Abstracts

BRIEF REPORT

Nursing personnel attitudes towards suicide: the development of a measure scale

Atitudes do pessoal de enfermagem em relação ao sucídio: a criação de uma escala de avaliação

Neury José Botega; Diogo Gomes Reginato; Sidney Volk da Silva; Carlos Filinto da Silva Cais; Claudemir Benedito Rapeli; Marisa Lúcia Fabrício Mauro; Janaína Phillipe Cecconi; Sabrina Stefanello

Department of Medical Psychology and Psychiatry, School of Medical Sciences, Universidade Estadual de Campinas (Unicamp), Campinas (SP), Brazil

^{Correspondence} Correspondence Neury J. Botega FCM-UNICAMP, Depto. de Psiquiatria, Caixa Postal 6111 13081-970 Campinas, SP, Brasil Tel/Fax: (19) 3788-7206 E-mail: botega@fcm.unicamp.br

ABSTRACT

OBJECTIVE: To describe the construction of the Suicide Behavior Attitude Questionnaire (SBAQ) which measures attitudes of nursing personnel towards suicide, and verify attitude differences among these professionals.

METHODS: The Suicide Behavior Attitude Questionnaire comprises 21 visual analogue scale items (beliefs, feelings and reactions on suicidal patients) selected from a pool of attitude statements generated by focal groups and experts' judgement. The questionnaire was completed by 317 nursing professionals who worked in a teaching hospital. Factor analysis and internal consistency were calculated.

RESULTS: Three interpretable factors were extracted, accounting jointly for 40% of the total variance: Feelings when caring for the patient, Professional Capacity and Right to Suicide, comprising 7, 4 and 5 items, respectively. The Cronbach's alpha coefficients were 0.7, 0.6 and 0.5, respectively. Greater Professional Capacity was reported by nursing assistants and those who had already took care of suicidal patients. The belief that a person does not have the right to commit suicide was stronger among older professionals, those who had never taken care of suicidal patients, those who had a family history of suicide, those who were Protestants and that used to go more frequently to church services.

CONCLUSIONS: The Suicide Behavior Attitude Questionnaire proved to be user-friendly and quite a simple instrument to assess attitude towards suicide among nursing personnel.

Keywords: Suicide; Attitudes; Health personnel; Nurse-patient relations; Questionnaires

RESUMO

OBJETIVO: Descrever a construção do Questionário sobre a Atitude Frente ao Comportamento Suicida (QACS), que mede as atitudes do pessoal de enfermagem em relação aos suicidas e verifica as diferenças de atitude entre esses profissionais.

MÉTODOS: O Questionário sobre a Atitude Frente ao Comportamento Suicida compreende uma escala de 21 itens visuais análogos (crenças, sentimentos e reações em relação a pacientes suicidas) selecionados a partir de uma série de frases sobre as atitudes geradas a partir de grupos focalizados e o julgamento de especialistas. O questionário foi completado por 317 profissionais de enfermagem que trabalhavam em um hospital escola. Foram calculadas a análise fatorial e a consistência interna.

RESULTADOS: Foram extraídos três fatores interpretáveis, responsáveis em conjunto por 40% da variância total: Sentimentos ao tratar do paciente, a Capacidade Profissional e o Direito ao Suicídio, englobando 7, 4 e 5 itens, respectivamente. Os coeficientes do alfa de Cronbach foram 0,7, 0,6 e 0,5, respectivamente. Uma maior Capacidade Profissional foi relatada por assistentes de enfermagem e aqueles que já tinham cuidado de pacientes suicidas. A crença de que uma pessoa não possui o direito de cometer suicídio foi mais forte entre profissionais mais velhos, entre aqueles que não tinham nunca cuidado de pacientes suicidas, aqueles com histórico familiar, os que eram protestantes e costumavam freqüentar mais cultos religiosos.

CONCLUSÕES: O Questionário sobre a Atitude Frente ao Comportamento Suicida comprovou ser de fácil uso e ser um instrumento bem simples para avaliar a atitude em relação aos suicidas por parte do pessoal de enfermagem.

