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Mental Health Nurses' Experiences of Caring for Suicidal Patients in Psychiatric Wards: An Emotional Endeavor

  • Julia Hagen
    Correspondence
    Corresponding Author: Julia Hagen, Rn, MHSc, PhD candidate in Health Science, Department of Applied Social Science, Norwegian University of Science and Technology (NTNU), 7491, Trondheim, Norway.
    Affiliations
    Department of Applied Social Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway

    Department of Social Work and Health Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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  • Birthe Loa Knizek
    Affiliations
    Department of Applied Social Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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  • Heidi Hjelmeland
    Affiliations
    Department of Social Work and Health Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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Open AccessPublished:August 02, 2016DOI:https://doi.org/10.1016/j.apnu.2016.07.018

      Abstract

      The purpose of the study is to investigate mental health nurses' experiences of recognizing and responding to suicidal behavior/self-harm and dealing with the emotional challenges in the care of potentially suicidal inpatients. Interview data of eight mental health nurses were analyzed by systematic text condensation. The participants reported 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 patients with suicidal behavior is one of the most challenging 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 C
      • Paterson B
      • Dowding D
      • Morrison R
      Long-and short-term risk factors in the prediction of inpatient suicide: A review of the literature.
      ,
      • Paterson B
      • Dowding D
      • Harries C
      • Cassells C
      • Morrison R
      • Niven C
      Managing the risk of suicide in acute psychiatric inpatients: A clinical judgment analysis of staff prediction of imminent suicide risk.
      ), 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 MD
      Suicide warning signs in clinical practice.
      ). The latter requires more involvement with the patient, exploring aspects relevant to the individual's suicide risk at that particular moment. In Norway, it is the therapist (psychiatrist/psychologist) who has the main responsibility for performing and documenting assessments of inpatients' suicide risk (National guidelines for Prevention of Suicide in Mental Health Care,
      • Norwegian Directorate for Health and Social Affairs
      National guidelines for the prevention of suicide in mental health care. IS-1511. Oslo.
      ). However, nurses provide most of the direct care of the patients and have the opportunity to identify warning signs of suicide and prevent suicidal behavior (
      • Bolster C
      • Holliday C
      • Oneal G
      • Shaw M
      Suicide assessment and nurses: What does the evidence show?.
      ,
      • Cutcliffe JR
      • Barker P
      Considering the care of the suicidal client and the case for ‘engagement and inspiring hope’ or ‘observations’.
      ). According to
      • Sun FK
      • Long A
      • Boore J
      • Tsao LI
      Nursing people who are suicidal on psychiatric wards in Taiwan: Action/Interaction strategies.
      ;
      • Sun FK
      • Long A
      • Boore J
      • Tsao LI
      A theory for the nursing care of patients at risk of suicide.
      , nurses assessed patients' suicide risk through vigilant observation, 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 JM
      • Ferszt GG
      Suicide assessment by psychiatric nurses: A Phenomenographic study.
      ,
      • Sun FK
      • Long A
      • Boore J
      • Tsao LI
      Nursing people who are suicidal on psychiatric wards in Taiwan: Action/Interaction strategies.
      ). However, some nurses are not properly educated and trained in suicide assessments (
      • Bolster C
      • Holliday C
      • Oneal G
      • Shaw M
      Suicide assessment and nurses: What does the evidence show?.
      ).
      The recognition of patients' suicide risk should lead to meaningful interventions (
      • Cutcliffe JR
      • Stevenson C
      Care of the Suicidal Person.
      ,
      • Cutcliffe JR
      • Stevenson C
      Never the twain? Reconciling national suicide prevention strategies with the practice, educational, and policy needs of mental health nurses (part one).
      ). The literature has pointed to the importance of nurses engaging in a close relationship with the suicidal patient (
      • Cutcliffe JR
      • Barker P
      Considering the care of the suicidal client and the case for ‘engagement and inspiring hope’ or ‘observations’.
      ,
      • Cutcliffe JR
      • Stevenson C
      Feeling our way in the dark: The psychiatric nursing care of suicidal people-a literature review.
      ,
      • Gilje F
      • Talseth AG
      How psychiatric nurses experience suicidal patients. A qualitative meta-analysis.
      ), where the patient feels confirmed as a significant human being (
      • Samuelsson M
      • Wiklander M
      • Åsberg M
      • Saveman BI
      Psychiatric care as seen by the attempted suicide patient.
      ,
      • Talseth AG
      • Lindseth A
      • Jacobsson L
      • Norberg A
      The meaning of suicidal psychiatric in-patients'experiences of being cared for by mental health nurses.
      ,
      • Vatne M
      • Nåden D
      Patients' experiences in the aftermath of suicidal crises.
