Gaps in Suicide Assessment and Management Among Accident and Emergency Nurses in Kenyatta National Hospital: a Qualitative Study

Abstract

This qualitative study was conducted using key informant interviews with Accident and Emergency and Mental Health staff at Nairobi's Kenyatta National Hospital to examine the current state of suicide assessment and management care at the Department. The interviews probed whether protocols were in place and if the key personnel were aware of these procedures and to what extent evidence-based protocol was used in managing suicidal patients at A&E. We interviewed eight key informants who rotated in the Accident and Emergency Department and Mental Health Department, and they were interviewed using a semi-structured interview guide. We included clinicians and administrators in addition to the nurses. Using NVivo Pro 11 software, themes and subthemes were derived with the final code system having patient assessment and patient management, as well as protocol and care gaps and further recommendations as the key themes. With regard to patient assessment, all the interviews identified stressful life situations, substance use, and violence as being the dominant presenting complaints in patients with suicidal tendencies who were seen at A&E. Five out of eight interviews with our key respondents mentioned depressive symptoms as a clinical presentation for suicidal patients. Six out of eight respondents also shared that there were no protocols for assessing and managing suicidal patients with some reporting that they used what they learnt in Nursing and Medical School to offer management in that point of time. Most of our respondents mentioned that clinical management of suicidal patients was mostly done with the use of force to deal with violent and resistant patients. Psychological management was essentially an ex post facto issue left to the very few counselors within the Department. Most of our respondents did not have information on their patients after discharge raising questions about patient safety and well-being. Our analyses of these interviews led us to the conclusion that there were significant gaps in assessment as patients were not routinely screened for suicidal ideation despite suicidal intent and psychological problems being undercurrent issues. Psychological management was sparse with most of it being left to very few staff. Training in suicide assessment for all patients and management we felt was critical in increasing the self-efficacy of nurses in Accident and Emergency Department in handling medical emergencies that are prompted due to mental health issues and suicidal and self-harming behaviors.Keywords Brief suicide assessment . Brief suicide interventions . Self-efficacy . Accident and emergency health care worker . Suicide assessment gaps . Suicide management gaps . Suicide protocols * Rachel Maina

Suicide prevention by emergency nurses: perceived self-efficacy in assessment, management and referral at Kenyatta National Hospital in Kenya

“…It could also be that if any suicidal symptom was detected using any means, the nurses integrated suicide management practices and referred patient for further management. This is evidenced in a qualitative study done among the same population where if a patient is found to be suicidal, they are referred for counseling [13]. The respondents in this study had a high index of suicide risk suspicion for patients who were raped, between ages 20 and 35 and who have an alcohol problem [13].…”

“…This is evidenced in a qualitative study done among the same population where if a patient is found to be suicidal, they are referred for counseling [13]. The respondents in this study had a high index of suicide risk suspicion for patients who were raped, between ages 20 and 35 and who have an alcohol problem [13]. The level of confidence in risk referral process was quite high in this study compared to the other two domains considering there are no formal referral protocols in this particular setting.…”

“…This underutilizes usage of emergency departments as suicide prevention sites as patients will most likely not tell if not asked. The lack of suicide assessment protocols in Kenyatta National Hospital’s emergency department further aggravates this outcome [13]. This leads to management of physiological symptoms such as stroke, chronic obstructive pulmonary disease and heart attacks; while 8–12% of occult suicides go undetected and unmanaged [6, 20].…”

The Nurse or Midwife at the Crossroads of Caring for Patients With Suicidal and Rigid Religious Ideations in Africa

“…Other pointers that nurse or midwife should look out for are voicing feeling trapped, increasing alcohol or drug use, withdrawal from friends, family, and social activities, being anxious or agitated, having sleep disturbances or sleeping all the time, and having dramatic mood or personality changes ( Talseth and Gilje, 2011 ). The nurse or midwife should be vigilant to identify patients at risk of suicide who talk or write about death, dying, or suicide and those who make statements such as “there’s no purpose in life” or “there’s no reason for living” and say goodbye to people as if they will not see them again or gives away cherished belongings ( Kuehn, 2013 ; Maina et al, 2019 ). The nurse or midwife assesses for nonverbal signs that may potentially indicate the patient is considering self-harm, such as avoiding eye contact, tearfulness, crying, or an abrupt change in behavior, such as sudden happiness, which may signal that the patient has solidified the plan to commit suicide ( Maina et al, 2019 ).…”

“…The nurse or midwife should be vigilant to identify patients at risk of suicide who talk or write about death, dying, or suicide and those who make statements such as “there’s no purpose in life” or “there’s no reason for living” and say goodbye to people as if they will not see them again or gives away cherished belongings ( Kuehn, 2013 ; Maina et al, 2019 ). The nurse or midwife assesses for nonverbal signs that may potentially indicate the patient is considering self-harm, such as avoiding eye contact, tearfulness, crying, or an abrupt change in behavior, such as sudden happiness, which may signal that the patient has solidified the plan to commit suicide ( Maina et al, 2019 ). If any of these signs are identified, it should be reported to the multidisciplinary team including a psychologist for a thorough assessment.…”