The Attitudes of Emergency Staff Toward Attempted Suicide Patients

Transcription

1 J. Suokas et al.: The Attitudes of Emergency Staff Tow ard Crisis Attempted 2009; Vol. Hogrefe Suicide 30(3): Publishing Patients Short Report The Attitudes of Emergency Staff Toward Attempted Suicide Patients A Comparative Study Before and After Establishment of a Psychiatric Consultation Service Jaana Suokas 1,2, Kirsi Suominen 1,3, and Jouko Lönnqvist 1,4 1 Department of Mental Health and Alcohol Research, National Public Health Institute, 2 City of Helsinki, Health Centre, Psychiatric Department/Hospital Functions, 3 Jorvi Hospital, Department of Psychiatry, Helsinki University Central Hospital, Espoo, 4 Department of Psychiatry, Helsinki University Central Hospital, all Finland Abstract. Background: The staff in the emergency room of general hospitals are under heavy work pressure and seem to reveal negative attitudes toward suicide attempters. From earlier studies there is indirect evidence that the attitudes of staff who have the opportunity to consult a psychiatrist are less negative. Aims: The study compare the attitudes of emergency room staff in a general hospital toward patients who had attempted suicide before and after establishment of a psychiatric consultation service. Methods: Attitudes were measured on the Understanding Suicidal Patients (USP) Scale. A total of 100 participants returned the questionnaire. Results: General understanding and willingness to nurse patients who attempted suicide did not increase. Conclusion: The results suggest that providing a psychiatric consultation service did not significantly affect attitudes among general hospital emergency room staff toward attempted suicide patients during its first year of operation, but in general, the emergency room staff was content with the opportunity for psychiatric consultation. Keywords: attempted suicide, attitude, personnel, emergency room Introduction Suicide and attempted suicide constitute a considerable public health problem in terms of both individual suffering and cost to society. Emergency room personnel in general hospitals encounter a large number of suicide attempters and their role is central in these patients management. They should be assessed comprehensively, preferably with a psychiatrist involved in the process (Isacsson & Rich, 2006). Although opinions differ on whether psychiatric consultation is always necessary in the care of self-poisoning patients (Black & Creed, 1988; Crawford, Turnbull, & Wessely, 1998), in Finland it is recommended that all suicide attempters receive a psychiatric evaluation after the attempt. Very few studies have investigated the effect of psychiatric consultation on the care of patients who attempt suicide. It has been suggested that psychiatric assessment and intervention might be useful in reducing the likelihood of subsequent suicides (Greer & Bagley, 1971; Rosenman, 1983; Suokas & Lönnqvist, 1991). The availability of psychiatric consultation seemed also to have a positive influence on staff s attitudes toward patients who had attempted suicide (Crawford, Geraghty, Street, & Simonoff, 2003; Creed & Pfeffer, 1981; Suokas & Lönnqvist, 1989a, 1989b). The staff in the emergency room are under heavy work pressure and there is indirect evidence from earlier studies (Crawford et al., 2003; Creed & Pfeffer, 1981; Suokas & Lönnqvist, 1989a) that the attitudes of personnel who have the opportunity to consult a psychiatrist are less negative because they can shift part of the workload and responsibility onto the psychiatric staff. Attitudes of personnel caring for suicidal and self-harming patients are considered a key element influencing whether these patients will ultimately commit suicide (Pompili, Girardi, Ruberto, Kotzalidis, & Tatarelli, 2005). Such attitudes have been examined in several studies, and the high prevalence of negative attitudes among personnel caring for suicide attempters has been interpreted as alarming (Samuelsson, Åsberg, & Gustavsson, 1997). Most of the studies of attitudes of general hospital emergency room staff were conducted almost 20 years ago (Ansel & McGee, DOI /

