Nursing Students Facilitating the Transition from Suicidal Ideation to Action in the Rural: A Qualitative Study

Background

Students are in their early adulthood, a time filled with challenges, rewards, and crises.¹ Individuals who reach adulthood, especially students, are the next generation of the nation, which is an essential foundation for the nation’s future development.² If there is no effort to prevent suicide in students, the negative impact will arise nation-building problems in the future. Nursing students understand the concept of being healthy and sick better than other majors, but a preliminary study that focuses on the phenomenon in nursing and midwifery colleges in Ghana states that there have been reports of suicide among college students.³

According to the 2017 World Health Organization (WHO), 20 people fail to make a suicide attempt every 3 seconds, and one life is lost due to suicide every 40 seconds.⁴ WHO, (2017) 20% of all death cases due to suicide range in the age range 15–29 years.⁵ Suicide was the second leading cause of death in this subject group. A preliminary study on students at the east java in 2019 showed that there were 32% high suicide ideas, 68% low suicide ideas, and the results of student research interviews consulted problems; some did not want to meet in person but only wanted to go through Whatsapp chat communication was because embarrassed, students blame and are disappointed in God with the problems they are experiencing.⁶

Traditional efforts to comprehend suicide risk have tended to concentrate on singular risk variables for suicidal behavior or on a specific risk domain, such as cognition.⁷ Although such techniques have led to a greater knowledge of specific risk factors for suicide behavior, their narrow focus does not do credit to the complexity of the elements that contribute to suicidal thinking and behavior.⁸ Indeed, recent models of suicidal behavior emphasize the intricate interplay between biological, environmental, psychological, and social components. This complexity poses obstacles not only for patients and clinicians, but also for researchers.⁹ Statistical techniques commonly used in the domains of psychology and psychiatry, such as analysis of variance and regression analysis, tend to concentrate on identifying risk variables but provide minimal insight into the relationships between the risk factors themselves.¹⁰ For instance, the integrated motivational-volitional model of suicide behavior, the most prevalent model of suicidal behavior, identifies defeat, entrapment, burdensomeness, and impulsivity as crucial variables. These variables are very likely to influence one another and the outcome variable.¹⁰

The lack of empirical research among these demographics means that the existing literature lacks scientific evidence of victims’ experiences and an understanding of the meanings and interpretations that victim students give of their experiences.¹¹ Responding to the lack of evidence in health higher education, this study attempted to transition from suicidal ideation to action in nursing colleges by looking at the phenomenon from the participants’ unique personal perspectives.

The factors that contribute to suicide attempts among nursing students in order to comprehend how they interact to offer a danger for suicide.¹² We conducted qualitative in-depth interviews with nursing students who were at risk of completing suicide attempts to determine the factors that contributed to their efforts, as well as the interactions between these factors, in order to answer the question of why nursing students attempted suicide, with a focus on the factors that facilitate the transition from suicidal ideation to action.

Methods

Sample and Recruitment

Using purposive sampling, 15 health science nursing students in the East Java region of 474 students were recruited for a study aimed at developing a safety planning intervention for nursing students at risk of suicide who had filled out the Risk for Suicide Questionnaire (RSQ) questionnaire indicating the likelihood of suicide. Participants aged between 17 and 29 were at high risk for committing suicide. 4 students reported having attempted suicide. Prior to participation, adolescent consent was obtained. Semi-structured in-depth interviews were conducted with nursing students to gather information about the variables they believed caused their suicide attempts and what facilitated the transition from suicidal contemplation to action. The researchers were then asked about the students’ suicide planning and technique preferences, as well as their opinions on current safety planning methods and suggestions for future safety planning treatments.

Ethical Clearance

The study was performed according to the Declaration of Helsinki guidelines and was approved by the Ethics Committees of Airlangga University (Approval Number: 1854-KEPK). The participants informed consent included publication of anonymized responses. Parental consent was sought for the participants under the age of 18 years.

