ARTÍCULO ORIGINAL / ORIGINAL ARTICLE / ARTIGO ORIGINAL

DOI: 10.17533/udea.iee.v33n2a16

Nursing students attitudes across the suicidal behavior

Actitudes de los estudiantes de enfermería frente al comportamiento suicida

Atitudes dos estudantes de enfermagem frente ao comportamento suicida

Nadja Cristiane Lappann Bott¹; Leandro Martins Costa de Araújo²; Elbert Eddy Costa³; Jacqueline Simone de Almeida Machado⁴

¹RN and Psychologist, Ph.D. Professor, Universidade Federal de São João del Rei -UFSJ-, Divinópolis, Minas Gerais, Brasil. email: nadjaclb@terra.com.br.

²Nursing undergraduate student. UFSJ, Divinópolis, Minas Gerais, Brasil. email: leandromartins19@gmail.com.

³Nursing undergraduate student. UFSJ, Divinópolis, Minas Gerais, Brasil. email: eddy.ufsj@gmail.com.

⁴Psychologist, Ph,D candidate. Professor, UFSJ, Divinópolis, Minas Gerais, Brasil. email: jack.machado@hotmail.com.

Receipt date: August 19, 2014. Approval date: April 15, 2015.

Article linked to research: Atitudes dos acadêmicos de enfermagem frente ao comportamento suicida.

Subventions: Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) e Pró-reitoria de Extensão da Universidade Federal de São João Del Rei.

Conflicts of interest: none.

How to cite this article: Botti NCL, Araújo LMC, Costa EE, Machado JSA. Nursing students attitudes across the suicidal behavior. Invest Educ Enferm. 2015; 33(2): 334-342.

DOI: 10.17533/udea.iee.v33n2a16

ABSTRACT

Objective. Examine the attitudes of nursing students with the suicidal behavior before and after a training course on the subject. Methodology. Performed quantitative, cross-sectional study, with 58 nursing students from a public university in Minas Gerais (Brazil) who participated in training on the theme. For data collection were used the Questionnaire of Attitudes Before Suicidal Behavior. The questionnaire was applied just before the start and the end of the training measuring attitudes toward suicidal behavior. Results. Were found statistically significant differences in negative feelings factors on the patient and perception of professional competence (p <0.05). The right factor to suicide was not significantly different among nursing students. Conclusion. The academic training may have influenced positively the desired changes regarding the attitudes of nursing students across the suicidal behavior.

Key words: students, nursing; attitude; suicide.

RESUMEN

Objetivo. Examinar las actitudes de los estudiantes de enfermería frente al comportamiento suicida después de un curso de capacitación sobre el tema. Metodología. Estudio de evaluación de una intervención. Participaron voluntariamente 58 estudiantes de enfermería de una universidad pública del interior de Minas Gerais (Brasil) que se inscribieron en el curso de extensión universitaria "Comportamiento Suicida", que no hace parte del currículo de enfermería. Para la recolección de la información se utilizó el Cuestionario de Actitudes Frente al Comportamiento Suicida de Botega et al., el cual fue aplicado al inicio y al final del curso. Resultados. El 89.7% de los participantes fue de sexo femenino. Se encontraron diferencias estadísticamente significativas en los factores de sentimientos negativos ante el paciente y percepción de la capacidad profesional. El factor derecho al suicidio no presentó diferencias en las dos evaluaciones. Conclusión. La capacitación recibida pudo haber influenciado positivamente en los cambios deseados en relación con las actitudes de los estudiantes de enfermería frente al comportamiento suicida.

Palabras clave: estudiantes de enfermería; actitud; suicidio.

