Demographic characteristics of participants
Eleven nurses (nine females and two males) working in the study setting participated in this study.
Study findings
The study findings are presented in this section. Firstly, an overview of the demographic data of the participants is provided (Table 1), followed by an overview of the themes that resulted from the data analysis (Table 2) and a detailed description of each of the themes. Four (4) themes and six (6) subthemes were extracted from the data analysis and presented in Table 2 below.
Table 1: Demographic data of participants
Table 2: Themes and subthemes
The themes are presented by describing each theme and subtheme, followed by relevant interview quotes. The quotes are referenced as ‘P’ (participant), followed by the participant number and relevant demographic information.
Theme 1: Mental healthcare providers experience it as challenging at times
Participants frequently expressed that providing health care to adolescents with suicidal behaviour was challenging at times. They expressed that the experience could be both emotionally and physically challenging and that the management of such patients was challenging at times due to the behaviours they presented. The behaviours were frequently described as different from adults and often accompanied by other challenging behaviours such as aggression, lying, and manipulation.
Subtheme 1.1: Emotionally challenging
Participants described the emotional challenges they faced while caring for adolescents with suicidal behaviour by stating that they felt responsible for their patients' lives and felt that they had failed when patients committed suicide or were readmitted. The participants expressed sympathy for the challenges their patients faced and the reasons they felt suicidal. Some participants went on to explain that they felt concerned for their patients' futures when they were discharged, worrying about the environments they returned to and whether someone could provide round-the-clock care as they did. While the majority of the participants discussed the emotionally challenging nature of caring for adolescents who are suicidal, it may be worth noting that participants with less than a decade of experience expressed this sentiment more frequently. Nonetheless, even the participant with the most experience, spanning two decades, emphasized the feeling of helplessness and disappointment associated with caring for such patients. In the outline of the themes, the words in square brackets indicate words omitted by the researcher or participants.
“It's almost like the extra responsibility when you're working with [adolescents] because you know, they're minors. So, it's almost for me, like it had a responsibility on myself as a nurse with the [care] of the minors. That's why I feel it’s more challenging”. – P7: Female with 10 years’ experience.
“Oh, it's very difficult. Let me say, it [is] very difficult. As a nurse, you need to watch them 24/7, everything they do. And then knowing that if anything can happen to them, you'll be responsible. And then sometimes you find it difficult because at the end of the day, it comes back to you as a nurse. [And] you know, it's very difficult … All I can say is that it's difficult and it make[s] a person emotional at times. Because you know, it's like their child's life is in your hands. Because anything that, that the child can do, you [are] accountable”. – P10: Female with five years’ experience.
“It's emotionally draining because, number one, you feel sorry for the patient, you know. And most of the times, you know the reason for them to be suicidal ... So, you know the problem, but at the same time you cannot help so, it drains you because it feels like you're not doing anything. The only thing you are preventing is suicide. This is for this moment and [then] thinking what's going to happen when they go outside, who's going to look after them … Who's going to look after them 24/7 at home, so that is why you feel for them, you know”. – P4: Female with four years’ experience.
“I feel like a failure, sister. Like as much as I am proud to see them go, but when they come back, I feel like now we are not doing enough … Once we discharge them, they're going to go back to their life, and everything is going to come back. They will end up going back and smoking and all this stuff … It's killing us, or it's killing me to see my patient coming back here. It's very painful because when they leave this place, they will tell you promising things, ‘Now I'm going to go back to school. I'm going to find a job.’ … Four or five months later, they come back. It's very sad”. – P5: Male with one year of experience.
Subtheme 1.2: Physically challenging
Providing health care to suicidal adolescents was also described as being physically challenging. It is tiring because the mental healthcare providers have to follow the patients to ensure that they do not hurt themselves. Nearly all participants detailed the necessity for constant and vigilant patient observation – a task made even more challenging due to the frequent issue of understaffing. The physically demanding nature of providing this care was highlighted by the fact that almost all participants, regardless of gender or years of experience, emphasised the critical need for continuous and vigilant patient monitoring.
“It is very exhausting because you must be with a patient 24/7, you must follow the patient wherever he or she goes, you must make sure that you don't, you know, even blink. Because they can pick up anything and use it within a slip of a second so, it is very, it's very challenging. It's very draining. I can say it is, you know”. – P4: Female with four years’ experience.