Data Collection

In the school health unit room of a health science institution, direct interviews were done with pupils. The average duration of an interview was 46 minutes, ranging from 27 to 93 minutes. Interviews were conducted by the principal investigator, a licensed social worker with a Ph.D., a research associate, a licensed social worker, and a doctoral student. The interviewer utilized a semi-structured interview guide with open-ended questions. For expert advice, the contents of the interview guide were evaluated with adult survivors of adolescent suicide attempts. Every interview began with the interviewer asking participants about their suicide attempts. The purpose of this initiation was to allow students who had survived a suicide attempt to share their efforts in a manner that felt authentic and autonomous. During the narrative of adolescent suicide attempts, we asked all participants the same three questions (see section on Data Analysis below), which provided a framework for calculating theme codes across adolescents for the analysis. The interviews were concluded, and each participant was given a $10 gift card. The interviews and analyses had a clinical and scientific focus on interventions for suicidal teenagers and their families; it is vital to mention that the researchers emphasized reflexivity. A medical anthropologist with substantial qualitative facilitation and analytic experience instructs teachers in qualitative methods.¹³

Interview Questions

Semi-structured interviews were conducted using guidelines to generate dialogue that discusses Suicide ideation, suicide attempts, and NSSI. Suicide thoughts and past suicide attempts were evaluated using a modified version of the Columbia-Suicide Severity Rating Scale.¹⁴ This includes questions about suicidal ideation (saying “yes” to either “Did you ever wish you were dead or would go to sleep and never wake up?” or “Did you ever have thoughts of killing yourself?”) and suicide attempts (“Have you ever attempted suicide?”) in the past year. This version of the scale has sufficient predictive validity.¹⁵ Self-report measures of nonsuicidal self-injurious behaviors utilizing items from the Self-Injurious Thoughts and Behaviors Interview.¹⁶ To quantify NSSI, participants were asked if they had ever engaged in self-injury without suicidal intent in the previous year (“Have you ever hurt yourself on purpose without wishing to die, such as cutting, striking, or burning yourself?”). This metric demonstrates solid psychometric qualities.¹⁶

Data Analysis

Analyses of data Following verbatim transcription, interview data were analyzed using a conventional approach to content analysis. Similarly, the data analysis began by reading all the transcripts repeatedly in order to comprehend the entirety and arrive at the coloring. Following that, the data were read verbatim, and texts elicited and integrated into the texts that formed the unit of analysis. Then, “meaning units” were created and shortened. The authors summarized the “units of meaning” and made notes of their initial thoughts, impressions, and preliminary analyses (open coding). Then, using axial coding, the various codes are classified into subcategories based on their connections and relationships. A discussion and reflection process is used to reach agreement among authors on how to organize code into subcategories. Depending on the relationships between the emerging subcategories, fewer categories are created to group and organize the emerging subcategories into meaningful categories in order to form tangible content. Finally, the category’s hidden meaning or latent content is distilled into a single theme. The themes and categories of raw data were thoroughly investigated and revised using the constant comparison method. To report the findings, examples from the data were selected for each category. The author makes the following provisions to bolster credibility. The research team reviewed the data from the interviews after they were transcribed and coded. Additionally, two participants had access to the full text of the interview as well as the NVivo code 12 (words used by the patient during the interview) in order to ascertain the suitability of the dialogue transcripts with their own experiences. The interviews were then examined by three experts in the field of qualitative research; codes, subcategories, categories, and themes were extracted; and, as necessary, synthesis and modification were made based on the suggestions and interpretations of the data.

Result

The demographic data of nursing students (Table 1) who became respondents were mostly women, with low economic status, large number of families, without parental supervision, and from divorced parents. In addition, they also often see and hear how people commit suicide, and when they have problems they always have the idea of committing suicide.

Table 1 Demographic Information

All participants were asked about the transition from idea to action suicide that occurred in nursing students. Researchers identified several transition factors from the concept to action of suicide, including themes (Table 2): (1) history, (2) sociocultural, (3) interpersonal, (4) intrapersonal, and (5) emotions, (6) be a good listener. Participants also provide explicit recommendations on how to deal with them and how they feel. This includes recommendations relating to the post-planned follow-up of the study.

Table 2 Contributing Factors: List of Themes, Frequencies, and Illustrative Quotes

College students from broken families would be plagued by suicidal thoughts at a later date than those with a more stable past. Students were more affected by seeing their parents’ marriages ruined. Living in a family where the parents are intolerant of one another can be a very devastating experience. Lack of love that a family should have is not a comfortable journey. This can have a disruptive effect not only on couples but on college students as well. College students living in broken families are more prone to clinical depression and anxiety.

Authoritarian parenting style (physical coercion and punishment) in the choice of college majoring in student relationships and attachment to parents (quality emotional bonding, separation anxiety and inhibition exploration and individuality), and suicidal ideation is increasing.

