).

Searching for Searching for explanations explanations

““The amount of experience that I The amount of experience that I have on the frontline is that suicide have on the frontline is that suicide happens, it’s a fact. People with happens, it’s a fact. People with mental illness are at risk of taking mental illness are at risk of taking their own lives. It’s a given and their own lives. It’s a given and there’s very little you can do to there’s very little you can do to prevent it” (M9).prevent it” (M9).

““The guy that killed himself, he was The guy that killed himself, he was diagnosed with depression but diagnosed with depression but there was no psychosis” (M13).there was no psychosis” (M13).

Soothing self Soothing self

“I remember discussing this with some very experienced colleagues afterwards, and asking them how, what did you do to cope with this? This was the first suicide I had been involved with in the community but I remember saying it to the other nurses and asking them “How do you cope?” (F8).

““Obviously I will never forget her and every time I drive past the site I Obviously I will never forget her and every time I drive past the site I think of her and her kids and the fact that the self-doubt has receded. I think of her and her kids and the fact that the self-doubt has receded. I have regained my confidence in my practice because it knocks my have regained my confidence in my practice because it knocks my confidence completely (F8). confidence completely (F8).

Hanging fear on theory Hanging fear on theory ““As I said earlier, there’s always a sense of worry and concern that the person As I said earlier, there’s always a sense of worry and concern that the person

might do it. I think it’s working with uncertainty, the main emotion it brings might do it. I think it’s working with uncertainty, the main emotion it brings up is worry and I think your theory as well as policies and procedures, they up is worry and I think your theory as well as policies and procedures, they may not take it away but they reduce it somewhat” (M 9). may not take it away but they reduce it somewhat” (M 9).

We all need something to hold onto. I hold onto my psychotherapy training We all need something to hold onto. I hold onto my psychotherapy training and understanding and hopefully from what I know of that theory that’s and understanding and hopefully from what I know of that theory that’s what I hold onto. Experience also counts for a lot. I am a long time in nursing what I hold onto. Experience also counts for a lot. I am a long time in nursing and it’s certainly a few years now since training in psychotherapy and I feel I and it’s certainly a few years now since training in psychotherapy and I feel I have a long way to go” (F5).have a long way to go” (F5).

““My DBT training …it gives me confidence about what I’m doing” (F9).My DBT training …it gives me confidence about what I’m doing” (F9). ““I think my anxiety has definitely reduced, if I hadn’t done this CBT course I I think my anxiety has definitely reduced, if I hadn’t done this CBT course I

probably wouldn’t be as informed as I am, it has probably forced me to go probably wouldn’t be as informed as I am, it has probably forced me to go and investigate how I work with clients” (M9). and investigate how I work with clients” (M9).

Making sense of nurses’ Making sense of nurses’ responsesresponses

““There is negativity about this client group and it’s very widespread;” (M9). There is negativity about this client group and it’s very widespread;” (M9).

““I just think that a lot of people’s attitudes towards that client group are I just think that a lot of people’s attitudes towards that client group are

unhelpful – it doesn’t help the communication with the person. They are unhelpful – it doesn’t help the communication with the person. They are people who spend a lot of the time in our service. I think if we could work with people who spend a lot of the time in our service. I think if we could work with them and understand them and understand what they are coming to us them and understand them and understand what they are coming to us because I think they are communicating something to me, it’s resonating in because I think they are communicating something to me, it’s resonating in me and I think to be able to use that communication helps to develop the me and I think to be able to use that communication helps to develop the relationship”. (F5)relationship”. (F5)

Taking therapeutic risksTaking therapeutic risks

““I I think that’s probably the most difficult question …it would probably be one think that’s probably the most difficult question …it would probably be one of my nightmares to end up in court having to defend myself because court of my nightmares to end up in court having to defend myself because court works differently to therapy or any type of psychiatry, it’s all black and white. works differently to therapy or any type of psychiatry, it’s all black and white. As you are aware therapeutic relationships are not black and white. If I am in As you are aware therapeutic relationships are not black and white. If I am in black and white I can’t function, it’s keeping myself out of the black and white black and white I can’t function, it’s keeping myself out of the black and white is my struggle sometimes and practice as safely as I can” (F7).is my struggle sometimes and practice as safely as I can” (F7).

““I’d like to think that any risks I have taken in my career have been educated I’d like to think that any risks I have taken in my career have been educated and informed risks. I am not sure I feel that it’s been always in the patients and informed risks. I am not sure I feel that it’s been always in the patients best interests to be a 100% sure that the patient is safe because I don’t think best interests to be a 100% sure that the patient is safe because I don’t think it’s possible. Sometimes patients do things impulsively and can you lock up it’s possible. Sometimes patients do things impulsively and can you lock up somebody and deprive them of their liberty in case that they might. (F5somebody and deprive them of their liberty in case that they might. (F5))

Limitations Limitations

Reflects the experiences of only one Reflects the experiences of only one locationlocation

Retrospective view of the participants’ Retrospective view of the participants’ experiences experiences

Sensitive topic – self censorshipSensitive topic – self censorship Spoken word –clinical practiceSpoken word –clinical practice Impact of researcher Impact of researcher Grounded theory method of data analysis Grounded theory method of data analysis

Implications and Recommendations Implications and Recommendations Nurse education and educators Nurse education and educators

Management & organisation Management & organisation

Nurses working in clinical practiceNurses working in clinical practice

Implications and Recommendations Implications and Recommendations Move away from current emphasis on Move away from current emphasis on Defensive practices to defendable Defensive practices to defendable

practices practices Reacting rather than respondingReacting rather than responding Feeling responsible Feeling responsible forfor rather than rather than

responsible responsible toto client client Recognising distress rather than prevent itRecognising distress rather than prevent it

Implications and Recommendations Implications and Recommendations Knowledge and competencies to engage with Knowledge and competencies to engage with

the person at risk of suicide in a recovery-the person at risk of suicide in a recovery-orientated manner orientated manner

Establish and promote a culture of openness in Establish and promote a culture of openness in which suicide / self-harm is anticipated as a which suicide / self-harm is anticipated as a possible outcome even with excellent standards possible outcome even with excellent standards of care and wherein staff are supported and of care and wherein staff are supported and encouraged to discuss and reflect on their encouraged to discuss and reflect on their anxieties while ‘anxieties while ‘taking therapeutic risk’taking therapeutic risk’ when when working with the suicidal person.working with the suicidal person.

Thank you Thank you