SUICIDE RISK AMONG NURSING STUDENTS ATTENDING A PUBLIC UNIVERSITY

ABSTRACT

Objective:

to describe the suicide risk rates in Nursing students from different nationalities in a public university.

Method:

a cross-sectional study conducted between August and November 2019 in Ceará, Brazil. The students included were those aged at least 18 years old and duly enrolled; the exclusion criteria were as follows: inactive link due to medical leave or course cancellation. The Suicide Risk Index was used for data collection. The following tests were performed: Chi-square; Fisher’s Exact and Mann-Whitney.

Results:

of the 192 participants, 28.6% did not have religious/spiritual factors susceptible of stopping the suicidal act, 12.5% had a family history of suicide, and 2.6% had suicide plans. An association was detected between gender and suicidal potential risk (p>0.000). There was a difference in the suicidal potential risk in relation to gender (p>0.000), nationality (p>0.000) and marital status (p=0.043).

Conclusion:

the study contributes to a reflection on suicide, to early detection and to understanding the impacts in the university.

DESCRIPTORS:
Nursing; Suicide; Attempted Suicide; Universities; Mental Health.

RESUMO:

Objetivo:

descrever os índices de risco de suicídio em estudantes de enfermagem de diferentes nacionalidades em uma universidade pública.

Método:

estudo transversal que ocorreu de agosto a novembro de 2019, Ceará - Brasil. Foram incluídos alunos com idade igual ou maior que 18 anos, matriculados, sendo os critérios de exclusão: vínculo inativo por licença médica ou trancamento do curso. Utilizou-se o Índice de Risco de Suicídio para coleta de dados. Realizou-se os testes: Qui-Quadrado; Teste exato de Fisher e Mann-Whitney.

Resultados:

dos 192 participantes, 28,6% não tinham fatores religiosos/espirituais suscetíveis de frenar o ato suicida, 12,5% possuíam história familiar de suicídio, 2,6% tinham plano suicida. Detectou-se associação entre sexo e risco de potencial suicida (p>0,000). Houve diferença nos escores do risco de potencial suicida em relação ao sexo (p>0,000), nacionalidade (p>0,000) e estado civil (p=0,043).

Conclusão:

o estudo contribui para reflexão sobre o suicídio, detecção precoce, e compreensão dos impactos na universidade.

DESCRITORES:
Enfermagem; Suicídio; Tentativa de Suicídio; Universidades; Saúde Mental.

RESUMEN

Objetivo:

describir los índices de riesgo de suicidio en estudiantes de Enfermería de distintas nacionalidades en una universidad pública.

Método:

estudio transversal desarrollado entre agosto y noviembre de 2019 en Ceará, Brasil. Se incluyó a estudiantes con una edad mínima de 18 años y debidamente inscritos en la carrera; los criterios de exclusión fueron los siguientes: vínculo inactivo por licencia médica o cancelación del curso. Se utilizó el Índice de Riesgo de Suicidio para la recolección de datos. Se realizaron las siguientes pruebas: Chi-cuadrado; Prueba exacta de Fisher y Mann-Whitney.

Resultados:

de los 192 participantes, el 28,6% no presentaba factores religiosos/espirituales susceptibles de detener el acto suicida, el 12,5% tenía antecedentes familiares de suicidio y el 2,6% tenía planes suicidas. Se detectó una asociación entre sexo y riesgo de potencial suicida (p>0,000). Hubo una diferencia en las puntuaciones del riesgo de potencial suicida en relación con el sexo (p>0,000), la nacionalidad (p>0,000) y el estado civil (p=0,043).

Conclusión:

el estudio contribuye en la reflexión sobre el suicidio, la detección precoz y la comprensión de los efectos en la universidad.

DESCRIPTORES:
Enfermería; Suicidio; Intento de Suicidio; Universidades; Salud Mental.

HIGHLIGHTS

1. To evidence the theme of suicide among Nursing students.

2. To understand the factors that lead to attempted and/or consummated suicide.

3. Prevention of psychological distress in the training process of professional nurses.

4. Welcoming and coping strategies for suicide.

HIGHLIGHTS

1. To evidence the theme of suicide among Nursing students.

2. To understand the factors that lead to attempted and/or consummated suicide.

3. Prevention of psychological distress in the training process of professional nurses.

4. Welcoming and coping strategies for suicide.

INTRODUCTION

Suicide is a severe public health problem¹. Despite having the same importance, it is necessary to understand that the individuals who commit suicide are in different conditions than those who attempt it. Suicidal ideation is a condition in which a person has thoughts about how to commit the suicidal act and end their own life². In turn, attempted suicide refers to any non-fatal or harmful suicidal behavior such as self-provoked poisoning or intentionally self-inflicted injuries. Suicide is understood as a premeditated, installed and finished action by someone duly conscious or with a wish to cause their own death².

