Attitudes of nursing professionals towards suicidal behavior: influence of emotional intelligence

1 Enfermera, MSc, España. 2 PhD, Profesor Titular, Universidad de Granada, España. Objetivo: Evaluar la actitud y la influencia de la inteligencia emocional es el objetivo de este trabajo. Método: Profesionales de enfermería contestaron un cuestionario que evaluó la actitud hacia el suicidio e inteligencia emocional. Resultados: Los resultados muestran una actitud general desfavorable hacia el comportamiento suicida. La dimensión moral del suicidio marca las diferencias entre los profesionales de salud mental y urgencias. Conclusiones: Poseer un mayor grado de formación en salud mental y un alto nivel de inteligencia emocional se asocia a una actitud más positiva hacia el paciente con comportamiento suicida. Formación y desarrollo de habilidades emocionales son fundamentales para el cuidado de los pacientes con conducta suicida.


Introduction
Suicide is considered a severe public health problem around the world, with almost one million cases per year and an estimated six people who are directly affected by each death.The psychological, social and economic impact of suicide on the family and community cannot be measured (1) .Based on current trends, it is estimated that, globally, deaths by suicide will reach 1.53 million people by 2020, and a number of suicide attempts between ten and twenty times higher (2) .
Multiple factors cause suicidal behavior, including biological, socio-environmental and psychological factors, each of which has a specific weight, and none of them separately may be sufficient to explain such behaviors by itself.From a health perspective, this is about secondary prevention, with increased survival and reduced morbidity and mortality rates after a suicide attempt.It is estimated that, for every consumed case of suicide, suicide attempts have led to five hospitalizations and 22 visits to emergency services (3) .
Few data have been collected with proper rigor about suicide attempts in different countries, so that the actual range of suicide attempts is unknown.One of the best places to collect data on suicide attempts and their characteristics is in hospital emergency services, although it is estimated that only a minimal part of people who attempt to commit suicide contact a public hospital.When people cannot treat their selfinflicted injuries by themselves and privately, they turn to the health system for help.Nursing professionals at the emergency service tend to be patients' first health contact after a suicide attempt or an episode of selfinjury.Appropriate evaluation and management of these patients is fundamental to prevent future suicidal behaviors.Health professionals frequently adopt a www.eerp.usp.br/rlaeCarmona-Navarro MC, Pichardo-Martínez MC.
negative attitude towards these patients though, with a lack of interpersonal skills for care delivery and inappropriate patient evaluation (4) .
Ninety percent of people who commit suicide have diagnosable and treatable psychiatric disorders (4) , which is why prevention efforts should focus on patients with mental illnesses.Health professionals tend to divide mental and physical problems though, leading to fragmented client care and devaluation of mental patients' needs (5) .
Stigmatizing attitudes influence the care and treatment patients receive negatively (6) and, moreover, they influence the care receivers' psychology and wellbeing, acting as a considerable obstacle in the search for help, treatment access, adherence and efficacy.
Studies demonstrate common prejudices among physicians and nursing professionals towards patients who injure themselves, describing them as manipulators and attention callers (7) .
One of the main reasons mental patients identify not to seek professional help or not to keep up their treatment is stigma, and they consider that the health staff contributes to stigma and discrimination (8) .
Nursing professionals' work is surrounded by feelings and emotions, which are sometimes difficult to classify and identify and originate in patients as well as professionals.The psychological burden present in daily nursing affects these professionals' quality of life and work (9) .Identifying these emotions and learning how to cope with them supposes gaining new tools to accomplish nursing work successfully.
Emotional Intelligence is the ability to acknowledge, understand and regulate one's own and other people's emotions, distinguish among them and use this information to guide one's thoughts and actions (10) .
The benefits of emotional intelligence have been demonstrated in different contexts of daily life and in professional activities.Emotionally intelligent people display better physical and mental health, higher levels of wellbeing and vital satisfaction, less risk conducts, such as drugs use, and better interpersonal and social relations in the professional and personal contexts (11) .
Through human relations, nursing professionals deliver care to patients, participating in the emotions that emerge inside them, whether these refer to pain, discomfort, sadness, relief or hope, obliging professionals to be emotionally intelligent (12) .
Studies show that Mental Health nursing professionals have a higher average emotional intelligence level than the general population (13) .Mental Health nursing professionals perform great emotional work in their daily practice by coping with problems like aggression, mistrust, depression or suicidal behavior.
Emergence nursing professionals are immerged in a highly stressful environment, due to the times, work overload and contact with death.The meaning of emotional intelligence needs to be investigated in situations that are marked by great emotional work, like care delivery to patients who injure themselves or attempt to commit suicide (13) .
The objective in this study is to get to know nursing