      ) and is moved from a ‘death-oriented’ position to a ‘life-oriented’ position through the process of ‘re-connecting with humanity’ (
      • Cutcliffe JR
      • Stevenson C
      Care of the Suicidal Person.
      ,
      • Cutcliffe JR
      • Stevenson C
      • Jackson S
      • Smith P
      A modified grounded theory study of how psychiatric nurses work with suicidal people.
      ). 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 AG
      • Lindseth A
      • Jacobsson L
      • Norberg A
      The meaning of suicidal psychiatric in-patients'experiences of being cared for by mental health nurses.
      ,
      • Samuelsson M
      • Wiklander M
      • Åsberg M
      • Saveman BI
      Psychiatric care as seen by the attempted suicide patient.
      ).
      Caring for suicidal patients is emotionally demanding (
      • Cutcliffe JR
      • Barker P
      Considering the care of the suicidal client and the case for ‘engagement and inspiring hope’ or ‘observations’.
      ,
      • Cutcliffe JR
      • Stevenson C
      Never the twain? Reconciling national suicide prevention strategies with the practice, educational, and policy needs of mental health nurses (part one).
      ,
      • Cutcliffe JR
      • Stevenson C
      Feeling our way in the dark: The psychiatric nursing care of suicidal people-a literature review.
      ), and suicide/suicide attempt/self-harm evoke painful feelings in the professionals (
      • Bohan F
      • Doyle L
      Nurses' experiences of patient suicide and suicide attempts in an acute unit.
      ,
      • Castelli-Dransart DA
      • Gutjahr E
      • Gulfi A
      • Didisheim NK
      • Séguin M
      Patient suicide in institutions: Emotional responses and traumatic impact on Swiss mental health professionals.
      ,
      • Joyce B
      • Wallbridge H
      Effects of suicidal behavior on a psychiatric unit nursing team.
      ,
      • Séguin M
      • Bordeleau V
      • Drouin MS
      • Castelli-Dransart DA
      • Giasson F
      Professionals' reactions following a patient's suicide: Review and future investigation.
      ,
      • Takahashi C
      • Chida F
      • Nakamura H
      • Akasaka H
      • Yagi J
      • Koeda A
      • et al.
      The impact of inpatient suicide on psychiatric nurses and their need for support.
      ,
      • Valente SM
      • Saunders JM
      Nurses' grief reactions to a patient's suicide.
      ,
      • Wilstrand C
      • Lindgren M
      • Gilje F
      • Olofsson B
      Being burdened and balancing boundaries: A qualitative study of nurses' experiences of caring for patients who self-harm.
      ,
      • Wurst FM
      • Mueller S
      • Petitjean S
      • Euler S
      • Thon N
      • Wiesbeck G
      • et al.
      Patient suicide: A survey of therapists' reactions.
      ). It has been suggested that nurses may distance themselves in meetings with suicidal patients to protect themselves from emotional discomfort (
      • Carlén P
      • Bengtsson A
      Suicidal patients as experienced by psychiatric nurses in inpatient care.
      ,
      • Talseth AG
      • Lindseth A
      • Jacobsson L
      • Norberg A
      Nurses' narrations about suicidal psychiatric inpatients.
      ). To cope with the challenges involved in the care of potentially suicidal patients the literature has emphasized sufficient education, training, supervision and support (
      • Bohan F
      • Doyle L
      Nurses' experiences of patient suicide and suicide attempts in an acute unit.
      ,
      • Cutcliffe JR
      • Barker P
      Considering the care of the suicidal client and the case for ‘engagement and inspiring hope’ or ‘observations’.
      ,
      • Cutcliffe JR
      • Stevenson C
      Never the twain? Reconciling national suicide prevention strategies with the practice, educational, and policy needs of mental health nurses (part one).
      ,
      • Gilje F
      • Talseth AG
      How psychiatric nurses experience suicidal patients. A qualitative meta-analysis.
      ,
      • Takahashi C
      • Chida F
      • Nakamura H
      • Akasaka H
      • Yagi J
      • Koeda A
      • et al.
      The impact of inpatient suicide on psychiatric nurses and their need for support.
      ,
      • Talseth AG
      • Gilje FL
      Nurses' responses to suicide and suicidal patients: A critical interpretative synthesis.
      ,
      • Wilstrand C
      • Lindgren M
      • Gilje F
      • Olofsson B
      Being burdened and balancing boundaries: A qualitative study of nurses' experiences of caring for patients who self-harm.
      ).
      The aim of this study is to extend the existing literature and develop further the knowledge of how mental health nurses deal with the variety of demands in the care of potentially suicidal patients in psychiatric 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 ‘suicidal 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 psychiatric 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 emphasized 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 convenience sampling (
      • Patton MQ
      Qualitative evaluation and research methods.
      ). Their professional experience in psychiatric 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 rehabilitation 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 experiences, including both good interactions with suicidal patients and challenging 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 relationship with a suicidal patient? Have you experienced that a patient have attempted suicide or taken his/her life? Can you describe your experiences with regard to that? All interviews were recorded and transcribed verbatim.

