Attitudes and associated factors related to suicide among nursing undergraduates

DOI http://dx.doi.org/10.1590/19820194201600090 Escola de Enfermagem, Universidade de São Paulo, Ribeirão Preto, SP, Brazil. Faculdade de Filosofia Ciências e Letras, Universidade de São Paulo, Ribeirão Preto, SP, Brazil. Conflicts of interest: there are no conflicts of interest to declare. Abstract Objective: To investigate the suicide-related attitudes and associated factors among nursing undergraduates Methods: A quantitative cross-sectional study, conducted with 244 nursing undergraduates from a rural higher education institution of São Paulo, Brazil. Data were collected in 2016, by self-administration of a sociodemographic questionnaire and the Suicide Behavior Attitude Questionnaire. The Spearman correlation coefficient and Mann-Whitney tests were used for data analysis. Results: Women presented more negative attitudes related to suicide. Men and students who participated in a psychiatric nursing discipline, class or laboratory on suicide, were perceived to be more capable professionally. Baccalaureate students who read specific material about suicide, or had ever thought about committing suicide, showed a less moralistic or condemnatory attitude related to suicide. Conclusion: The study highlights the need for educational interventions on suicide involving attitudinal knowledge.


Introduction
The World Health Organization recommends that suicide be prioritized in the health agenda and in the formulation of public policies.Suicide is the second leading cause of death among people aged 15 to 29 years old, and more than 800,000 people die each year from suicide, even if that event is underreported.Suicide attempts can reach as many as 20 times the number of completed suicides. (1)onsidering the severity and the possibility of suicide prevention, the Ministry of Health introduced Ordinance 1,876 in 2006, which establishes National Guidelines for Suicide Prevention and emphasizes the importance of research on this subject. (2) study conducted in Australia showed that approximately 90% of people who died of suicide had at least one contact with a health professional during the three months prior to their death, and emphasized the importance of these contacts as opportunities to prevent suicidal behavior.(3) The quality of care provided after an attempted suicide is particularly important, as such clients are at greater risk of a new, and successful, suicide attempt.(4) It is important to highlight that the nursing team that acts in emergencies maintains frequent contact with clients after suicide attempts, and plays a central role in the initial management of these cases.(4,5) However, in suicide-related interventions, health professionals present difficulties that involve, among others, lack of planning, inability to manage the risk of suicide, and lack of available resources.(6) Caring for the suicidal client can be influenced by a variety of factors, including suicide beliefs and attitudes, professional education, the ability to assess suicide risk, and planning of care.(3)(4)(5)(7)(8)(9) The literature indicates the lack of preparation and educational exposure regarding suicide in the undergraduate courses of the health area, and emphasizes the importance of investing in educational interventions related to suicide for health professionals.(10) Therefore, studies that incorporate the understanding of the attitudes of professionals in relation to suicide are necessary (4,11) considering variations among different countries, cultures and epochs.Attitude can be defined as a response to a stimulus that involves cognitive, affective and behavioral components, extending to all aspects of intelligence and behavior.(12) It is an inner disposition that affects the choice of action or conduct to be adopted in relation to persons, events or goals.Thus, attitude is not specifically behavior, but a propensity to action, or a way to approach, react or face a situation or problem in a variety of circumstances.
The relationship between attitudes and factors such as sex, age, time of clinical experience, and previous education is variable and poorly clarified in the literature. (13)The attitude toward suicide in future healthcare professionals, such as nurses, is also poorly investigated.Understanding attitudes attributed to suicide by nursing students may facilitate the understanding of suicide-related experiences and behaviors.
Hypotheses were established that attitudes related to suicide would be associated with gender, age, professional education (year and undergraduate course), exposure to different educational strategies course, classroom, laboratory and events), previous reading about suicide, and personal experience (contact with person who attempted suicide, or suicidal thoughts).Thus, the results of the present study may provide support for the planning of academic training strategies and psychosocial support for students, contributing to the improvement of care qualification.
This study aimed to investigate attitudes and associated factors related to suicide among nursing undergraduates.