RESUMO

Objetivo. Examinar as atitudes dos estudantes de enfermagem frente ao comportamento suicida depois de um curso de capacitação sobre o tema. Metodologia. Estudo de avaliação de uma intervenção. Participaram voluntariamente 58 estudantes de enfermagem de uma universidade pública do interior de Minas Gerais (Brasil) que se inscreveram no curso de extensão universitária "Comportamento Suicida", que não faz parte do currículo de enfermagem. Para o recolhimento da informação se utilizou o Questionário de Atitudes Frente ao Comportamento Suicida de Botega et at., o qual foi aplicado ao início e ao final do curso. Resultados. 89.7% dos participantes foram de sexo feminino. Encontraram-se diferenças estatisticamente significativas nos fatores de sentimentos negativos ante o paciente e percepção da capacidade profissional. O fator direito ao suicídio não apresentou diferenças nas duas avaliações. Conclusão. As capacitação recebida pôde ter positivamente as mudanças desejadas em relação com as atitudes dos estudantes de enfermagem frente ao comportamento suicida.

Palabras chave: estudantes de enfermagem; atitude; suicídio.

INTRODUCTION

Historically healthcare professionals are prepared to save lives. Therefore, impotence and frustration at the death are common.¹ It is noteworthy that, since the beginning of their training, the Nursing student has the idea that while health care provider, will fight for the preservation of life as opposed to death.² Thus, they feel empowered to preserve life and when they need to deal with situations involving death-dying, in general, consider themselves unprepared.¹ In this context is recognized the importance of formation among healthcare professionals, that offers subsidies for understanding this process. Especially regarding preventable death, as in the case of suicide, the issue of process death-dying is presented in a more complex way.

An international study with emergency service professionals points out that there is common prejudice among physicians and nursing professionals in relation to the patients who self-injure, describing them as manipulators and attention callers. Stands out the need for qualification among professionals as unfavorable attitudes are likely to negatively influence the quality of provided care.³ A Greek study also indicated that the unfavorable attitudes among doctors and nurses towards patients with attempted suicide have a negative impact on the quality of care.⁴ Also in this sense, an Asian study conducted in seven major hospitals in Taiwan, aiming to investigate the attitudes of nurses towards patients who had attempted suicide, reaffirms the need to encourage qualification in order to promote more positive attitudes towards these patients.⁵ Analogous study carried out with physicians and nursing staff of a psychiatric emergency room of a Brazilian public hospital in the state of São Paulo, shows the need of specialized knowledge aiming at improving the professional care of people who attempt suicide. And this qualification should begin with the analysis of the professionals themselves of their prejudices and difficulties.⁶

International revision study on the contact between people who committed suicide and the healthcare services shows that three out of four patients had contact with primary care services in the year of suicide, about a third had contact with mental health services. In the month prior to suicide one in five people who committed suicide had contact with mental health services and approximately 45% with primary care services. Therefore, primary care professionals play a key role in the early detection of risk factors for suicide.⁷ It is estimated that for every death by suicide, occur two hospitalizations and twenty-two admissions in emergency rooms for attempting to suicide.⁸ In the emergency field is common the nursing professionals to be the first contact of the patient with the health service after a suicide attempt or episode of self-injury. The evaluation and the appropriate management of these patients are essential to prevent future attempts. However, health professionals generally have a negative attitude towards these patients with a lack of interpersonal skills in service and inadequate assessment.⁹ The Nursing team, also in primary care services, plays an important role as the link it has with the community allows the identification of risk factors for suicide enabling thus prevent anticipation of the end.¹⁰ Among the difficulties related to professional of primary care stands out the lack of qualification for nurses and community health workers thus jeopardizing the identification and approach of individuals with a history of suicide attempts.¹¹ It is common for professionals do not consider themselves prepared to deal with individuals with suicidal behavior.¹² Thus, in general there is by health professionals, due to stigmatization, prejudice and personal difficulty, contempt in relation to suicide attempts.^6.13 It is evident that they are not yet prepared to accept this patient as someone who needs help, and that often, the nursing professional has positions marked by prejudice and discrimination against the patient. Although, some professionals reflect on the suicidal act, questioning its reason and thus placing a help position; most get emotional distance to not be involved with the event or with the difficulties of pacient.¹³