      Data Analysis

      The data were analyzed by means of systematic text condensation (
      • Malterud K
      Kvalitative metoder i medisinsk forskning.
      ,
      • Malterud K
      Systematic text condensation: A strategy for qualitative analysis.
      ). The approach is inspired by Giorgi's phenomenological analysis (Giorgi, 1985, cited in
      • Malterud K
      Kvalitative metoder i medisinsk forskning.
      ), and is described as a four-step procedure: (1) reading the transcripts to get an 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 K
      Kvalitative metoder i medisinsk forskning.
      ,
      • Malterud K
      Systematic text condensation: A strategy for qualitative analysis.
      ). Two simplified examples of the analytic approach are illustrated in Table 1. All authors read the transcripts, 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 developed 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 grounded in the empirical data (
      • Malterud K
      Kvalitative metoder i medisinsk forskning.
      ,
      • Malterud K
      Systematic text condensation: A strategy for qualitative analysis.
      ).
      Table 1Examples of the Analytic Approach.
      Excerpt of meaning unitCodesCode group condensed unitDescription
      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 emitted, capture signals of self-harmResponding to suicidality

      The informant seems sensitive, and picks up signs of self-harm/suicidal acts
      Alertness to suicidal cues
      …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, danger of becoming mom, sister, friend warm and empathetic, but do not become everything, an artManaging emotion

      It seems important to be close, but prevent being too emotional close to the patients
      Balancing emotional involvement and professional distance

      Ethical Considerations

      The Regional Committee for Medical and Health Research Ethics approved the study. The mental health nurses signed an informed consent to participate. They were informed that they at any time could withdraw 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 referred 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 inspiring hope. Further, experiences of suicide and suicidal acts evoke various 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 sensitive 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 acknowledge 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, you have supervision of a patient every 15minutes, but that does not mean that 15minutes is 15minutes, you can die within 15minutes, 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 surprise 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 “.
      The nurse seemed to respond to subtle non-verbal signs communicated by the patient. Several statements from the participants show that, in addition to the assessments and decisions made by the therapist/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’
      ‘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.
      suicidal, they seem to think that the outcome (suicide) can be the same regardless if they do not act to rescue them in time.“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, or make 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 patients really, it is. But the outcome can be the same“.
      The statement suggests that it might not always be useful to distinguish between suicide attempts and self-harm, (or ‘acute’ vs. ‘chronic’ suicidal), and to claim that only the former action is suicidal and the latter is not. The nurses' alertness to suicidal cues seems to relate to all patients engaging in suicidal acts.
      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.

