Suicidal individuals often communicate their intention to commit suicide, but not necessarily verbally. Psychiatric nurses play a central role in the care of patients exhibiting suicidal behaviour or thoughts. Thus, the aim of this study was to explore nurses’ experiences of the indirect messages about forthcoming suicide from patients’ everyday life before they committed suicide. A qualitative design was used with a phenomenological hermeneutical approach. Seven nurses working in specialist psychiatric care were interviewed about their experience of the phenomenon communication about suicide. Results show how the nurses noticed changes in patients just before they committed suicide. These changes included rapid improvement, disguise of real feelings, and unreceptiveness to further treatment or encouragements. The nurses also described patients becoming aware of painful life conditions of losing hope and confidence in the future and experiencing feelings of powerlessness or an inability to influence the situation. Their last moments were characterised by a greater preoccupation with thoughts about death and finding ways to express farewells. This manifested itself in practical preparations and expressing gratitude to people, which was understood by the nurses as a way of saying goodbye. This study shows that it is possible for skilled staff to develop an understanding of a suicidal patient’s internal state and to recognise the non-verbal messages of someone who later committed suicide. The knowledge of how patients prepare and act before suicide could be used to complement a structural suicide risk assessment.
KeywordsPhenomenological HermeneuticsPreparations for SuicideSuicide CommunicationRisk AssessmentPsychiatric Nursing
Appleby, L., Dennehy, J. A., Thomas, C. S., Faragher, E. B., & Lewis, G. (1999). Aftercare and Clinical Characteristics of People with Mental Illness Who Commit Suicide: A Case-Control Study. The Lancet, 353, 1397-1400. https://doi.org/10.1016/S0140-6736(98)10014-4
Berglund, S., Astrom, S., & Lindgren, B. M. (2016). Patients’ Experiences after Attempted Suicide: A Literature Review. Issues in Mental Health Nursing, 37, 715-726. https://doi.org/10.1080/01612840.2016.1192706
Bernert, R. A., Hom, M. A., & Roberts, L. W. (2014). A Review of Multidisciplinary Clinical Practice Guidelines in Suicide Prevention: Toward an Emerging Standard in Suicide Risk Assessment and Management, Training and Practice. Academic Psychiatry, 38, 585-592. https://doi.org/10.1007/s40596-014-0180-1
Beskow, J. (1979). Suicide and Mental Disorders in Swedish Men. Acta Psychiatrica Scandinavica, 1-138.
Carlen, P., & Bengtsson, A. (2007). Suicidal Patients as Experienced by Psychiatric Nurses in Inpatient Care. International Journal of Mental Health Nursing, 16, 257-265. https://doi.org/10.1111/j.1447-0349.2007.00475.x
Dahlberg, K., Dahlberg, H., & Nystrom, M. (2008). Reflective Lifeworld Research. Lund: Studentlitteratur.
Fredriksson, L., & Eriksson, K. (2001). The Patient’s Narrative of Suffering: A Path to Health? An Interpretative Research Synthesis on Narrative Understanding. Scandinavian Journal of Caring Sciences, 15, 3-11. https://doi.org/10.1046/j.1471-6712.2001.1510003.x
Hawton, K., Houston, K., & Shepperd, R. (1999). Suicide in Young People: Study of 174 Cases, Aged under 25 Years, Based on Coroners’ and Medical Records. The British Journal of Psychiatry, 175, 271-276. https://doi.org/10.1192/bjp.175.3.271
Hoyer, E. H., Licht, R. W., & Mortensen, P. B. (2009). Risk Factors of Suicide in Inpatients and Recently Discharged Patients with Affective Disorders. A Case-Control Study. European Psychiatry, 24, 317-321. https://doi.org/10.1016/j.eurpsy.2008.03.011
Hunt, I. M., Windfuhr, K., Swinson, N., Shaw, J., Appleby, L., Kapur, N., & The National Confidential Inquiry into Suicide and Homicide by People with Mental Illnes (2010). Suicide amongst Psychiatric In-Patients Who Abscond from the Ward: A National Clinical Survey. BMC Psychiatry, 10, 14. https://doi.org/10.1186/1471-244X-10-14
