Attitudes Toward Suicide: Examining Qualitative Data

Suicide Prevention in Students

Assessing APRNs’ attitudes toward suicide and examining their comments about suicide can promote awareness and opportunities for education in teens and young adults who may consider being involved as peer mentors in campaigns to prevent suicide.

Examining studies that were conducted in schools demonstrates prior suicide prevention efforts in these settings. Most teens and young adults were enrolled in high school or undergraduate studies. Four researchers focused on suicide prevention with schools. The first study comprised 700 adolescents in high school classrooms, in which adolescent peer leaders delivered a suicide prevention program. The study found peer modeling to be a healthy coping mechanism and students with a history of suicidal ideation benefitted from participation in this program (Petova et al., 2015).

Petova et al. (2015) focused on positive outcomes as opposed to negative consequences or outcomes that suicide prevention campaigns generally focus on. The authors reported that their study was the first to evaluate the impact of positive themed suicide prevention on high school aged students. APRNs who intervene to assess for suicide in their patients are encouraging discussion about mental health topics in their practice settings. These adolescents will be empowered to get help for themselves in the future and act as peer models in their own school communities (Petova et al., 2015).

The second research team investigated the extent to which non-suicidal self-injuries in young adults contributed to suicidal thoughts and behaviors. More than 1,400 students in a national sample participated from five colleges in a longitudinal study. The instrument used was called A Survey of Student Wellbeing, which participants accessed via the internet. The results demonstrated that self-injury contributed to suicidal thoughts and behavior in 61.6% of cases. Because suicidal self-injury can contribute to suicidal thoughts and behaviors, it is an important topic to address for practitioners treating teens and young adults (Whitlock et al., 2013).

The third research team examined whether belonging to a fraternity or sorority had an influence on suicidal behavior or depression. The hypothesis that membership in a fraternity or sorority would be associated with social support, increased self-esteem, lower depression, and decreased suicidal ideation was not supported by the study. Participants included approximately 300 students nationally who were primarily female. The Beck Depression Inventory, Rosenberg Self-Esteem Scale, and Multidimensional Scale of Perceived Social Support were used. The study comprised less than one third males (Ridgway et al., 2014).

The fourth research team examined emotion regulation difficulties in high school students and youth–adult relationships. This study had approximately 8,000 students participating from more than 30 high schools in upstate New York and North Dakota. There were several scales used to measure suicide attempts, emotion regulation, and adolescents’ perceptions of a trusted adult in the family, at school, and/or in the community. The study found that having a trusted adult in the community was associated with fewer suicide attempts. APRNs screening youth and their family members can provide support and positive reinforcement for healthy interactions between youth and adults as a source of strength (Pisani et al., 2013).

Suicide Prevention in Rural Communities

Walker et al. (2009) examined the pre- and post-test measures of attitudes, knowledge, self-esteem, and self-acceptance related to suicide in a national sample of 63 high schools from rural communities that participated in a suicide prevention training program. Results indicated a significant increase in participants’ self-esteem, positive attitudes, and knowledge of suicide prevention but not an increase in self-acceptance. The authors suggest future work be conducted on improving peer support efforts. APRNs who complete training programs will have exposure to suicide prevention strategies that can lead to increasing knowledge and self-acceptance in teens and young adult patients.

Depression and Suicide

Researchers recommend psychiatrists incorporate depression and suicide screening at each encounter (Horowitz et al., 2009; Mann et al., 2005). However, it is imperative that pediatric and psychiatric APRNs incorporate depression and suicide screening during each well visit as an assessment measure (Shain & the Committee on Adolescence, 2016). These measures should occur for all patients as a baseline assessment and APRNs should create opportunities to have discussions with patients about depression and suicide.

Two groups of researchers discussed depression, with relevance to suicide awareness and prevention. In the first study, secondary data analysis was conducted by nurse researchers using the Beck Depression Inventory-II in a sample of >400 U.S. naval recruits in basic training to determine whether a sense of belonging was a buffer against depression (Sargent et al., 2002). The results of the study showed that a sense of belonging was inversely related to depression among persons with depression.

The second group of researchers evaluated a school program designed to prevent depression in adolescents (Garmy et al., 2014). This quasi-experimental study took place in Sweden with 62 students who were 14 years old. These students completed a pre-test, post-test, and 1-year follow up. Most students scored lower on depression after they attended a school program on prevention of depression. APRNs can recommend school districts referring students for evaluations conduct school-based programs focused on prevention of depression and suicide in their school settings.