Poor students have been disadvantaged. They do not have the privilege of good education, are active extracurricular activities and sometimes even support their families. They struggle to survive. That stress can be overwhelming and can exacerbate underlying depression, bipolar disorder or substance use, which can lead to suicidal thoughts.

My parents divorced when I was little (P1,P2,P3,P6,P7,P8,P9,P12,P13,P14,P15)

I majored in nursing, because my parents forced me to become a nurse (P1,P5, P7,P13,P14,P15)

My family finances are so low that I have to fight hard (P5,P6, P15)

A high burden accompanied by demands that exceed the ability of students in extracurricular activities causes them to feel increasingly helpless and increase their suicidal thoughts.

One mistake makes a student feel like the smallest person in the world. You are considered a loser if you do not go to college or if you get a certain GPA or exam score. So much pressure is put on students that failure is the end.

Taking part in activities outside the campus that require me to be more, so I feel depressed (P1,P2,P6,P7 P13,P14,P15)

A lot of tasks, as well as the value that does not match expectations (P3,P4,P5,P6, P9,P10,P11,P12)

A family that experienced fighting, criticism, competitiveness and anger was associated with a higher likelihood of suicidal ideation and non-suicide among college students. Low parental monitoring - the degree to which children are tracked and supervised by their parents - is associated with suicidal ideation, suicide attempts, and self-harm.

Peer suicide definitely affects the minds of the kids and they take this shortcut to register their differences of opinion. When a young person’s psychological problems go unnoticed, it leads to complexity. And in anger they take extreme steps without knowing the consequences. Here a similar case plays an important role of authority.

I am always an outlet when there are family problems (P1,P2,P3,P4 P11,P12,P13,P14,P15)

My friends find me weird and don’t want to be friends with me (P7,P8,P9,P10, P13,P14,P15)

The burdens he felt in his life were getting heavier, and the lectures were getting heavier. Various factors, including childhood trauma, resonate with his present life. They even think that their life is only a burden for others, so that when they die they will not become a burden for others

All problems feel a burden in my life (P1,P2,P3,P4,P5,P6,P7,P8,P9, P11,P12,P13,P14,P15)

Depression became something they used to feel because it seemed real to them. The slightest problem will always make their mind seem like a big thing and will destroy him.

Talking is a very boring thing for them, because no one will understand about their feelings, and what they are going through. The more they tell stories, the more they get stigmatized.

Lack of enthusiasm for doing something because they have considered themselves useless to those around them. Otherwise they will always be the object of other people’s mistakes.

Excessive guilt and inappropriate feelings are commonplace and they animate. They start feeling guilty about a lot of things to disappoint people. It’s just that the feeling of guilt that is very unrealistic is the opinion of the people around him

I feel depressed with every problem that befall me (P1,P2,P3,P4,P5, P8,P9,P10,P11,P12,P13,P14,P15)

I’m always wrong, so it’s better if I don’t do much or even talk (P1,P2,P3,P4,P5,P6,P7,P8,P9,P10,P14,P15)

I don’t want anything, and I’m not excited about going through anything (P1,P2,P3,P4,P5,P8,P9,P10,P11,P14,P15)

Everything I do wrong, even my life is a mistake (P4,P5,P6, P9,P10,P11,P15)

Being a good listener is the simplest and best way you can help people who are contemplating suicide. Give your loved one space to share unpleasant feelings or experiences that made him or her think or attempt suicide. Active listening techniques can help to improve the quality of interactions between you and your loved ones.

Having someone they trust to talk to can have a big impact on people with suicidal thoughts. Therefore, do not hesitate to offer help and provide opportunities for them to pour their heart out. Be a good listener, respond empathically, and build positive communication to help push them to become better.

They only judge me from the outside, don’t touch my real problem (P1,P2,P3,P4,P5,P6,P7,P14,P15)

Often they just give advice, we don’t need advice (P1,P2,P3,P7,P8,P9,P10,P14,P15)