Cuestionario de Creencias Actitudinales sobre el
Comportamiento Suicida or CCCS-18 (14) , which serves to evaluate attitudes towards suicidal behavior and is appropriate to discover how nursing professionals' position towards this fact, which is increasingly present in Spanish hospitals.In addition, this instrument offers the opportunity to further elaborate aspects that are closely related to nursing professionals, like the moral dimension and legitimacy of suicide and suicide in terminal patients.
On the other hand, the instrument was created in Spanish scored inversely, so that high scores on these items refer to nursing professionals who disagree from these statements, while low scores refer to nursing professionals who agree.
The fourth factor centers on suicide itself.This factor also includes four items (4, 9, 13 and 17) and indicates a view of one's suicidal conduct as an exit from a given situation.
The TMMS-24 (Trait Meta-Mood Scale) (15) questionnaire, which measures one's Perceived Emotional Intelligence or the ability to acknowledge, understand and regulate one's own and other people's emotions.
This instrument has been adapted to Spanish (16) and consists of 24 items, with a five-point Likert scale ranging from 1 (strongly agree) to 5 (strongly disagree).In this In addition, a scale was included to measure social desirability or the need to get approval from subjects, responding in a culturally acceptable and appropriate way.The scale was developed by Crowne and Marlowe and adapted to Spanish by Ferrando and Chico (17) .It To contrast the results of the attitude questionnaire towards suicide, the sample was classified in groups according to the following characteristics: service the participant works for (mental health or emergency), genders (man and woman), experience with suicidal patients (yes or no), mental health education (yes or no) and duration of mental health education less than 30 hours or more than 30 hours.For the sake of these contrasts, Mann-Whitney's non-parametric U-test was used, due to the non-normal distribution of the scores in the moral dimension factor of the attitude questionnaire.To prove whether attitude towards suicide is related with the emotional intelligence level, besides other possible associations between the variables measured, Spearman's correlation test was used, as the normality requisite was not attended to.

Results
The results reflect that, in general, nursing After Spearman's test, the results reveal a positive and significant relation between disagreement from the immorality of suicide and higher scores on "Emotional Intelligence", "Emotional Clarity", "Emotional Regulation" and "higher educational level in mental health" (Table 3).A positive and significant correlation also exists between "social desirability" and "emotional intelligence" (r s =.234; p< .05)and "emotional clarity" (r s =.259; p < .05).