Important highlight that the studies are not intended to generalize undue attitudes among health professionals, but to give visibility and place to the problem and the implications arising from these acts with the intention of seeking solution to this problem. It is believed that training and a change in attitudes of future professionals in relation to the suicidal behavior can contribute to risk identification and qualification of care. It is known that it is essential the role of nurses in attendance of these people and their attitudes have an important role in this care. Therefore considering the difficulty of caring for patients with suicidal behavior, the connection between hostile attitude and lack of knowledge and/or professional lack of preparation and the evidence that the positive attitudes and skills of nurses are elements that can intervene in the care of patients with suicidal behavior is presented as research question: What are the attitudes of nursing students before suicidal behavior before and after a training course on the theme? The research presupposition refers to the importance of including content about suicidal behavior in Nursing undergraduate curriculum in Brazil. From these considerations, this study aims to examine attitudes of nursing students before suicidal behavior before and after a training course on the themet.

METHODOLOGY

Exploratory quantitative transversal study held with nursing students from São Joao del Rei Federal University (Minas Gerais, Brazil) who participated in the Fundamental Studies Cycle: Suicidal Behavior, related to an Extension Project of the University. This project was proposed because the content is not covered in the course curriculum. The Fundamental Studies Cycle aimed to qualify regularly registered nursing students in suicidal behavior and its prevention. The training took place in two meetings every fifteen days, being a meeting per week lasting 4 hours/meeting. The content was taught by the project coordinators teachers with the approach: 1) epidemiology of suicide, 2) overview of suicidal behavior, 3) mental disorders and suicidal behavior, 4) attitudes of health teams and suicidal behavior, 5) psychodynamic view of suicide, 6) evaluation of the risk of suicide and 7) suicide prevention strategies. The invitation to participate in the Fundamental Studies Cycle was conducted via email to each class specifically enrolled in the nursing course.

Were performed 4 editions of the Fundamental Studies Cycle: Suicidal Behavior. The sample was from intentional non-probabilistic type, consisting of 58 students of the nursing course, of both genres, enrolled in a public university, and who attended from the 1st to the last period. From the 250 students enrolled in the 2nd half of 2013, 118 have done registration and 58 took part in the Cycle meetings. This sampling criterion was chosen over a representative sample of the study population according to the voluntary participation of students in Fundamental Studies Cycle. For data collection were used the Questionnaire of Attitudes Before Suicidal Behavior (QABSB). This refers to an analog visual instrument with 25 statements, followed by visual analogue scales of self-report, which measures attitudes in their cognitive, affective and behavioral aspects. Its internal consistency was evaluated statistically and through factor analysis was possible to cluster related items on three factors in order to facilitate the evaluation of attitudes changes. The factors are: Factor 1- negative feelings with patient with suicidal behavior; Factor 2- perception of professional competence to deal with patients with suicidal behavior and Factor 3- right to suicide.¹² It is highlighted that the QABSB is in the public access. In the same questionnaire demographic and academic data were answered.

Each QABSB item corresponds to a visual analog scale of 10 cm between complete disagreement and total agreement so that this markup distance is transformed into a score from 0 to 10 in each item response. The score of each one of the three created factors, right to suicide, negative feelings with patient with suicidal behavior and perception of professional competence may vary between 0 and 30 points, because each of them has three items. Although in these last two factors (negative feelings and perception of professional competence) some items enter the sum with opposite sign, the amplitude remains at 30 points in such a way that centers the distribution in order to be computed as if it were from 0 to 30. In right to suicide a higher score can mean at least "moralist/judicious" attitude; in negative feelings with patient the higher the score, higher the presence of such feelings, which can hamper the aid to the individual who incurred in suicidal behavior; in relation to the perception of professional competence factor a higher score may mean more confident professionals in dealing with individuals with suicidal behavior.¹² The QABSB was applied during the initial 15 minutes of the first day of training and the final 15 minutes of the last day measuring attitudes toward suicidal behavior. The significance level for the statistical tests was 5% (p <0.05). First the data were grouped into an electronic spreadsheet in Microsoft Office Excel for further analysis. Statistical analysis was performed using the statistical software Statistical Package for Social Sciences (SPSS), version 17.0.