Methods
This was a quantitative, cross-sectional study, conducted at a higher education institution in the interior of the State of São Paulo, Brazil, from February to March of 2016.
Nursing undergraduates enrolled from the fifth semester of the Bachelor of Science in Nursing (BSN) degree and the Licentiate's Degree in Nursing (LDN) were eligible for the study.The option to approach the students of the last semesters is justified by the fact that it is at this stage of the course that students are more likely to come into contact with suicide in theoretical and practical activities of the undergraduate course.At the time of data collection, the eligible population for the study was composed of 282 graduates: 142 BSN and 140 LDN.
Three graduates who did not return the instruments during data collection, and 33 who were absent on the day of collection, were excluded.Two students refused to participate in the study.Thus, 244 nursing undergraduates were included in the sample.
The students who met the study selection criteria were invited to respond to a questionnaire containing sociodemographic and information related data, education and exposure to educational strategies on suicide and to the Suicide Behavior Attitude Questionnaire (SBAQ). (14)Initially, the researchers obtained the list of students who met the inclusion criteria.An undergraduate student who was a member of the research team obtained authorization from professors who had classes with the students and, in a previously agreed class period, the researcher entered the classroom, presented by the professor, who then suspended class and left the room.After explanation, the students who agreed to participate in the study received the terms of free and informed consent form, and the data collection instrument.The average time for completing the instruments was 20 minutes.
The SBAQ is an instrument developed in the Brazilian context, which contains 21 statements about attitudes related to suicide.Each statement is followed by a 10cm (10cm) analogue visual scale, ranging from "totally disagree" to "totally agree".
Respondents were asked to indicate a point on each line that best reflected their opinions, feelings or reactions. (14)e to theoretical and practical limitations of instruments available for measurement of attitudes, an instrument was developed.For the development of the SBAQ, a review of the literature and focus groups with nursing professionals was initially performed to develop the statements that would compose the instrument.The pertinence and adequacy of the sentences were evaluated by experts and submitted to a pilot test.Thus, 21 affirmations were selected.The internal consistency of the scale was evaluated by factoral analysis, using maximum likelihood and Varimax orthogonal rotation.Three interpretable factors were extracted, accounting for 43% of the total variance. (14)hus, in the original study, the items were grouped into three factors: 1 -Feelings towards the patient; 2-Perception of professional capacity, and 3-Right to suicide.The Cronbach's alpha coefficient was calculated for each factor and the results obtained were, respectively, 0.7, 0.6 and 0.5.The score of each of the three factors can range from 0 to 30 points.
The instrument does not present cut-off scores, to categorize the results.Factor 1 -"Negative feelings towards the patient" includes items 5, 13 and 15 of the questionnaire.The higher the score on this factor, the greater the presence of such negative feelings.In Factor 2 -"Perception of professional capacity" -the scores obtained are summed for items 1, 10 and item 12, with negative value.A higher score on Factor 2 indicates more confident professionals in dealing with individuals with suicidal behavior.Factor 3 -"Right to Suicide" -is obtained by the sum of items 3, 6 and 16, these last two items having an inverted value.Higher scores on this factor represent a less "moralistic/condemnatory" attitude.The authors authorized the use of the questionnaire in the present study. (14)he score on each SBAQ item was considered from the point of intersection between the line available on the instrument and the line drawn by the study participant.The score was computed in centimeters and the values were transferred to the database, with one decimal place.
The data obtained by application of the questionnaires were double entered into the Microsoft Excel Program.Subsequently, the data were transported from the spreadsheet to the software program, Statistical Package for the Social Sciences (SPSS), version 19.0, and the program, R GUI 3.0.1.
The data did not present normal distribution, as assessed by the Shapiro-Wilk test.Thus, non-parametric tests were used to analyze the data.The Spearman's correlation test was used to test the association between numerical quantitative variables and the SBAQ factor scores; the Mann-Whitney U-test was used to test hypotheses between categorical variables and scores on the SBAQ factors.The level of significance was set at p <0.05.
The recommendations for the development of research with human beings were met.The research was initiated after approval by the Committee of Ethics in Research with Human Beings of EERP/USP (Protocol CAAE: 48028215.1.0000.5393).

Results
Data related to the population characteristics are presented in table 1.
Table 2 presents the participants' scores on each of the three SBAQ factors.
Table 3 shows the comparisons between the means obtained in the SBAQ according to the variables related to sociodemographic and educational characteristics.
Women presented higher scores on Factor 1 (p=0.01),therefore, more negative attitudes towards suicide.In Factor 2, which indicates a higher perception of professional ability, male students (p = 0.00), those who completed the psychiatric nursing course (p=0.01), and those who participated in a class/laboratory on suicide had higher scores (p=0.03).Regarding Factor 3, students with a bachelor's and licentiate´s degree (p=0.03), and who read specific material on suicide (p = 0.01), had higher scores.

