Attitudes towards suicidal behavior among nursing students

Roberto Nascimento de Albuquerque roberto.albuquerque@ceub.edu.br

Centro Universitário de Brasília, Brasil

Elisa Marina Silva Araújo

Centro Universitário de Brasília, Brasil

Tatiana Bernardes Moreira

Centro Universitário de Brasília, Brasil

Esta obra está bajo una Licencia Creative Commons Atribución 4.0 Internacional.

Deaths caused by intentionally self-inflicted injuries, commonly referred to as suicide, are a serious public health issue and have drawn the attention of studies in various scientific fields. According to the World Health Organization [WHO] (2014), over 800,000 people die by it every year – around one person every forty seconds. In addition, for every adult who commits suicide, at least another 20 attempt on their own lives.

Another important piece of data related to suicide is the high rate among young people aged 15 to 29 years old. Self-extermination appears as the second leading cause of death in this age group, second only to traffic accidents (Nascimento, Diaz, & Ruiz, 2016; Pereira & Cardoso, 2015).

Although the discussion about suicide has strengthened in recent years, the difficulty in dealing with a person with suicidal behavior can be a major factor in increasing the stigma and discrimination towards this individual (Rivera-Segarra, Rosário-Hernández, Carminelli-Corretjer, Tollinchi-Natali, & Polanco-Frontera, 2018).

Suicide becomes a more important topic among health professionals. Negative attitudes combined with technical unpreparedness can boost feelings of hostility and rejection towards someone with suicidal behavior and, consequently, lower the quality of the care provided (Karman, Kool, Poslawsky, & Van Meijel, 2014).

Thus, the phenomenon of suicide must be debated early, starting from the training process of health professionals. However, this subject has been silenced or dealt with in the university environment only in specific moments, such as awareness campaigns for suicide prevention (Kelly, McCarthy, & Sahm, 2014; Moraes, Magrini, Zanetti Santos, & Vedana, 2016).

Therefore, a more thoughtful discussion about the perceptions and feelings towards suicidal behavior from the early stages of higher education courses in the health field and, especially, among Nursing students, is an important action for breaking with the taboos around the matter and rethinking the care provided to people who have thought about, planned or attempted self-extermination (Santos, 2015).

Human attitudes, although they can remain stable throughout life, are subject to change, since they are learned and socially built predispositions, not an innate skill. Thus, knowing in advance the attitudes of nursing students towards suicidal behavior helps future professionals be actually willing to care comprehensively for these people in intense psychological distress (Magalhães et al., 2014).

In light of the foregoing, the general objective of this research is to verify attitudes towards suicidal behavior among nursing students from a private institution in the Federal District.

This is a quantitative, descriptive and exploratory study conducted at a private Nursing higher education institution in the Federal District, Midwest of Brazil, during the months of October and November 2019.

The following inclusion criteria were used: students aged 18 years or over, regularly enrolled in the Nursing course, and who signed the Free and Informed Consent Form (FICF). Whereas the exclusion criteria were: students under the age of 18; students who were not enrolled or were taking some time off from college at the time of data collection; and students who did not accept or agree to sign the FICF.

Two questionnaires were applied: one covering sociodemographic and academic variables, and another one with questions concerning attitudes towards suicide, called QUACS – Questionnaire on Attitudes Towards Suicidal Behavior –, which is validated in Brazil and allows assessing the respondents’ attitudes in terms of their cognitive, affective and behavioral components (Botega et al., 2005).

QUACS has 21 statements, followed by continuous 10-centimeter lines, that range from ‘strongly disagree’ at one end to ‘strongly agree’ at the other. In accordance with what is said in each statement, the respondents must indicate the point on each line that best reflects their opinions, feelings or reactions regarding three factors: negative feelings towards the patient, perception of their own professional competence, and the right to suicide. The score for each QUACS item is defined by the point of intersection between the continuous line of the instrument and the line drawn by the participant. The scores for each item in the questionnaire are calculated in centimeters, and the values are transferred with one decimal place to the database. The scores on each of the three factors can vary between 0 and 30 points (Botega et al., 2005; Vedana & Zanetti, 2019).

To achieve the proposed research objectives, the researchers took the following steps: (1) After approval by the Research Ethics Committee, the researchers contacted the course coordination to obtain data on the students enrolled in the Nursing course and authorization to enter the classrooms of each academic semester; (2) With authorization granted, the researchers contacted the professors, requested prior authorization and agreed on the most appropriate days to enter the classroom and apply the data collection instruments; (3) On the scheduled day, they entered the room, explained the study and the research objectives; then, those students who felt comfortable taking the survey were asked to sign the Free and Informed Consent Form. The average time for applying the questionnaires was 25 minutes per room.

