Attitudes of the professionals in the care provided in situations of suicide: a cross-sectional study

Fernanda Pinto da Silva1, Ândrea Cardoso de Souza1

1 Fluminense Federal University, RJ, Brazil 

ABSTRACT

Objective: To know the beliefs and attitudes of the professionals working in the Family Health Strategy of Santa Cruz Cabrália/Bahia on the issue of suicide. Method: A cross-sectional and quantitative study, carried out with 37 professionals. The professionals had to answer a questionnaire on attitudes in relation to suicidal behavior (QUACS) of the users assisted by the Family Health Strategy in the municipality, as well as a professional training form. The data were analyzed by means of the Statistical Package for the Social Science – SPSS, verifying the mean and standard deviation of the factors. Results: Lack of preparation of the professionals is evidenced in the care for users at risk of suicide, with feelings of incapacity and moralistic attitudes. Discussion: The professionals working in Primary Health Care are fundamental in the early detection and intervention of suicide. Conclusion: Better preparation of the professionals is necessary to monitor these users in the Family Health Strategy. It is the managers' responsibility to ensure that these users are comprehensively monitored in the health services.

Descriptors: Suicide; Psychological Stress; Knowledge, Attitudes and Practice in Health; Health Professionals; Primary Health Care.

INTRODUCTION

Suicide is a major public health problem, involving social, emotional and economic aspects. In order to face it, effective measures must be adopted; such as, for example, investments in the economic and/or social areas and the implementation of robust care technologies(1). 

There are research studies pointing out that, there is a suicide in the planet every 45 seconds; it is estimated that more than 800,000 people commit suicide each year(2). Data from Brazil indicate that there are approximately 10,000 deaths due to suicide per year, recording an increase in the suicide mortality rate per 100,000 inhabitants, its figure being 5.3% in 2011; reaching 5.7% of the deaths in 2017(3).

As Primary Health Care (PHC) is the subject's gateway and preferential contact with the health system and with promotion and prevention actions, ensuring accessibility, longitudinality, comprehensiveness and coordination of care(4), it plays a fundamental role in preventing, evaluating and approaching patients at risk of suicide, in order to reduce the rates of attempted and consummated suicides. Therefore, a collective effort by managers and Educational Institutions is necessary to qualify the professionals who work at this care level, aiming at early intervention in cases of attempted suicide(5). 

As they are in close and prolonged contact with users, family members and the community, the professionals who work in the Family Health Strategy (FHS) are in a privileged position to assess patients at risk of suicide, and must be alert to the signs of risks and vulnerabilities(6). 

Therefore, through its team, the FHS plays a primary role in the construction and management of care for users at risk of suicide. However, the teams must be prepared and qualified to provide care to these users to be able to offer effective assistance and adequate support, as it is not simple to provide this care in a comprehensive, resolute and humanized manner(6).

Some factors can interfere with the care offered, compromising the quality of the assistance provided to the users. They are mainly related to beliefs, attitudes, values, lack of knowledge and stigma, which make it difficult to listen to, welcome and bond with these people(7), essential attributes for the practice of the expanded clinic.

Thus, the objective of this research is to know the beliefs and attitudes of the FHS professionals facing the problem of suicide.

METHOD

An exploratory field study with a cross-sectional design and a quantitative approach, carried out in the municipality of Santa Cruz Cabrália, Bahia. The research was carried out with 11 Type II FHS teams and 6 teams of oral health, modality 1, from the FHS units, which constituted the totality of the FHS services in the municipality.

The following individuals would participate in the study: all the medical professionals (11), nurses (11) and nursing technicians (21) from the FHS, totaling 43 professionals. However, the study was carried out with only 37 professionals, since 3 were on vacation, 1 was on sick leave; and 2 were not present on the day of visits to the units.

The inclusion criteria adopted were as follows: professionals who had a minimum performance of six months in the FHS team and who were present on the day of the visit to the units. Exclusion criteria: professionals on sick leave, vacation and with a medical certificate.

The data collection process took place via a professional qualification form and municipal incentive, as well as by means a self-administered questionnaire on Attitude in Relation to Suicidal Behavior (QUACS), applied to nursing professionals(8).

The QUACS corresponds to a scale containing 21 analogous visual items that bring together the beliefs, feelings and reactions in relation to suicidal patients, each item corresponding to a 10 cm visual scale between agreement and total disagreement(8,9).

