Introduction

Suicide is a phenomenon that occurs worldwide and, in view of the increase in the number of cases, it is considered an important public health problem. Suicidal behavior is characterized as any and all acts in which an individual causes violence to himself/herself, that is, he consciously wishes his/her own death and is aware of the results of his acts (Moreira & Bastos, 2015).

According to data from the World Health Organization, in 2012 alone, more than 804,000 suicide deaths occurred in the world (World Health Organization [WHO], 2014). It is estimated that for each suicide death there are more than 20 attempts (Marcolan & Silva, 2019). In Brazil, in 2013, there were 9,852 suicide deaths, 27 deaths per day in the country are caused by suicide, not to mention the cases of underreporting (Botega, 2014 apud Antoniassi, Rodacoski, & Figel, 2019). In the state of Paraná, suicide mortality in the years 1996 to 2012 averaged 8.4 deaths per 100,000 inhabitants, surpassing the country's averages (5.7 deaths by suicide per 100,000 inhabitants). Despite this, there is the possibility of underreporting cases, that is, the data is possibly larger than the ones presented (Rosa, Oliveira, Arruda,& Mathias, 2017).

The lack of information that attests to suicide results in lower values than the real ones (Botega, 2014). This failure in the data can make interventions difficult, as it is necessary to detect risk and vulnerability factors so that the health system establishes preventive actions against suicidal acts.

Self-inflicted injuries are the most important risk factor for suicide. They have multiple causes and are determined by social, economic, cultural, biological factors and personal life history (Antoniassi et al., 2019). Suicide attempts are, in many cases, considered injuries with low death intent, but surviving individuals become more vulnerable to new attempts, thus needing to consider the high recurrence between episodes (Silva, Sougey, & Silva, 2015).

The high rates of suicide attempts mean that health professionals who work in urgent and emergency situations are increasingly present in the care of these individuals, from the reception and adherence of the patient to the treatment to the prevention of suicide (Fontão, Rodrigues, Lino, Lino, & Kempfer, 2018). In this context, expert authors in this area claim that care in these units can be decisive for the prognosis of individuals who attempted suicide (Gonçalves, Silva, & Ferreira, 2015; Fontão et al., 2018). Thus, the evaluation and adequate intervention, as well as the limitation of the individual's access to the means to carry out the act, are fundamental to prevent deaths (Gonçalves et al., 2015).

Considering that the Nursing professional is usually the first member of the health team to have contact with the patient after suicidal ideation (Fontão et al., 2018), it is questioned: “How do the Nursing professionals in a hospital emergency department perceive and meet the people who attempt suicide?” In view of the above, the objective of the present study was to understand the perception and performance of the Nursing staff of the hospital emergency care before the care of patients after attempting suicide.

Methodology

This is an exploratory study, with a qualitative approach, carried out with the Nursing team working in the Emergency Department of the University Hospital of a municipality in the state of Paraná.

The study informants were 24 nurses and Nursing technicians who worked in the emergency room, observation, and ward of the hospital's Emergency Room. The workers were approached in person at the workplace and invited to participate in the study. On that occasion, they were informed about the objectives of the study and the type of participation desired. The inclusion criteria were to work at the service for at least 6 months and to have seen patients after attempting suicide. In turn, workers who were on vacation during the data collection period and those who were not available for the interview during or outside working hours were excluded. Eight professionals refused to participate in the study and three did not meet the inclusion/exclusion criteria.

Data were collected from January to August 2019, through individual audio-recorded interviews with the aid of digital media, after consent. Some interviews were conducted immediately before or after the end of the workday, but most of them took place during the same period, but at a time that did not compromise work activities. They lasted from 10 to 38 minutes, were held in a reserved room at the workplace and were conducted by a single person - a graduate student in the last year of the Nursing course, after training in qualitative interviews. On data collection days, the interviewer remained in the service for about three hours.

During the interviews, a script consisting of questions addressing sociodemographic characteristics and a guiding question was used: “Tell me how it was for you to assist the patient after attempting suicide”. When necessary, five support questions were used: “What is your opinion about suicide attempts?”; "In what situations do you believe they occur?"; "How do you think health professionals should act in the care of these people?"; "Have you participated in the care of a patient with suicidal ideation?"; "How was that for you?"

