Nursing “Best Practices” for Patients at Risk for Suicide: Adolescent Perceptions of Helpful Care Catherine P. Gros, N, MSc (A) Assistant Professor, McGill University School of Nursing Nurse Clinical Specialist, Douglas Mental Health Institute Tamsin Mulvogue, MSc(A); Sacha Jarvis, MSc(A); Johanne Renaud, MD 3rd Nursing Research & Evidence-Based Practice Symposium: The Power of TEAM Inquiry University of Vermont & FAHC November 12, 2011 The Power of TEAM Inquiry: What’s wrong with this picture? The Power of TEAM Inquiry: Who Decides? In Collaborative Nursing Practice, Patients & families are •ESSENTIAL team members •ACTIVE PARTICIPANTS in assessment, planning & evaluation of care Patient & Family-Centered Care: means the person & family are at the center of care! Therefore, Nursing “Best Practices” are ultimately determined by patients & families… What are the perceptions of adolescents regarding “helpful” Nursing care during suicide risk? Suicide in Context: Suicide is a principal cause of death in the adolescent population in Québec & a significant health concern worldwide Suicide is a complex phenomenon: Influenced by an open system of biophysical-socialenvironmental interactions Related to personal life experiences, gene expression & human bio-pscho-social development Epigenetic Research Findings: Human studies: traumatic relational life experiences (child abuse) alters gene expression, leading to changes in the brain & increased susceptibility to anxiety, depression and suicide (McGowan et al, 2009) Animal Studies: Rat pups experiencing caring maternal interactions showed healthy brain development & were significantly calmer than ‘high stress’ rats from low care mothers. Conclusion: caring interactions affect gene expression & determine hypothalamic-pituitary-adrenal (HPA) functioning, affecting healthy brain development and behaviour (McGowan, et al, 2009). Helping Suicidal Patients: The Nurses’ Role Frontline nurses spend more time intervening with hospitalized patients than any other professional group; admission to discharge During suicide risk: Nurse-patient contact is intense Intervention is: close” to “continuous” 24/7 High dose nursing care = High impact on patient outcomes In the Literature: The vast majority of healthcare research related to suicide focuses on interventions delivered by professionals other than nurses Regarding Nursing Interventions & Suicide Risk… Existing research is: •Qualitative •Rare (few in number) •Narrow in scope Current studies focus on: Prescribed treatments & control measures1-5 •Evaluating risks •Searching for & removing dangerous objects •Implementing close or constant “surveillance” Research on Nursing Intervention during Suicide Risk… Target outcomes focus mainly on: • Patient safety • Physical protection • Preventing self-harm1-5 However… • The Nurse’s attitude & interpersonal approach has a significant impact on patient health outcomes. Existing qualitative data indicate: •Suicidal patients on “close observation” report feelings of hope & self esteem resulting from their interactions with nursing staff 6,7 In Conclusion… •Little attention has been paid to the interventions nurses implement in their daily interactions with suicidal in-patients • Relational nursing interventions offered throughout the course of hospitalization are poorly described •Little is known about the impact of nursing care on patient health outcomes •The patient’s perspective of “helpful” Nursing interventions during suicide risk requires further study... What are the perceptions of adolescents at risk for suicide regarding “helpful” nursing care during hospitalization? % (n=6) Age 16 17 18 66.6 16.6 16.6 Sex Men Women 16.6 83.3 Ethnicity Caucasien Other 100.0 0 Language French English Bilingual 16.6 50.0 33.3 Diagnosis Depression Anorexia/Bulimia & Dépression Borderline Personnality 33.3 16.6 50.0 Length of Hospital Stay 1 – 7 days 1 – 4 weeks > 1 month 50.0 33.3 16.6 Suicide Risk Current Previous 33.3 66.6 Results: Based on Interviews with Suicidal Teens: Helpful Nursing Interventions occur across 3 Domains of Care Developing a unique & caring human relationship Working in partnership to manage illness & suicide risk Creating a health-promoting hospital environment SMILE! “Be kind & friendly”. “If someone’s smiling, you’re smiling; it can spread.” GET UP-CLOSE & PERSONAL: “Be intimate.” “[Don’t] talk in the doorway…Come in & sit down on my bed.” IDENTIFY & ACCOMMODATE INDIVIDUAL PREFERENCES: “Notice [what’s] unique to me... If there’s something special I want, like chocolate milk, make sure [it’s] there for me.” INITIATE CONVERSATION: “Talk to me.” “It really helps when someone tries to start a conversation”…“Ask about my life & take an interest in what we do. Asking everyday questions like: ‘How’s your day going?’ helps us feel safe.” LISTEN WTHOUT IMPOSING CONSEQUENCES: “If I speak of suicidal ideas, be present & listen. Don’t panic & take away my privileges. We just need to talk when we’re feeling bad.” UNDERSTAND THE PAIN: “…probably the most important thing, [is ]actually understanding, not just on a scientific level, but on an emotional level, how deep the despair is” EARN TRUST: “[having a nurse you can trust] helps you get better, because …it’s really hard to find people you trust when you’re in that situation” [suicidal] LEARN TO TRUST: “Believe in us. We’re the best judge. No one knows better than me if I’m going to kill myself.” OFFER PERSPECITVE: “Give a different point of view… ’cuz when you’re in that mindset, your vision is very tunneled, so to open [the patient’s] mind really could make a difference” IDENTIFY & WORK WITH STRENGTHS: “Focus on the positive”… “like notice the parents care”… “that will help so much, cuz… if you’re going to therapy, you’re saying your problems. It’s negative, negative…” “[pointing out the things you’re good at] makes you want to live. It really does. It makes you think that you’re not completely worthless.” BE WELCOMING TO PATIENTS & FAMILIES: “The nurses would try to build this cooperative family atmosphere. Like: ‘Oh, right this way. Come on in’.” BRIDGE HOSPITAL & HOME LIFE: “Do normal activities” “… more like you’re having like your real life” “Make us feel like we’re not so detached from our normal world” ACCOMPANY PATIENTS OUTDOORS! “Just being able to feel the sun, being outside really helped me because… you got that feeling of liberation”… “It felt like I wasn’t in prison.” Summary of Findings: This study offers detailed examples of “helpful” nursing interventions as reported by suicidal teens. However, ONE SIZE DOESN’T FIT ALL! Findings indicate that there is variability amongst what individual patients find helpful This is consistent with Collaborative, “Situation-Responsive” Nursing (The McGill Model / The Developmental Health Model) which involves timing & tailoring interventions to achieve “goodness of fit” (Allen, 1977; Gottlieb & Feeley, 2005 & others) • What is helpful to THIS person/family? • in THIS situation? • at THIS time? In the hospital setting: Strongly Agree When I’m on “constant observation”, it helps when the nurse lets me spend some time alone, if I say I need it. 100% It helps when my nurse keeps in touch and continues to take an interest in me; especially when I’m feeling better & I’m no longer considered suicidal. 100% Reported health outcomes resulting from nursing care: Strongly Agree The nursing care I receive in the hospital can decrease my risk of suicide by helping me feel more hopeful & positive regarding myself, my family &/or my situation. 100% The nursing care I receive when I’m in the hospital has an impact on my ability to cope at home, at school & with my family following discharge. 100% Feedback on the Questionnaire: Completing a questionnaire like this during my hospital stay can help the nurse better understand me and my needs. 100% Conclusions & Implications Nursing interventions make a significant difference to the health & recovery of hospitalized teens at risk for suicide Relational nursing interventions are low cost & relatively easy to apply. 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