Descritores: Suicídio; Atitude do pessoal de saúde; Relações enfermeiro-paciente; Questionários

Introduction

It is estimated that the risk of suicide among patients in a general hospital is three times higher than that found in the general population.¹ A mental disorder is detected in 88% of suicide occurrences in a general hospital.² The training of Nursing Personnel can be a valuable resource on the attention imparted to the people who are suicidal. This training should involve not only knowledge acquisition, but also a change in attitudes.³

Two instruments have been frequently used to assess attitudes towards suicide: the Suicide Opinion Questionnaire (SOQ) and the Suicide Attitude Questionnaire (SUIATT). Both focus on attitudes towards the person who commits suicide.^4-5 There is, however, lack of consensus on the psychometric properties of these instruments, therefore hampering to know what exactly is being measured.^6-7 The SOQ, in one of its versions, contains 15 factors, many of them explaining less than 5% of the variance. From its 100 items, all derived from a literature review, only 61 presented factorial loading above 0.3.^4,8 As far as the SUIATT is concerned, up to 19 sub-scales can be derived, providing, from the sum of various items, a global score and one score for each situation.⁵ These scores are actually difficult to interpret. A third instrument, the Understanding of Suicide Attempt Patient Scale (USP Scale) was especially developed to assess attitudes of a group of professionals working in psychiatric care facilities, who were used to nurse psychiatric patients.⁹ Although its reliability and validity were satisfactory in the original study, the USP Scale is presumed to measure the empathy towards patients who have attempted suicide. It does not include the cognitive and behavioral dimensions which are essential in the attitude assessment together with the affective one. Nursing staff working in medical and surgical wards of a general hospital probably have a different appraisal of suicidal patients and a peculiar way of assessing the risk of suicide.

Due to the theoretical and practical limitations of these instruments, we have developed the Suicide Behavior Attitude Questionnaire (SBAQ), which measures attitudes in their cognitive, affective and behavioral components. Its content comprises clinical situations fully experienced by general, and not only psychiatric, nursing personnel. The aims of this study were: 1) To assess the psychometric properties of SBAQ (factorial structure and internal consistency); 2) To verify if the attitudes towards suicide vary according to the characteristics of the assessed professionals.

Methods

1. Subjects

Among 554 nursing professionals who worked at the wards of the general hospital of the Universidade Estadual de Campinas, 317 (57.2%) accepted the invitation to attend a course on suicide prevention, being the latter the subjects of the present study. Everyone complied with answering, anonymously, an attitude questionnaire just before the start of the course.

2. Development of the SBAQ

The following steps were followed in the development of the SBAQ:

1) A review of the literature and three focal groups (90 minutes each, totaling 25 nursing professionals who would not participate in the main study, coordinated by three of the authors) produced a list of 54 propositions on suicidal behavior. The leading questions of the discussions were: 'In your opinion, what leads to suicide?'; 'How do you feel towards a patient who tried suicide?'; 'Do you feel capable of evaluating the suicidal risk of a patient and to handle this situation?'

2) Ten specialists scored the pertinence and adequacy of each phrase on 5-point Likert scales. This resulted in the selection of the 25 highest scored propositions intended to generate eventually a 15-25 item instrument.

3) The pool of 25 propositions was applied to 20 individuals (nursing staff working at the outpatient clinic) as a pilot test. Three items with low variance and one considered to be poorly formulated were eliminated.

4) The final version of the SBAQ comprises 21 attitude statements followed by visual analogue scales (VAS), i.e., a 100-mm line-continuum ranging from 'strongly disagree' at one end to 'strongly agree' at the other. The respondent is asked to indicate a point on each line, which best reflects his/her opinions, feelings or reactions.

Data on gender, year of birth, job position, religion and attendance to church services, experience in attending patients who manifest suicidal ideation and suicide family history were also collected.

3. Data analysis

The VAS were measured in millimeters. A Factor Analysis was performed, using maximum likelihood and orthogonal Varimax rotation.¹⁰ Factors associated to eigen values > 1 were chosen and, to compose these factors, the variables with higher factor loadings. The score in the factorial sub-scale was obtained by the sum of the scores of their component items (in the cases of items with negative loading, the scores obtained were subtracted from 100). The variability of the factorial scores was tested in some groups (Table 1), using ANOVA, with rank transformation. The Cronbach's coefficient was calculated for each sub-scale.

Results

Few professionals (17% of the answers) regarded themselves as 'prepared to handling with patients under the risk of suicide', and not more than 36% of the professionals felt 'capable of perceiving when a patient is under the risk of suicide'. Only 12% agreed with the right a person has to commit suicide. It is defended the notion that 'life is God's gift, therefore only He can take it back' (85%).

Three interpretable factors were extracted, accounting jointly for 43% of the total variance. Sixteen statements attained reasonable factor loading to figure in one of these factors. For didactic purposes, these factors were denominated Feelings towards the patient, Professional Capacity to handle situations which involve suicidal behavior and conceptions on the Right to Suicide (Table 2). The proportions of variance explained by each one of these factors were 0.47, 0.29 and 0.24, respectively. The scores in these factors varied from 0-700, 0-400 and 0-500, respectively. The Cronbach's alpha coefficients were, respectively, 0.7, 0.6 e 0.5.