Medical Illness and Suicide

Research conducted by Donald et al. (2006) discussed medically serious suicide attempts, characterized by patients requiring treatment in the emergency department (ED) in hospitals versus a population-based sample of adults. The age range of the 100 participants was 18 to 24 years and a questionnaire was designed to assess suicide risk and protective factors. The researchers identified risk factors associated with medically serious suicide attempts and factors that were protective against suicide attempts. One of the protective factors was social connectedness. The researchers wished to explore an understanding of risk factors for suicide because prior suicide attempts were the greatest predictors of completed suicides. They recommended designing evidence-based practice suicide prevention activities for young adults as a preventive measure (Donald et al., 2006).

Suicide Prevention in Health Care Professionals

Studies With Nurses. Traditionally, APRNs do not receive formal training in their educational programs in assessing for suicide, preventing suicide, and counseling families about suicide. APRNs’ experiences with suicide assessment and prevention may be learned on the job through various experiences in practice. APRNs may not have a consistent protocol to follow related to suicide assessment. The literature and research about suicide prevention and education is primarily conducted in the medical community with the purpose of training medical residents to be competent in assessing suicide risk. The nursing literature that exists on this topic is limited and focuses on prevention in community settings, such as schools and community centers.

Botega et al. (2005) assessed nursing personnel’s attitude to suicide prevention in Brazil and found that few professionals felt prepared to handle the risk of suicide. Nebhinani et al. (2013) assessed nursing students’ attitudes toward suicide prevention in India and found that only one half of participants had positive attitudes toward suicide prevention as measured by the Attitudes to Suicide Prevention (ATSP) Scale (Herron et al., 2001), showing the need for education and training programs.

Another study using simulated standardized patients was conducted with a national sample of baccalaureate nursing students for the purposes of improving suicide screening behaviors (Luebbert & Popkess, 2015). Results of the study showed that the experimental group, which received the simulation versus standard lecture, demonstrated a significant difference in all measures compared to the control group.

Neville and Roan (2013) investigated nurses’ attitudes toward suicide in hospitalized medical–surgical adult patients. A national convenience sample of 45 nurses, which included some APRNs, from five medical–surgical units and the ED, participated. The Attitudes Towards Attempted Suicide Questionnaire was used to gain an understanding of nurses’ attitudes toward suicide and how to improve nursing care for vulnerable populations (Neville & Roan, 2013). Results demonstrated nurses with more education had higher mean scores on this scale.

Studies With Health Professionals. Four studies focused on health professionals’ attitudes toward suicide. The first study was conducted in Australia and examined health professionals’ attitudes toward suicide prevention initiatives. Participants were non-mental health professionals, with 26.9% being midwives. The researchers used the ATSP Scale in this study (Brunero et al., 2008). The second study was a multidisciplinary study of clinicians’ views regarding assessing suicidal patients, with primarily physicians (88%) and a combination of physician’s assistants and nurse practitioners (12%) with internal medicine practices. The study found that female primary care providers had lower confidence in assessing and treating suicide compared to male primary care providers; however, 88% of participants were physicians. The results are not specific to nurse practitioners (Graham et al., 2011).

The third study examined attitudes of health professionals toward suicide in the United Kingdom. There were 168 participants in the study, including general psychiatric nurses; however, there was no mention of advanced practice nurses being included. This study investigated adults, not specifically teens and young adults. The findings showed the most positive attitudes of suicide prevention were among community psychiatric nurses. The researchers also found more positive attitudes toward suicide prevention among staff with prior training (Herron et al., 2001).

The fourth study examined a suicide prevention program for mental health professionals. This study took place in Australia, with 242 public mental health staff members being trained in suicide prevention. There was a 3-day intensive workshop for 53 workers. The researchers stated evidence-based practices related to suicide were incorporated into the training, but those specific evidence-based practices were not reported. The study aimed to determine if the two groups of participants had differences in knowledge because of the training programs. Results demonstrated the group with more training had significantly higher knowledge when tested at Time 3. This study, which has the components of prevention inherent in the training program, could be replicated, but the training tools and instruments used need to be made available. This study does not specifically include adolescents (Donald et al., 2013).

Suicide Prevention in Primary Care

Many individuals who die by suicide visit their primary care provider within a short period before the end of their lives. APRNs would benefit from education about suicide prevention and detection, and incorporating assessment measures into each encounter would ultimately help detect this problem (Luoma et al., 2002; Mann et al., 2005).