Currently, self-inflicted injuries constitute one of the main problems for health services³. It is estimated that suicide accounts for more than 700,000 deaths per year in the world, representing the fourth leading cause of death among young people aged from 15 to 29 years old at the global level in 2019¹. Recently, the age group that includes the suicide rates among young people has generated concern and alert about the need to develop public policies since, in this life phase, suicide rates have come to be the second cause of death among individuals aged 19 to 25, which is commonly the age group attending universities⁴.

University life is associated with routines that can be harmful to health, such as poor eating habits and sleep, and ineffective rest. It is very usual for undergraduate students to develop psychological disorders and to have pre-existing problems worsened⁵.

It is known that university students present various risk factors that can contribute to mental distress and illness, namely: social isolation and abuse of substances such as alcohol, high anxiety, depression and stress levels considered psychological risk factors for suicide, and lower scores in self-esteem and purpose in life are related to the increase in suicide among undergraduate students, contributing to psychological illness⁶-⁸.

However, the stress condition that is established on Nursing students is even greater and ranges from the fear of making mistakes during the learning process with patients to lack of time to socialize with family members and friends due to excessive academic activities, which leads to insecurity, anxiety and emotional instability⁵.

A research study carried out in the Brazilian Federal District with 1,567 university Nursing students from private institutions found that: most of them were young adults and female, that 11.55% university students had attempted suicide, and that high rates were evidenced in the first, third and fourth semesters of the undergraduate course. Of these, 36.5% presented depressive ideation, 33.7% had depression signs or hopelessness, and 56.4% remained with suicidal thoughts⁵.

In this sense, this study is of major importance, as it contributes to highlighting the theme of suicide among university Nursing students, stimulating debate, alerting the academic community and reflecting on possible strategies for managing and coping with suicide. In addition, this research is useful to propose interventions and programs aimed at mental health promotion, as well as to guide public health policies on suicide prevention. Consequently, the current study intends to identify the suicide risk rates among Nursing students from an international public university.

METHOD

This is a cross-sectional study with a quantitative approach, developed with Nursing students attending the University for the International Integration of Afro-Brazilian Lusophony (Universidade da Integração Internacional da Lusofonia Afro-Brasileira, UNILAB), located in the Brazilian Northeast, between the months of August and November 2019.

UNILAB is a university linked to the Brazilian Ministry of Education and is located in Redenção, state of Ceará. Its objective is to provide higher education, develop research studies in various knowledge fields and promote university extension, with the mission of training professionals to contribute to the integration between Brazil and the other constituent countries of the Community of Portuguese-Speaking Countries (Comunidade dos Países de Língua Portuguesa, CPLP), particularly from Africa.

The formula for finite populations was used to calculate sample size. Having considered the total sample of 376 students, 50% prevalence was adopted, with 5% sampling error and 95% confidence level. Thus, a total of 192 students was obtained to comprise the sample. To ensure this proportional representation between national and international students, stratification was performed by calculating the relative weight of each of the strata in the population, obtaining the following: 62 foreign students and 130 Brazilian students. Selection of the sample was non-probabilistic.

The inclusion criteria adopted were as follows: students aged at least 18 years old and regularly enrolled in the institution’s Nursing course. The following exclusion principles were applied: undergraduate students with inactive links due to medical leave or course cancellation during the collection period.

The data collection instruments were the Suicide Risk Index (SRI) and a sociodemographic form. The SRI is a validated instrument that aims at psychometric assessment in three specific dimensions, namely: sociodemographic (gender, age and religiousness), context (isolation, recent significant loss, physical disease, abuse, severe psychiatric disease, history of psychiatric hospitalization and family history of suicide) and the suicidal sphere (personal history of suicidal behavior). At the end, a score from zero to 20 is assigned by means of which it is possible to classify the interviewees into Low risk (< five), Medium risk (≥ five < 10) And High risk (≥ 10)⁹.