The questions contained in the QUACS were grouped into three reasons: “negative feelings towards the suicidal patient”, “perception of professional capacity” and “right to suicide”. In “negative feelings towards the suicidal patient”, the higher the score, the greater the presence of negative feelings, which can make it difficult to assist the individual who exhibits suicidal behavior: Q2- Whoever is threatening to commit suicide, usually does not kill themselves; Q5- Deep down, I prefer not to get too involved with patients who attempted suicide; Q9- I am afraid to ask about suicide ideas and end up inducing the patient to do so; Q13- Sometimes it makes me angry because there are so many people wanting to live and that patient wanting to die; Q15- People feel powerless in front of a person who wants to kill themselves; Q19- Whoever wants to kill themselves is not "trying"; with the exception of question Q17- In the case of patients who are suffering a lot due to a physical disease, I find the idea of suicide more acceptable, which had its value reversed during the sum of points.

Regarding the “perception of professional capacity” element, the higher the score, the more confident the professional feels to deal with individuals with suicidal behavior: Q1- I feel able to help; Q7- I feel capable of perceiving when a patient is at risk of killing themselves; Q10- I think that I have professional training to deal with patients at risk of suicide; however, regarding question Q12- I feel insecure to care for patients at risk of suicide, it is necessary to have its value inverted.

In the “right to suicide” element, a higher score can mean a more “moralistic” attitude, with the exception of question Q3- After all, I think that a person has the right to kill themselves, which, when verifying the sum of the scores, had its value inverted. The rules are valid for questions Q4- Faced with suicide, I think: if someone had talked, the person would have found another way; Q6- Life is a gift from God and only He can take it away; Q16- Whoever has God in their hearts will not kill themselves; Q18- When a person speaks about ending their life, I try to get it out of their head.

To analyze the quantitative data, the scores of the three QUACS factors were initially calculated. These scores are the result of the sum of questions characteristic of the questionnaire, as shown below:

• Factor 1 (Feelings towards the patient) = Q2 + Q5 + Q9 + Q13 + Q15 + Q17 + Q19.

• Factor 2 (Professional capacity) = Q1 + Q7 + Q10 + Q12.

• Factor 3 (Right to suicide) = Q3 + Q4 + Q6 + Q16 + Q18. 

Questions Q8, Q11, Q14, Q20 and Q21 will not be added to the elements of the scale, as they do not present affinity with the constructed factors. Thus, they can be analyzed separately or excluded from the scale analysis(9).

The data were tabulated in an Excel® spreadsheet and subsequently exported to the Statistical Package for the Social Science - SPSS, version 23. The mean and standard deviation of the factors in the questionnaire of attitudes in relation to the suicidal behavior held by all the professional groups (physicians, nurses and nursing technicians) were verified, and displayed in tables.

This research was approved by the Research Ethics Committee of the State University of Santa Cruz under No. 2,776,444.

RESULTS

The initial study proposal anticipated the participation of all the professionals who worked in the Family Health Strategy of Santa Cruz Cabrália/Bahia; however, after applying the exclusion criteria, the study sample was composed of 10 physicians, 9 nurses and 18 nursing technicians. Of these, 70%, 89% and 94.5%, respectively, considered themselves religious individuals. As well as that, in mean values and in this order, 69%, 79% and 52% believe that people who attempt suicide have some type of mental disorder. 

The training profile of these participating professionals is shown in Table 1.

Table 1. Professional profile of the physicians, nurses and nursing technicians from the FHS units regarding training, in the municipality of Santa Cruz Cabrália, Bahia, 2018 (n=37)

Source: Research data.

In relation to the time of professional training, it was evidenced that 43.2% of the professionals have more than 15 years since graduation. In addition, 62.2% had some experience in the field of mental health; and 51.4% of these professionals reported having attended undergraduate courses that addressed the theme of suicide. According to the data presented in Table 2, participation in graduate courses that addressed the theme of suicide was mentioned by only 5.4% of the respondents.

Table 2. Municipal incentive for the qualification of the FHS physicians, nurses and nursing technicians, training and support in the municipality of Santa Cruz Cabrália, Bahia, 2018 (n=37)

Source: Research data.

