This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included.
Health care professionals (HCPs) are challenged in caring for persons with suicidal ideation or behavior. For affected persons, professional care is essential, and being interviewed about their experiences can be stressful. The experiences of persons ideating or attempting suicide are essential to designing eHealth products to support them in crises and provide continuous care.
This study aimed to synthesize published qualitative research about how persons with suicidal thoughts or behavior experience inpatient or outpatient care. A model will be derived from the meta-synthesis to guide HCPs in their work with affected persons and provide a thorough needs assessment for eHealth development.
A qualitative meta-synthesis was conducted using an inductive approach, as proposed by Sandelowski and Barroso. The inclusion criteria were studies in English and German that dealt with persons who ideated or attempted suicide. Relevant articles were identified by searching the PubMed and Cinahl databases and by hand searching relevant journals and reference lists. The findings of each study were analyzed using initial and axial coding, followed by selective coding. Finally, a conceptual model was derived.
In total, 3170 articles were identified in the systematic literature search. Articles were screened independently by 2 researchers based on the eligibility criteria. Finally, 12 studies were included. The central phenomenon observed among persons ideating or attempting suicide is their process from feeling unanchored to feeling anchored in life again. During inpatient and outpatient care, they experience being dependent on the skills and attitudes of HCPs. While helpful skills and attitudes support persons ideating or attempting suicide to reach their feeling of being anchored in life again, adverse interactions are experienced negatively and might lead to prolonging or maintaining the feeling of being unanchored in life.
The study promotes a differentiated view of the experiences of persons ideating or attempting suicide. The derived conceptual model can guide HCPs in their work with affected persons to support affected persons during their recovery. Moreover, the conceptual model is useable as a springboard to develop eHealth solutions for crisis situations and long-term care.
Since 2000, the suicide rate worldwide has decreased. Nevertheless, in 2016, nearly 800,000 deaths were registered due to suicide, with a mortality rate of 10.6 per 100,000 inhabitants. While women attempt suicide 2 to 4 times more often than men, there are nearly 2 male suicide deaths for 1 female death [
The term suicide describes a “death caused by self-directed injurious behavior with an intent to die as a result of the behavior” [
The consequences of suicidal ideation and behavior are complex. On a personal level, people who are ideating or attempting suicide experience a crisis. Persons who attempted suicide also have difficulties coping with stigma in their interpersonal relationships [
On a broader level, suicide causes high costs for society, as studies in Spain, Ireland, and Australia indicate. They recommend increased efforts for suicide prevention and health education [
These studies show the need for support of health care professionals (HCPs) in their work with persons who ideate or attempt suicide and for the development of evidence-based eHealth interventions derived from the experiences of persons in a suicidal crisis. Therefore, we decided to synthesize the existing qualitative research about how persons with suicidal thoughts or behavior experience inpatient or outpatient care. Our study sought to assess the experiences persons with suicidal thoughts or behavior have had with the professional care they receive in an inpatient or outpatient setting. The aim is to derive a conceptual model to guide HCPs in working with affected persons and provide support during their recovery. Furthermore, the model will be reviewed critically with current literature in the context of health services and eHealth usage of affected persons, from which conclusions will be drawn for the development and revision of eHealth applications. HCP refers to nurses with or without mental health or psychiatric specialization, psychologists, and psychiatrists.