“But with suicidal patients, you need to [always] be [there] and always have your eyes. You need to watch all what they're doing, what they're taking, where they're going. So, if you're not, but sometimes you know you're not all, sometimes you don't even see the stuff and they're taking, yeah, those are the things, [and then] there's always incidents ... I don't like incidents. … Our eyes is not always there but you cannot [be] everywhere, so to speak, we do what we can do”. – P8: Female with 13 years’ experience.
“If there is patients like that, can they maybe provide us with more staff? Because sometimes watching this suicidal patient and there's other patients on the other side, it makes you not cope, at least if maybe they can provide more staff like someone that's going to watch like this specifically patient that is suicidal. And then the other nurses can watch the other patient as well because it's not easy to deal with someone that is suicidal, and you need to take care of your other patients as well. Then it’s a bit difficult”. – P10: Female with five years’ experience.
“And then you need to look at the [staff] because sometimes we [are short] of [staff] and we can't do anything. Like everything, I can't be [on] the floor, and then I'm following the child at the same time”. – P7: Female with one year of experience.
Subtheme 1.3: Challenging to manage adolescent behaviour.
A significant number of participants conveyed that adolescents with suicidal behaviour pose unique challenges in terms of difficult and unpredictable behaviour compared to adults with suicidal behaviour, frequently stating that distinguishing between normal adolescent behaviour and mental illness was challenging. Additionally, these participants noted that the adolescents' suicidal behaviour often was accompanied by challenging behaviour such as manipulation, lying, and aggression and that they experienced this behaviour as difficult to manage. They experienced the adolescents’ behaviour as frustrating, irritating, and difficult to distinguish as part of the mental illness or part of normal adolescent behaviour, and they felt uncertain regarding the most effective response.
“Training needs to be about how to manage a patient who is feeling suicidal but specifically for children, not adult[s]. There should be management for the adult[s] and management for the children and because the management is sort [of] different and even the presentation is sort [of] different. Many people don't even know that the presentation is sort [of] different like when it comes to depression in a child and depression in adult[s]. Um so, sometimes they mess them up with it, the child gets misdiagnosed even because like the child is just irritable and the child's just naughty or just acting out and stuff like that”. – P1: Female with eight years’ experience.
“And sometimes we cannot distinguish between illness and behaviour, also cause sometimes like [a] teenager like this, [this is] normal sort of teenage behaviour. So that also makes it even more challenging because it's difficult to distinguish between each other sometimes”. – P7: Female with 10 years’ experience.
“The other thing that is frustrating with suicidal patients. You know they can also be aggressive. Besides being suicidal, if they are suicidal and aggressive, you can't seclude them because you cannot check with the person that is [suicidal] then. So, you have to deal with the aggression out of the exclusion. So, it's because suicide is contraindicated for seclusion… So, it's difficult to contain them while they're [aggressive] because you can't make use of seclusion. – P4: Female with four years’ experience.
“Sometimes [it’s] very challenging because of their different behaviour… different children from different environments and yeah, it can be very problematic at times because of their behaviour – the way they grew up and where they're coming from. In that way, that's very challenging for you. They come with their own minds and whatever”. – P9: Female with 14 years’ experience.
“[Talking about a patient] So, she had that she was hiding it [a sharp object] …so they can be very manipulative. They can be very, what is that word I'm looking for now? Very good in hiding. Very, very good in masking this. Something very, very good, especially if they've been doing it for some time … It's a challenge for all of us”. – P5: Male with one year experience.
“With the children, you like, you need to be a mother [but] you need to be a nurse on the other side as well”. – P15: Female with five years’ experience.
Subtheme 1.4: Stressful environment
Participants described working with adolescents as working in a stressful environment that is tense and requires all their attention. Not being able to relate to these adolescents makes it difficult for the participants to be their mental healthcare providers.
“I can say for the first time very stressing, because I haven't been to psychiatric hospital. I only came here just that time because I was an agent staff and working all over and then I came here I just thought it is only old people psychiatry but now I came to adolescents’ suicidal issues”. – P2: Female with eight years’ experience.
Theme 2: Mental healthcare providers experience it as rewarding at times.
While the provision of health care to adolescents with suicidal behaviour was often described as challenging, participants also noted moments of reward, especially when witnessing positive progress in their patients or when the patients were discharged. Many participants further expressed that they felt they continued to learn from their time in the ward and considered the experience interesting despite the challenges. Some participants conveyed a sense of fulfilment: feeling that they had made a meaningful difference in their patients' lives. The participants also mention teamwork as form of a reward as they can help each other overcome whatever obstacle they can come across in the ward. This theme was observed among nurses with little to extensive work experience and encompassed both male and female participants.