Discussion

Different contributing factors arise in qualitative investigations of nursing students who attempt suicide, but they virtually always interact with one another to pose a suicide risk. Particularly, intrapersonal elements emerge in the presence of many historical, sociocultural, and/or interpersonal influences.¹⁷ We found that strain induced by historical, sociocultural, and/or interpersonal factors alone is insufficient to induce suicide attempts among individuals. In contrast, the interplay between these tensions and concurrent intrapersonal factors seem to skew cognition and amplify emotions to the point where they become intolerable and suicide becomes the chosen option. Individual and sociocultural factors including family conflict, peer conflict, and psychiatric and/or medical disorders were the most frequently mentioned causes of suicide attempts in our sample, with two or three of these factors frequently occurring simultaneously.¹⁸ However, these elements are insufficient to move a youngster from suicidal ideation to actual suicide attempts; an intrapersonal spark is necessary.¹⁹ Recent longitudinal research supports this finding by demonstrating that the intrapersonal features of future thinking have low positive effects,⁸ low positive effects have significant negative effects,²⁰ and peer cancellation. Family²¹ as a predictor of future suicide and/or suicide attempts among individuals who previously shown symptoms at home²² following a suicide event. In this study, the amount of time that has passed between suicidal ideation and attempted suicide was a significant factor.

Eleven of fifteen participants claimed that the total elapsed period was less than three hours, and one participant said they had never contemplated suicide prior to acting. Nine of the ten contestants executed their ideas within 10 minutes or less. Although the limitation of not knowing the adolescent’s history of suicidal thought processes (ie, whether the adolescent has a long history of suicidal thoughts or whether this is the first time the adolescent is contemplating suicide) mitigates these findings, it is consistent with prior research that the risk of suicidal behavior increases with age. During the acute phase, it typically lasts barely minutes.²³ To intervene during a brief period of increased danger is a very brief window of opportunity, thus underlining the significance of safety measures in preventing suicide.²⁴ Intrapersonal elements that enhance and prevent ownership, two psychological states that contribute to suicidal ideation, played a role in the suicide attempts of most individuals, although not always simultaneously, and only in two instances did they contribute to the transition from concept to action.⁴ When evaluating a network of 20 psychological characteristics and suicidal ideation (network four), the majority of components appear to be directly associated to suicidal ideation, even after controlling for other variables. The key components of defeat and thwarted belongingness have indirect effects on suicidal thoughts. In addition, all psychological components were associated with other psychological factors, even when adjusting for all other network nodes; none of the factors were isolated. This supports the hypothesis that suicidal ideation is the result of the interaction of numerous factors, some of which have a direct and others an indirect association with suicidal thought.⁷ To prevent and reduce suicide within this cohort, the full inquiry should include an examination of risk factors that place some students at a higher risk for developing suicidal thoughts and behaviors, as well as protective variables.²⁵ However, this is feasible due to the fact that some adolescents have experienced both, but chose to mention only one in the interview. Five of the fifteen individuals had a combination of interpersonal difficulties and intrapersonal variables that weigh down or impede ownership. For participants who supported burdens, disputes with others worsened their state and induced grief and/or guilt, particularly for those who had strong relationships with burdensome others.²⁶

These thoughts appear to contribute to a rationalization of suicide, a cognitive distortion connected with depressed symptoms observed by study participants, in which teenagers believed that suicide would give comfort to burdened family members or friends.²⁷ Given the widespread belief that suicide is an act of selfishness, this discovery is significant since, in the eyes of these adolescents, the motivation for suicide is the exact opposite. The ability to commit suicide is acquired, which refers to an individual’s habituation to pain, fear, and death; nevertheless, adolescents in our study did not support this as a factor driving suicidal thoughts to action.²⁸ It is not surprising that gained skills are not included in the narrative of their youth. The acquired suicidal talents did not develop overnight; rather, exposure to painful events causes them to develop gradually over time.²⁹ Therefore, it is unsurprising that participants did not first recognize their ability to commit suicide as a factor that facilitated the transition from ideation to action. Thus, the acquired talents may be a characteristic that differentiates persons who contemplate suicide from those who attempt suicide but do not require an ideational spark. This concept is reflected by the 3ST suicide theory,⁷ which broadens the view of capacity (beyond acquired) to include dispositional (important genetic characteristics) and/or practical elements (concrete factors that make suicide attempts easier).³⁰ Component Emotional dysregulation appears to fall within the dispositional category as an intrapersonal component.³¹ Other intrapersonal factors may also fall into this group, however they may be mediated by cognitive distortions typical of those who are genetically susceptible to depression.^32,33 Invalidation is another intrapersonal characteristic.³⁴

A factor that appears to be a stimulant for some adolescents to act on suicidal thoughts.³⁵ It appeared as if participants’ sentiments of insignificance directly contributed to their miscommunication. In some circumstances, feelings of being misunderstood and invalid correlate not only with emotional dysregulation but also with the internalization of faulty statements during adolescence, which contributes to cognitive distortions such as believing everything or never comprehending.³⁶ These causes contribute to suicide attempts because ending emotional anguish becomes a need, to prove their emotional agony, to have their emotional pain understood by others, or because live with feelings of being misunderstood seems pointless. Disgrace, remorse, and despondency.