The score in the Feelingssub-scale did not vary among the different interest groups. In the Professional Capacity sub-scale, the nursing assistants feel more capable to handle suicidal patients (average scores: Nurses = 174.5; Technicians = 194.6; Assistants = 210.5; p = 0.02). The fact of having already attended people under the risk of suicide was associated with a higher perception of capacity (average score = 199.7 vs 165.9; p = 0.004).

In the Right to Suicide, higher scores, which we will denominate 'more condemnatory', represent the belief that a person does not have the right to take away their own life, this decision owing only to God's will:

1) Older professionals ( > 50 years of age), compared to the younger ones (20-29 years of age), regardless their job position, expressed a more condemnatory attitude towards the right a person has to kill him/herself (Average Scores: 414.9 and 366.9, respectively; p = 0.04).

2) Nursing technicians, more than assistants and nurses, expressed a condemnatory attitude towards the right a person has to take away their own life (average scores, respectively: 440.3; 368 and 367.6; p = 0.007).

3) The condemnatory attitude was stronger among the ones who had never handled suicidal patients (average scores: 404.5 and 382.4, respectively; p = 0.04) and among the 93 (31%) who had a suicide family history (average scores: 401.5 e 380.3, respectively; p = 0.08).

4) Protestants manifested a more condemnatory attitude than Catholics and Spiritualists towards the right a person has to commit suicide (average scores: 416, 384 and 368, respectively; p = 0.008).

5) The ones who more often attended church services, with a frequency of at least once a month, had a more condemnatory attitude when compared to the ones who hardly ever or never went to church (average scores: 404 and 361, respectively; p = 0.0001).

Discussion

The instrument here described is the first attempt to measure in our country, by means of a standardized instrument, the attitudes of health personnel towards suicide. It allows delimiting a basis line from which it becomes possible to know the profile of these professionals, as well as to verify, after intervention strategies, if these attitudes are liable to change.

Even though the evaluation of attitudes is more complex than the expression of agreement or disagreement with a set of statements, the adoption of VAS on subjective measures is well-known, and makes measurement possible.¹¹ Test-retest reliability measures are yet to be calculated. Unfortunately, we can not verify whether this group differs from the one who had not attended the course.

The three factorial sub-scales, altogether, seem to cover the extension of what is understood as attitude in its affective ('Feelings '), cognitive ('Right to Suicide') and behavioral ('Professional Capacity') components. The homogeneity of the answers towards Feelings deserves attention. If we accept the hypothesis that the referred sub-scale would have been able to detect differences, in case they existed, we are left with the interpretation that, in the presence of the suicidal behavior of our patients, we react in a similar way. The greatest differences are to be found in the Right to Suicide sub-scale. In this field, generally, the more liberal attitudes, or less condemnatory, were reported by the younger ones, by nurses, and by the ones who had already been in contact with suicidal patients. A Swedish study also demonstrated more positive attitudes among nurses who had already had professional experience with patients prone to suicide.¹²

We were not able to make comparisons according to place of work due to an expressive staff replacement among the services because of the temporary closing of many hospital beds. Other studies suggested that the attitudes towards suicidal patients are more negative in the Emergency Room personnel,¹³ when compared to the ward's and the Intensive Unit Care staff.¹⁴ It is important to note that the negative attitude towards the suicidal behavior, frequently reported, might be more the result of lack of knowledge and uncertainty than the true hostility towards the patient.

The findings regarding religion and the intensity of religious practice suggest that, despite the fact that both Kardecism and Protestantism condemn suicide, more than a canonical prohibition, a strict and penetrating religious moral on the followers, as the one found among the Protestants, seems to have more consequences in the condemnatory attitude towards suicidal behavior.¹⁵

Conclusions

It was possible to develop an easy-to-fill-in instrument to measure the Nursing Personnel's attitudes towards the suicidal behavior, in which Factor Analysis produced three sub-scales. The usage of this instrument denoted differences among the groups of professionals.

Acknowledgement

We are grateful to The State of São Paulo Research Foundation - FAPESP and Andréa F. Semolina and Priscila Y. Yassunaga for the statistical advice.

Rev Bras Psiquiatr. 2005;27(4):315-8 Botega NJ et al.

Financing: Fundação de Amparo à Pesquisa do Estado de São Paulo - FAPESP (grant n° 03/08850-1)

Conflict of interests: None

Submitted: 23 March 2005

Accepted: 22 June 2005

Department of Psychiatry, School of Medical Sciences, Universidade Estadual de Campinas (Unicamp), Campinas (SP), Brazil

The study was approved by the Research Ethics Committee of the School of Medical Sciences of Unicamp: nº 343/2003

Publication Dates

History