A modified grounded theory study of how psychiatric nurses work with suicidal people

doi:10.1016/j.ijnurstu.2005.09.001

International Journal of Nursing Studies

Volume 43, Issue 7, September 2006, Pages 791-802

https://doi.org/10.1016/j.ijnurstu.2005.09.001 Get rights and content

Abstract

Background: People with mental health problems continue to present a disproportionately high risk of suicide. Despite the relevance of suicide to psychiatric/mental health (P/MH) nurses, there is a documented paucity of research in this substantive area undertaken by or referring specifically to P/MH nurses; there is currently no extant theory to guide P/MH nursing care of the suicidal person.

Objectives: Accordingly, this paper reports on a study undertaken to determine if P/MH nurses provide meaningful caring response to suicidal people, and if so how.

Design: The study used a modified grounded theory method and was conducted in keeping with the Glaserian tenets of Grounded Theory.

Settings: The study was conducted in two geographical locations within the United Kingdom, one in the North and the other in the Midlands; both locations contained large urban centres.

Participants: A total of 20 participants were selected across the locations by means of theoretical sampling. All the participants were over 18 years old, had made a serious attempt on their lives or felt they were on the cusp of so doing and had received ‘crisis’ care from the ‘emergency’ psychiatric services.

Methods: The study adhered to the principle features of Glaserian grounded theory namely—(a) theory generation, not theory verification; (b) theoretical sampling, (c) the constant comparative method of data analysis; and (d) theoretical sensitivity (searching for/discovering the core variable, one which identified the key pychosocial process and contains temporal dimensions stages). Further, the authors ensured that the study was concerned with generating conceptual theory, not conceptual description.

Findings/Conclusion: The findings indicate that this key psychosocial problem is addressed through the core variable, ‘re-connecting the person with humanity’. This parsimonious theory describes and explains a three-stage healing process consisting of the sub-core variables: ‘reflecting an image of humanity’, ‘guiding the individual back to humanity’ and ‘learning to live’.

Section snippets

What is already known about the topic?

•
Psychiatric/mental health (P/MH) nurses have a major role to play in the care of the suicidal person.
•
The current ‘care’ emphasis for this client group can be described as ‘defensive’, ‘observation led’ and short term.

What this paper adds

•
The key psychosocial processes involved in moving the suicidal person from a ‘death orientated’ position to a ‘life orientated’ position can be encapsulated by the core variable, ‘re-connecting the person with humanity’.
•
People in suicidality need a different form of care than is currently being practiced in most mental health units and within the community.
•
The participants in this study were clear in indicating that they do not want to be treated mechanically, as epitomised by being ‘under’

The study of suicide: a brief historical overview

Even a cursory examination of the extant literature will show that a substantial associated body of work exists. The focused study of factors associated with suicide has been well documented during the last 60 years. Not surprisingly, this has resulted in a body of knowledge that is far from unified and unequivocal; containing, as it does, many unresolved controversies (Silverman, 1997). Encouragingly, two issues that appear to have a very high degree of consensus within the scientific academy

Research method and design: modified Grounded Theory

The research team decided that a modified Grounded Theory method would be the most appropriate method for this study. This method was chosen as the most appropriate for the study as a result of the following reasons.

•
It is well documented that a qualitative method is usually used when little is known about a phenomenon (Morse and Field, 1995).
•
Qualitative methods are particularly useful when describing a phenomenon from the ‘emic’ perspective (i.e. from the native's or participant's point of

Data analysis

It is important to note, that given the process of the constant comparison method within modified Grounded Theory, the stages of data collection and data analysis do not occur in a linear sequence, they are cyclic in nature. However, for the purposes of reporting the research, the process of analysis is described in stages. The first stage involved transcribing each interview. Following this, Glaser and Strauss’ (1967) process of open coding was applied. This entails examining the text line by

Findings

Since the core variable has been described in detail elsewhere (Cutcliffe and Stevenson, in press) this paper contains a brief summary of the core variable and then focuses on the sub-core variables: ‘reflecting an image of humanity’ (stage one), ‘guiding the individual back to humanity’ (stage two), and ‘learning to live’ (stage three).

Stage one: relecting an image of humanity

This sub core variable explains how the first stage of meaningful, transformative care for the suicidal person is actualized through a combination of two key processes, and these are captured in the conceptually robust categories—‘experiencing intense, warm, care-based human to human contact’ and ‘implicitly challenging suicidal constructs as a result of encountering contrary experiences’.

Stage two: guiding the individual back to humanity

This sub core variable explains how the second stage of meaningful, transformative care for the suicidal person is actualized through a combination of three key processes, and these are captured in the conceptually robust categories—‘Nurturing insight and understanding’, ‘Supporting and strengthening pre-suicidal beliefs’, and ‘Encountering a novel interpersonal, helping relationship.’ Furthermore, it is important to note that while the first stage had a distinct sense of stillness rather than

Stage three: ‘learning to live’

This sub-core variable explains how the third stage of meaningful, transformative care for the suicidal person is actualized through a combination of two key processes, and these are captured in the conceptually robust categories—‘accommodating an existential crisis, past, present and future’ and ‘going on in the context set by the existential relationship with suicide.’

Discussion

Given that nursing is a practice-based or practice-orientated discipline, a hallmark of high-quality nursing research then would be implications for practice that arise from the study findings (Cutcliffe and Ward, 2003). Accordingly, we have identified seven distinct practice implications and these are summarized in Cutcliffe et al. (2003). However, as a result of word/space limits, we have decided to focus on the first of these namely, any nurses who wish to work with suicidal people will need

Conclusions

The findings of the study indicate that the key psychosocial processes involved in moving the suicidal person from a ‘death orientated’ position to a ‘life orientated’ position can be encapsulated by the core variable, ‘re-connecting the person with humanity’. This re-connection is brought about through a three-stage process comprised of the sub-core variables: Reflecting an image of humanity; guiding the individual back to humanity; and learning to live. The findings further indicate that

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View full text

A modified grounded theory study of how psychiatric nurses work with suicidal people

Abstract

Section snippets

What is already known about the topic?

What this paper adds

The study of suicide: a brief historical overview

Research method and design: modified Grounded Theory

Data analysis

Findings

Stage one: relecting an image of humanity

Stage two: guiding the individual back to humanity

Stage three: ‘learning to live’

Discussion

Conclusions

Relationship between hopelessness and ultimate suicide: a replication with psychiatric outpatients

American Journal of Psychiatry

CASP Blueprint for a Canadian National Suicide Prevention Strategy

Levelling the playing field: considering the ‘ethics as process’ approach for judging qualitative research proposals

Qualitative Health Research

Critiquing Nursing Research

Introduction: entering the field of qualitative enquiry

Safety First—Five Year Report of the National Confidential Inquiry into Suicides and Homicides by People with Mental Health Problems

National Suicide Prevention Strategy for England (2nd) Annual Report on progress

The Social Meanings of Suicide

Suicide: A Study in Sociology

Theoretical Sensitivity: Advances in the Methodology of Grounded Theory

The Grounded Theory Perspective: Conceptualisation Contrasted with Description

The Discovery of Grounded Theory: Strategies for Qualitative Research

Report on the Workshop on Suicide-Related Research in Canada