The content of the interviews was transcribed in full, preferably right after it ended and necessarily before a new interview. The transcribed data were textualized, taking into account the intonation, emotion and pauses present in the narrative, as well as language and slang vices.

After transcription, the data were analyzed for content according to Bardin's thematic modality (Bardin, 2011). To this end, the narratives were organized by systematizing the initial ideas: first, through the floating reading of the statements and formulation of the hypotheses, elaborating indicators that guided the interpretation; then, the interviews were coded and categories were formed, grouping similar ideas; later, the lines were classified by differentiation and regrouped to obtain the thematic categories; and finally, the categories went through the interpretation phase, basing the perspectives pertinent to the objective of the study (Bardin, 2011).

The study was developed in accordance with CNS Resolution 466/2012 and its project was authorized by the HUM's Academic Activities Regulation Committee (COREA) and approved by the Standing Committee on Ethics in Research with Human Beings at the State University of Maringá (Opinion No. 3,328,585). All participants signed the Informed Consent Form in two copies.

To preserve the identity of the participants, codenames ENF were used for nurses and TEC for Nursing technicians, followed by a number indicating the order of the interviews.

Results

Eleven members of the Nursing team were included in the study, seven nurses and four Nursing technicians. The average age was 39 years old and ranged from 21 to 51 years old, 7 of them were female, 4 divorced and white. The average length of experience in the Nursing field was 18 years. Detailed information on the characterization of the participants is presented in Table 1.

Three empirical categories emerged from the data analysis: “How can so many people struggling to live and someone wanting to take their own life?”; “The perception between idealized care versus practiced care”; and “A look at the (un)preparation of the Nursing professional”. These will be described below.

"How can so many people struggling to live and someone wanting to take their own life?"

This first category addresses the health professional's understanding of the motivations that drive the individual to try against their own lives. The Nursing professionals approached here believe that individuals who attempt against their own lives are in fact experiencing ‘psychological suffering’, but associated with feelings of failure, lack of professional realization, conflicts in personal relationships, problems to which they cannot find a solution and feeling of helplessness that causes pain that cannot be endured. Thus, they conceive that the victim sees death as the only way out of suffering.

An unbearable pain, I think it is a feeling of complete failure, of 'I failed, I cannot handle it anymore and I do not want to continue going through this pain'. ENF02

It is very difficult, because everyone has a problem that they think is big enough, so that she has to take her own life to think that she will be able to solve it. ENF03

The person cannot see any solution other than death. ENF01

Ahead, the professionals refer to suicide as a way to draw attention to something or someone, mainly family members, spouse, boyfriend/girlfriend. In this sense, they infer their perceptions through questions about the methods used for the suicidal act, judging cases of medication ingestion and self-mutilation as low intentionality of death. They found humor in the varied ways in which individuals who attempted self-extermination arrive at the emergency room, without taking into account the factors that motivated the individual to commit the extreme act.

There are people who really want to take their lives, so they look for definitive things [...] when the person really wants, she goes and usually she uses definitive means, like jumping out of a building, hanging, something like that. People who take medication, capsules of medicine, several people usually arrive at the hospital, so you see a difference in that [...]. ENF04

Then you see when the person is supposed to draw attention or when the person really wants to exterminate himself/herself, like cutting off his/her wrists then you see that the person now wants to swallow a nail? An 18- to 19-year-old girl did this, so I already think it is to get attention. Then, in a joke like that, you know (laughs). ENF07

In some cases, we observe that it is a way of calling attention [...] the person usually does not want to kill himself/herself, he/she just wants to call the attention of the other. ENF01

Often in these suicide attempts, we realize that it is a way to get attention in some way. ENF04

According to the reports, another factor that interferes with the suicidal tendency is religious attachment or belief in the divine. For professionals, the patient who does not have a religion tends to find no way out or solution to the problem that afflicts him/her. In view of this, the individual is described as a ‘weak mind’ and is susceptible to ‘evil’ acting and leaving him/her with no hope of improvement, without perspective, so that he/she sees no other way out than death.