      Relieving Psychological Pain and Inspiring Hope

      Several of the mental health nurses' descriptions of interactions with suicidal patients were about relieving their psychological pain and inspiring hope. This process seems to involve gaining a joint understanding 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 and making the patient more receptive to positive input seem to be part of this process.“…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 revolving around the sad, terrible, and…then I think we are like taping black 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“.
      This metaphorical description illustrates the importance of drawing attention to life and possibilities for change and improvement in the situation, and not only focusing on the suicidality and related problems, although exploring the person's psychological pain and the background of the suicidality seems to be part of the process. However, although all participants are specialized in mental health nursing, one of them stated that she does not feel educated or confident enough to talk with patients about suicide, and another informant stated that there should be much more focus on caring for suicidal persons in the education.

      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 participants' 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 been more attentive. Another informant 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 addition, 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 suicide attempt may lead to self-judging among the nurses, who may not feel good or competent enough. This reflects a strong sense of responsibility for the patient's safety.
      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 she was putting me in the situation where 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 responsibility, yet she is left with uncertainty, anxiety and fear. Three other participants also shared experiences of feeling anger and frustration, particularly when a patient repeatedly engaged in suicidal acts.
      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 participant 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 suicide put an end to some of her burdens, and the feeling of sadness was accompanied with relief.

      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 sadness. Several participants used words such as “being steady”, and talked about how they had to withstand threats of suicide/self-harm, and endure the pain communicated by suicidal patients in order to provide good care.“Yes, it is about being the calm and confident one. (…) We represent, or in my opinion should represent, when someone in a deep crisis is admitted, and then someone in the surroundings has to stay calm and steady. And appear like confident then. (…) You must be aware of it so that the patient's crisis does not color [affect] you so much 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’“.
      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 the patient to share personal experiences on sensitive issues.
      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 and professional 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 thereby making it easier to act in a caring and professional manner.
      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.

      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 who were at the same age as her children, whereas another nurse mentioned it with regard to avoiding a too close connection with 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 relationships 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.
      Another nurse was challenged by what she perceived as too intimate care provided by some of her colleagues to a traumatized and (occasionally) 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.
      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 the way 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' feelings seems to help the nurses to clarify for themselves what their responsibilities 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 patients [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.