A qualitative meta-synthesis was conducted using the approach by Sandelowski and Barroso [
The systematic literature search was performed between July and October 2016, with an update in June 2021, in PubMed, Cinahl, Medline-OVID, Embase-OVID, Psyndex-OVID, and PsycINFO-OVID. The search terms were (experience OR “lived experience” OR attitudes OR “patient perspective” OR perception) AND (“qualitative research” OR qualitative OR “qualitative design” OR “qualitative study” OR “phenomenological study” OR phenomenology OR “grounded theory”) AND (“suicidal ideation” OR suicidal OR suicide OR “suicidal patient” OR “suicidal behavior” OR “suicidal behaviour“) AND (nursing OR nurses OR hospitalization OR “inpatient care” OR outpatient). Search terms were slightly adjusted to fit the different search systems; in Cinahl, subject headings were used, and in PubMed, medical subject headings were used. Since we aimed for a sensitive search strategy, an additional manual search was conducted in 8 specialist journals (ie, Zeitschrift für Psychologie, The Journal of Crisis Intervention and Suicide Prevention, European Journal of Psychological Assessment, GeroPsych, Nordic Psychology, PRAXIS, Zeitschrift für Kinder-und Jugendpsychiatrie und Psychotherapie, and European Psychologist). Afterward, a literature search of the reference lists of the included studies was conducted.
We included studies with a qualitative study design, reported experiences of persons with suicidal thoughts or behavior regarding nursing care, and were published in English or German. Studies that reported experiences of persons with self-injuring tendencies without suicidal self-directed violence were excluded. We also excluded studies that focused solely on the experiences of family members or HCPs. Studies were excluded if a theory-based or deductive qualitative approach was used. Records were independently screened and identified for eligibility by 2 independent researchers. Discrepancies were discussed with a third researcher. Based on the title and abstract, 2 researchers read the full texts of the studies that appeared to meet the inclusion criteria. Next, the included studies were appraised using the checklist for qualitative research of the critical appraisal skills program (CASP) [
When conducting a qualitative meta-synthesis, the findings of studies should be read to assess which methods were applied and how the data were interpreted. Therefore, the included studies were classified with a recommended typology [
The basic assumption for conducting a meta-summary and developing a meta-synthesis was that the results of the included studies are interpretations of the data collected by the researchers. Consequently, the results sections of the included studies were treated as transcripts of a qualitative study and used as meta-synthesis data. The results sections of the studies were read several times and then analyzed inductively [
A total of 3169 studies were identified based on a systematic literature search of databases. One additional study could be identified by a hand search in relevant journals or by screening the references of the included articles. The flowchart of the literature search is shown in
In order to address the research question, a conceptual model was synthesized based on the analysis of all articles comprising two main concepts that reflect experiences during inpatient or outpatient care of people with suicidal ideation and behavior. The first main concept, “from suicidal ideation and behavior to feeling anchored in life,” describes the person with suicidal thoughts or behaviors in a process from feeling unanchored while experiencing a suicidal crisis to feeling anchored in life at the end of the subsequent recovery. This phenomenon includes the categories that describe the experience of suicidal ideation and behavior: (1) suicide as an option, (2) communication, and (3) transformation. Persons who ideate or attempt suicide are individually motivated to consider suicide because they cannot communicate their suffering. When speaking about suicide ideation is not taken seriously, they can experience suicide attempts as transformations. Moreover, suicide attempts serve as entrances to health care services. During the recovery process, individuals are being cared for by HCPs. The second main concept describes the “dependency on the skills and attitude of HCPs” in the recovery process. This phenomenon includes the categories (1) “adverse therapeutic experiences” and (2) “helpful therapeutic experiences” (2). These findings reveal certain hindering and helpful skills and attitudes of HCPs. Helpful skills support affected persons in reaching their feeling of being anchored in life again. Hindering skills are experienced negatively and might lead to prolonged or maintained feelings of being unanchored in life.
Flow diagram of the review process.
Overview of included studies.