Everyone has to have a belief, so if the person does not have a belief in something, a faith in God, then the person has no support for it, so they have no hope of improving, they have no perspective. ENF01

Sometimes the person no longer has the right mind, the mind is a little week, sometimes he/she thinks that there is no way out of anything, and I believe that the empty mind works in the head and makes things happen. ENF07

Nursing professionals reported that before a person tries to commit suicide, he/she manifests some signs of psychological alteration, characterized by depressive behaviors, small-scale self-mutilation, among others. For the interviewees, it is up to the close people and/or family members to identify these signs and act in order to prevent the situation from reaching self-extermination. However, in a contradictory way, they report on the importance of welcoming people who hear the outburst of the victim of attempted suicide.

People sometimes think that everything is lost, that there is no way out, sometimes they will talk to a person instead of helping you, throw you down, so sometimes there is a lack of a person to help, to be motivating, sometimes you throw it down and think there is no way out. ENF07

The person gives signs, you know, I think the person warns, but other people never notice, somehow, they speak, and no one ever believes, or does not understand what he is trying to say, he cannot interpret what he is saying, knowledge is lacking the family. TEC03

The idealized care x the care practiced

The professionals under study believe that in the care of patients who attempted suicide, humanization, ethics, and sensitive reception should prevail. That is, the suicidal patient must have a differentiated care from other patients, because, in this case, active and responsible listening is essential, given the need to consider psychological components in the planning, prescription and execution of care, emphasizing the importance of not judge the reasons that led you there.

It has to be a humanized service indeed, the person to see that person with love, and attend to him/her and do what needs to be done, but have compassion, compassion for the person, and not accuse, because in those hours it is no use. ENF01

As welcoming as possible than it is with other patients, this is the moment when the person is already fragile and needs some support and really needs to be a little bit more than he/she already does with other patients. ENF04

I think it has to be a little more sensitive, not because other patients do not need it, but it is that besides being physically fragile, he/she is already psychologically fragile, so one needs a more sensitive approach. ENF03

Listen, understand, talk. Why did you do that? What are you feeling? We will have to do this procedure, so, not be a psychologist or a psychiatrist, but try to learn another part of Nursing, try to talk calmly. TEC03

In contradiction to previous speeches, when specifically asked about their own performance in assisting suicide attempts, some professionals reported that the care practiced is limited to saving life and meeting the clinical needs presented.

The care, then, according to them, is based on the recovery of organic functions and rescue of the imminent risk of death, and for that they employ techniques such as catheterization, gastric lavage, and medication administration, following the institution's protocols, but without taking into account the psychosocial factors that led the patient there. That is, they do not feel responsible for the practice of qualified listening and counseling, since, according to them, this attitude is the role of other health professionals, such as psychologists and psychiatrists, fleeing the reach of Nursing care. Thus, he/she ceases to assist the patient in a holistic and integral way, as he/she forwards to other professionals that he/she considers more competent to deal with problems identified during his/her care.

Usually the service is: if the person ingested something, it is an emergency service: gastric lavage, depending on the time he/she ingested this substance, be it poison, pills or something like that. So, if it is the case: gastric lavage, venous access, hydration, try to know what type of substance he/she ingested to see if he/she has any type of antigen. ENF04

You must act naturally, try to conduct the case according to the protocol, right and do not try to understand the case, because that is not the case, this is a part of another area, of another professional. TEC02

Explain the procedures and treat them with humanity, as if it like any other disease. TEC03

All respondents, when questioned, mentioned having witnessed scenes of prejudice on the part of other health professionals, attitudes such as statements of prejudice and judgment and also in the practice of care. They even mentioned having witnessed negligence and aggressiveness when dealing with patients, such as the lack of attention due to the individual who attempted suicide, or even an aggressive attitude during the performance of procedures such as gastric catheterization and physical examination.

Sometimes even the professional's way of passing a catheter [...] the aggressive way the professional approaches it already comes with that prejudice, right? ENF01

But there are a lot of people who criticize: why did you try to commit suicide? TEC01

Some comments like: look why you did this, just took these thinks? Why did not you do it all at once, right? Why didn't you take a stronger thing already? ENF03

The (un)preparation of the Nursing professional

This category discusses the feelings of Nursing professionals when attending cases of suicide attempts in the emergency room, which show the lack of information and preparation for attending cases of suicide attempts during professional training.

