Nursing “Best Practices” for Patients at Risk for Catherine P. Gros, )

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. However:
• They are neither routinely nor deliberately practiced
• Their therapeutic value may be underestimated
Study Findings:
 Illustrate the importance of collaborative, strengths-based
nursing practice with suicidal in-patients
-Call for a critical review of current policies/procedures
 Provide evidence for staff education & development
-Knowledge translation requires staff coaching &
support
Future research includes: To develop, validate & test the HNQ
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