Author(s), year | Country of study | Sample/setting | Focus of interest | Method/analysis |
Berg, Rørtveit, Walby, & Aase, 2020 [ |
Norway | 18 adults (mean age 40) with suicidal ideation and behavior in psychiatric wards in hospitals. | Exploring the experiences of persons in suicidal crisis with safe clinical practice during hospitalization. | Semistructured interviews; phenomenological-hermeneutic approach |
Cardell & Pitula, 1999 [ |
USA | 20 adults (mean age 32 years) with suicidal ideation in psychiatric wards in hospitals. | Exploring the experiences of persons with suicidal ideation who have been constantly monitored within the last 2 weeks to determine whether this protective intervention had therapeutic benefits for the affected persons. | In-depth interviews, at least 2 times for each person; grounded theory analysis (Hutchinson) |
Cutcliffe, Stevenson, Jackson, & Smith, 2006 [ |
UK | 20 adults who ideated or attempted suicide. They received care from “emergency” psychiatric services as inpatients, outpatients, or day hospital patients. | Investigating whether and how psychiatric or mental health nurses provide meaningful, caring care to persons with suicidal ideation or behavior. | Semistructured interviews; analysis adhered to principles of grounded theory (Glaser) |
Cutcliffe, McKenna, Keeney, Stevenson, & Jordan, 2013 [ |
Northern Ireland | 36 male persons with suicidal ideation or behavior between 18 and 34 years old who had been treated in mental health inpatient or outpatient facilities. | Developing a theory on how informal and formal services can be better configured or reconfigured to respond more effectively to the needs of young men with suicidal ideation or behavior. | Semistructured interviews; analysis based on principles of grounded theory (Glaser & Strauss) |
Hagen, Knizek, & Hjelmeland, 2018 [ |
Norway | 5 adults with suicidal ideation or behavior between 33 and 54 years old who had been admitted to a district psychiatric center. | Exploring the experiences of former suicidal inpatients with treatment and care in psychiatric wards. | Semistructured interviews; interpretative phenomenological analysis |
Holliday & Vandermause, 2015 [ |
USA | 6 adolescents (15-19 years) who were treated in an emergency room after a suicide attempt. | To gain a comprehensive understanding of the experiences of adolescents who attempted suicide and were taken to an emergency room and their meaning of ideating or attempting suicide as adolescents. | Open, unstructured interviews; Heideggerian hermeneutic methodological approach, phenomenology |
Lees, Procter, & Fassett, 2014 [ |
Australia | 9 adults (mean age 41 years) receiving care due to suicidal crisis and 11 mental health nurses who assisted persons in suicidal crises (hospital and community setting). |
Exploring the experiences and needs of individuals who had a suicidal crisis, the degree to which their needs have been met, the role of mental health nurses, and the key factors to improve quality of care. | Qualitative findings from a multimethod study. In-depth, semistructured interviews; analysis based on critical discourse, constant comparison, and classical content analysis |
Montreuil, Butler, Stachura, & Pugnaire Gros, 2015 [ |
Canada | 5 children (11-14 years) with suicidal risk factors and one of their parents. They were recruited from pediatric mental health inpatient, outpatient, and day hospital settings. | Assessing perceptions of children with risk factors associated with suicide and their parents regarding helpful care in a pediatric psychiatric setting. | Observations of children and semistructured interviews with parents; inductive data analysis (Colaizzi) |
Samuelsson, Wiklander, Asberg, & Saveman, 2000 [ |
Sweden | 18 adults (18-53 years) who attempted suicide and were treated in an inpatient psychiatric ward. | Investigating the experiences of patients in a psychiatric ward after having attempted suicide. | Semistructured interviews; content analysis (Burnard) |
Sun, Long, Boore, & Tsao, 2006 [ |
Taiwan | 15 persons (16-47 years) with suicidal ideation or suicidal behavior and inpatient treatment on psychiatric wards; 15 psychiatric nurses | Exploring experiences of nurses and affected persons to develop a care theory that guides the care of people with suicidal thoughts or behavior. | Semistructured interviews and observations; grounded theory (Strauss & Corbin; Eaves) |
Sun, Long, Tsao, & Huang, 2014 [ |
Taiwan | 14 adults (22–83 years) who attempted suicide were recruited from an outpatient clinic; 6 caregivers (family members, psychiatrists, a psychiatric nurse) | Exploring contextual and intervening conditions that influence individual healing after a suicide attempt. | Semistructured interviews; grounded theory (Strauss & Corbin) |
Vatne & Nåden, 2014 [ |
Norway | 10 adults (21-52 years) who ideated or attempted suicide. They were recruited in emergency psychiatric units and from a crisis resolution team. | Exploring the experiences of being suicidal and encounters with health care personnel. | Semistructured interviews; thematic analysis (Braun & Clarke) |
Suicide as an option:
Being unanchored in life
Wanting to escape
Seeing no way out
Suicide as communication:
Having difficulties speaking about suicidal ideations
Hiding behind a mask
Shouting without words
Suicide as transformation:
Reconnecting through help
Giving meaning to life
Moving towards feeling anchored in life again
Adverse therapeutic experiences:
Having an impersonal or unempathetic attitude
Lacking commitment and acknowledgment
Applying coercive interventions
Lacking time
Not building a trusting relationship
Helpful therapeutic experiences:
Empathetic attitude
Acknowledging affected persons
Appreciative communication
Promotion of a trusting relationship
Presenting and providing a safe environment
Legend:
Category
Subcategory 1
Subcategory 2
Conceptual model of therapeutic experiences.