SD -Standard deviation
The Spearman's correlation test was applied to test correlations between SBAQ factors and age variables and scores on question 21.There was no significant correlation between age and SBAQ factors.Item 21 presented a weak correlation (r=0.215) with Factor 3 (p=0.01)indicating that people who already had situations that made them think about committing suicide showed less condemnatory attitudes towards the suicidal patient.

Discussion
The study has as limitations the transversal design, the use of non-parametric tests (justified by the abnormality of the data distribution), and the fact that it included a delimited population from a specific context.
Despite these limitations, this study is the first to investigate the association between exposure to different educational strategies and suicide-related attitudes among nursing undergraduates.According to the results, nursing undergraduates had low specific educational exposure on the subject of suicide, and suicide-related attitudes were associated with sex, previous experience, and characteristics of nursing undergraduate education.,8) Negative attitudes related to suicidal behavior can promote stigma and discrimination, increase the barriers for seeking treatment, and impair the quality of care offered. (7)he literature, predominantly, points out that health professionals show more negative attitudes towards people with self-mutilation and suicidal behavior (7,15) than other patients. (16)The present study shows that when the values obtained in the three factors are compared, lower scores in Factor 1 and higher scores in Factor 3 are identified, indicative of less negative and moralistic attitudes.
Women had more negative attitudes, and felt less prepared to provide care for the person with suicidal behavior.In the literature, a variety of results related to attitudes about suicide between men and women are found. (13)One study identified a less moralistic attitude (15) among women, while in other investigations, there was no difference in attitudes according to sex. (13,17)ducation in mental health and suicide appears to promote consistent improvements in attitude and knowledge related to suicide. (7,15)In the present study, participation in events, courses and lectures on suicide was not associated with better attitudes.On the other hand, attending a psychiatric nursing course or a suicide class and laboratory was associated with a greater perception of professional capacity, but it was not associated with more positive or less condemnatory atti- recommended care actions in the management of suicidal patients. (19,20)

Conclusion
This study identified that nursing undergraduates had minimal educational exposure specific to the subject of suicide.Women had more negative attitudes related to suicide.Men, and students who participated in a psychiatric nursing course, suicide class or laboratory were more confident in caring for the individual with suicidal behavior.Graduates of the bachelor's and licentiate's degree, people who read specific material about suicide, or had ever thought about committing suicide, had a less moralistic and condemnatory attitude toward suicidal behavior.
tudes.The characteristics of educational activities may have different potential in the transformation of attitudes.In addition, this finding indicates the importance of developing attitudinal knowledge, not just cognitive and procedural knowledge, to enhance the incorporation of more positive attitudes towards suicidal behavior.Previous contact with a person who attempted suicide was not associated with attitudes related to suicidal behavior.The relationship between clinical experience and attitudes about suicide is unclear, (13) suggesting that contact with a suicidal patient is not sufficient to provide greater empathy or understanding.Education and clinical supervision could enable professionals to achieve more productive and empathic interactions to understand patients' experiences without giving value judgments.
A less moralistic and condemnatory attitude was found among bachelor's and licentiate's undergraduates, who read specific material on suicide, and between people who had already thought about committing suicide.It is possible that reading, an interest in materials on suicide, the experience of personal suffering, and the increased workload of the humanities disciplines have contributed to a more comprehensive and less condemnatory attitude.
Nurses play an important role in suicide prevention and care, and the education of these professionals needs to be reviewed and improved.Education of health professionals needs to includes skills related to self-knowledge, empathy, understanding, communication, attitudes and knowledge about suicidal behavior, (13,17) the possibility of suicide prevention, and the clarification of the role of nursing in the care of the suicidal patient. (18)egative, moralistic, or condemnatory attitudes toward suicidal behavior are among the many factors that interfere with the quality of care for a person at risk for suicide.However, the idea that suicide is reprehensible and censurable may favor more prescriptive approaches. (5)Suicide is not desirable as an acceptable option; however, it is important to pay attention to extremist, condemnatory or nonempathic attitudes, asempathy and a therapeutic bond are necessary for implementation of several

Table 1 .
Sociodemographic and educational characteristics of nursing undergraduates participating in the study (n=244)

Table 2 .
Nursing undergraduates' scores on the factors of the Suicidal Behavior Attitudes Questionnaire (SBAQ) (n = 244)

Table 3 .
Sociodemographic and educational characteristics of nursing undergraduates according to the scores obtained in the factors of Suicidal Behavior Attitudes Questionnaire (SBAQ) (n=244) Test used: Mann-Whitney; SD -Standard deviation