“So, it's nice, like it is amazing to watch someone who has been through a lot and then going out when she's being discharged. Like you see that this child is improving, or she has improved, like you, you managed to help this child. Yeah, that's how and by saying it is also amazing, I mean, you don't want to see a child who's going to come back again or some a child who's not progressing in whatever. So, when you see a [child] progress, you know, you feel proud and happy about it”. – P6: Female with one year of experience.
“Most of the time what I notice is that they come in [they’re] suicidal. But when they leave, they’re so much better, and that also makes you feel good. Because even if it's a little thing, you, you are a part of it”. – P2: Female with eight years’ experience.
“If you know every, every day is a learning experience with us because we learn a lot of things from different patients. So, it's challenging and educational for us”. – P8: Female with 13 years’ experience.
“OK, let me just say I enjoy my work first of all. So, for me, every moment it's like I am going to learn something. I need to learn something. I need to learn something”. – P5: Male with one year of experience.
“I'm learning, and it's quite interesting. Also, as much as it's challenging, [it’s] interesting as well because I'm learning”. – P7: Female with ten years’ experience.
Theme 3: Mental healthcare providers need emotional and/or psychological support.
When asked about the support mental healthcare providers deemed necessary for providing health care to adolescents with suicidal behaviour. A significant number of participants emphasised a need for emotional and/or psychological support, like counselling by a psychologist or the management talking to them. Particularly in instances when negative incidences occurred such as adolescents committing suicide in the ward or self-cutting. The participants frequently stated that they lacked access to counselling or debriefing services within the hospital, with some participants expressing that they felt the focus was placed almost exclusively on patients' mental well-being. Interestingly, while only two male participants were available for this study, they did not express a need for psychological or emotional support. Instead, they focused on more tangible forms of support, such as environmental suitability and follow-up programmes for discharged patients.
“And also, some like some sort of debriefing; to talk, to just [talk about your] experiences and not be judged for, you know, the way you, the way things make you feel at the end of the day. Because there's a lot going on and yeah, there's a lot going on and it seems that you just carry on. You just carry on. It's like, yeah, it's almost like it's one that is the way things are. But yeah, it could, it could be better if we have those kind[s] of support. … And we also, we told [them] previously that we needed to like have our own, like a team [psychologist], you know like a private psychologist, but people are not keen to do that, not everybody”. – P7: Female with 10 years’ experience.
“Whenever [something] happens to the patient you like, feel like not good enough to do your job and all that stuff. But I mean us nurses also, we need someone that can maybe [counsel] us [when] something happened. ‘How do you guys feel? How are you coping?’ Something like that, you know. Because really, if you don't get that support you, you will always feel emotional and you [end] up harming yourself because they only, they only focused on the patient … You know, I think we also need like someone that's going to [counsel] us because, at the end of the day, it affects us emotionally”. – P10: Female with five years’ experience.
“You can be traumatized from what you heard; you know the story of what happened to that child. So, also, they need to, we need support. Like for instance, there should be, like therapists, you know, a [therapist] that nurses go to, let's say, twice a week or once a week, you see. Yeah, just to – because sometimes other nurses, they do keep things inside. Not knowing that that story of that child traumatized her and then in the long run, the nurses commit suicide as well. It can happen. It can happen. Or, you know, or she is having or is having a child like that you know at home”.– P7: Female with one year of experience.
Theme 4: Mental healthcare providers need organisational support.
There was a clear demand for organisational support among the participants. They expressed a need for specialised training on adolescents with suicidal behaviour, which had not been extensively covered during their initial qualifications. Furthermore, there was a desire for more constructive managerial support. The participants conveyed a sense of inadequacy in the level of support provided to them during investigations after incidences. Additionally, concerns were raised regarding the safety of patients within the wards, which is exacerbated by the persistent challenge of staff shortages. The participants felt that these concerns needed to be acknowledged and addressed by the management. Specifically, they expressed a need for training and constructive support from management.
Subtheme 4.1: Training
The participants highlighted the necessity for training by advocating for in-service programmes and external workshops and courses facilitated by hospital management. The desired training encompassed topics such as understanding adolescent suicidal behaviour, the impact of substance abuse and smoking on suicidal tendencies, self-harm, and the management of co-morbid conditions. It is noteworthy that even experienced participants, with up to 20 years of professional experience expressed a clear desire for additional specialised training in the provision of care for adolescent patients with suicidal behaviour.