The sociodemographic questionnaire was prepared based on social determinants and aims at supplying points relevant to the research, such as age, admission semester, nationality, marital status, sexual orientation, skin color/race, religion, if the person does some type of leisure activity, how often they feel alone, mean monthly income and who they live with, multiple-choice objective questions being asked¹⁰. In order to understand the economic variable of this study, the minimum wage considered was R$ 998.00 (nine hundred and ninety-eight reais)¹¹.

Data collection took place at the premises of the university itself by one of the research team members and through an individual interview, in a suitable place in order to protect the participants’ privacy and absolute secrecy of the answers provided, as determined in Resolution No. 510 of the National Health Council, dated April 7^th, 2016.

The data were stored in a database created in Microsoft Excel; their analysis was performed using the SPSS program, version 26.0, and were later explored in terms of absolute and relative frequencies and central tendency and dispersion measures. The Chi-square and Fisher’s Exact tests were used for the analysis of the categorical variables. In turn, the Mann-Whitney test was employed for the continuous variables. The significance level adopted for the study was <0.05, presenting all the information in tables.

The study was approved by the Research Ethics Committee of the University for the International Integration of Afro-Brazilian Lusophony (UNILAB), under no. 3,349,257.

RESULTS

The study participants were 192 students: 160 women (83.3%) and 32 men (16.7%), with a mean age of 23.47 (Standard Deviation: 4.14), and varying between 18 and 58 years old. The data referring to the profile of the university students are presented in Table 1.

Table 1
Characterization of the students attending the International Public University. Redenção, CE, Brazil, 2019

Variable	n	%
Gender
Female	160	83.3
Male	32	16.7
Skin color/Race
Brown	98	51.0
Black	69	35.9
White	22	11.5
Asian	3	1.6
Nationality
Brazil	130	67.7
Guinea-Bissau	39	20.3
Angola	15	7.8
Cape Green	4	2.1
Saint Thomas and Prince	3	1.6
Mozambique	1	0.5
Sexual orientation
Heterosexual	172	89.6
Homosexual	12	6.3
Bisexual	5	2.6
Not reported	3	1.6
Marital status
Single	179	93.2
Married	8	4.2
Stable union	5	2.6
Religion
Catholic	97	50.5
Protestant	45	23.4
Other	33	17.2
Muslim	7	3.6
Atheist	7	3.6
Spiritist	3	1.6

Source: The authors (2019).

Regarding the data considered for the Suicide Risk Index, 55 (28.6%) asserted that there were no religious or spiritual factors susceptible of stopping the suicidal act. Of the total, 31 (16.1%) were living alone, 55 (28.6%) reported a recent significant loss, 18 (9.4%) reported current alcohol or substance abuse, 21 (10.9%) reported severe psychiatric diseases, 24 (12.5%) had a family history of suicide, and five (2.6%) had suicide plans. A statistically significant association was found between gender and suicidal potential risk. The data are shown in Table 2.

Table 2
Association between suicidal risk and the sociodemographic characteristics. Redenção, CE, Brazil, 2019

Variables	n (%)	Suicide risk		p-value
		Low n (%)	Medium/High n (%)
Gender
Female	160 (83.3)	148 (92.5)	12 (7.5)	0.0001
Male	32 (16.7)	17 (53.1)	15 (46.9)
Nationality
Brazilian	130 (67.7)	115 (88.5)	15 (11.5)	0.1831
Foreign	62 (32.3)	50 (80.6)	12 (19.4)
Marital status
With a partner	179 (93.2)	152 (84.9)	27 (15.1)	0.1522
No partner	13 (6.8)	13 (100)	0 (0)
Income
Less than 1 wage	97 (50.5)	82 (84.5)	15 (15.5)	0.6791
Equal to or greater than 1 wage	95 (49.5)	83 (87.4)	12 (13.4)
Sleep
Less than 8 hours	163 (84.9)	137 (84.6)	26 (16.0)	0.0862
Equal to or greater than 8 hours	29 (15.1)	28 (96.6)	1 (3.4)
Activity in free time
Yes	124 (64.6)	106 (85.5)	18 (14.5)	0.8331
No	68 (35.4)	59 (86.8)	9 (13.2)

• ¹
  Chi-square test;
• ²
  Fisher’s Exact test.
Source: The authors (2019).