Very little is said about it or almost nothing {at graduation}. [...] in my training I was not prepared, what I learned was day-to-day experiences, courses, which I searched by myself. ENF04

The student graduates without any preparation, and this is serious, because we know that it affects younger people, students, adolescents every day. ENF03

The speeches also denote the difficulty in dealing with such a situation due to the pre-judgment, the attribution of labels and the taboo that the suicidal act represents for society. Many professionals see themselves as having the right to judge whether the victim's motivation is pertinent to trying against their own lives and try to measure whether suffering is enough for such an extreme act.

What we observe is that there is a label on this patient who is the victim of an attempt, [...] we observe that professionals are often not prepared to provide this care. ENF04

At first, I had a certain prejudice in attending to certain patients, but so after you do the first care, that you start talking to them, that you start to understand their side, you are more sensitized. ENF06

In this context, some participants showed interest in courses that can assist in the care of cases of attempted suicide and, also, reported missing the approach of this theme in the continuing education courses offered by the hospital.

At the general hospital you end up having to be prepared for all the patients, because you do not know what type of patient you are going to meet [...] so I think I had to invest in this issue of the professionals being trained in this sense, especially people who work in the urgency and emergency sector. ENF04

I think the hospital itself should offer something, you know, like, they already offer a training course for so many topics, why not this topic, right? ENF03

One of the main difficulties reported by professionals refers to the unpreparedness to deal with cases of suicide attempts, since, after the assistance, they feel psychologically shaken, but do not receive support to deal with these emotions. In addition, some professionals stressed the importance of each recognizing their own limitations.

Then there are the consequences for us because you come home and you are going to think and “Why did he do that?” and there are people who really die, so you end up felling blue. TEC01

You also need to have a profile to develop that specific care and not everyone has this profile or is able to deal with this type of situation, so I think it is important that the professional who does not feel capable, who does not feel qualified, he/she does not provide that kind of assistance. ENF04

Discussion

Suicide attempts are often associated with ‘psychic pain’ that is opposed to the principles of preserving life. This action often causes suicidal behavior to be frowned upon by health professionals and a large part of society (Gonçalves et al., 2015).

Both attempt and suicide are subjects that are constantly censored. However, fostering discussions about their modalities and ways of prevention is extremely important, since they contribute to raising people's awareness, in order to elicit a more welcoming look and qualified listening to the pain of others. In this context, religion can be considered a protective factor against suicide, providing relief and control in the face of problems (Silva & Barbosa, 2019).

It is noteworthy that religions, especially monotheistic ones, positively influence the reduction of suicide rates (Bteshe, Oliveira, Clébicar, Estellita-Lins, & Salles, 2010). This may be related to a better way of facing life's stresses, reducing substance abuse, incidence of depression, promoting recovery from depression, increasing social support, and providing sources of meaning and hope (Koenig, King, & Carson, 2012).

Suicide, in many religions, is considered a punishing conduct, disrespectful of religious principles (Bteshe et al., 2010). Western society treats suicide as a weakness of spirit, linked to diabolical possessions, which causes stigma and shame (Domingos & Baracuhy, 2020). Regarding this, a study indicates that religions such as Christianity, Islam, Judaism and Hinduism believe that life is something sacred, provided by God and that it is up to the Divine to decide when the end of life will be. Even Buddhism, which does not consider the existence of God, is against suicide (Silva & Barbosa, 2019), as perceived by the professionals in this study.

Individuals who have difficulty in dealing with pain and suffering may see, in death, a possibility for the extinction of the problem. For these people, facing reality is a greater torment, so they begin to question their own existence (Silva & Azevedo, 2018). Thus, the suicide attempt occurs when there is an association between socio-cultural factors, traumatic experiences, history of psychiatric problems and/or genetic vulnerability (Rosa et al., 2015).

In the present study, it was found that some professionals question the methods used for the suicidal act, judging those with low intentionality of death to be easily reversed, since hospital care tends to guarantee the patient's survival.

Therefore, they believe that the patient does not always want to take life, but, rather, ‘draw attention’. They were emphatic in stating that someone who wants the end of his/her life takes more drastic measures, more likely to die. The perceptions apprehended here, in addition to raising professional ethical questions, are, above all, worrisome, as they highlight the form of care provided to these patients, not considering its holistic, universal, and integral scope of their needs, as determined by the law of professional Nursing practice (Law 7,498/86), without even considering the need for empathic and welcoming care, which could prevent further suicide attempts.