      Discussion

      The findings indicate that mental health nurses experience having specialized skills in detecting and responding to suicidality among psychiatric inpatients. In addition, caring for potentially suicidal patients involves managing emotions, emotional expressions and balancing emotional involvement and professional distance, which may be a way of providing good care of patients and oneself.
      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 R
      • Talseth AG
      • Fagerström L
      Mental health nurses' experiences of caring for patients suffering from self-harm.
      , where mental health nurses were able to observe signs of self-harm and sometimes experienced a sense of intuition regarding a patient's impending self-harm. Furthermore, our findings are in keeping with
      • Sun FK
      • Long A
      • Boore J
      • Tsao LI
      Nursing people who are suicidal on psychiatric wards in Taiwan: Action/Interaction strategies.
      ,
      • Sun FK
      • Long A
      • Boore J
      • Tsao LI
      A theory for the nursing care of patients at risk of suicide.
      who found that nurses observed overt and covert suicidal cues (verbal and behavioral) displayed by the patients. Observing non-verbal communication is important (
      • McLaughlin C
      An exploration of psychiatric nurses' and patients' opinions regarding in-patient care for suicidal patients.
      ,
      • Vråle GB
      • Steen E
      The dynamics between structure and flexibility in constant observation of psychiatric inpatients with suicidal ideation.
      ), and nurses continue to assess suicide risk through observations and conversations with the patients (
      • Larsson P
      • Nilsson S
      • Runeson B
      • Gustafsson B
      Psychiatric nursing care of suicidal patients described by the sympathy-acceptance-understanding-competence model for confirming nursing.
      ), and implement safety measures if necessary (
      • Vråle GB
      • Steen E
      The dynamics between structure and flexibility in constant observation of psychiatric inpatients with suicidal ideation.
      ). According to
      • Benner P
      • Tanner CA
      • Chesla CA
      Expertise in nursing practice: Caring, Clinical Judgement & Ethics.
      , ‘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 JM
      • Ferszt GG
      Suicide assessment by psychiatric nurses: A Phenomenographic study.
      ), and that the intuition is linked to formal and tacit knowledge (
      • Welsh I
      • Lyons CM
      Evidence-based care and the case for intuition and tacit knowledge in clinical assessment and decision making in mental health nursing practice: An empirical contribution to the debate.
      ). Whereas
      • Akerjordet K
      • Severinsson E
      Emotional intelligence in mental health nurses talking about practice.
      stated that intuition is a part of mental health nurses' emotional intelligence,
      • Klein G
      The power of intuition.
      described it as a skill built up through repeated 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 C
      Semiotics.
      ). 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 education and training of nurses could promote their skills in caring for suicidal patients.
      Some of the participants point to the lack of competence among temporary and/or inexperienced staff, leading to higher demands on experienced 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, potentially suicidal patients should be cared for by the most experienced professionals, as these persons need specific and sophisticated forms of care (
      • Cutcliffe JR
      • Barker P
      Considering the care of the suicidal client and the case for ‘engagement and inspiring hope’ or ‘observations’.
      ).
      Suicide and suicide attempt/self-harm among patients evoke various strong feelings in the participants, such as sadness, guilt, anger, frustration, fear, helplessness, and feelings of having failed. These painful emotions are common following a patient's suicidal behavior (
      • Bohan F
      • Doyle L
      Nurses' experiences of patient suicide and suicide attempts in an acute unit.
      ,
      • Joyce B
      • Wallbridge H
      Effects of suicidal behavior on a psychiatric unit nursing team.
      ,
      • Valente SM
      • Saunders JM
      Nurses' grief reactions to a patient's suicide.
      ,
      • Wilstrand C
      • Lindgren M
      • Gilje F
      • Olofsson B
      Being burdened and balancing boundaries: A qualitative study of nurses' experiences of caring for patients who self-harm.
      ). In addition, one nurse's sadness was accompanied with relief after a patient suicide, which is less reported (
      • Castelli-Dransart DA
      • Gutjahr E
      • Gulfi A
      • Didisheim NK
      • Séguin M
      Patient suicide in institutions: Emotional responses and traumatic impact on Swiss mental health professionals.
      ,
      • Wurst FM
      • Mueller S
      • Petitjean S
      • Euler S
      • Thon N
      • Wiesbeck G
      • et al.
      Patient suicide: A survey of therapists' reactions.
      ). However, people bereaved by suicide have described relief as part of the reaction when the suicide is the end of a long period of suffering and difficulties (
      • Sveen CA
      • Walby FA
      Suicide survivors' mental health and grief reactions: A systematic review of controlled studies.
      ). Several participants reported that caring for potentially suicidal patients was emotionally straining, particularly when the patient repeatedly 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 A
      • Gijbels H
      Understanding psychiatric nursing care with nonsuicidal self-harming patients in acute psychiatric admission units: The views of psychiatric nurses.
      ,
      • Tofthagen R
      • Talseth AG
      • Fagerström L
      Mental health nurses' experiences of caring for patients suffering from self-harm.
      ,
      • Wilstrand C
      • Lindgren M
      • Gilje F
