According to the World Health Organization (WHO; 2014), in Egypt, 800,000 people die by suicide every year. Acute psychiatric symptoms and disorders are identified as the strongest risk factors for suicide, and psychiatric inpatients constitute a high-risk group for suicide attempts (De Leo & Sveticic, 2010). For these reasons, nurses working in psychiatric hospitals and on psychiatric units are more likely to encounter suicidal ideation, suicide attempts, or completed suicides than nurses in other hospital departments.
The completed suicide of a patient represents a critical event for any nurse who was in charge of or had some contact with the individual or their family. Nurses may blame themselves and experience feelings of worthlessness associated with their inability to prevent the patient's death. Concern over the increasing number of suicides and the belief that many of these deaths could be prevented led the WHO to include the reduction of suicide rates among its major health goals for the new millennium (Hogan & Grumet, 2016). One way to prevent an attempted or completed suicide on an inpatient unit is to educate psychiatric nursing personnel in suicide prevention (Takahashi et al., 2011). The focus of the current article is to present and discuss the unique issues faced by nursing educators in Egypt and whether the education and training of nurses employed at a rural hospital in Egypt would be a useful step toward mitigating these high-risk behaviors and lethal actions.
Egyptian Nurses and Psychiatric Inpatient Units
The role of a nurse in Egypt is the same as that in other progressive countries; and, for the most part, nurses are employed in acute care hospitals according to specialized areas of care (e.g., psychiatric–mental health). Suicide attempts are higher on inpatient psychiatric units in Egypt because of several factors, including lack of (a) monitoring devices that would allow nurses to carefully observe patients; (b) nursing staff (poor nurse-to-patient ratio), which can influence the level of risk, especially when large numbers of patients are on the same ward; (c) attention to objects that can be used to attempt suicide; and (d) education and training of nursing staff about how to assess and manage these risks and behaviors (Abdel Moneim et al., 2011).
The education and training of nursing staff were found to be important to prevent suicide attempts and develop an awareness of the risk factors that may be present on each hospital ward in Egypt (Adams, 2015). An example of increasing awareness would be to teach nurses to be mindful of how hospital furniture or equipment can be used as a weapon to harm or injure oneself. Doorknobs or door levers can also provide a point of attachment for patients to use to attempt or complete suicide by hanging; yet, nurses often were unaware of this safety precaution (Brodsky et al., 2018). In addition, patients are also at high risk for suicide attempts due to lack of training and the development of skills by nursing staff to identify the signs and symptoms of suicidal ideation as well as how to provide appropriate care once the patient is at risk.
Perhaps the most important problem in Egypt is that there is no public health data bank for measuring the number of attempted or completed suicide cases that occur within a hospital system. This lack of documentation leads to the potential problem of underreporting and/or miscalculating the prevalence of deaths, which are basically unknown to government agencies. In addition, once a patient is discharged from the hospital, there is no specific community referral or treatment as an outpatient except medication management provided by a physician. Therefore, patients do not receive psychotherapy or counseling once they leave the hospital, placing the risk for mortality to be heightened and for the patient to be readmitted to the inpatient ward.
According to the WHO, the annual rate of suicide in Egypt was 10 per 100,000 individuals (Abdel Moneim et al., 2011); however, this statistic has not been validated due to lack of a consistent system of data collection. Although some reports speculate the trends, the most prominent finding reported in 2011 was related to age of completed suicides, with a high percentage of those in the 15- to 44-year-old age group, with no major difference between males and females (Abdel Moneim et al., 2011). Similar to other regions in the world, Egyptian men tend to be more violent than women when ending their lives (James et al., 2012).
The underreporting of suicide attempts and associated mortality in the public domain also impacts outcomes in hospitals mainly because it is not identified as a critical issue that needs to be addressed. It is well known that once hospitalized, individuals who have a history of suicidal ideation, attempts, and/or even violence toward themselves are at higher risk for expressing suicidal behaviors while they are inpatients (Adams, 2015). This consequence of not knowing the number of deaths by suicide both in Egyptian hospitals and in the wider community led the current Egyptian author (S.M.M.E.) to begin to explore options for planning suicide prevention in nursing education of students and also within the nursing workforce. The first step was to justify a need for this specialized education for nurses.