While having suicidal thoughts or attempting suicide, affected persons experience feelings of being unanchored in life. For different reasons, they consider “suicide as an option” and ideate or attempt suicide. The motivation for suicide has to be taken into account to understand the phenomenon of being unanchored in life. A suicidal crisis is multifactorial and is described individually [
Another motive is the desire to end or escape from emotional as well as psychological pain and suffering. Painful experiences and the inability to cope with life or problems were further statements [
Another subcategory describes “suicide as communication.” Persons attempting suicide described that they wanted to hide their suffering and end their indescribable suffering. The suicide attempt was a cry “for” help but not only in the sense of calling attention. It was like a cry “of” pain that allowed their pain to become visible to others. Before the suicide attempt, they could not communicate their suffering to their environment through speech. The suicide thus served as a message for others. They put their pain into a social context by making others “hear” their pain [
The subcategory “suicide as transformation explains” the process of feeling unanchored during suicidal ideation and attempting suicide to recovery with professional help and feeling anchored again. Before the suicide attempt, young people describe the feeling of being disconnected. They feel lonely, rejected as outsiders, neglected, unloved, and spiraling down. They believe that no one else could understand these feelings of emotional pain [
Affected persons state that without the suicide attempt, they would not have received the necessary treatment. Some consider attempting suicide when talking about suicidal ideation is not taken seriously. Although some already had treatment in the past, they described the treatment after attempting suicide as helpful and gaining better insights [
Cutcliffe et al [
In the second stage, “guiding the individual back to humanity,” nurses have a more active part in their nursing role than in the first stage [
In the third stage, “learning to live,” persons with suicidal ideation or behavior focus on the balance between reconnecting with family, friends, and other people and disconnecting gradually from HCPs [
Affected persons can re-establish internal emotional control when treated as individuals as their stressors can be addressed [
The second concept describes experiences of persons with suicidal thoughts or behavior as dependent on the HCPs’ skills and attitudes. During inpatient or outpatient care, affected persons need professional care and support. According to the HCPs’ skills and attitudes, the analysis revealed that affected persons experienced therapeutically adverse or helpful aspects during their recovery process.
Persons with suicidal ideation or behavior experienced these skills and attitudes as therapeutically hindering (ie, having an impersonal or unempathetic attitude, lacking commitment and acknowledgment, applying coercive interventions, lacking time, and not building a trusting relationship).
