Nursing Best Practices for Patients at Risk for Suicide: Adolescent Perceptions of Helpful Care

Catherine P. Gros, N, MSc (A) Assistant Professor, McGill University School of Nursing Nurse Clinical Specialist, Douglas Mental Health InstituteTamsin Mulvogue, MSc(A); Sacha Jarvis, MSc(A); Johanne Renaud, MD3rd Nursing Research & Evidence-Based Practice Symposium: The Power of TEAM InquiryUniversity of Vermont & FAHC November 12, 2011

The Power of TEAM Inquiry:Whats wrong with this picture?

In Collaborative Nursing Practice, Patients & families are ESSENTIAL team membersACTIVE PARTICIPANTS in assessment, planning & evaluation of carePatient & Family-Centered Care:means the person & family are at the center of care! Therefore,Nursing Best Practices are ultimately determined by patients & familiesWhat are the perceptions of adolescents regarding helpful Nursing care during suicide risk? The Power of TEAM Inquiry: Who Decides?

Suicide is a complex phenomenon: Influenced by an open system of biophysical-social-environmental interactionsRelated to personal life experiences, gene expression & human bio-pscho-social development

Suicide in Context:

Suicide is a principal cause of death in the adolescent population in Qubec & a significant health concern worldwide

Human studies: traumatic relational life experiences (child abuse) alters gene expression, leading to changes in the brain & increased susceptibility to anxiety, depression and suicide (McGowan et al, 2009)

Animal Studies:Rat pups experiencing caring maternal interactions showed healthy brain development & were significantly calmer than high stress rats from low care mothers.

Conclusion: caring interactions affect gene expression & determine hypothalamic-pituitary-adrenal (HPA) functioning, affecting healthy brain development and behaviour (McGowan, et al, 2009).

Epigenetic Research Findings:

Helping Suicidal Patients: The Nurses Role

During suicide risk: Nurse-patient contact is intense Intervention is: close to continuous 24/7

High dose nursing care = High impact on patient outcomes

Frontline nurses spend more time intervening with hospitalized patients than any other professional group; admission to discharge

In the Literature:

The vast majority of healthcare research related to suicide focuses on interventions delivered by professionals other than nurses

Evaluating risksSearching for & removing dangerous objectsImplementing close or constant surveillance

Regarding Nursing Interventions & Suicide Risk Existing research is:Qualitative Rare (few in number)Narrow in scope Current studies focus on: Prescribed treatments & control measures1-5

Research on Nursing Intervention during Suicide Risk Target outcomes focus mainly on: Patient safety Physical protection Preventing self-harm1-5

In Conclusion

Little attention has been paid to the interventions nurses implement in their daily interactions with suicidal in-patients

Relational nursing interventions offered throughout the course of hospitalization are poorly described

Little is known about the impact of nursing care on patient health outcomes

The patients perspective of helpful Nursing interventions during suicide risk requires further study...

What are the perceptions of adolescents at risk for suicide regarding helpful nursing care during hospitalization?

% (n=6)Age16171866.616.616.6SexMenWomen16.683.3Ethnicity CaucasienOther100.00LanguageFrenchEnglishBilingual16.650.033.3DiagnosisDepressionAnorexia/Bulimia & DpressionBorderline Personnality33.316.650.0Length of Hospital Stay1 7 days1 4 weeks> 1 month50.033.316.6Suicide RiskCurrentPrevious33.366.6

Developing a unique & caring human relationship

Working in partnership to manage illness & suicide riskCreating a health-promoting hospital environmentResults: Based on Interviews with Suicidal Teens: Helpful Nursing Interventions occur across 3 Domains of Care

IDENTIFY & ACCOMMODATE INDIVIDUAL PREFERENCES: Notice [whats] unique to me... If theres something special I want, like chocolate milk, make sure [its] there for me.INITIATE CONVERSATION: Talk to me. It really helps when someone tries to start a conversationAsk about my life & take an interest in what we do. Asking everyday questions like: Hows your day going? helps us feel safe. SMILE! Be kind & friendly. If someones smiling, youre smiling; it can spread. GET UP-CLOSE & PERSONAL: Be intimate. [Dont] talk in the doorwayCome in & sit down on my bed.