There were three other intrapersonal elements that contributed to the suicide attempt. Guilt appears to lead instantly to emotional excess and, over time, to a maladaptive self-scheme.³⁷ It appears that the burden of guilt causes youngsters to turn inside and reluctant to seek assistance from others.³⁸ Despair appears to be associated with a lack of purpose and a lack of a reason to live, both of which contribute to the belief that suicide is a reasonable option because life lasts longand will never improve.³⁹ Thus, the concepts of purpose, reasons for living, and despair are distinct, but appear to be interrelated and contribute in both directions to adolescent suicide attempts.⁴⁰ Most frequently mentioned by adolescents in our study were feelings of confinement, insignificance, and emotional dysregulation. Four individuals supported the specific mix of emotional dysregulation and invalidity as promoting the shift from concept to action. Participants can no longer endure intrapersonal experiences of being trapped in feelings or situations without assistance. Many adolescents are unable to quit ruminating on these emotions, which contributes to their conviction that suicide is painful and/or the only way out of an uncomfortable predicament.⁴¹ Rejection by family and/or friends is another cognitive and emotional experience that appears to drive suicidal ideation in adolescents. Emotional regulation is another experience so intolerable that it seems suicidal to experience relief. According to the individuals, their emotional dysregulation pushed them inadvertently “beyond the line”. Our findings have implications for the therapeutic treatment of suicidal teenagers.

Since suicidal thoughts are efforts to be changed into intrapersonal variables, it is essential that therapy modalities incorporate cognitive behavioral strategies that confront the mental distortions that emerge in the context of various levels of tension. Additionally, emotional control strategies are crucial. Specific technique-containing therapeutic modalities will also be beneficial for overcoming sentiments of innocence and entrapment. Students in the nursing program who wished to commit suicide were taught how to recognize emotions of inadequacy and/or entrapment, as well as particular cognitive and behavioral tools to help them escape or eliminate these sentiments. Obviously, these results should be interpreted with caution, given that our investigation was restricted to a single hospital. Although the small sample size prevents us from generalizing the results, the demographic profile of the⁴² participants is representative of the general community of teenagers who have attempted suicide.⁴³ Consumption as the most prevalent experimental approach reflects bigger tendencies.⁴⁴ The outcomes of this study highlight the need to go beyond basic identification of risk factors as a tool for assessing the shift from suicidal thinking to action among adolescents.⁴⁵ Certain historical, sociocultural, or interpersonal risk factors may not be indicative of the intrapersonal risk factors exhibited by many teenagers.⁴⁶ Similarly, teenagers may be exposed to historical, sociocultural, or interpersonal circumstances that appear to be minor, but which conceal undiscovered intrapersonal aspects that pose a significant suicide risk.⁴⁷ In order to prevent adolescent suicide, it is crucial that we comprehend the interrelationships of these various contributors and how they interact to present risks, paying special attention to the potentially damaging effects of intrapersonal factors, which appear to be a catalyst in - preventing suicidal ideation implemented in this research. The identification of these characteristics and their interplay underscores the need for particular interventions and prevention techniques that target cognitive distortion, emotional dysregulation, and emotions of being invalid and trapped in teenagers at risk for suicide.dskq.

Being a good listener is the simplest and best way you can help people who are contemplating suicide.⁴⁸ Give your loved one space to share unpleasant feelings or experiences that made him or her think or attempt suicide. Active listening techniques can help to improve the quality of interactions between you and your loved ones. Having someone they trust to talk to can have a big impact on people with suicidal thoughts.⁴⁹

Conclusion

The intrapersonal element is the most influential catalyst in the progression from suicidal ideation to action. As prospective targets for preventive interventions and practices with nursing students at risk of suicide, our findings suggest the need for specific measures addressing freshman recruitment during selection for faculty, emotional dysregulation, and feelings of invalidity and entrapment. Nursing students need intrapersonal training. Being a good listener for all students, lecturers and staff is important to create a support system for suicide prevention in the nursing environment.