Attitudes and Perceptions of Emergency Department Nurses Toward Attempted Suicide: A Systematic Review

Sunday, 22 July 2018

Mikayla Mishel Cooksey, SN
Anna Marie Kastelic, SN
Kim Schafer Astroth, PhD, RN
Wendy M. Woith, PhD, RN, FAAN
Mennonite College of Nursing, Illinois State University, Normal, IL, USA

Purpose: The leading predictor for one of the 800,000 successfully completed suicides globally is having a previous attempt (World Health Organization, 2017). If these attempts are managed effectively, it may be possible to decrease the number of repeat attempts, thereby decreasing the number of successful suicides (Giacchero Vedana et al., 2017; Suokas, Suominen, & Lonnqvist, 2008). After a suicide attempt, care management usually begins in the emergency department (ED) where patients are met with a fast paced and overwhelming environment (Carmona-Navarro & Pichardo-MartAnez, 2012). Emergency departments typically focus on physiological needs instead of a holistic approach necessary to treat this vulnerable population (de Oliveira Santos et al., 2017). In addition, the attitudes of emergency department nurses, who are often the first individuals to interact with these patients, may have a significant impact on these patients' health, future treatment, and overall perception of the healthcare system (de Oliveira Santos et al., 2017). Patients with unsuccessful suicide attempts reported experiencing negative attitudes and feelings of stigmatization by ED nurses and physicians (Frey, Hans, & Cerel 2016). Patients who receive poor quality care and negative attitudes from their nurses are much less likely to attend follow up visits for further psychological support (de Oliveira Santos et al., 2017). An individual's hesitancy to reach out for support due to negative experiences with emergency department nurses could potentially lead to a successful suicide (Frey, Hans, & Cerel, 2016). The aim of this systematic literature review is to report a multifaceted and comprehensive analysis of the attitudes and perceptions that emergency department nurses have toward patients who have attempted suicide.

Methods: A literature search was conducted utilizing the National Institutes of Health supported database PubMed and the following EBSCO databases: Cumulative Index to Nursing and Allied Health Literature (CINHAL), Academic Search Complete, and PsychInfo. In the EBSCO databases, search terms included: “emergency” OR “emergency department” OR “emergency room” OR “emergency nursing” AND “suicide” OR “suicide attempt” OR “attempted suicide” AND “attitude” OR “perception” OR “bias.” Limiters were English, 1990-2017, and peer reviewed. The search in the EBSCO databases yielded 368 articles: CINHAL (n=109), Academic Search Complete (n=101), and PsychInfo (n=158). In PubMed the search differed, using the following MeSH terms: “attitude of health personnel” AND “suicide, attempted” with limiters of English, 1990-2017, and humans. This resulted in 165 articles. After duplicates were removed from the combined searches, articles retrieved equaled 409: CINHAL (n=109), Academic Search Complete (n=65), PsychInfo (n=96), and PubMed (n=139). While reviewing the 409 abstracts, additional exclusion criteria were applied: adolescent, pediatric, non-emergency department focus, non-suicidal self-harm, and suicidal ideation, which resulted in 37 articles. Upon analysis of the 37 articles, only those relevant to the aim of the review were kept for further study. These articles were evaluated using the John Hopkins Evidence Based Practice rating scale, and only original research of level three or above were included. Hand searches of the reference lists of the 37 articles resulted in no additional articles from those reference lists. This resulted in six final articles consisting of those that evaluated ED nurses, as well as those comparing ED nurses' perceptions and attitudes to those of psychiatrically trained nurses. Before the conclusion of this review, the original searches were rerun with the same search terms and limiters, which resulted in an additional 12 articles: CINHAL (n=4), Academic Search Complete (n=5), PsychInfo (n=2), and PubMed (n=1). Of these, two were included; hand searches of these articles did not yield any additional studies. In total, eight articles were included in the final review.

Results: The final articles consisted of two qualitative studies, utilizing exploratory-descriptive or Grounded Theory methods, and six quantitative studies, consisting of descriptive, cross-sectional, or comparative methods. Publication dates ranged from 1994-2017; all were level three according to John Hopkins Evidence Based Practice rating scale and of good or high quality. Location of the studies were as follows: United Kingdom (n=1), Spain (n=1), Brazil (n=3), Australia (n=1), Northern Ireland (n=1), and Taiwan (n=1). The attitudes and perceptions of emergency department nurses towards patients who attempted suicide varied. Four studies found ED nurses reporting more positive attitudes, two studies found ED nurses reporting more negative attitudes, one study found inconclusive results, and one study focused on ED nurses’ lack of humanized care. Additionally, six of the studies focused exclusively on the emergency department, while two studies compared mental health and ED nurses. In these two comparison studies, attitudes were generally positive; however, ED nurses in one study held more negative attitudes than their mental health counterparts, while the other study had non-significant findings. Overall, attitudes of ED nurses were reported to be more positive for nurses who were older (n = 2), had more experience (n = 3), and had higher levels of education or mental health training (n=2). Attitudes were more negative for nurses with deeper religious affiliations (n = 1) and those who provided care to greater numbers of patients with suicide attempts (n = 1). ED nurses were seen to be more technical with a greater emphasis on caring for physiological needs (n=3). There were also direct reports of judgment regarding suicide attempts among ED nurses (n=2); a different study mentioned nurses hearing inappropriate comments by other staff regarding this patient population.

Conclusion: Findings suggest that increased age, mental health experience, and education are correlated with more positive and understanding attitudes toward patients who have attempted suicide. Nurses also described the emergency department as a fast paced, technical, and physiologically focused environment. Caring for a suicide attempt patient was an emotionally taxing experience, providing additional challenges to the nurses’ ability to provide care. Often these situations provoked feelings of unpreparedness and incompetence in emergency room nurses. With regard to the discovered gap in the literature and the subjectivity of this topic, more research is necessary to evaluate ED nurses’ attitudes, thereby improving the quality of care received upon admission to the emergency department following a suicide attempt.