Impersonal HCPs and those who lack empathy and commitment are experienced negatively by those who ideated or attempted suicide [
Affected persons and HCPs state a lack of knowledge [
These attitudes towards care resulted in people feeling lonely and not cared for, which ultimately led to fear, aggression, and a lack of trust in HCPs, although they longed for trust [
Experiencing a lack of trust leads to withdrawal from seeking help from HCPs [
Some people mentioned the lack of time for care, with busy HCPs looking after many patients and having no time for the affected persons [
This also had an impact on the relationship between persons with suicidal behavior and HCPs. Instead of sharing their thoughts, they kept them to themselves if they did not feel safe with the HCP [
In addition to therapeutically adverse experiences, persons with suicidal thoughts or behavior also experience therapeutically helpful experiences. These concerns relate to an empathetic attitude, acknowledging affected persons, appreciative communication, promoting a trusting relationship, and presenting and providing a safe environment.
Persons with suicidal thoughts or behavior in the included studies describe the importance of an empathetic attitude from HCPs [
Communication between HCPs and those affected plays a central role in recovery. The basis is a holistic assessment of persons with suicidal thoughts or behavior, including their needs and causes of suicidal tendencies. Some people actively seek dialogue with HCPs to talk about their suicidal thoughts and behaviors, about issues they have not yet entrusted to anyone, or answers to questions they have [
She wasn’t...yes, “pitying” again then. We were two people talking together on equal terms, not prisoner and jailer...She would not divert the conversation, no matter what
It was considered important that HCPs should not scream but speak in a calm tone [
A trusting relationship between the HCPs and their entrusted persons with suicidal thoughts or behavior served as a basis for both parties [
Additionally, worthiness was fundamental as it increased well-being and reduced anxiety, dysphoria, and loneliness in persons with suicidal ideation [
Another helpful experience with HCPs was present [
Being present also affected the therapeutic environment. Experiencing protection and safety through 24-hour care of HCPs positively affects therapy and the relationship between caregivers and persons with suicidal ideation or behavior [
Persons with suicidal self-directed violence also experienced care without coercion as therapeutically helpful. The participants expressed that they felt relief through unconstrained hospitalization. Although hospitalization was described as a terrible feeling, HCPs stressed that the need for inpatient care was helpful if treated voluntarily. In addition, not being forced to speak but simply to be allowed to sit quietly was experienced positively [
This study aimed to synthesize qualitative research to develop a model that supports HCPs in their work with persons with suicidal thoughts or behavior and provides an evidence base for developing eHealth tools. The results of the meta-synthesis revealed two central categories shown in the conceptual model (
In the following discussion, we focus on two main aspects. First, a suicide attempt can function as an entrance to health care services. Second, adverse therapeutic experiences that hinder affected persons from feeling anchored in life again versus helpful experiences that promote their way toward being anchored. Aspects concerning eHealth are taken into account within each point.
The meta-synthesis revealed that persons with suicidal ideation sometimes considered attempting suicide when they felt they were not being taken seriously. Through suicide attempts, they enter the health care system and receive necessary or more appropriate treatment [
Regarding the aims of this study, using eHealth tools could potentially intervene when persons have suicidal thoughts or behavior or are at risk for self-harm [
Nevertheless, it is vital to guide affected persons to helpful resources. A survey indicated that a search for suicide-specific themes could lead to preventive (68%) resources but also to mixed (22%) and neutral (8%) content concerning attitudes towards suicide or even prosuicide content (1%) [
The meta-synthesis revealed that persons with suicidal thoughts or behavior had therapeutically helpful experiences when HCPs had an empathetic attitude, acknowledged affected persons, used appreciative communication, were present, promoted a trusting relationship, and provided a safe environment. Two systematic literature reviews, a meta-synthesis, and a mixed-methods study of persons who self-harm and have suicidal ideation or behavior identified a positive relationship between patients and HCPs as crucial. They find it important that HCPs are supportive, compassionate, and ready to listen [
Our results show that affected persons experienced skills and attitudes of HCPs as therapeutically adverse when they have an impersonal, unempathetic attitude, lack commitment and acknowledgment, apply coercive interventions, lack time, and do not promote a trusting relationship. Similar results were found in literature about adults who self-harm, have suicidal ideation, or behavior. HCPs who have a judgmental attitude, are unsupportive, lack empathy, or exert power are seen as part of unsatisfactory care [