“It was like if you don't know, like you know, you fresh out of university and when I was at university, we didn't do child and adolescents in psychiatry, we did it as in like some theory, but we didn't focus much on it. And then practically we never came to the child and adolescent units at all. So there was no experience in terms of working with children with suicidal behaviour… Like since I've been here, to be honest with you, we didn't have specific training in terms of dealing with adolescence [suicidality], we mostly go for management of aggression, uh things like that. But specifically with suicidality, in our hospital no”. – P1: Female with eight years’ experience.
Training will make a huge difference even for me. Like I used to get into their shoes when they are in this situation, but if I can get the training, I think I can be a better person for them. [Interviewer: What do you think the training should include?] Their mental state, their suicidality, others like those kids that they have been smoking and, and stuff which destroyed their minds”. – P2: Female with eight years’ experience.
“You know, support is very important. It would be nice to have something like in-service training. Because I mean some of us, also not everyone, has children. So, yeah, but would make it easier if you get like regular in-service training, if you attend courses, you know, if it's not, maybe on the premises, maybe outside the hospital”. – P7: Female with 10 years’ experience.
Subtheme 4.2: Constructive support from management
The participants emphasised that managerial support is needed, for example, a need for a non-punitive management approach. The participants also mentioned that the management can create a receptive environment where staff concerns, such as incidents when patients commit suicide or hurt themselves, patient safety concerns, and staffing shortages, are actively heard and addressed. The participants also mentioned that if their good work can be recognised, this can motivate the staff to outperform. Hiring agency staff who have experience in working with adolescents, rather than hiring agency staff who do not know anything about the environment, was recommended to fill the gap without having to train new staff, which makes them less productive when caring for these adolescents. This theme was noted among participants with different levels of professional experience, regardless of gender. This finding indicates that addressing this need is significant within the context of this study sample.
“We just need them to be there for nurses, and I don't say you must take [my] side when I'm wrong; I'm wrong. If I'm right; I'm right. So, at least they [can] have [a] talk with us and assist us and just be there for their staff because I don't know. If like [then], you called in to ask what really happened during [the] investigation and why you are investigating me; [then] asking the question is wrong at the end of the day, but still you going to take that patient side. [And then] we get removed out of, out [of the] ward for what [happened] because [of] the third person that is not even here that doesn't even know what is going on this place. So, they, they not making it easy for us”. – P9: Female with 14 years’ experience.
“These patient[s] sometimes they know what they are doing, so now we cannot do anything about it but environment, the environment is not always [a] safe space. Because with different diagnoses, some of them, they do not want to kill themselves, but when you mix them together, they end up wanting to kill themselves too. So, the environment is too limited for this patient. They need more space and [a] space that will be comfortable for them. … They need one one-on-one, they will look, they will want to [get] one-on-one, [they] want to stay [in] the site where they will feel comfortable, be one-on-one and [with] security. So, I think if maybe we can have the right spaces for different purposes, for those who want to commit suicide have their own space away from the others”. – P11: Male with 22 years’ experience.
“If there are patients like that, can they maybe provide us with more staff? Because sometimes watching this suicidal patient and there's other patients on the other side, it makes you not cope, at least if maybe they can provide more staff like someone that's going to watch like this specifically patient that is suicidal. And then the other nurses can watch the other patient as well because it's not easy to deal with someone that is suicidal, and you need to take care of your other patients as well. Then it’s a bit difficult”. – P10: Female with five years’ experience.
“Oh, because even if something happens then – nothing happened – but most of the time, even when they, they, the, the children do things, then they will never come back to the staff and maybe ask, ‘Do you need counselling or what happened?’ Or like as management they, they always focus on the patient, they never focus to the staff, like to see how the staff is doing”. – P10: Female with five years’ experience.
“Support, we need all the support that we can get. I mean from the doctors as well [as] from our managers. Because if anything happens, most of the time they don't, they don't try to find out like, what was the problem. Or they [are easy] to blame you, like you want to blame nurses. … And then you need to look at the [staff] because sometimes we [are short] of [staff] and we can't do anything, like everything. I can't be on the floor, and then I'm following the child at the same time. So, they need to also accommodate us and if we say that, okay, we [are] short of [staff] that we need to bring that person that we want; book overtime, book you know agencies”. – P6: Female with one year of experience.