Nursing Education and Training for Suicide Assessment and Management
Studies in the past few decades report that most patients who are suicidal experience ambivalence toward life and death (McCann et al., 2007), and that insufficient engagement with nursing staff can increase the risk of suicide during hospitalization and after discharge (Wheatley & Austin-Payne, 2009). Despite this knowledge, poor nursing care and absence of a therapeutic relationship after suicide attempts were still experienced, reported, and described in the United States (Ellis et al., 2012; Hung et al., 2012). Studies have also suggested that lack of competent care may be related to the complicated interaction between nursing staff and patients, as well as lack of knowledge and deliberate and systematic care to counteract these problems (Ramberg et al., 2016).
In Egypt, there are no known nursing studies to understand how nurses recognize suicidal behaviors or how, as nurses, they perceive their work with patients who attempt or complete suicide. Yet, nurses need to know the importance of being able to assess and manage patients' anxiety and despair acutely and over time, as uncertainties may be fatal, including a completed suicide on an inpatient unit. Training, supervision, and support for all health care professionals is important to consider in Egypt and needs to be at the forefront of future training and education of nurses.
Nurses working in psychiatric hospitals in Egypt can play a crucial role in suicide prevention and management of these high-risk behaviors. Because nurses have the highest level of contact with patients, they are in a key position to identify those at risk of suicide and subsequently provide appropriate interventions. However, as previously described, Egyptian nurses frequently do not have the appropriate knowledge, skills, or attitudes toward suicide prevention, and frequently do not know how to engage patients when assessing for suicidal ideation, plans, or prior attempts.
These factors suggest that without this specific knowledge and training, Egyptian nurses will not be able to deliver competent care (McLaughlin et al., 2014). For many nurses, these skills are difficult because they often challenge the very core of human existence: the desire to live, not die. Suicide prevention in the Egyptian health care system needs to involve not only suicide risk assessment and risk factors (Kishi et al., 2014; Paterson et al., 2008), but also warning signs: “What is my patient doing (observable signs) or saying (expressed symptoms) that elevates their risk to die by suicide?” (Rudd, 2008, p. 88).
The latter question requires more involvement with the patient, such as exploring aspects relevant to the individual's suicide risk at that particular moment (Bolster et al., 2015; McLaughlin et al., 2014). And because nurses in Egypt provide the majority of direct patient care, they also have the opportunity to identify warning signs of suicide behaviors and prevent actions leading to serious harm or death.
The engagement of patients also requires empathy and compassion. The more skilled nurses become at conveying empathy, the more patients may feel “cared for” and understood, which then leads to trust within the interpersonal relationship (Ellis et al., 2012). It is this trusting relationship between nurses and patients that can encourage individuals experiencing thoughts of suicide to confide and talk about their intentions. Moreover, a trusting relationship can encourage an “alliance for safety” that emphasizes the partnership between patient and caregiver (Sun et al., 2019). Patient safety is a primary responsibility of psychiatric nurses.
A thorough, comprehensive intake assessment of a patient's family history of suicide; details about personal history of past and present suicidal thoughts, intentions, plans, gestures, and attempts; and current life circumstances are essential standards of care, but cannot take place in the absence of compassion and empathy.
Furthermore, providing frontline staff with the knowledge and skills to promote good emotional health and deliver early interventions for patients at risk of developing suicidal behaviors is widely advocated as an important part of addressing the issue of inpatient suicide (EU Health Program, 2017; Hodge et al., 2009). In the United States, the National Strategy for Suicide Prevention (Substance Abuse and Mental Health Services Administration, 2017) specified that all staff working directly with suicidal patients should have sufficient knowledge, training, and support to promote psychological well-being and identify early indicators of difficulty. This key theme has been reiterated and developed in successive review policy documents and clinical guidelines in Europe (National Collaborating Centre for Mental Health, 2005; National Institute for Health and Care Excellence, 2013; Stone et al., 2017).