      • Olofsson B
      Being burdened and balancing boundaries: A qualitative study of nurses' experiences of caring for patients who self-harm.
      ). Nurses might be burdened with feelings (
      • Wilstrand C
      • Lindgren M
      • Gilje F
      • Olofsson B
      Being burdened and balancing boundaries: A qualitative study of nurses' experiences of caring for patients who self-harm.
      ), or feel traumatized after a suicide/suicide attempt (
      • Bohan F
      • Doyle L
      Nurses' experiences of patient suicide and suicide attempts in an acute unit.
      ). Some of the emotional burden may 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 R
      • Talseth AG
      • Fagerström L
      Mental health nurses' experiences of caring for patients suffering from self-harm.
      ).
      • Richards B
      Impact upon therapy and the therapist when working with suicidal patients: Some transference and countertransference aspects.
      maintained that suicidal patients might find it difficult to share their distressing feelings, and thus project (unconsciously) 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 countertransference reactions (
      • Cureton JL
      • Clemens EV
      Affective constellations for countertransference awareness following a client's suicide attempt.
      ,
      • Richards B
      Impact upon therapy and the therapist when working with suicidal patients: Some transference and countertransference aspects.
      ).
      Mental health nurses' care of potentially suicidal patients seems to involve a great deal of ‘emotional labor’, a concept developed by the sociologist Arlie
      • Hochschild AR
      The managed heart.
      .
      • Hochschild AR
      The managed heart.
      argued that jobs with face-to-face or voice contact with the public imply ‘emotional labor’ with the purpose to affect the emotional state in others in a desirable way and to act in an appropriate and socially accepted manner. The author suggested that the emotional work is influenced by ‘feeling rules’ (expectations of what we should feel), and ‘display rules’ (corresponding outer display). Furthermore, the emotional labor may be performed through either ‘deep acting’ (attempting to experience the feeling that one wishes or is expected to display), or ‘surface acting’ (working on appearance but concealing/suppressing feelings) (
      • Hochschild AR
      The managed heart.
      ). In our study, both techniques seem to be involved when the mental health nurses attempt to feel and appear calm, confident and caring (deep acting), or to just appear as such (surface acting), 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, sadness, anger) may protect the professionals from being too involved and weakening their clinical judgment (
      • Mann S
      A health-care model of emotional labour. An evaluation of the literature and development of a model.
      ).
      However, the participants in our study also seem to spontaneously experience and express care of the patients, and although
      • Ashforth BE
      • Humphrey RH
      Emotional labor in service roles: The influence of identity.
      , 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 S
      A health-care model of emotional labour. An evaluation of the literature and development of a model.
      ). Two of the participants shared examples of expressing genuinely felt negative emotions (e.g. anger) in encounters with patients engaging in suicidal acts, suggesting that it is not always easy or desirable to comply with the common display rules in professional care. This raises the questions of what it means to be professional and of which display rules apply to mental health care, particularly with regard to the expression of felt negative emotions.
      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 S
      A health-care model of emotional labour. An evaluation of the literature and development of a model.
      ), including higher levels of stress (
      • Mann S
      • Cowburn J
      Emotional labour and stress within mental health nursing.
      ). In our study, there are examples of experiences in which a mismatch between feelings and appearance (surface acting) seems to be emotionally straining. It has been suggested that experiencing emotional dissonance over time may contribute to emotional exhaustion and depersonalization (
      • Brotheridge CM
      • Grandey AA
      Emotional labor and burnout: Comparing two perspectives of “people work”.
      ,
      • Hochschild AR
      The managed heart.
      ); signs of burnout (
      • Maslach C
      • Jackson SE
      The measurement of experienced burnout.
      ). 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 repeatedly and over time, as these patients seem to evoke more anger, fear and frustration. This is consistent with
      • Wilstrand C
      • Lindgren M
      • Gilje F
      • Olofsson B
      Being burdened and balancing boundaries: A qualitative study of nurses' experiences of caring for patients who self-harm.
      findings, where nurses reported that caring for patients who self-harm sometimes involved being so overwhelmed by fear and frustration that they struggled with their professional demands. This aspect of mental health nurses' emotional labor should be further explored in future research.
      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' care may resemble a mother'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 described by other nurses as well, for instance in research describing nurses experiences of preventing patient violence (
      • Virrki T
      The art of pacifying an aggressive client: ‘Feminine'skills and preventing violence in caring work.
      ), or caring for patients with eating disorders (
      • Malson H
      • Ryan V
      Tracing a matrix of gender: An analysis of the feminine in hospital-based treatment for eating disorders.
      ).
      • Hochschild AR
      The managed heart.