2 162 J. Suokas et al.: The Attitudes of Emergency Staff Toward Attempted Suicide Patients 1971; Ghodse, 1978; Goldney & Botril, 1980; Hawton, Marsack, & Fagg, 1981; O Brien & Stoll, 1977; Patel, 1975; Platt & Salter, 1989; Ramon, 1980; Ramon & Breyter, 1978; Ramon, Bancroft, & Skrimshire, 1975; Suokas & Lönnqvist 1989a,), and many are limited by the lack of reliability and validity tests for the instruments used. The suicide attempt is most powerful single predictor of subsequent suicide. Whether a psychiatric consultation take place influences patients after-care planning. The staff in the emergency room work from time to time under heavy work pressure and patients psychic distress may arouse feelings of helplessness. We expected that the establishment of a psychiatric consultation service would lessen the staff s workload because they could shift part of the responsibility onto the consulting psychiatrist. This study evaluated whether any changes occurred in the attitudes of general hospital emergency room staff toward suicide attempters after provision of a systematic psychiatric consultation service. The first evaluation was made before psychiatric consultations were available in the emergency room, and the second one a year after the service was established. Methods General Design This study took place in the emergency room of Malmi Hospital, a municipal hospital in Helsinki City. The hospital s catchment area comprises the eastern part of Helsinki (274,540 inhabitants in 2004). A systematic psychiatric consultation service for attempted suicide patients in the emergency room was initiated at the beginning of The study was conducted in two stages: The first took place in late 2004, when Malmi hospital had no psychiatric consultation referral service for attempted suicide patients. The second stage took place in late 2005, after the psychiatric consultation service had been operating for almost one year. Participating staff were asked to complete the Understanding Suicidal Patients (USP) Questionnaire before and after the service began. Psychiatric Consultation Service Systematic psychiatric consultations were arranged on weekdays. The consulting team consisted of a psychiatric liaison nurse and a part-time senior psychiatrist. The psychiatric liaison nurse was based in the emergency room full time and worked one shift. She belonged to the emergency room s multidisciplinary team but worked in close collaboration with the psychiatric consultant and the local psychiatric service. Her responsibilities included initial phase assessments of patients referred for psychiatric consultation and practical arrangements for psychiatric after-care. Crisis 2009; Vol. 30(3): Instrument The USP was used. This questionnaire was developed from a questionnaire by Suokas and Lönnqvist (1989a) and modified by Samuelsson, Åsberg et al. (1997). The 11 items were summed to form the USP Scale, which is intended to measure understanding and willingness to care for patients who have attempted suicide. In earlier studies (Samuelsson & Åsberg 2002; Samuelsson, Åsberg et al., 1997, Samuelsson, Sunbring, Winell, & Åsberg, 1997; Mackay & Barrowlough, 2005) the scale has demonstrated satisfactory internal consistency and good reliability. Each statement was scored on a five-point Likert scale ranging from I agree completely to Idisagree completely. The participants were also asked about their opinions regarding the need for psychiatric consultation and the role of the psychiatric liaison nurse in the care of attempted suicide patients. Participants The subjects of the study were the staff members of the emergency room and all the doctors in Malmi Hospital. The chief physician and the head nurse were approached by telephone and letter, and the design and the aims of the study were explained to them. In order to improve response rates, the contact person in the emergency room delivered the information sheet and survey form, along with a selfaddressed envelope, to every long-term staff member: 83 in the first stage of the study and 71 in second. During the second stage the emergency room was understaffed and there were a lot of short-term employees who were not taken into the study. A total of 100 participants (year 2004: N = 66, 80%; year 2005: N = 34, 48%) returned the questionnaire. The response rate was significantly higher in the first stage (2004), χ² = 16.81, DF =1,p <.001. The low response rate in the second stage (2005) was biased toward one professional group: The response rate in 2004 among medical staff was 52% and nursing staff 90%, compared to 23% and 62%, respectively, in The majority of the respondents were women (74% in 2004, 77% in 2005) aged years, most having substantial work experience Data and Analysis To ensure reliability of the scale, the 11 USP items were subjected to an item analysis. The mean interitem correlation for the scale was 0.28, and Cronbach s α was Positive attitude was defined as a USP Scale score of 22 or under and negative attitude as a score of 30 or over, based on the 25th and 75th percentiles Hogrefe Publishing