For eHealth interventions, it is a challenge to consider how affected persons benefit from the skills and attitudes of HCPs. Some eHealth resources are solely informational or unguided self-management applications, while others provide exchanges with other persons seeking help or provide virtual contact with HCPs. From the meta-synthesis results, it has to be considered how an empathetic attitude, appreciative communication, being present, and promoting a trusting relationship can be transferred into an eHealth application. The use of artificial intelligence for mental health care provides a multifaceted opportunity, although unanswered ethical questions remain [
The strength of this meta-synthesis is the conceptual model derived from how persons with suicidal ideation and behavior experience inpatient and outpatient care. To our knowledge, this is the first meta-synthesis of these experiences with professional care. This is important for ethical reasons, as no affected persons need to be newly involved in this meta-synthesis. The results can be used as a basic needs assessment for eHealth development and nurture an empathetic culture among HCPs. However, our findings are limited by the different study designs exploring the experiences of affected persons. Half of the studies relied on grounded theory or were analyzed with the principles of grounded theory. The other studies used content analysis, inductive data analysis, or a Heideggerian hermeneutic approach. Through the grounded theory–based analysis, we gained a high theoretical level of abstraction. Nevertheless, we could not formulate theory but could speak of a conceptual model. Including experiences from the different samples broadened the range of perspectives. However, it must be taken into account that the samples had different cultural origins. Therefore, we suppose the results could be transferred to different cultural contexts, but they must be checked beforehand.
We derived a conceptual model of experiences made by persons with suicidal ideation and behavior. The model showed the main helpful skills and attitudes of HCPs that can support affected persons to be anchored in life again. Conversely, we also identified hindering skills and attitudes that lead to adverse therapeutic experiences, which may prolong the recovery of persons with suicidal ideation and behavior.
We focused our research on persons who have suicidal ideation or have already attempted suicide. The discussion in previous studies showed that persons with self-harming behavior experience similar challenges and can likewise benefit from eHealth tools that address suicidal thoughts or behavior. It is useful to address these groups with one application, as the boundaries may be indistinct for affected persons.
This meta-synthesis has some practical and theoretical implications. As practical implications, the results can be used as a blueprint for technicians and HCPs to develop eHealth interventions. These could especially address younger persons, as they are more likely to use online resources or eHealth applications in cases of suicidal ideation or behavior. Especially during the COVID-19 pandemic, eHealth tools are a convenient solution. Another practical implication addresses HCPs. Our results show that suicidal ideation should be taken seriously by HCPs. They could use the conceptual model for training and education to improve professional care and improve outcomes for affected persons. HCPs need to be sensitized for the effects their skills and attitudes have on persons with suicidal ideation and suicidal self-directed violence. They should react with appreciative communication and an empathetic attitude and be present to promote a trusting relationship. Moreover, they should ensure a safe environment to help affected persons feel anchored in life again without using a suicide attempt as another effort to benefit from health care services.
As theoretical implications, further research is needed. Research should focus on experiences made by persons with suicidal ideation or behavior from a hermeneutical perspective. The meta-synthesis with the derived conceptual model can function as a basis for developing new interventions to support affected persons. These interventions could focus on deepening the helpful skills and attitudes of HCPs in interactions with persons with suicidal thoughts or behavior. Other interventions should promote eHealth applications for affected persons, which are evaluated as to whether they accurately fit and support persons with suicidal thoughts and behavior. More research is also needed to identify helpful interventions for affected persons. Moreover, a questionnaire could be developed from the conceptual model to promote the quality of care of affected persons.
critical appraisal skills program
health care professionals
We would like to thank Tanja Lemp and Nadine Saladin for their initial work in this meta-synthesis. They did the systematic search and open coding, which formed the basis for the meta-synthesis. Saladin and AF did axial coding. MH and AF carried out the selective coding, drafted the manuscript, and approved the final version.
None declared.