According to the research findings, it was possible to infer that there was very little incentive for the training and updating of the FHS professionals in the field of mental health, a fact pointed out by 83.8% of the professionals, with 10.8% indicating network discussions as the main strategy adopted. 78.4% of the professionals reported that the frequency of incentives for training and qualification was non-existent.

In addition to that, 29.7% considered themselves able to assist users with suicide attempts, while 24.3% considered themselves partially able; and 10.8% did not feel prepared.

The participants (70.3%) mentioned having support to develop better care for users with a history of attempted suicide; of these, 18.9% have the Extended Family Health Centers (Núcleos Ampliados de Saúde da Família, NASF), 13.5% reported NASF and matrix support, and 5.4% reported having only institutional support.

Table 3 below displays information on the mean and standard deviation, also presenting the minimum and maximum deviations observed on the factors of the questionnaire of attitudes in relation to suicidal behavior by profession, facilitating the observation of differences in the answers among the professionals.

Table 3. Descriptive analysis of the three assessment factors of the “questionnaire of attitudes in relation to suicidal behavior” among the medical professionals, nurses and nursing technicians, in the municipality of Santa Cruz Cabrália, Bahia, 2018 (n=37)

Source: Research data.

Table 4 below displays information about the three professions related to factors of the questionnaire of attitudes in relation to suicidal behavior, presenting the differences in perceptions held by the higher and mid level professionals who operationalize the care of these users in their health territories. What the means by category already evidenced can be clearly perceived.

Table 4. Descriptive analysis of the three assessment factors of the “questionnaire of attitudes in relation to suicidal behavior” among the medical professionals, nurses and nursing technicians, in the municipality of Santa Cruz Cabrália, Bahia, 2018 (n=37)

Source: Research data.

When comparing the three factors of the scale between physicians, nurses and nursing technicians, it was observed that, in relation to factor 1, “negative feelings towards the patient”, nursing technicians have higher scores, followed by physicians, presenting more negative feelings when compared to nurses. Regarding factor 2, “professional capacity”, the physicians have a higher professional capacity score, followed by the nursing technicians. The nurses obtained a lower score in relation to professional capacity. When addressing factor 3, “right to suicide”, the nursing technicians had a higher score, followed by the physicians, evidencing more moralistic attitudes towards the problem.

DISCUSSION

The professional's time in the labor market is an indicator of quality, as well as contributing to maturity in the work processes. In this study, 43.2% (n=16) had a time of training of more than 15 years, while 54.1% had a short period between 1 year and 4 years of experience in the municipality's FHS(10) .

Most of them had no experience in the field of mental health (62.2% – n=23); however, 51.4% (n=19) reported having attended undergraduate courses that addressed the theme of suicide. It was evident that 91.1% of the professionals did not take any discipline that dealt with or contemplated the theme of suicide in their respective graduate courses. However, the theme of suicide needs to be inserted in the training of the professionals, since it is a public health phenomenon, in addition to the social and economic crossings, requiring the professionals to be qualified to cope with and prevent suicide(11).

Regarding the municipal incentive given to the FHS professionals in the municipality, 83.8% (n=31) stated that it was nonexistent; of those who reported that it was present, 10.8% (n=4) reported that it occurs via network discussions; however, they reported that it occurred infrequently. It is through investments in the training of the professionals that we will gradually be able to overcome obstacles, by means of a permanent process, by improving health care(12); the incentives may be a set of stimuli, financial or not, aimed at adjusting and optimizing the components of the production process in the health services, enabling better access to the essential health services by the population and ensuring greater quality in health care. 

As for considering themselves able to assist a patient with suicide attempts, 16.2% (n=6) reported that they certainly did; 29.7% (n=11) stated that, in general, they consider themselves capable; 43.2% (n=16) consider themselves more or less capable; and 10.8% (n=4) do not consider themselves capable in any way. Most of the health care professionals are not prepared to assist suicidal patients, needing qualification, for changes in perception and negative attitudes that may interfere in resolute care(13,14).

In relation to the support received from the municipality for the qualification of the professionals to care for users with mental disorders, 70.3% (n=26) said that they had received it, mostly from the NASF (18.9%), matrix support (10.8%) and NASF/matrix support (13.5%). Matrix support in mental health is a fundamental practice, as it contributes to the support of complex cases and situations, as well as to the organization of actions and permanent education of the entire health team(15).