Discussion
This study is relevant and important in health care, and a study done by [28] supports this statement as it was found that the sharing of health care provision experiences contributes to helping others and delivering better service. This study revealed how mental healthcare providers experience providing health care to adolescents with suicidal behaviour and how they can be supported to fulfill their duties when caring for adolescents with suicidal behaviour. The aims and objectives of the study were reached, namely: to provide a description of the experiences of mental healthcare providers providing health care to adolescents with suicidal behaviour and to establish the support they need. Consequently, this study is useful as the researcher was an independent person with no influence on the participants.
The findings of the study provide a detailed description of the experiences of mental healthcare providers in providing healthcare to adolescents with suicidal behaviour in the context of a public psychiatric hospital. Findings from the study indicate that mental healthcare providers experience caring for adolescents with suicidal behaviour as challenging in different ways, including, emotional and physically challenging and a stressful environment. It is experienced as emotionally challenging as caring for someone creates feelings of empathy, which allow them to experience the same journey as these adolescents with suicidal behaviour. Prior evidence asserts that it is common for mental health providers caring for suicidal patients to experience distress [29], [30]. Providing mental health care to adolescents with suicidal behaviour can be physically challenging as constant monitoring of all the patients’ movements is required to ensure that they do not find anything that can be used to hurt themselves. The participants even mentioned that they must follow the adolescents to the bathroom. Similar studies confirm that this experience results in healthcare providers feeling overwhelmed and hopeless, which can affect their coping mechanisms when caring for adolescents with suicidal behaviour in the future [31]. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [32] supports this statement as it mentions that a stressor can be experienced directly and personally by witnessing a traumatic event or indirectly by learning about a certain traumatic event. Therefore, even if these mental healthcare providers are not the ones experiencing the situation, it can negatively affect their mental well-being. In a study by [33], the mental healthcare providers experienced caring for the adolescents as rewarding as it provided an opportunity for personal and professional development, and they felt motivated as they could impact the lives of these adolescents.
Furthermore, the findings of the study provide insight into the support needed by mental healthcare providers when providing healthcare to adolescents with suicidal behaviour in the context of a public psychiatric hospital. Mental healthcare providers require emotional and psychological support. Staff counselling and debriefing are required on a regular basis. Similar findings were reported by [34], who found that mental healthcare providers providing health care to adolescents with suicidal behaviour can have overwhelming feelings that prevent them from coping, which indicates the need for counselling. According to [35], the shortage of mental healthcare providers causes heavy workloads that can lead to burnout. In addition, the study's findings indicate that mental healthcare providers need support from the health facility’s management. The support can be in the form of formal or informal training. Meaningful listening and responding to their perspectives on negative incidents, and not only to the patient’s portrayal of the incident, should be practiced avoiding demotivation among the mental healthcare providers. Supporting this study's findings, existing literature indicates that suicide-related training can boost mental health providers' confidence, knowledge, assessment, and intervention skills while also reducing negative reactions toward suicidal patients [36].
Adequate skills are indeed essential when caring for adolescents with suicidal behaviour. Participants in this study expressed the need for enhanced skills through the sharing of knowledge, as it is difficult for them to provide care to adolescents with suicidal behaviour. Training is essential in health care to improve the quality of care and should include training in communication skills, diagnoses, and referrals [37]. Another study by [38] advocated for the integration of digital innovations in caring for suicidal adolescents. Digital innovation can be provided to patients in the form of tablets, serving as digital therapeutic tools (treatment via smartphones, tablets, or computers). This approach offers a cost-effective means to support individuals in suicide crises (such as suicidal thoughts, plans, or behaviors) who present at hospitals, while their technology-enabled delivery models can simultaneously enhance hospital workflow and optimize resource allocation [39]. This innovation can be implemented during both the admission and discharge of suicidal adolescents. These digital innovations have shown to be effective tools for reducing suicidal symptoms among adolescents [40]. Caring for adolescents with suicidal behaviour can be challenging for mental healthcare providers. It is important to understand how they experience providing health care to these adolescents to be able to provide the appropriate emotional or/and psychological support. The participants mentioned the need for regular psychological debriefing with fellow staff, management, or psychologists. If these healthcare providers are in a good state of mind, their productivity will improve. If the emotional support could be internal, it would benefit these adolescents as the staff would not need to be absent from work numerous times, unlike when attending external counselling and training.