Suicide Prevention Training
Application of Theory to Practice
Using theoretical constructs in nursing practice is a challenge in Egypt because of the differences in culture and lack of access to therapeutic interventions once patients are discharged from the hospital. Therefore, it was essential to review the literature to design a pedagogy and training program that would include assessment and management of the complex symptoms and behaviors related to suicide for inpatient nursing staff. Direct and indirect outcomes of literature were central to this process.
Direct outcomes of the knowledge base related to suicidality would focus on the nurse's ability to understand how to identify suicidal behaviors such as ideation, defined as the creation of a plan in the revised nomenclature of suicidality (Puntil et al., 2013; Sun et al., 2019). Patients who have made multiple suicide attempts are different from those who only have suicidal thoughts but do not act on them. Past suicide behavior has been shown to distinctly predict behaviors; however, predicting first attempts has perpetually posed problems in risk assessment (O'Connor & Portzky, 2018). The duration of risk can be a few hours, days, or even years in patients with chronic suicidal behavior, thereby hampering accurate prediction (Bryan et al., 2008).
Intermediate outcomes (also referred to as indirect outcomes, variables, or proxies) occur in the causal pathway between a determinant and the final health outcome. These outcomes can include increases in knowledge; changes in attitudes; acquisition of skills (i.e., identification of at-risk persons); and referrals, which can lead to decreases in depression, anxiety, and hopelessness in these at-risk patients (York et al., 2013).
The overall aim of suicide prevention in Egyptian hospitals is to train nurses to improve the standard of in-patient nursing care to include ongoing education to reduce suicide morbidity and mortality in persons who are hospitalized for inpatient psychiatric treatment. These competencies would aim to increase nurses' comfort, confidence, and competence in suicide assessment and management of suicide risk. It would be important to cover the following areas: the phenomenon of suicide; managing personal reactions, attitudes, and beliefs; developing and maintaining a therapeutic relationship; collecting accurate assessment information; communicating suicide risk to appropriate persons; formulating a risk assessment; developing an ongoing nursing plan of care; assessing the safety of the patient environment; legal and ethical issues; and documenting suicide risk.
The Challenge of Professional Nursing Education and Training in Egypt
The challenge of professional education is to prepare competent nurses who can translate theory into practice and take into account the contextual variables in each patient encounter, rather than relying solely on textbook knowledge (Ma et al., 2011). The literature suggests that reflective learning can help bridge the gap between theory and practice (Holst et al., 2017).
Reflective learning is the process of internally examining and exploring an issue of concern triggered by an experience, which creates and clarifies meaning in terms of self and results in a changed conceptual perspective (Hagen et al., 2017). Examples of reflective learning activities include writing a journal, keeping a diary, and engaging in dialogue. Engaging in dialogue is a form of reflective conversation and can enhance one's ability to form perspectives, which serves to strengthen the bond between theory and practice (Takahashi et al., 2011; Valente & Saunders, 2010). A more structured form of dialogue can be experienced through activities such as case discussion or role play. Through reflective learning, the learner can challenge existing knowledge and practice, which is particularly conducive to promoting deep learning (Birch et al., 2011). Reflection can also lead to greater self-awareness (Dishon et al., 2017), a particularly important element of suicide prevention that involves personal values and attitudes.
Using the reflective process is the next step in creating a pedagogy for training nurses in Egypt to learn these skills. The following section highlights excerpts from a project implemented in Egypt as part of a doctoral program.
Reflection as the Foundation for Skill Building
There are a number of different skills that nurses can learn to use when intervening with patients who are at risk for suicidal ideation on inpatient units, including: (a) awareness of suicidal cues; (b) relieving psychological pain and inspiring hope; (c) regulation of emotions and emotional expressions; (d) balancing emotional involvement and professional distance; and (e) observation. Each of these skills is presented briefly and discussed for application to practice.