      suggested that women's maternal role may attach 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. However,
      • Hochschild AR
      The managed heart.
      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 experience of some colleagues' providing a too intimate care might also reflect transference–countertransference mechanisms between the colleagues and the patient. Becoming overinvolved and assuming too much responsibility for the patient are common countertransference responses (
      • Ens IC
      The lived experience of countertransference in psychiatric/mental health nurses.
      ,
      • O'Kelly G
      Countertransference in the nurse–patient relationship: A review of the literature.
      ). Our findings add to previous research addressing challenges with regard to closeness and distance (
      • Talseth AG
      • Lindseth A
      • Jacobsson L
      • Norberg A
      Nurses' narrations about suicidal psychiatric inpatients.
      ,
      • Tofthagen R
      • Talseth AG
      • Fagerström L
      Mental health nurses' experiences of caring for patients suffering from self-harm.
      ,
      • Tzeng WC
      • Yang CI
      • Tzeng NS
      • Ma HS
      • Chen L
      The inner door: Toward an understanding of suicidal patients.
      ) and balancing professional boundaries (
      • Gilje F
      • Talseth AG
      • Norberg A
      Psychiatric nurses' response to suicidal psychiatric inpatients: Struggling with self and sufferer.
      ,
      • Wilstrand C
      • Lindgren M
      • Gilje F
      • Olofsson B
      Being burdened and balancing boundaries: A qualitative study of nurses' experiences of caring for patients who self-harm.
      ) in the relationship between the nurse and the potentially suicidal patient.
      The present study shows that the nurses appreciate the informal support from their colleagues. Caring for suicidal patients is demanding (
      • Cutcliffe JR
      • Barker P
      Considering the care of the suicidal client and the case for ‘engagement and inspiring hope’ or ‘observations’.
      ,
      • Cutcliffe JR
      • Stevenson C
      Feeling our way in the dark: The psychiatric nursing care of suicidal people-a literature review.
      ), and nurses need informal and formal support (
      • Gilje F
      • Talseth AG
      How psychiatric nurses experience suicidal patients. A qualitative meta-analysis.
      ) of emotional and educational character (
      • Talseth AG
      • Gilje FL
      Nurses' responses to suicide and suicidal patients: A critical interpretative synthesis.
      ).
      • Castelli-Dransart DA
      • Gutjahr E
      • Gulfi A
      • Didisheim NK
      • Séguin M
      Patient suicide in institutions: Emotional responses and traumatic impact on Swiss mental health professionals.
      found that respondents that had received sufficient support reported low emotional response and traumatic impact after a patient suicide. However, our study indicates a need for more formal support, which is also reported by other nurses caring for potentially suicidal patients (
      • Bohan F
      • Doyle L
      Nurses' experiences of patient suicide and suicide attempts in an acute unit.
      ,
      • Takahashi C
      • Chida F
      • Nakamura H
      • Akasaka H
      • Yagi J
      • Koeda A
      • et al.
      The impact of inpatient suicide on psychiatric nurses and their need for support.
      ,
      • Wilstrand C
      • Lindgren M
      • Gilje F
      • Olofsson B
      Being burdened and balancing boundaries: A qualitative study of nurses' experiences of caring for patients who self-harm.
      ). Clinical supervision may lead to increased self-reflection and competence (
      • Akerjordet K
      • Severinsson E
      Emotional intelligence in mental health nurses talking about practice.
      ), and enhanced emotional awareness related to transference and countertransference reactions (
      • Cureton JL
      • Clemens EV
      Affective constellations for countertransference awareness following a client's suicide attempt.
      ,
      • Rayner GC
      • Allen SL
      • Johnson M
      Countertransference and self-injury: A gognitive behavioural cycle.
      ). Furthermore, supervision might enable the nurses to continue caring for suicidal patients (
      • Cutcliffe JR
      • Barker P
      Considering the care of the suicidal client and the case for ‘engagement and inspiring hope’ or ‘observations’.
      ,
      • Cutcliffe JR
      • Stevenson C
      Never the twain? Reconciling national suicide prevention strategies with the practice, educational, and policy needs of mental health nurses (part one).
      ), and contribute to lower levels of burnout (
      • Edwards D
      • Burnard P
      • Hannigan B
      • Cooper L
      • Adams J
      • Juggessur T
      • et al.
      Clinical supervision and burnout: The influence of clinical supervision for community mental health nurses.
      ,
      • Sherring S
      • Knight D
      An exploration of burnout among city mental health nurses.
      ). Considering the adverse effects burnout may have on professionals' mental health (
      • Pompili M
      • Rinaldi G
      • Lester D
      • Girardi P
      • Ruberto A
      • Tatarelli R
      Hopelessness and suicide risk emerge in psychiatric nurses suffering from burnout and using specific defense mechanism.
      ) and on quality of care (
      • Maslach C
      • Jackson SE
      The measurement of experienced burnout.
      ,
      • Sherring S
      • Knight D
      An exploration of burnout among city mental health nurses.
      ), our study suggests that there should be more focus on formal support systems for 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 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 AR
      The managed heart.
      ) has extended our understanding. Our study points to the importance of providing the mental health nurses with sufficient resources and support to enable them to provide good care.

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