Data were tabulated with the aid of the SPSS 25 software for Windows. For a better data analysis, the students were analyzed in accordance with the academic year in which they were enrolled. It is noteworthy that the Nursing course in question has 10 semesters, that is, 5 academic years.

This study was approved by the Research Ethics Committee under Opinion No. 3.626.380, of October 7, 2019, and complied with all ethical principles of Resolution No. 466, of December 12, 2012, of the National Health Council (Brasil, 2012).

The sample was determined by convenience (non-probabilistically) and included 253 nursing students. Most students were female (85.8%), youths between 18 and 24 years old (78.7%), white and brown (88.6%), single (88.5%), and childless (87.7%), as shown in Table 1.

Table 2 presents data regarding previous training on suicide, as well as suicidal behavior both on the part of the research subjects and of friends and family.

The data revealed that 64.4% of the respondents have never had any training on suicide prevention; 51.4% have had suicidal ideation; 20.2% of the students have tried to kill themselves; 41.1% have a family member who has attempted suicide, and 18.2% of them have a family member who has died as a suicide victim. They also revealed that 72.3% of the students have friends who have attempted suicide, and 26.5% have friends who have died because of suicide.

Table 1. Sociodemographic data on the research participants by sex, age, race, marital status and maternity/paternity. Brasília, 2019 (n=253).

Source:The authors themselves.

Table 2. Data on the research participants related to previous training on suicide prevention, suicidal ideation, suicide attempts, and cases of suicide among friends and family members. Brasília, 2019.

Source: The authors themselves.

Next, data referring to the students’ responses regarding QUACS Factor 1 – Negative feelings towards suicidal patients will be presented.

Most students disagreed with questions 2, 5, 13, 17 and 19 and did not either agree or disagree (score close to 5) with questions 9 and 15. It is noteworthy that students in the first and fifth years of the course presented the highest/lowest means compared to those in the other academic years.

First-year students believe that ‘those who threaten to kill themselves usually do it’; ‘that they prefer to get involved with people who have attempted suicide’ they are more afraid to ask about suicidal ideas and end up inducing the person to suicide; and those who really want it just kill themselves. These data are presented in Table 3.

Table 3. Mean of the survey participants’ answers, by academic year, in accordance with the questions related to Factor 1 of the Questionnaire on Attitudes Towards Suicidal Behavior. Brasília, 2019.

Source:The authors themselves.

The next table presents the means of the survey participants’ answers, by academic year, in accordance with the questions related to QUACS Factor 2 – Perception of one’s own professional capacity. Students in the first and fifth years of the course also presented higher/lower means compared to those in the other academic years.

The data revealed that, although first-year students perceive themselves able to notice when a person is at risk for suicide, they did not feel prepared to take care of these people. In addition, they felt more insecure to care for a suicidal individual.

Fifth-year students reported greater capacity to help and better preparation to assist a person who have tried to kill themself. However, it is noteworthy that the mean of their answers remained between 4 and 6 points, that is, they neither disagree nor fully agree with such statements.

The greatest insecurity when it comes to caring for people who have gone through suicide was found among second-year students. These data are displayed in Table 4.

Table 5 shows the mean of the survey participants’ answers, by academic year, in accordance with the questions related to QUACS Factor 3 – Right to suicide.

First-year students presented the lowest mean when it was said that a person who wants to kill themself has this right, that is, they disagree with this statement; and agreed that talking to said person could be a good suicide prevention strategy. Fifth-year students presented the highest mean when it was said that life is a divine gift and that only God can take it away.

This factor was the one that most presented a stigmatized attitude towards suicide. This was evident in the close connection that the respondents made between the gift of life and the divine power/gift, in addition to them disagreeing, for the most part, that a suicidal person would have the right to kill themself. However, they disagreed that suicidal behavior would be a ‘lack of God’. These data are presented in Table 5.

Table 4. Mean of the survey participants’ answers, by academic year, in accordance with the questions related to Factor 2 of the Questionnaire on Attitudes Towards Suicidal Behavior. Brasília, 2019.

Source:The authors themselves.

Table 5. Mean of the survey participants’ responses, by academic year, in accordance with the questions related to Factor 3 of the Questionnaire on Attitudes Towards Suicidal Behavior. Brasília, 2019.

Source: The authors themselves.