Researchers reviewed suicide screening in the following settings: schools, primary care clinics, and EDs nationally. They highlighted the importance of the connection between depression and suicide and recommended a minimum standard of assessment for suicide at each encounter. The researchers stressed the importance of the development of instruments specific to measuring suicide that were age appropriate for youth, as opposed to using measurements only validated in adults. Another crucial factor was for youth to have a safe place to be discharged following a suicide attempt (Horowitz et al., 2009).

A national sample of individuals who ended their lives found that 45% contacted their primary care provider within 1 month prior to their death, and 77% had contact within 1 year of their death (Luoma et al., 2002). Universal screenings conducted in primary care while routine vital signs are taken (e.g., height, weight, blood pressure) would help detect at-risk patients who might otherwise not be assessed. Suicide risk and depression screenings for pediatric patients aged 11 to 21 years are endorsed by the American Academy of Pediatrics (2014, 2020).

After analyzing a national study, Wintersteen (2010) suggested screening adolescents from the ages of 12 to 17.9 to detect suicidal individuals in the pediatric population. Wintersteen (2010) trained staff at three clinics on suicide risk. By adding assessment of suicide risk to standard questions, the detection of suicidal ideation allowed quick referral to safe levels of care and prevented fatal outcomes.

Studies Examining Risk and Protective Factors

Raising awareness about risk and protective factors for suicidal patients will allow APRNs to identify suicidal clients or those at risk to receive counseling, an intervention, and/or potentially lifesaving treatment. As discussed earlier, Ridgway et al. (2014) investigated the relationship among belonging to a fraternity or sorority in college, depression, and suicidal ideation and found depression and suicidal ideation correlated negatively with self-esteem and social support. Whitlock et al. (2013) investigated the extent to which non-suicidal self-injury contributed to later suicidal thoughts and behaviors independent of shared risk factors.

In a seminal study, Resnick et al. (1997) conducted a cross-sectional analysis of data from the National Longitudinal Study of Adolescent Health, in which >12,000 adolescents from grades 7 through 12 participated to identify risk and protective factors in multiple domains. The importance of the authors’ study over time and the identification of risk factors created relevance for the current author. Using data from a longitudinal analysis provides information about risk factors to educate teens and young adults so that they may pursue healthy lifestyles.

Mann et al. (2005) examined global plans for suicide prevention by performing a MEDLINE search and identified >5,000 articles related to suicide. One of the identified interventions was prevention programs in terms of primary and secondary outcomes. The important issues identified were that most clients who experienced completed suicide had contact with their primary care physician within 1 month of death and more than 90% of suicides in depressed youths were untreated pharmacologically at the time of death (Mann et al., 2005). Therefore, the importance of conducting suicide assessments at each encounter is underscored. The need to provide pharmacological intervention for teens and young adults with depression is paramount to treat and prevent suicide.

In a research study published in the American Journal of Psychiatry, children (aged 5 to 14 years) prescribed selective serotonin reuptake inhibitor antidepressant medications had lower suicide rates, and therefore being on a medication for depression was seen as a protective factor (Gibbons et al., 2006). Waldvogel et al. (2008) examined suicide risk factors and suicide prevention. Whitlock et al. (2014) examined the concept of connectedness and suicide prevention in adolescents aged 11 to 20 years.

Suicide Contagion

Two studies investigated contagion peer suicidal behavior after exposure to suicide. The first study used a cluster method sampling design to obtain a national sample of >12,000 school-aged adolescents. The group exposed to a peer’s suicide had a higher rate of suicide attempts in both waves or years examined. Some limitations of this study include: information was gathered from self-report interviews, which could lead to possible biases; information may have been misclassified; and data were collected more than 20 years before the study (Randall et al., 2015). The second study was taken from data in a Canadian sample of >16,000 teenagers aged 12 to 17 years. Results indicated the prevalence of exposure to a school-mate’s suicide and personally knowing an individual who died by suicide increased with age. Exposure to suicide predicted suicidality in all age groups. Limitations of the study included self-report (Swanson & Colman, 2013).

Psychological Autopsy

Dr. Edwin Shneidman (1981) developed the psychological autopsy as a blueprint to recreate the events prior to and leading up to a suicide and focuses on the psychological aspects of the death. The process has been refined and now is a best practice postmortem procedure. The purpose of this blueprint is to make sense for survivors and foster preventive measures to reduce suicides in the population at large (American Association of Suicidology, 2016).

