Commentary on Sun F‐K, Long A, Boore J & Lee‐Ing T (2006) Patients and nurses' perceptions of ward environmental factors and support systems in the care of suicidal patients. Journal of Clinical Nursing 15, 83–92
Suicide, a major mental and public health problem, is a leading cause of death and a major challenge to mental health professionals worldwide. The World Health Organisation over many years set an explicit target to reduce suicide rates, however, the reality is that the suicide rates continue to increase. It is now the situation that suicide is one of the main causes of death in men in the industrialized world, along with road traffic accidents (Eurostat 2004), yet the amount of government activity and campaigns targeted at increasing road safety and transport initiatives far outweighs efforts to reduce suicide rates. The paper by Sun et al. (2006) in the first instance serves to place a focus on suicide and then goes on to expose some of the attitudes of nurses and patients underpinning the complex dynamics of a therapeutic relationship in the management of suicidal patients. The relationship between suicide and a previous episode of psychiatric inpatient care has been established (Pirkis & Burgess 1998) and this suggests that initiatives to reduce suicide must be primarily located at the suicidal patient's first point of contact with formal health services. Therefore, it is important to focus research efforts on suicide prevention around the area of suicide assessment/screening of patients at the first point of contact with mental health services and conduct longitudinal studies. The initial focus of such research work would be to screen first time attendee's with psychiatric pathology presenting to the health services and investigate suicidal tendency and ideation within a framework of primary care and prevention. Primary care and prevention must be central for research efforts on suicide if we are to redress the problem of suicide in our society. The study by Sun et al. is primarily focused on secondary care and on patients who have already attempted suicide. Sun et al. provide interesting insights into the inpatient management of suicidal patients and the inclusion of patients voicing their opinions and views is a particular strength of the paper. The patient's perception that medication was the most effective treatment from the whole range of treatments and therapies provided does highlight certain failings in the mental health care system as in recent years the mental health professions have targeted considerable efforts on the development of various therapies such as group therapy; psychotherapy; and recreation therapy. The findings of Sun et al. (2006) would support the requirement for rigorous evaluation of available services using patient perception and, in future, the views of service users must become a central pillar directing professional services and treatment regimes. Sun et al. have been quite forthright and honest in acknowledging the limitations of the study. The inclusion of a sample of single sex nurse respondents provides for an unbalanced account of attitudes, given the role of gender in psychiatric therapeutic relationships and their centrality in the reported findings of the study. A further limitation of the study, which is not highlighted clearly by the authors, is the exclusion of other mental health professionals, for example medical staff, from the data collection phase of the study. The authors do highlight the centrality of team work and collaboration in the management of patients who attempt suicide, furthermore direct comments are attributed to other members of the healthcare team. However, the absence of corroboration or any alternative perspective or responses from other members of the healthcare team makes such comments and discussion rather spurious. A selective quotation from a nurse: It is not only psychiatric nurses that can prevent suicide but all members of the team. Consequently we need team co-operation. This may be seen as unbalanced comment in that it portrays an impression that the lack of team work emanates from other members of the health care team. As proposed by the authors, team work is essential for the successful clinical management of suicidal patients therefore every effort must be made to ensure inclusiveness in research efforts. The authors discuss treatment and therapy in suicide as including five main modes, which are conventional including: medication; electroconvulsive therapy; group therapy; psychotherapy and recreation therapy. There is, however, an over simplistic, minimalist, unsubstantiated approach taken in portraying the role of the psychiatric nurse in very traditional terms and this may not be a reflection of the evolving role of the psychiatric nurse in suicide prevention as it evolves internationally. For example, in the article it is suggested that psychiatrists diagnose the condition and prescribe the medications. The psychiatric nurse administers the medication and ensures that the patients receive it. Psychiatric nursing is and has always been more then this rather basic manual intervention and in modern parlance psychiatric nurses are showing leadership in some areas of suicide prevention. It is well established that the expanded and extended role of the psychiatric nurse includes autonomous and independent therapeutic roles (Cowman et al. 2001). Safety and security in acute psychiatric wards is an essential element in the management of suicide. Violent death by suicide is occurring with increasing frequency and within the hospital setting, environmental dangers must be reduced including the absolute requirement for security precautions to protect suicidal patients from themselves. However, there is a wide variation in safety and security procedures in acute psychiatric wards (Cowman & Walsh 2004). A coherent policy and procedure is an essential requirement in ensuring a safe environment for the suicidal patient. Sun et al. (2006) in the paper are quite correct in drawing our attention to the situation of ensuring a safe environment, which may be restrictive and therefore impairing the autonomy and freedom of patients. However, a further dilemma relates to the tension between on the one hand attempting to provide a nursing therapeutic presence and on the other hand operationalising security procedures (Burrows 1991). In the management of suicidal patients the nursing challenge is to ensure an environment where procedures for safety and security are inextricably fused with a caring perspective. An unusual finding was the strength of judgmental attitudes held by psychiatric nurses towards suicidal patients. The extent to which such attitudes may be culturally context dependent and therefore not generalizable to other jurisdictions requires further discussion. Some very unacceptable and unprofessional nursing practices are reported by patients particularly in relation to the ‘protection room’. Such nursing practices are unethical and from a statutory regulatory nursing perspective in the UK and Ireland would not be consistent with a code of professional conduct and would merit attention through Fitness to Practice procedures. Such findings of malpractice create a dilemma for researchers and are worthy of further discussion in the realm of research ethics. In conclusion, the paper does raise awareness and highlight the centrality of the psychiatric nursing role in the management of the suicidal patient in the acute psychiatric ward. The views of patients are an important inclusion in the study, however, in only presenting the views of nurses an opportunity may have been missed by not examining the views of all members of the professional team in the management of suicidal patients.
Read more
6