3 J. Suokas et al.: The Attitudes of Emergency Staff Toward Attempted Suicide Patients 163 Table 1. Attitudes to methods for psychiatric assessment in the care of attempted suicide patients 1. All suicide attempters should be given the possibility for psychiatric consultation after somatic first-care. 2. The psychiatric liaison nurse working it the emergency room can make the psychosocial assessment of suicide attempter and evaluate the need of after-care. Before psychiatric consultation (year 2004) After psychiatric consultation (year 2005) Yes a No b Yes a No b χ² p n (%) n (%) n (%) n (%) 63 (95.5%) 3 (4.5%) 30 (90.9%) 3 (9.1%) 0.80 ns 53 (89.8%) 6 (10.2%) 31 (91.2%) 3(8.8%) 0.05 ns a I agree completely and I agree up to a certain point ; b I disagree up to a certain point, and I disagree completely. The mean differences before and after beginning the psychiatric consultation service were tested by the unpaired t-test. In order to keep anonymity as strict as possible, the individual answers before and after the psychiatric consultation could not be identified. Therefore, a paired t-test could not be used. To test differences in proportions on single items, the χ² test was used. The one-way ANOVA test was used to analyze attitude differences between the various groups. Nonparametric methods (Mann-Whitney U-test and the Kruskal-Wallis test and Spearman rank correlation) were also used in parallel and the results were similar to those obtained with the parametric methods. Results Most staff members perceived the psychiatric consultation of suicide attempters as important (Table 1). Ninety percent of staff members thought that the psychiatric liaison nurse could evaluate the psychosocial situation of a suicide attempter. The provision of the psychiatric consultation service did not alter these opinions. The mean score for the whole USP Scale was 26.9 ± 7.1 (range 13 47; 25% percentile 22.0, median 27.0, 75% percentile 30.0). Lower scores signify more empathetic responses. The distribution of the scores on most items tended to be somewhat skewed toward the more empathetic end of the scale. After 1 year of the consultation service, the understanding and willingness to care for attempted suicide patients, as measured by the USP Scale, had not significantly changed: The mean score before the psychiatric consultation was 26.4 ± 6.6, and after 27.8 ± 8.0 (statistically: ns). Overall, there were no statistically significant differences in individual items of the USP Scale. Gender, age, profession, and length of work experience did not have a statistically significant effect on staff attitudes. Those who often (at least weekly) took care of suicide attempters did not differ statistically from those who did so less often. Discussion The level of positiveness of attitudes in the beginning of the study was fairly good. In this study the attitudes of staff in the emergency room were examined before and after the establishment of a psychiatric consultation service. Psychiatric consultation was seen as important by staff members. However, as measured on the USP Scale, understanding and willingness to care for suicide attempted patients did not change. The overall results show that attitudes before and after the psychiatric consultation service were generally homogeneous. The findings from the first evaluation (before the psychiatric consultation began) reveal the general tendency among the emergency room staff to view attempted suicide patients positively and sympathetically. This supports some recent findings (McCann, Clark, McConnachie, & Harvey, 2006; May, 2001) that attitudes of emergency room staff are improving. Establishment of the psychiatric consultation service did not have any effect on staff attitudes, which contrasts with some earlier speculations (Crawford et al., 2003; Creed & Pfeffer, 1981; Suokas & Lönnqvist, 1989a, 1989b). The findings of the present study suggest that close cooperation with psychiatric staff and the possibility of shifting part of the responsibility onto the consulting psychiatrist or psychiatric liaison nurse does not influence attitudes. Attitudes toward patients who attempted suicide are complex and multidimensional (McAllister, Creedy, Moyle, & Farrugia, 2002). It seems that it is difficult to influence them with simple methods like providing a psychiatric consultation service. According