There are numerous studies using psychological autopsy. Two relevant studies include research by Portzky et al. (2009) and Houston et al. (2001). Using psychological autopsy, Portzky et al. (2009) investigated psychosocial and psychiatric risk factors of individuals aged 15 to 19 years living in Belgium who completed suicide. Relationship difficulties, adverse living conditions, and lack of treatment influenced the risk of suicide. Houston et al. (2001) investigated individuals aged 15 to 24 years who completed suicide in the United Kingdom and conducted psychological autopsy, examining coroner and medical records and conducting interviews with the living, close friends, or providers of the decedents. In this study, suicidal acts were not impulsive, but were attributed to a long history of problems starting in childhood and adolescence.

Assessing Attitudes of Health Professionals Toward Suicide

The Suicide Opinion Questionnaire. The SOQ measures individuals’ attitudes to suicide as opposed to being an instrument assessing or predicting suicide in a person (Domino, 2005). This instrument comprises 100 items that measure attitudes to suicide using a Likert scale (Domino, 1980). The questionnaire has been used nationally, as well as internationally, and examines staff attitudes, as opposed to measuring an individual’s level of suicide or suicidal behavior. The SOQ has been used in various studies, including a cross-cultural study of physicians in the United States and Italy, among college students in Canada and the United States, to compare Jews and Christians, and many other cross-cultural comparisons of groups (Domino, 2005). The study conducted using the SOQ with physicians compared attitudes and found that Italian physicians scored higher on seven of eight subscales. Researchers hypothesized that Italian physicians scored higher due to religious influences of Catholicism and the stigma associated with suicide in Italian culture (Domino & Perrone, 1993).

Suicide Opinion Questionnaire in Studies With Nurses. Alston and Robinson (1992) surveyed 184 nurses, who were members of the North Carolina State Board of Nursing, about their attitudes toward suicide using the SOQ. The nurses had various levels of education, including diploma, associate, baccalaureate, and master’s degrees. Although the entire survey was administered, only 16 items were analyzed. Results indicated that older nurses and those with more experience agreed with the patient’s right to die under certain circumstances. Participants were permitted to add free text comments after the survey.

Another group of nurse researchers assessed attitudes toward suicide in nurses and physicians working with the self-harm pediatric population in England. This study had 179 participants, of which 134 were nurses. Both groups had agreement on six of the clinical scales that were analyzed; however, physicians scored higher (which suggests a more positive attitude) on the subscale for mental illness (Anderson & Standen, 2007). The two studies with nurses are the only such studies the current author was aware of that focused primarily on nurses’ attitudes toward suicide, being assessed with the SOQ. These studies, Alston and Robinson (1992) and Anderson and Standen (2007), guided the current author in formulating the research of APRNs attitudes toward suicide in the 15- to 24-year-old population (Glodstein et al., 2018).

Representative Full Text of Statements

First statement:

Every suicide attempt has a story. So generalizations are not useful. Culture, unreasonable expectations, loss, feelings of worthlessness or undeserved success may be the motivating factor. Concerned caring listening can help.

Second statement:

In my career, I have had several patients, a former student and two coworkers who have committed suicide. Each one takes something out of the provider. The current epidemic among servicemen and women is disturbing on many levels and we must do something about it. Two years ago a former PMHNP [psychiatric–mental health nurse practitioner] student took her own life after graduation. This time I did something by establishing a scholarship in her name for future PMHNP graduates. It is an epidemic.

Third statement:

My nephew committed suicide when he was 18 years old. He had thoughts of suicide most of his life. He finally told his parents approximately 6 months before he committed suicide. He did get intensive treatment that included several hospitalizations, therapy, ECT [electroconvulsive therapy]. He had attempts that usually took place during the time of an activity that he did well in the past but due to body changes, competition, he was no longer coming in first place. Something that he took pride in became an event where he committed suicide.

Fourth statement:

My younger brother committed suicide at age 19 after two previous unsuccessful attempts. My father may have also committed suicide, but we are not sure. Loneliness, broken family, etc., had nothing to do with it. In my opinion, depression is usually the cause of suicide, but not always.

Fifth statement:

I have had three patients [commit] suicide while active patients in my practice. It is a difficult tragedy to overcome. There is too much concern now placed on “risk management” and not enough attention on the grieving process for a therapist when a patient dies by suicide.

Sixth statement:

I interrupted the suicide attempt of a friend when we were 18, in the long run she was grateful, as was I. She was depressed, lonesome, and upset at family members.

Seventh statement:

…I am a survivor, just lucky and recovered. And I try to prevent suicide in my patients and learn as much about this as I can, but the more I study, the more I realize this is often not preventable.