The project was approved by the Ethics Committee on Research in Human Beings of UFSJ/CCO (Report nº 361.459). Participants who agree to participate in the study were informed about the research being asked to sign the Informed Consent (IC), according to Resolution CNS/MS 466/2012, regarding the ethical aspects of research involving human subjects and the principles of autonomy, beneficence, non-maleficence, justice and equity. In order to avoid ethical constraint by reason of the relationship of student-teacher dependency the IC was applied by a nursing student not enrolled in the study either in the organization of the training.

RESULTS

Participated of this research 58 students of the nursing course, being 52 women, representing 89.7% of the total sample. The age group that most contributed to this study was that of 21-25 year consisted of 32 students (55.2%). 20 students from the first periods of the course took part (1st, 2nd and 3rd semester), 22 students from the 4th, 5th and 6th semester and 16 students that were at the end of the course (7th, 8th and 9th semester). Most of the research participants declared themselves as religious (89.7%), being 39 Catholics, representing 67.2% of the total sample (Table 1).

Table 1. Characterization of the nursing students participating in the study

Table 1.

Table 2 shows the difference in the factors of the Questionnaire of Attitudes Before Suicidal Behavior identified before the training and the end of it. Under the three factors that constitute the questionnaire statistically significant differences were found in the negative feelings factors to the patient with suicidal behavior and perception of professional competence (p <0.05). The right to suicide factor was not significantly different between nursing students. Among the items making up factor 1 (negative feelings with the patient), there was significant difference after the training in items: 1) who is threatening, generally does not kill himself and 2) anyone really looking to get yourself killed, does not keep "trying". Regarding the factor 2 (perception of professional competence) change is identified with significant differences in item: 1) I think I have professional preparation to deal with patients at risk for suicide. Factor 3 (right to suicide) showed a significant difference in the items: 1) life is a gift from God, and just He can take and 2) when a one speaks of ending the life, I try to take that away of her head.

Table 2. Change of attitudes from the beginning towards the end of the course by factors and items from Questionnaire of Attitudes Before Suicidal Behavior (QABSB)

Table 2.

DISCUSSION

The suicide rate increased by 60% in 45 years (1950-1995) in the world and the number of suicide attempts is up to twenty times more frequent than completed suicide.¹⁴ The significant increase in suicide rates and the World Health Organization appeals for countries to face the phenomenon as a public health problem contributed to Brazil become the first Latin American country to draft a national action aimed at suicide prevention, defined in 2006 by Administrative Rule no 1.876.¹⁵ it is known that the challenge of building a suicide related care policy involves the training of sensitive professionals regarding to the magnitude of the problem.

From the 250 nursing students regularly registered in the 2nd half of 2013, 47.2% had enrollment and 23.2% attended the editions of the Fundamental Studies Cycle: Suicidal Behavior. This can be understood as a concern in the training of these future professionals regarding the theme. Regarding the academic preparation, a study reveals that nursing students feel themselves unprepared to meet the technical requirements of the care with terminal patients, resulting in troublesome experiences and self guiltiness. Students stated that had very few opportunities in the internships to take care of terminal patients and that, when they do it, they do not feel guided and supported.¹⁶

In the evaluation of the attitudes before suicidal behavior were identified changes, occurred among nursing students, regarding the perception of professional capacity to deal with these patients and negative feelings before these patients. The increase in the perception of own professional competence among future nurses (p <0.05) is critical to the qualified care of patients with suicidal behavior.^5,12 This change in attitude runs counter the reality that needs to be modified for the improvement of the care of the professionals towards people who do not see meaning in their lives from the reflection of the prejudices and difficulties of the owns professionals and consequently the negative attitude change towards these people such as lack of interpersonal skills in attendance and inadequate assessment. ^6,9