Awareness of Suicidal Cues
Psychiatric nurses need to be aware of patients' emotional states at all times while they are hospitalized on inpatient units. Nurses need to observe the subtle suicidal cues or warning signs, and act on them to prevent patient self-harm/suicidal acts. However, one important challenge is that many inpatient nurses in Egypt lack competence and/or clinical experience (e.g., temporary nurses working in the summer and occasionally on the afternoons/weekends), and also lack the skills to assess for suicidal cues or other signs that indicate that the patient is decompensating.
Relieving Psychological Pain and Inspiring Hope
Several mental health nurses' descriptions of interactions with suicidal patients are about relieving patients' psychological pain and inspiring hope (Hung et al., 2012). This process seems to involve gaining a joint understanding of the patient's life situation and suicidality and helping the patient to be more oriented toward life and the future. Broadening the patient's perspective and making the patient more receptive to positive input is an important part of this process. Another critical challenge is nurses' lack of confidence in talking with patients about suicide, which may result from lack of education that they receive as part of their training.
Regulation of Emotions and Emotional Expressions
Nurses work hard to be confident and calm, or at least to appear as such, in acute and difficult situations (e.g., when facing distressed and suicidal patients or verbal/physical aggression). A calm and controlled appearance sometimes involves suppressing or concealing negative feelings, such as fear, anger, and sadness. Several participants in training used words such as “being steady” and talked about how they had to withstand threats of suicide/self-harm as well as to endure the emotional pain communicated by suicidal patients to provide good care (York et al., 2013).
Balancing Emotional Involvement and Professional Distance
To balance the emotional involvement and professional distance that is part of a therapeutic relationship, nurses need to be empathetic and caring, yet maintain boundaries with patients. Difficulties facing nurses balancing these skills appear to involve reflecting upon challenging interactions (e.g., with colleagues or alone in the car on the way home), processing the experiences, and attempting to separate their feelings from their patients' feelings.
Routine monitoring of patients is always done in psychiatric settings, and checks should be staggered within the interval so as to be less predictable. This monitoring also provides an opportunity to do more than just count heads and note locations. Temkin and Crotty (2004) recommend using the check function to notice and record the patient's visual appearance and behavior so as to increase the quantity and quality of information. They developed a Precaution Monitoring sheet that aids in this approach. Nurses' knowledge of risk factors and risk predictors (Weber et al., 2017), as well as particular alertness to any change in clinical condition, is important to evaluate the information gleaned from verbal exchange or patient observation. Because of their continuous presence on the hospital unit, nurses regularly contribute to the awareness and remediation of environmental risks (Flynn et al., 2017; Weber et al., 2017).
In addition, many modern units provide the capacity to observe patients with strategically placed mirrors or closed-circuit television monitors. Although it is recognized that the best efforts may not always be sufficient to prevent the tragedy of inpatient suicide, a concentrated, focused, and ongoing assessment, including observation and protective interventions, combined with genuine empathetic attention to patient distress, can minimize the risk (Ferrell et al., 2015).
Suicide Intervention Model
Psychiatric hospitals in Egypt do not have a specific nursing care model for suicide prevention. Rather, nurses and hospital staff focus on the notion of safety and protection, particularly with those patients who exhibit warning signs of suicide and/or those who express suicidal ideation through a mutually established safety plan. The aim is to protect suicidal patients from themselves. However, nurses on inpatient wards can actively implement safeguards in patient rooms by removing articles that can be used for self-harm. These items include belts, suspenders, bathrobe cords, shoelaces, glass, vases, razors, nail clippers, knitting needles, bottle and can openers, and disposable utensils. Nurses also check all items brought by visitors, similar to practices implemented in the United States and other countries (Sakinofsky, 2014).
In Egypt, nurses are instrumental in creating and reviewing policies and procedures that secure patients' belongings and also restrict their access to dangerous equipment and materials that may be accessible on hospital wards (e.g., detergents, chemical substances) (Taha, 2011). Patients' belongings are thoroughly reviewed and secured at admission (as purses and backpacks may contain weapons, cigarette lighters or matches, medications, or other potentially toxic substances). In addition, nurses are cognizant of maintaining these safeguards over patients' entire hospital stay. Monitoring items used within the daily functioning of the unit has been found to be key in suicide prevention. For example, a common linen hamper could be dismantled and used as a weapon (Polacek et al., 2015).