A statistically significant difference was pointed out in the suicidal potential risk scores in relation to gender, nationality and marital status. The comparison between the suicide risk scores is presented in Table 3.

Table 3
Comparison between the Suicide risk scores in relation to the sociodemographic characteristics. Redenção, CE, Brazil, 2019

Variables	Suicide risk scores				p-value
	n	Mean	Standard Deviation	Median
Gender
Male	32	4.09	0.22	4.00	0.000
Female	157	2.28	0.28	2.00
Nationality
Brazilian	130	2.13	0.27	2.00	0.000
Foreign	62	3.52	0.49	4.00
Marital status
No partner	179	2.67	0.26	2.00	0.043
With a partner	13	1.31	0.41	1.00
Sexual orientation
Heterosexual	172	2.69	3.49	2.00	0.514
Homosexual/Bisexual	17	2.53	1.46	2.00
Income
Less than 1 wage	97	2.76	0.35	2.00	0.249
Equal to or greater than 1 wage	95	2.39	0.34	2.00
Sleep
Less than 8 hours	163	2.58	0.23	2.00	0.096
Equal to or greater than 8 hours	29	2.59	1.01	2.00

• ¹
  Mann-Whitney’s U test.
Source: The authors (2019).

DISCUSSION

Suicide is a significant problem with worrying prognoses and has become a topic of debate and reflection in public health¹². It affects men and women differently. Thus, in this study, a higher proportion of men with a suicide risk classified as medium or high was identified, when compared to women. There is a higher number of deaths among men and predominance of attempts among women¹³-¹⁴.

It is known that men have a 3.8 times higher risk of death by suicide than women in Brazil⁴. Among men, the mortality rate due to suicide in Brazil was 10.7 per 100,000 inhabitants in 2019, whereas this value was 2.9 among women⁴. This relationship can be explained due to the facts that men are more aggressive, intend to die, use more fatal methods, enjoy greater access to firearms and other lethal objects, there is greater susceptibility to the impacts of economic instabilities among men and difficulties in managing feelings⁴.

People who attempt or even consummate suicide do not have a pattern. Initially, young individuals/adolescents aged 15-24 are detected, students and mostly women¹⁵. In the university environment, a study pointed out that Nursing students experiencing financial difficulties, who need to move to another city to attend the course, with a sensation of loneliness, a history of suicide attempts and depression may present mental illness and suicidal ideation¹⁶.

In addition to that, it is worth noting that migrant people are more likely to attempt suicide, as they tend to experience greater conflicts, a sense of loss and social isolation, and difficulties handling and coping with daily stressful situations, such as the experience of a new context and reality far from a support network and family members¹⁷. Thus, as a multifactorial phenomenon, suicide requires assertive strategies and interventions, mainly in an international university that welcomes students from different nationalities.

In the current study, the individuals without a partner presented higher suicide risk scores than those with a partner. In this context, the statistics point to the existence of a greater number of attempted suicide cases in young people, and most of them therefore in the condition of single people, which refers to risk predictors such as the isolation they experience in the absence of emotional support in the face of feelings of frustration, sadness or despair¹⁸. With regard to the risk of suicide among university Nursing students, it was found that those who did not have a partner were more likely to commit suicide; probably, the fact of having a partner can mean that there is a good relationship, a social support bond and willingness to seek help, resulting in better adaptation²⁰.

An analytical cross-sectional research study carried out with 637 students at a Federal University from Mato Grosso detected that 9.9% of the university students had suicidal thoughts and, in the bivariate analysis, the “economic class”, “sexual orientation”, “religious practice”, “suicide attempts in the family and among friends”, “alcohol consumption” and “depressive symptoms” variables were associated with suicidal ideation²¹.

Several factors can stimulate suicidal ideation in university students: exhaustive demand for studies; differences in interpersonal relationships; difficulties adapting to the academic context; and issues inherent to adapting to new contexts to attend an undergraduate course, as there is often a need to move to another city, among others ¹². This entire “new” context causes feelings of anguish and loneliness, culminating in the distress inherent to university life.

In the current research, no statistical difference was identified between the scores obtained by heterosexual and homosexual/bisexual students; however, it is worth noting that some factors that can instigate suicidal thoughts are sexual orientation and gender identity. In a study carried out with university students, regarding sexual orientation, suicidal ideation was significantly associated among homosexuals and bisexuals (p=0.008 and p<0.001, respectively)²⁰.