to the literature (Morgan, Evans, Johnson, & Stanton, 1996; Samuelsson & Åsberg, 2002), one possible way of changing attitudes has been educational interventions. There are some methodological limitations in this study. First, the attitudes of the emergency room personnel were studied using a questionnaire. This method is somewhat deficient for studying attitudes, because the results merely reflect the conscious feelings of the interviewee. However, questionnaire studies are considered to be useful as baseline measures in intervention studies to assess the effectiveness of projects targeting attitudinal changes (McAllister et al., 2002). Second, less than half of the questionnaires were

4 164 J. Suokas et al.: The Attitudes of Emergency Staff Toward Attempted Suicide Patients returned in the second stage of the study. Low response rates (35 49%) have been found in previous questionnaire studies of staff attitudes (Mackay & Barrowlough, 2005; McAllister et al., 2002; Sidley & Renton, 1996). During the second stage, the emergency room had long been understaffed and there was a chronic shortage of adequate personnel. Given the busy and unpredictable workload of emergency room staff, the problem might simply have been that a substantial proportion of them had insufficient time to complete the questionnaire. Furthermore, as we had no information on those who failed to return the questionnaire, we could not compare those who returned it with those who did not. The possibility remains that the study sample was biased and we must be careful when drawing conclusions from these findings. It is theoretically possible that the establishment of a psychiatric consultation service can change staff s attitudes in either a positive or negative direction: The psychiatric consultation may improve the affective and behavioral aspects of attitudes or the psychiatric consultation may psychologically distance emergency room personnel from suicide attempt patients. The staff s attitudes did not change so what? We assumed that the positive attitudes of the staff in the emergency room might improve the quality of the assessments of suicide attempters, but does the actual management of these patients or improved outcome really depend on the staff s attitudes? The treatment of attempted suicide patients in Malmi Hospital is now arranged according to recommendations (Isacsson & Rich, 2006): Most receive psychiatric evaluation after the attempt. In general, the staff in the emergency room of Malmi Hospital is content with the facility for psychiatric consultation and with the work of the psychiatric liaison nurse (according to an interview clarification in autumn 2005 by J.S.). In conclusion, during its first year of operation, providing a psychiatric consultation service for suicide attempters did not change significantly attitudes among general hospital emergency room personnel toward patients who had attempted suicide. Acknowledgments This study was financially supported by a grant from the Health Center of Helsinki. We thank Pirjo Vilhunen for research assistance. References Crisis 2009; Vol. 30(3): Ansel, E., & McGee, R. (1971). Attitudes toward suicide attempters. Bulletin of Suicidology, 8, Black, D., & Creed, F. (1988). Assessment of self-poisoning patients by psychiatrists and junior medical staff. Journal of the Royal Society of Medicine, 88, Crawford, M., Turnbull, G., & Wessely, S. (1998). Deliberate selfharm assessment by accident and emergency staff An intervention study. Journal of Accident and Emergency Medicine, 15, Crawford, T., Geraghty, W., Street, K., & Simonoff, E. (2003). Staff knowledge and attitudes toward deliberate self-harm in adolescents. Journal of Adolescence, 26, Creed, F., & Pfeffer, J. (1981). Attitudes of house physicians toward self-poisoning patients. Medical Education, 15, Ghodse, A.H. (1978). The attitudes of casualty staff and ambulance personnel toward patients who take drug overdoses. Social Science and Medicine, 12, Goldney, R., & Botrill, A. (1980). Attitudes to patients who attempted suicide. Medical Journal of Australia, 2, Greer, S., & Bagley, C. (1971). Effect of psychiatric intervention in attempted suicide: A controlled study. British Medical Journal, 1, Hawton, K., Marsack, P., & Fagg, J. (1981). The attitudes of psychiatrists to deliberate self-poisoning: Comparison with physicians and nurses. British Journal of Medical Psychology, 54, Isacsson, G., & Rich, C. (2006). Management of patients who deliberately harm themselves. British Medical Journal, 