Although the current suicide risk model used in Egypt incorporates a safety plan to protect patients from suicide or self-harm, it limits important prevention strategies and lacks other elements compared to the global model. For example, in the United States, the National Action Alliance for Suicide Prevention has put forth the Zero Suicide (ZS) Model, a framework and resources to coordinate a multilevel approach to implementing evidence-based practices for suicide prevention (Brodsky et al., 2018). Founded on the principle that death by suicide is preventable for patients in behavioral health systems, the ZS Model offers an integrated, system-wide strategy for suicide prevention. Four components (Identify, Engage, Treat, and Transition) address aspects of clinical care, whereas three other components (Lead, Train, and Improve) concern administrative approaches (Brodsky et al., 2018).
The discrepancy between the suicide model in Egypt and other global models can be attributed to two factors. The first is organizational and the second is professional education and training. Many hospitals and health care systems in Egypt lack administrative policies and a tracking system (such as risk management) to ensure that there are effective guidelines in place. Many health care systems lack monetary support to help staff put a systematic and comprehensive plan in place and continue to apply it. The second factor, professional education and training of nurses, is critical to ensure that hospital nurses have the knowledge and skills to follow a necessary protocol for suicide prevention.
Developing a Training Module for Inpatient Psychiatric Nurses
Based on the factors listed above and lack of a suicide prevention model, health care in Egypt currently provides a basic plan for minimizing suicide risk for those who have exhibited suicidal behaviors or acts and has ignored the development of any other suicide prevention strategies. Therefore, a critical need exists for administrative policies and procedures to impose a strict protocol for nurses and hospital staff to follow to provide comprehensive suicide prevention on all levels of care—primary, secondary, and tertiary. For these strategies to be applicable, nurses in Egypt need education and training of an evidence-based suicide intervention from early identification of suicide risk through rehabilitation and recovery after discharge. The training module for inpatient psychiatric nurses needs to be comprehensive for all suicide intervention levels and culturally relevant. Table 1 highlights an outline for the development of a training module for nursing knowledge and acquisition of skills.
Training Module Outline for Nursing Knowledge and Acquisition of Skills for Suicide Assessment and Prevention
Mental health nurses in Egypt have an important role in preventing suicidal acts/self-harm among patients. By providing close care and getting to know patients, they have opportunities to recognize and respond to expressions (verbal and nonverbal) of mental distress and possible warning signs of suicide or self-harm. However, caring for patients who are potentially suicidal involves a great deal of emotional work and maturity, as well as skill and competence.
Based on the need for training in-patient psychiatric nurses on suicide prevention skills, recommendations for the future are to implement a module with significant outcome measures. The effectiveness of training (i.e., as experienced by nurses) as well as outcome measures in suicide attempts or completion could be measured and compared. Future research regarding prevalence of suicide risk in Egypt might be helpful in asse ssing effectiveness of a suicide training module. In addition, future research will need to assess the efficacy of different suicide intervention strategies in mitigating suicide risk and suicide ideation among psychiatric inpatients.
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Training Module Outline for Nursing Knowledge and Acquisition of Skills for Suicide Assessment and Prevention
| Mental health issue(s) surrounding suicidal ideation|
| Meaning, prevalence, causes, and risk factors for patient's suicidal ideation/attempt|
| Psychiatric disorders and psychiatric symptoms associated with suicide|
| Ethical responsibility of nurses toward patients who are suicidal|
| Role of nurses when intervening with patients who are suicidal on primary, secondary, and tertiary care levels|
| Suicide risk screening skills|
| Suicide assessment skills|
| Therapeutic communication techniques for patients who are suicidal|
| Cognitive restructuring techniques and behavioral strategies for controlling suicidal ideation|
|Problem Solving and Coping Skills|
| Mental health first aid training|
| Patient education and rehabilitation strategies|
| Documentation of suicide incident|