In this context, it is emphasized that, in assisting people in situations of attempted suicide, the intervention and evaluation carried out by health professionals have a fundamental and critical role in the patient's life, since suicide represents a permanent solution for a patient problem that could be temporary (Soreff, Basit, & Attia, 2021). In Nursing care, the professional must associate scientific knowledge with the patient's ability to observe in order to identify in advance the signs that may increase the risk of suicide (Santos, Hildebrandt, Kinalski, Fukes, & Leite, 2019). Thus, it is essential that the care provided by the Nursing team consider the patient's needs in a holistic and interdisciplinary way.

A positive example that corroborates the above statements is found in a study carried out in Norway, which identified the main characteristics that contributed to the recovery of people assisted after a suicide attempt, focused on demonstrating and providing a sense of companionship with the team and receiving individualized care and treatment, in addition to being treated with respect, appreciation and recognition of their needs and suffering. This provided the establishment of bonds of trust with the professionals, in addition to the patient's recovery. However, although most participants reported positive experiences about care, there were also reports that showed dissatisfaction (Hagen, Knizek, & Hjelmeland, 2018).

We emphasize that, differently from what was pointed out in some testimonies of this study, the suicide attempt is not an event of low/little seriousness, it expresses the illness of people, in addition to the lack of family and social support. However, there are professionals who have difficulty in dealing with the psychological distress of others and, for this reason, they judge suicidal patients as ‘drawers of attention’, treating them with indifference (Burigo, Fagundes, Medeiros, Losso, & Correa, 2015). It is worth mentioning that, although the victim uses methods that do not lead to death, this does not suggest that there was no real intention of death (Rosa, Agnolo, Oliveira, Mathias, & Oliveira, 2016).

Studies show that for every three suicide attempts at least one is attended by the emergency medical service. Thus, health professionals must have a scientific basis for the factors related to this problem, in order to offer quality care (Rosa et al., 2016), since the effective management of the suicidal patient tends to decrease the morbidity and mortality rates caused by the suicide (Burigo et al., 2015). Even though the patient is unwilling to collaborate with the assistance, it is necessary to establish a bond with him/her in order to gain his/her trust and greater participation in the care. In addition, listening properly allows for a more reliable risk evaluation (Freitas & Borges, 2017).

Practicing humanized and welcoming care is an action expected from health professionals, who must offer care, support, and clarification. In this sense, welcoming the patient with a mental disorder is fundamental and represents an important assistive technology for enabling active listening and comprehensive care, which in turn interferes with the patient's acceptance and adherence to treatment. However, this is not always the case. The neglect of this care is justified by the precarious conditions of the institutions, characterized by a high number of patients, overload of the professional, lack of structure and stressful working conditions (Gutierrez, 2014).

Some professionals realize that the suicide victim may show signs before committing the extreme act. These signs can be perceived or worsened by some lifestyle behaviors used to cope with psychological suffering, such as alcohol use or drug abuse, which reduce the cognitive ability to resolve the source of the suffering. In addition, the reduction in quality of life observed in some psychiatric disorders can be accentuated by excessive smoking, few exercises, and an inadequate diet, especially when associated with pharmacological treatment (Berardelli et al., 2018).

People with mental health problems and those with a suicidal tendency need help from family members and professionals in order to obtain enough information, enough to allow them to break barriers and seek help. In turn, the participation of the family during the hospitalization and recovery of the suicide victim will promote greater understanding of the act and assist in the treatment (Santos et al., 2019).

In this context, the development of interventions that enable the incorporation of lifestyle education is substantial, such as mental health programs, assertive community treatment, psychoeducational family treatment, psychosocial therapies, and social skills training (Berardelli et al., 2018). These activities can be extended to the community, so that mental health is understood as a collective demand, and not in an individualized way only for the people who are most vulnerable.

With regard to Nursing care, the emphasis is on the marked presence of care that is still technicist by professionals, since most of the interventions performed by them involve procedures such as medication administration, nasoenteral catheterization for substance drainage, monitoring and referral (Oliveira, Felix, Mendonça, Lima, & Freire, 2016). However, the victim of a suicide attempt needs to be considered in its entirety by the professionals. In addition, the health service, even if it is not appropriate for the specific treatment of this patient, must guarantee his/her safety, receiving, welcoming, and directing him, in addition to using the available resources to serve him/her in the most appropriate way possible (Plano Distrital de Prevenção ao Suicídio 2020-2023, 2019).