LISTEN WTHOUT IMPOSING CONSEQUENCES: If I speak of suicidal ideas, be present & listen. Dont panic & take away my privileges. We just need to talk when were feeling bad.UNDERSTAND THE PAIN: probably the most important thing, [is ]actually understanding, not just on a scientific level, but on an emotional level, how deep the despair isEARN TRUST: [having a nurse you can trust] helps you get better, because its really hard to find people you trust when youre in that situation [suicidal]LEARN TO TRUST: Believe in us. Were the best judge. No one knows better than me if Im going to kill myself.

IDENTIFY & WORK WITH STRENGTHS: Focus on the positive like notice the parents carethat will help so much, cuz if youre going to therapy, youre saying your problems. Its negative, negative [pointing out the things youre good at] makes you want to live. It really does. It makes you think that youre not completely worthless.

OFFER PERSPECITVE: Give a different point of view cuz when youre in that mindset, your vision is very tunneled, so to open [the patients] mind really could make a difference

BRIDGE HOSPITAL & HOME LIFE: Do normal activities more like youre having like your real life Make us feel like were not so detached from our normal world ACCOMPANY PATIENTS OUTDOORS! Just being able to feel the sun, being outside really helped me because you got that feeling of liberation It felt like I wasnt in prison.

BE WELCOMING TO PATIENTS & FAMILIES:The nurses would try to build this cooperative family atmosphere. Like: Oh, right this way. Come on in.

Summary of Findings:

In the hospital setting:Strongly Agree When Im on constant observation, it helps when the nurse lets me spend some time alone, if I say I need it. 100%It helps when my nurse keeps in touch and continues to take an interest in me; especially when Im feeling better & Im no longer considered suicidal.100%

Reported health outcomes resulting from nursing care:Strongly AgreeThe nursing care I receive in the hospital can decrease my risk of suicide by helping me feel more hopeful & positive regarding myself, my family &/or my situation. 100%The nursing care I receive when Im in the hospital has an impact on my ability to cope at home, at school & with my family following discharge. 100%Feedback on the Questionnaire:

Completing a questionnaire like this during my hospital stay can help the nurse better understand me and my needs. 100%

Nursing interventions make a significant difference to the health & recovery of hospitalized teens at risk for suicideRelational nursing interventions are low cost & relatively easy to apply. However:They are neither routinely nor deliberately practicedTheir therapeutic value may be underestimated

Study Findings:Illustrate the importance of collaborative, strengths-based nursing practice with suicidal in-patients-Call for a critical review of current policies/procedures

Provide evidence for staff education & development-Knowledge translation requires staff coaching & supportFuture research includes: To develop, validate & test the HNQ Conclusions & Implications

1. Fletcher, R. F. (1999). The process of constant observation: Perspectives of staff and suicidal patients. Journal of Psychiatric and Mental Health Nursing, 6, 9-14.2. Cutcliffe, J. R., & Stevenson, C. (2008). Feeling our way in dark: The psychiatric nursing care of suicidal people A literature review. International Journal of Nursing Studies, 45, 942-953.3. McLaughlin, C. (1999). An exploration of psychiatric nurses and patients opinions regarding in-patient care for suicidal patients. Issues and innovations in nursing practice, 29(5), 1042-1051.4. Yonge, O. (2002). Psychiatric patients perceptions of constant care. Journal of Psychosocial Nursing & Mental Health Services, 40(6), 22-29.5. Stewart, D., Bilgin, H. & Bowers, L. (2010). Special observation in psychiatric hospitals: A literature review. Report from the Conflict and Containment Reduction Research Programme, London: Institute of Psychiatry at the Maudsley. November, 2010.6. Jones, J., Ward, M., Welman, N., Hall, J., & Lowe, T. (2000). Psychiatric inpatients experience of nursing observation. U.K perspective. Journal of Psychosocial Nursing & Mental Health Services, 38(12), 10-20. 7. Cardell, R., & Pitula, C. R. (1999). Suicidal inpatients perceptions of therapeutic and nontherapeutic aspects of constant observation. Psychiatric Services, 50(8), 1066-10708. Gottlieb, L. N., Feeley, N., with Dalton, C. (2005). The Collaborative Partnership Approach to Care: A Delicate Balance. Toronto, ON: Elsevier-Mosby9. Pless, I.B., Feeley, N, Gottlieb, L.N, et al. (1994). A randomized trial of a nursing intervention to promote the adjustment of children with chronic physical disorders. Pediatrics. (94) 70-7510. Gros, C. P., & Young, L. (2007). Teaching the McGill Model of Nursing and client-centered care: Collaborative strategies for staff education and development. In L. E. Young & B. L. Patterson (Eds.), Teaching Nursing: Developing a Student Centered Learning Environment (pp. 190-221). Philadelphia: Lippincott, Wms & Wilkins 11. Stewart, M.A. (1995). Effective physician-patient communication and health outcomes: a review. Can Med Assoc Journal . 152 , 1423-33.12. Anthony, W. A. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16(4), 1-23.13. Park, N, Peterson, C & Brunwasser, SM (2009). Positive Psychology and therapy in: N.Kazantzis, MA Reinecke, A Freeman (eds). Cognitive and behavioural theories in clinicla practice. New York: guilford. 278-306. 14. Seligman, MEP, Steen, TA, Park, N & Peterson, C (2005). Positive psychology progress:Empirical validation of interventions. American Psychologist, 60, 410-21.