It is important the decrease of the negative feelings toward patients who incur a suicidal behavior (p <0.05), since it is a change that can lead to less moralistic and judicious posture and therefore, more welcoming and understanding.¹⁷ Another important aspect found is the considerable difference after the training of items: who is threatening to, generally does not kill himself and who wants to kill yourself, is not trying to kill of the factor negative feelings toward patients. Since the suicide attempt has the same phenomenological characteristics of suicide, differs from this only on the outcome, which is not fatal.¹⁸ The suicide attempt is not always stopped, but some factors may prevent the realization of death result. Depending on the cases, the rapid assistance or failure to perform the act that seeks finitude can save the individual's fateful outcome. But the act tried can cause physical damage, and does not exempt the person from pain and physical suffering.¹³

It can be understood that the academic qualification was effective in enabling students favoring desired changes regarding their own attitudes about the negative feelings with the patient and perception of their professional competence. The negative attitude, often reported by health professionals, may be more the result of lack of knowledge and uncertainty than the real hostility to the patient.¹² Besides that many health professionals do not ask about suicidal behavior for fear of not knowing how to drive ahead the situation in case of an affirmative answer.¹⁹ In this study the factor right to suicide was not significantly different among nursing students after the training. It is known that suicide is still seen as an assault on society and not only to the individual who tried. Given this, some health professionals have paradoxical attitude where by saving lives, refuse (or hinder) the care to who presents an attempt of suicide.¹³

In Brazil, in several states, multiple studies were performed bringing to light information about the relationship between professionals and people who have attempted suicide. The information obtained is not different as the need to promote vocational qualification to attend the suicide attempts, however, show that in addition to the incipience of information/training, there is existence of stigma and prejudice toward people who require care for attempted suicide. We know the difficulty patients care of these patients, however, it is noteworthy that the classification increases the chances of close and continuous contact.¹³

The lack of information of health professionals in relation to the issue of suicide has perpetuated an inadequate approach to the issue.²⁰ In general, for health professionals, the person who attempted suicide is not seen as a patient either victim because his attitude is loaded with intentionality, the result of a choice, which can result in carelessness demand and lack of identification.²¹ Besides that there is the danger of making use of a subjective personal judgment to decide on someone's life^{. 22} One should not judge a suicide attempt because the attempt to separate those trying to those who complete the act, it may result in neglect of serious consequences.²³ Important health professionals take heed to the fact that suicide does not constitute an act of cowardice, either, of heroism, but as an act of desperation.²⁴ In this context, it is important to discuss the right to suicide during the training of future health professionals.

Conclusion. The Fundamental Studies Cycle: Suicidal behavior, while a cycle of brief studies, was effective in empowering students with clarifications and information about suicide, and that may have influenced positively in changing some attitudes of nursing students across the suicidal behavior, according to the assessment by QABSB; based on the understanding that registered negative attitudes may reveal lack of knowledge on the subject. We believe that the changes contribute to the early detection of people at risk of suicide and to a better management of the situation. The training can be a major pathway for knowledge about suicide and care practices to people who tried to reap their own lives, tending also to provide a reflection on the subject, which could facilitate the construction of absent attitudes of moral judgment. In this regard, we suggest the inclusion of an elective course, about the theme, in the curriculum of undergraduate courses in Nursing.

For judging if the changes among nursing students were consistent would be important the review after a few months of capacity building, so, as a study limitation arises that was not made a control group with academics not subject to the Fundamental Studies Cycle: Suicidal Behavior with the questionnaire of attitudes toward suicidal behavior to claim that the observed changes in attitudes occurred at the expense of qualification and not to some other external factor. Another limitation relates to participation in the study of students from different semesters of the undergraduate course, which can interfere with the results, mainly regarding to students at the end of the course, at the expense of already are under strong influence of the training courses and academic instruction considering that they can have better basis for understanding and interpretations, as well as reflections on the content from the training and thus easier to change their attitudes.

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