The articulation of the network services in the territory plays an essential role, mainly addressing the psychosocial issue, stimulating an exchange of knowledge, with actions in an integrated and complementary manner, producing comprehensive care through permanent dialog across the networks, enhancing the actions developed(16).

When analyzing the result of the factors in the questionnaire of attitudes in relation to suicidal behavior, the nurses were the least likely to feel secure and capable of caring for a patient at risk of suicide. In addition to that, a very high score was observed in relation to moralistic attitudes among physicians and nursing technicians, portraying, with these findings, the deficiency of the primary care professionals, who are the preferential gateway to health care, in dealing with this serious and important public health problem, resulting in inadequate assistance to users in mental distress.

An unprepared team can make the users' condition to worsen, as they may feel uncomfortable and stigmatized, as a consequence, distance from the service and the professionals who work there, avoiding seeking help again(7).

Regarding the “negative feelings”, a low score was evidenced in all the professional categories, resulting in more positive feelings. However, when making a comparison across the three categories, the nursing technicians presented higher scores, followed by the physicians, demonstrating that they had more negative feelings towards people who attempt suicide. In contrast, the nursing technicians were the ones who reported feeling more prepared, with high scores, for the care of the suicidal patient. The low score of nurses in relation to “professional capacity” stands out, evidenced by little security when dealing with patients at risk of suicide and with suicide attempts.

As the nurse is a professional who is in permanent contact with the patient, it is quite worrying to know that they do not feel prepared to care for people in mental distress who seek care in the FHS. It was verified that these professionals are qualified to intervene in patient care, aiming at care and at the appreciation of life; however, they are not prepared to deal with death, nor with the desire to die, even feeling frustrated in the care process(17). Thus, it is necessary for the Nursing team to be qualified to know the factors that can lead people to attempt suicide, with the use of preventive strategies, modifying negative attitudes and setting aside possible judgments, allowing for more welcoming care(6). In contrast, according to the questionnaire, the physicians had greater professional capacity, followed by the nursing technicians.

Regarding the “right to suicide”, the physicians and nursing technicians demonstrated more moralistic attitudes towards suicide, although the nurses also obtained significant scores. Although the nursing technicians feel more confident and prepared to deal with the situation of patients at risk of suicide, they were the ones who obtained the highest scores on moralistic attitudes.

The attitudes of the professionals are surrounded by beliefs and values. Stigmatizing attitudes and mistaken beliefs can generate inadequate care, becoming an obstacle to access treatment, requiring these professionals to have greater reflection and understanding of the emotional processes that people at risk of suicide are experiencing(18).

It is known that 3 out of 4 individuals who committed suicide had contact with primary care services in the year of their death, with 1 out of 3 people having had contact with mental health services. In the month prior to suicide, 1 out of 5 people had contact with mental health services; and nearly 45%, with primary care services, thus showing the fundamental role of the PHC professionals in the early detection of risk factors and in suicide prevention(13). Therefore, attention by the professionals is necessary in order to identify and possibly care for these people in order to prevent suicide(19).

CONCLUSION

It is perceived that the FHS professionals are unprepared to care for users at risk of suicide, presenting feelings of insecurity, incapacity and moralistic attitudes towards these patients. 

We can conclude that the FHS is a fundamental point of attention for this care because, in it, the professionals are more likely to perform early detection of these users in distress, screening, monitoring and adoption of preventive actions.

It is indispensable that the professionals should be prepared to assist users with suicidal behavior. For such, it is necessary to adopt permanent education actions, including matrixing and conversation circles to demystify suicide, and to develop less prejudiced, stigmatizing and moralistic behaviors in the face of the problem and of the users themselves. 

It is believed that this research study can contribute to the construction of new encounters and knowledge with the theme by bringing the perception and feelings of the family health professionals towards suicide; therefore urging professionals and managers to implement care strategies for differentiated and qualified care to people with a suicidal trajectory. However, this study warns about the need to think about how to insert, in health education, themes that are little explored in the educational institutions and that integrate the routine of the health services, such as suicide, drugs and others, in a transversal, integrated and interprofessional manner.

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Received: 09/15/2020

Revised: 03/03/2021

Approved: 03/29/2021