A worrisome information from this survey was the high rate of suicidal ideation (51.4%) and previous suicide attempts by the respondents (20.2%). These high numbers are in line with data from the Ministry of Health (Brasil, 2021), which revealed a high rate of cases of attempted self-extermination among young people aged 15 to 29 old in the country.

These high rates of suicidal behavior were also pointed out in a research with other nursing students in Brazil. This survey highlighted that the profile of young people from Generation Z, to which many nursing students belong, are, to some extent, distant from the profile required for the provision of nursing care. This profile requires the use of interpersonal and communication skills, in addition to patience, dedication, empathy and co-responsibility. This possible mismatch can negatively impact students during their training period, triggering serious psychological problems, including suicidal behavior (Albuquerque, Borges, & Monteiro, 2019).

Another important piece of data from the current research was the interaction of students with close people (family members and/or friends) who exhibit or have exhibited suicidal behavior. This tie can cause a negative psychological impact on these people who lived with individuals who thought about/planned/attempted suicide (Batista & Santos, 2014). The literature has shown that being around people who have experienced suicidal behavior can both facilitate the occurrence of suicidal thoughts and increase the fear and anxiety towards caring for people who have gone through such a situation (Karman et al., 2014; Rother, Henriques, Leal, & Lemos, 2014; Pitman et al., 2017).

On the other hand, it is inferred that previous experience with suicidal behavior (ideation, planning or attempt) may have been an important predictor for the nursing students in this survey to present more understanding and less prejudiced attitudes towards suicidal people.

In this sense, it is necessary to talk carefully about suicide to students who have had experiences related to the subject. In addition, it is paramount to investigate the risk of suicide in detail among these students considered potentially vulnerable, as suicidal thoughts have been relatively common in the university environment (Klonsky, May, & Saffer, 2016).

Lack of training on suicide has been constantly addressed among university students in the health field. Most medical schools do not encourage teaching about suicide, or do so poorly. As a result, students cannot grasp the necessary information or develop skills to diagnose and treat prevalent psychiatric disorders (Magalhães et al., 2014).

Other studies have also shown that there is some discontent and lack of preparation on the part of both trained and aspiring health professionals to deal with suicidal behavior. Students, in particular, felt unable to deal with a situation in which a person committed or was thinking of committing suicide (Moraes et al., 2016; Vedana & Zanetti, 2019).

Additionally, students do not always search for suicide prevention material on their own initiative or prioritize studying issues addressed on the tests they took in the undergraduate course (Moraes et al., 2016; Vedana et al., 2017). For effective changes to happen in these students’ attitudes and behaviors, it is necessary to discuss the approach to suicide prevention systematically in undergraduate Nursing courses, as this is a frequent problem that impacts society (Carmona-Navarro & Pichardo-Martínez, 2012; Norheim, Grimholt, Loskutova, & Ekeberg, 2016).

There is a need to deconstruct individual beliefs and values impregnated by prejudices and concepts about suicide, as such attitudes can interfere with the comprehensive and humanized care for these people who have gone through the situation of self-extermination (Botega, 2015).

Therefore, for effective changes to happen in these students’ attitudes and behaviors, it is important to discuss suicide frankly, free from religious concepts and prejudices (Norheim et al., 2016; Loureiro & Costa, 2019). Moreover, contextualized discussions should be included together with practical activities and curricular internships that can contribute to the incorporation of positive attitudes towards death and suicide (Magalhães et al., 2014). Solely having discussions with students during their internships is not enough to change negative attitudes related to suicide (Moraes et al., 2016).

Thus, the first step towards this change is to talk about suicide clearly and objectively in higher education institutions, especially among future health professionals who will have to deal with this reality every day (Almeida, Benedito, & Ferreira, 2017). Possible negative perceptions related to suicide can be demystified as soon as universities allow an adequate approach to the theme in these spaces (Kirchner & Queluz, 2019).

This study assessed the attitude of nursing students towards suicidal behavior in order to find possible gaps in their learning process involving this theme. However, it is not feasible to state that the results reported in this survey would be found in all nursing colleges in the country. However, the results of this study raise relevant questions regarding how this issue is treated or how it should be approached in Brazilian universities.

Difficulties in talking directly about the subject, powerlessness when faced with a person who thinks about killing themself, lack of training on how to care for suicidal people, combined with a conservative and religious attitude towards suicide, were important predictors for the creation of pedagogical and training strategies during the education process of these students.

Understanding the attitudes of students in the health field, especially nursing students can bring about a change in the understanding of suicidal behavior and, consequently, a prejudice-free nursing care, besides the attempt to provide a comprehensive and humanized care.