322, Mackay, N., & Barrowlough, C. (2005). Accident and emergency staff s perceptions of deliberate self-harm: Attributions, emotions, and willingness to help. British Journal of Clinical Psychology, 44, May, V. (2001). Attitudes to patients who present with suicidal behavior. Emergency Nurse, 9(4), McAllister, M., Creedy, D., Moyle, W., & Farrugia, C. (2002). Nurses attitudes toward clients who self-harm. Journal of Advanced Nursing 40, McCann, T., Clark, E., McConnachie, S., & Harvey, I. (2006). Accident and emergency nurses attitudes toward patients who self-harm. Accident and Emergency Nursing, 14, Morgan, H., Evans, M., Johnson, C., & Stanton, R. (1996). Can a lecture influence attitudes to suicide prevention? Journal of Research in Social Medicine, 89, O Brien, S., & Stoll, K. (1977). Attitudes of medical and nursing staff toward self-poisoning patients in a London hospital. International Journal of Nursing Studies, 14, Patel, A. (1975). Attitudes toward self-poisoning. British Medical Journal, 2, Platt, S., & Salter, D. (1989). Health workers attitudes to parasuicide in two different treatment settings. In R.F.W. Diekstra, R. Maris, S. Platt, A. Schmidtke, & G. Sonneck (Ed.), Suicide and its prevention: The role of attitudes and imitation (pp ). Leiden: E.J. Brill. Pompili, M., Girardi, P., Ruberto, A., Kotzalidis, G., & Tatarelli, R. (2005). Emergency staff reactions to suicidal and self-harming patients. European Journal of Emergency Medicine, 12, Ramon, S. (1980). Attitudes of doctors and nurses to self-poisoning patients. Social Science and Medicine, 14, Ramon, S., Bancroft, J., & Skrimshire, A. (1975). Attitudes toward self-poisoning among physicians and nurses in a general hospital. British Journal of Psychiatry, 127, Ramon, S., & Breyter, C. (1978). 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5 J. Suokas et al.: The Attitudes of Emergency Staff Toward Attempted Suicide Patients 165 atric hospital. The Israel Annals of Psychiatry and Related Disciplines, 16, Rosenman, S. (1983). Subsequent death after attempted suicide by drug overdose in the western region of Adelaide, Medical Journal of Australia, 2, Samuelsson, M., & Åsberg, M. (2002). Training program in suicide prevention for psychiatric nursing personnel enhance attitudes to attempted suicide patients. International Journal of Nursing Studies, 39, Samuelsson, M., Åsberg, M., & Gustavsson, J.P. (1997). Attitudes of psychiatric nursing personnel toward patients who have attempted suicide. Acta Psychiatrica Scandinavica, 95, Samuelsson, M., Sunbring, Y., Winell, I., & Åsberg, M. (1997). Nurses attitudes to attempted suicide patients. Scandinavian Journal of Caring Sciences, 11, Sidley, G., & Renton, J. (1996). General nurses attitudes to patients who self-harm. Nursing Standard, 10(30), Suokas, J., & Lönnqvist, J. (1989a). Staff s attitudes toward patients who attempt suicide. In R.F.W. Diekstra, R. Maris, S. Platt, A. Schmidtke, & G. Sonneck (Ed.), Suicide and its prevention the role of attitudes and imitation (pp ). Leiden: Brill. Suokas, J., & Lönnqvist, J. (1989b). Work stress has negative effects on the attitudes of emergency personnel toward patients who attempt suicide. Acta Psychiatrica Scandinavica, 79, Suokas, J., & Lönnqvist, J. (1991). Selection of patients who attempted suicide for psychiatric consultation. Acta Psychiatrica Scandinavica, 83, About the authors Jaan Suokas, MD, PhD, is a senior physician of the Department of Psychiatry in the Helsinki University Central Hospital. Her main research interests include the epidemiology of suicide attempts, risk factors for suicidal behavior, and staff attitudes toward patients having attempted suicide. Kirsi Suominen, MD, PhD, is a senior physician of the Department of Psychiatry, Jorvi Hospital, in the Helsinki University Central Hospital. The main research areas are attempted suicide, epidemiology, and risk factors for suicidal behavior and mood disorders. Jouko Lönnqvist, MD, PhD, is a research professor and director of the Department of Mental Health and Substance Abuse Services at the National Institute for Health and Welfare (THL) in Helsinki, Finland. His main research areas have been self-destructive behavior and suicide prevention, depression, substance use, psychiatric genetics, and epidemiology. He has published more than 400 research articles in international journals. Jaana Suokas Department of Mental Health and Alcohol Research National Public Health Institute Mannerheimintie 166 FIN Helsinki Finland Tel Fax jaana.suokas@hel.fi