Jones, R. (2010). The Development of Nurse-Led Suicide Prevention Training for Multidisciplinary Staff in a North Wales NHS Trust. Journal of Psychiatric and Mental Health Nursing, 17, 178-183. https://doi.org/10.1111/j.1365-2850.2009.01526.x
Kapur, N., Hunt, I. M., Windfuhr, K., Rodway, C., Webb, R., Rahman, M. S., Shaw, J., & Appleby, L. (2013). Psychiatric In-Patient Care and Suicide in England, 1997 to 2008: A Longitudinal Study. Psychological Medicine, 43, 61-71. https://doi.org/10.1017/S0033291712000864
Lindseth, A., & Norberg, A. (2004). A Phenomenological Hermeneutical Method for Researching Lived Experience. Scandinavian Journal of Caring Sciences, 18, 145-153. https://doi.org/10.1111/j.1471-6712.2004.00258.x
Lizardi, D., & Stanley, B. (2010). Treatment Engagement: A Neglected Aspect in the Psychiatric Care of Suicidal Patients. Psychiatric Services, 61, 1183-1191. https://doi.org/10.1176/ps.2010.61.12.1183
Lönnqvist, J. (2009). Major Psychiatric Disorders in Suicide and Suicide Attempters. In D. Wasserman & C. Wasserman (Eds.), Textbook of Suicidology and Suicide Prevention: A Global Perspective (pp. 275-286). New York: Oxford University Press. https://doi.org/10.1093/med/9780198570059.003.0038
Park, S., Choi, J. W., Kyoung Yi, K., & Hong, J. P. (2013). Suicide Mortality and Risk Factors in the 12 Months after Discharge from Psychiatric Inpatient Care in Korea: 1989-2006. Psychiatry Research, 208, 145-150. https://doi.org/10.1016/j.psychres.2012.09.039
Paykel, E. S., Myers, J. J., Lindentahl, J. J., & Tanner, J. (1974). Suicidal Feelings in the General Population: A Prevalence Study. British Journal of Psychiatry, 124, 460-469. https://doi.org/10.1192/bjp.124.5.460
Pennel, L., Quesada, J.-L., Begue, L., & Dematteis, M. (2015). Is Suicide under the Influence of Alcohol a Deliberate Self-Harm Syndrome? An Autopsy Study of Lethality. Journal of Affective Disorders, 177, 80-85. https://doi.org/10.1016/j.jad.2015.02.006
Pokorny, A. D. (1974). A Scheme for Classifying Suicidal Behaviors. In A. T. Beck, H. L. P. Resnick, & D. J. Lettieri (Eds.), The Prediction of Suicide (pp. 29-44). Bowie, MD: Charles Press.
Rehnsfeldt, A., & Eriksson, K. (2004). The Progression of Suffering Implies Alleviated Suffering. Scandinavian Journal of Caring Sciences, 18, 264-272. https://doi.org/10.1111/j.1471-6712.2004.00281.x
Ricoeur, P. (1976). Interpretation Theory: Discourse and the Surplus of Meaning. Fort Worth, TX: Texas Christian University Press.
Rimkeviciene, J., O’Gorman, J., Hawgood, J., & De Leo, D. (2016). Timelines for Difficult Times: Use of Visual Timelines in Interviewing Suicide Attempters. Qualitative Research in Psychology, 13, 231-245. https://doi.org/10.1080/14780887.2016.1170913
Ringel, E. (1976). The Presuicidal Syndrome. Suicide and Life-Threatening Behavior, 6, 131-149.
Runeson, B. S., Beskow, J., & Waern, M. (1996). The Suicidal Process in Suicides among Young People. Acta Psychiatrica Scandinavica, 93, 35-42. https://doi.org/10.1111/j.1600-0447.1996.tb10616.x
Runeson, B., Haglund, A., Lichtenstein, P., & Tidemalm, D. (2016). Suicide Risk after Nonfatal Self-Harm: A National Cohort Study, 2000-2008. Journal of Clinical Psychiatry, 77, 240-246. https://doi.org/10.4088/JCP.14m09453
Runeson, B., Odeberg, J., Pettersson, A., Edbom, T., Jildevik Adamsson, I., & Waern, M. (2017). Instruments for the Assessment of Suicide Risk: A Systematic Review Evaluating the Certainty of the Evidence. PLoS ONE, 12, e0180292. https://doi.org/10.1371/journal.pone.0180292
Sellin, L., Asp, M., Wallsten, T., & Wiklund Gustin, L. (2016). Reconnecting with Oneself While Struggling between Life and Death: The Phenomenon of Recovery as Experienced by Persons at Risk of Suicide. International Journal of Mental Health Nursing, 26, 200-207.