In the practice of the Nursing profession, especially in emergencies, the nurse often does not exercise all the beneficial actions that he could with the patient. There are many difficulties, such as work overload and professionals' unpreparedness, to deal with the patient's subjectivities. Furthermore, it was observed in the speeches of the participants the lack of responsibility in caring for people who attempted suicide, that is, they do not feel responsible for the practice of qualified listening and counseling. It is essential that professional nurses understand the patient and his/her family as a whole, so they need to be prepared, to be an attentive listener and offer personal and professional support in an appropriate way to restore the person, as well as their return to social life (Braz, Ramos, & Álvares, 2019).

The speeches also show the difficulty in dealing with patients who attempted suicide. This situation is due to the pre-judgment, the attribution of labels and the taboo that the suicidal act represents for society, which corroborates the result of a review study, which found that Nursing professionals who work in the emergency sector they are not sufficiently prepared to approach patients in psychiatric emergency, using unscientific knowledge (Liba et al., 2016). In this regard, the lack of knowledge leads to the reproduction of practices and stigmas of common sense, making the patient not seek health care and/or do not continue the care, generating consequences in different areas of his life (Freitas & Borges, 2017).

The professionals reported that they had not received adequate training to deal with emergency mental health situations. Thus, professionals in secondary and tertiary care report not understanding the psychological suffering that motivates suicide attempts (Burigo et al., 2015). Suicide is often misinterpreted by health professionals, as it subverts the medical order from the principle of preserving life. This makes the subject who tries against his life an unwanted patient, subjected to abuse by the team (Silva & Azevedo, 2018).

Therefore, the literature reinforces the importance of continuing education for health professionals working in the emergency care network so that they know how to deal with such situations, so that belief and judgment are not imposed in the practice of assisting victims (Freitas & Borges, 2017). One should work with a focus on reducing the stigma about suicide and mental disorders, so that it is referred to in the media as a public health issue that deserves to be addressed in an appropriate and responsible manner (Plano Distrital de Prevenção ao Suicídio 2020-2023, 2019).

Health professionals must be prepared to receive patients with psychological and psychiatric problems, offering comfort to that person, since the act generates intense emotional imbalance to the patient, and these interventions are implemented more effectively when professionals know the history and reality surrounding that patient's life (Lopes, Araújo, Neri, & Name, 2019). Therefore, care goes beyond medication administration and compliance with protocols, it is a process that encourages the protagonism of the patient and individualized care (Oliveira et al., 2017). It is necessary to train health professionals on how to approach patients who are victims of attempted suicide so that care can be provided that meets the perspective of comprehensiveness, universality, and equity, promoting welcoming, bonding and accountability for life (Fontão et al., 2018).

The process of death and dying expresses the need for health professionals to seek strategies to face such an event, which is often based on the individual's own experiences. Studies point out that, in order to understand situations about the terminality and death of people, the need for psychological support from a professional is remarkable, which will encourage acceptance of this event, making it less painful (Silva et al., 2018).

The study in focus has some limitations, such as the number of participants and their responses are very direct and brief, resulting in a very short average interview time to deal with such a complex topic. It is believed that the high number of refusals is due to the difficulty of professionals in talking about the subject, since it is a complex topic that generates resistance in professionals.

Conclusion

Most health professionals had a stereotyped, prejudiced, and taboo view of patients who attempted suicide. Although the Nursing team recognizes that there must be humanized and complete care for suicide victims, its action, in most cases, focuses only on the biological aspects of the patient. Consequently, assistance occurs without empathy and bonding, with a focus on compliance with protocols and procedures. Few professionals reported the most holistic care directed to the patient's needs.

Thus, it is important that Nursing is properly trained to practice caring for the individual who attempted suicide. Likewise, professionals need psychological support to deal with this situation. In this sense, the results of this study allowed to identify the aspects that need to be addressed in order to improve assistance to this audience. The need to address this issue in health institutions and in the training of professionals is also emphasized, since their training positively influences the identification of suicide risks, the prevention of new cases and the continuity of treatment of surviving individuals.

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Notas de autor

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