****Ferand, Renaud, Changnon (2004)Murray & Wright (2006)Bowley & Bratley (2005)Paulson & Everall (2003)Walsh & Minor-Shork (1997)Langlois & Morrison (2002)De Munck, Portzky & Van Heerington (2009)Sorter (2010)Allen & Warner (2002)Gottlieb, Feeley, Dalton (2005)Gros & Young (2007)Thorne, Kirkham & MacDonald-Emes (1997)

*Ferand, Renaud, Changnon (2004)Murray & Wright (2006)Bowley & Bratley (2005)Paulson & Everall (2003)Walsh & Minor-Shork (1997)Langlois & Morrison (2002)De Munck, Portzky & Van Heerington (2009)Sorter (2010)Allen & Warner (2002)Gottlieb, Feeley, Dalton (2005)Gros & Young (2007)Thorne, Kirkham & MacDonald-Emes (1997)

*Ferand, Renaud, Changnon (2004)Murray & Wright (2006)Bowley & Bratley (2005)Paulson & Everall (2003)Walsh & Minor-Shork (1997)Langlois & Morrison (2002)De Munck, Portzky & Van Heerington (2009)Sorter (2010)Allen & Warner (2002)Gottlieb, Feeley, Dalton (2005)Gros & Young (2007)Thorne, Kirkham & MacDonald-Emes (1997)

**Ferand, Renaud, Changnon (2004)Murray & Wright (2006)Bowley & Bratley (2005)Paulson & Everall (2003)Walsh & Minor-Shork (1997)Langlois & Morrison (2002)De Munck, Portzky & Van Heerington (2009)Sorter (2010)Allen & Warner (2002)Gottlieb, Feeley, Dalton (2005)Gros & Young (2007)Thorne, Kirkham & MacDonald-Emes (1997)

*Ferand, Renaud, Changnon (2004)Murray & Wright (2006)Bowley & Bratley (2005)Paulson & Everall (2003)Walsh & Minor-Shork (1997)Langlois & Morrison (2002)De Munck, Portzky & Van Heerington (2009)Sorter (2010)Allen & Warner (2002)Gottlieb, Feeley, Dalton (2005)Gros & Young (2007)Thorne, Kirkham & MacDonald-Emes (1997)

*Ferand, Renaud, Changnon (2004)Murray & Wright (2006)Bowley & Bratley (2005)Paulson & Everall (2003)Walsh & Minor-Shork (1997)Langlois & Morrison (2002)De Munck, Portzky & Van Heerington (2009)Sorter (2010)Allen & Warner (2002)Gottlieb, Feeley, Dalton (2005)Gros & Young (2007)Thorne, Kirkham & MacDonald-Emes (1997)

*Cette recherche, dirige par une approche collaborative centre sur le patient, mne des entrevues ainsi quun questionnaire exploratoire auprs des adolescents a risque suicidaire pour mieux comprendre quelles sont, selon eux, les meilleures actions, attitudes et approches offertes par les infirmires dans le milieu hospitalier*****

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