SFS (Swedish Statute Book) (2003). Law on Ethical Considerations in Research Involving Human Beings (p. 460). (In Swedish)
Shneidman, E. S. (1998). Perspective on Suicidology: Further Reflections on Suicide and Psychache. Suicide and Life-Threatening Behavior, 28, 245-250. https://doi.org/10.1521/suli.2007.37.3.245
Simon, R., & Gutheil, T. G. (2009). Sudden Improvement among High-Risk Suicidal Patients: Should It Be Trusted? Psychiatric Services, 60, 387-389. https://doi.org/10.1176/ps.2009.60.3.387
Sun, F. K., & Long, A. (2013). A Suicidal Recovery Theory to Guide Individuals on Their Healing and Recovering Process Following a Suicide Attempt. Journal of Advanced Nursing, 69, 2030-2040. https://doi.org/10.1111/jan.12070
Sun, F. K., Long, A., Boore, J., & Tsao, L. I. (2006). Patients and Nurses’ Perceptions of Ward Environmental Factors and Support Systems in the Care of Suicidal Patients. Journal of Clinical Nursing, 15, 83-92. https://doi.org/10.1111/j.1365-2702.2005.01232.x
Sundvall, M., Titelman, D., & Baarnhielm, S. (2018). Challenges of Combining Perspectives. Crisis, 39, 326-334.
Tidemalm, D., Langstrom, N., Lichtenstein, P., & Runeson, B. (2008). Risk of Suicide after Suicide Attempt According to Coexisting Psychiatric Disorder: Swedish Cohort Study with Long Term Follow-Up. BMJ, 337, a2205. https://doi.org/10.1136/bmj.a2205
Todres, L., Galvin, K. T., & Dahlberg, K. (2014). “Caring for Insiderness”: Phenomenologically Informed Insights That Can Guide Practice. International Journal of Qualitative Studies on Health and Well-Being, 9. https://doi.org/10.3402/qhw.v9.21421
Todres, L., Galvin, K., & Dahlberg, K. (2007). Life World-Led Healthcare: Revisiting a Humanising Philosophy That Integrates Emerging Trends. Medicine, Healthcare and Philosophy, 10, 53-63. https://doi.org/10.1007/s11019-006-9012-8
Tzeng, W. C., Yang, C. I., Tzeng, N. S., Ma, H. S., & Chen, L. (2010). The Inner Door: Toward an Understanding of Suicidal Patients. Journal of Clinical Nursing, 19, 1396-1404. https://doi.org/10.1111/j.1365-2702.2009.03002.x
Van Orden, K. A., Wiktorsson, S., Duberstein, P., Berg, A. I., Fassberg, M. M., & Waern, M. (2015). Reasons for Attempted Suicide in Later Life. The American Journal of Geriatric Psychiatry, 23, 536-544. https://doi.org/10.1016/j.jagp.2014.07.003
Vatne, M., & Nåden, D. (2014). Patients’ Experiences in the Aftermath of Suicidal Crises. Nursing Ethics, 21, 163-175. https://doi.org/10.1177/0969733013493218
Verrocchio, M. C., Carrozzino, D., Marchetti, D., Andreasson, K., Fulcheri, M., & Bech, P. (2016). Mental Pain and Suicide: A Systematic Review of the Literature. Front Psychiatry, 7, 108. https://doi.org/10.3389/fpsyt.2016.00108
Wasserman, D. (2001). A Stress-Vulnerability Model and the Development of the Suicidal Process. In D. Wasserman (Ed.), Suicide (pp. 13-27). London: CRC Press. https://doi.org/10.1201/b14713-5
Wasserman, D. (2016a). Negative Life Events and Suicide. In D. Wasserman (Ed.), Suicide an Unnecessary Death (2nd ed.). New York: Oxford University Press. https://doi.org/10.1093/med/9780198717393.003.0014
Wasserman, D. (2016b). The Suicidal Process. In D. Wasserman (Ed.), Suicide an Unnecessary Death (2nd ed.). Oxford: Oxford University Press. https://doi.org/10.1093/med/9780198717393.003.0003
Werbart Tornblom, A., Werbart, A., & Rydelius, P. A. (2015). Shame and Gender Differences in Paths to Youth Suicide: Parents’ Perspective. Qualitative Health Research, 25, 1099-1116. https://doi.org/10.1177/1049732315578402
World Medical Association (2018). Declaration of Helsinki-Ethical Principles of Medical Research Involving Human Subjects.