Another study carried out with 251 students from different courses in the health area offered by a federal Higher Education Institution detected that 41.07% of the participants who stated being homosexuals revealed suicidal ideation, unlike those who declared themselves as heterosexuals, who had 21.99% of suicidal ideation²¹.

Not being heterosexual points to greater vulnerability to suicide among self-declared homosexual and bisexual subjects, as there are several factors that lead to suicidal ideation: presence of depressive states, anxiety, internalized homophobia, verbal and physical aggression, prejudice and stigma by society and reduced socialization space, among others, that lead men to psychological distress, which can culminate in the manifestation of suicidal behavior²².

To try and minimize suicidal ideation, some people seek religious support. However, in the current study, nearly one-fourth of the students stated that there were no factors of a religious or spiritual nature that could prevent the suicidal act. A study shows that, in relation to religious practice, among those who did not have it, the prevalence ratio of suicidal ideation was higher when compared to those who reported having it (p<0.001)²³. Another study indicates that, in the absence of religion, there was higher occurrence of suicidal behavior in all phases²⁴.

It is worth emphasizing that, although it cannot be asserted that religious participation can be a factor preventing suicide acts, it is noted that it is not possible to deny that participation in religious activities such as prayer and meditation is a factor that contributes to inhibiting suicidal behavior. Religion enables an interpersonal scenario through a harmonious link between people, thus improving quality of life and reducing suicidal ideation. The fact that the students have some belief can assist in coping with situations of hopelessness, sadness and pain²⁵. However, when subjects do not fit within religious dogmas, there may be an increase in mental distress and suicidal ideation, as they deny their own existence as beings.

The results presented reinforce the debates about the lack of public intervention in the mental health of university students, rendering them vulnerable and unassisted, which can lead to suicidal thoughts and probably death²⁶. In the university environment, suicide ideation and attempts among undergraduates is a subject matter that is debated, problematized and researched in an incipient way¹².

A study has shown that negative attitudes towards suicidal behavior are associated with unpreparedness on suicide prevention by professionals, stigmatization (and discrimination) and low care level²⁷. The identification and prevention of potential suicide cases demand breaking taboos and mechanization of the health services, sensitivity at the welcoming and care moments, training of professionals on the subject matter, and establishment of protocols for the analysis of the subjective conditions of each individual³.

It is noticed that suicide has multiple causes; the topic needs deepening on how these variables are correlated and how coping and handling can take place. There is an urgent need for intersectoral interventions that encompass the various health devices, public agencies, social organizations, universities and colleges, among others, that can carry out suicide prevention and early detection activities. As a public health problem, suicide requires the active participation of governments, authorities, professionals and citizens so that adequate and effective coping and management can take place. Given the above, one can think of intensifying psychological support, meetings, lectures, symposiums, courses and cultural, leisure and entertainment activities, among other strategies.

The study limitations include the cross-sectional method, which does not allow inferring causal associations; the non-probabilistic sampling; and the fact that the study was conducted only in one university and one course. Research studies with a prospective and longitudinal design are indicated for detecting and understanding the suicidal ideation phenomenon, as well as studies evaluating interventions to promote mental health in Nursing students.

CONCLUSION

This study described that male international Nursing students who lived without a partner had the highest suicide risk rates. Thus, the need to devise strategies for welcoming and coping with suicide is evidenced, promoting mental health and preventing psychological distress in the training process of Nursing professionals. The academic community needs to be prepared to debate and problematize this subject matter in order to reduce its prevalence and incidence, through qualified listening, actions and targeted courses of action with the objective of strengthening bonds and minimizing such situation.

It is necessary to understand the factors linked to the causes that lead university students to attempted and/or consummated suicide, as well as to the scientific practices created to benefit the university community. In addition to this, the study contributes to the Nursing area, in the perspective that both students and professionals can appropriate knowledge about suicide and develop practices and interventions in suicide prevention, mental health promotion and early detection, in addition to critically reflecting about the impacts that attempted and/or consummated suicide have in the academic context, providing a change in the praxis.

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Edited by

Associate editor: Dra. Luciana Nogueira

Publication Dates

• Publication in this collection
  05 June 2023
• Date of issue
  2023

History

• Received
  15 Feb 2022
• Accepted
  03 Nov 2022