Discussion
Nursing professionals in this study share a negative attitude towards suicidal behavior.This result is in accordance with a society that, being mortal, rejects death, which is no longer admitted as a necessary natural phenomenon and is considered as failure, by society as well as by the health system (18) .Professionals with better acceptance levels of suicidal behavior reveal greater probabilities of positive health care delivery to suicidal patients (19) .Previous studies confirmed greater understanding of patients with suicidal behavior among mental health professionals (20)(21) .Mental health nursing professionals have been trained to deliver care to psychiatric patients and are more confident to treat suicidal patients.Emergency care nursing professionals usually have neither formal training nor specialization to treat suicidal patients.One of the main reasons psychiatric and mental health care consumers identify not to seek or continue treatment is the stigma they are confronted with (8) .Inappropriate care delivery to patients with suicidal behavior can aggravate the situation that made them attempt to commit suicide and avoid health services on future occasions.
As shown among the women in this study, earlier studies have confirmed a more favorable and comprehensive attitude towards suicidal behavior among women (6) .In this study, nursing professionals with an educational background in mental health reject the moral aspects attributed to suicidal conduct, and rejection levels increase among professionals with longer training backgrounds.Previous studies have confirmed the importance of education to achieve more positive attitudes towards suicidal behavior (4)(5)(6)(7) and the greater impact of more specialized education on attitudes (22) .
In this study, nursing professionals who are opposed to the immorality concept of suicide have a clearer view of their emotions and, in addition, are more capable of effectively regulating or repairing their emotions.In earlier studies, it has been demonstrated that people with higher scores on emotional clarity and regulation factors better tolerate stress, are more protected against burnout, feel more satisfied with their work, less anxious about death and their health is better (23) .
In self-reported measures like the TMMS-24, one of the difficulties patients present are social desirability problems, that is, that subjects respond with the social objective of transmitting a distorted image, whether positive or negatively.Answers on emotional intelligence in this study are influenced by social desirability.Nevertheless, even if non-voluntarily, subjects' subjective evaluation of their ability to manage emotions can cause perceptive and memory bias (24) .
As a part of society and culture, nursing Although not all people who attempt to commit suicide want to die, branding them as boastful is a mistake, as these are people whose useful adaptation mechanisms have failed and who do not find alternatives, except threatening their own life (25) .Health professionals usually attempt "not to talk about suicide", so as not to encourage this conduct among patients.Instead of encouraging, provoking or putting this idea into the patient's head, however, talking about suicide with a professionals' attitudes towards patients with suicidal behavior in two groups that have more contact with this kind of patients: emergency and mental health nursing professionals.Secondary objectives are to get to know whether the nursing professionals' Perceived Emotional Intelligence is related with a more or less favorable attitude towards suicidal behavior and the possible relation between this attitude and variables like the professional's gender, experience in care delivery to suicidal patients, mental health training, professional experience in nursing and time working at the same service. of means to compare groups and undertake a correlational analysis of the variables involved, searching for associations.The reference population consists of baccalaureate nurses working at emergency and mental health services in the province of Granada, Spain and who are affiliated with the Servicio Andaluz de Salud (N= 255).Data were collected in April, May and June 2011.In the end, 81 (31.8%) nursing professionals participated, 52 working at emergency services and 29 at mental health services.Table1shows the participants' characteristics according to the study variables.Before distributing the questionnaires, permission was obtained from the nurse supervisors at each service and, at the centers where this was required, hospital management gave its approval.The questionnaires were distributed among the professionals at their place of work, where they were informed about the voluntary nature of their participation, confidentiality and anonymity.In addition, instructions were provided on how to complete the instrument and its future return, so as to permit completion beyond work hours.The selfadministered questionnaire consisted of 82 items and included the following measures: www.eerp.usp.br/rlaeRev. Latino-Am.Enfermagem 2012 Nov.-Dec.;20(6):1161-8.
and validated in a college population of Spanish nursing and psychology students.The CCCS-18's internal structure consists of four factors and a seven-point Likert scale, ranging from 1 (totally disagree) to 7 (totally agree).The first factor is called Legitimization of suicide and includes six items (1, 5, 8, 10, 14 and 18), related to the view of suicide as something rationally acceptable.The second factor refers to suicide in terminal patients and includes four items (2, 6, 11 and 15), related to suicide in people without any further possibilities to live.The third factor seems to indicate the moral dimension of suicide from a social perspective and consists of four items (3, 7, 12 and 16), scale, three factors are distinguished: attention, clarity and regulation.Attention refers to the ability to feel and express one's feelings adequately, acknowledging one's emotions and identifying one's own feelings.Clarity is related to the ability to integrate feelings in one's thoughts and understand the complexity of emotional changes.Regulation refers to effective and correct coping with positive and negative emotions.
consists of 33 items, with forced answer options between right or wrong.Together with the above instrument, an ad hoc questionnaire was used to collect data on the participants' sociodemographic variables.Data were analyzed using Statistical Package for the Social Sciences (SPSS) software, version 18.0.Initially, the corresponding descriptive analyses were developed to get to know the sample's characteristics, as well as the scores obtained on the CCCS and its factors, TMMS and its factors and Social Desirability.
professionals have a range of attitudes and beliefs that affect their professional activities and, in turn, influence patients with suicidal behavior.Mistaken beliefs or myths towards suicidal behavior are also present in health professionals.One of the most frequently formulated examples is suicidal behavior as a "call for attention".

Table 1 -
Distribution of Participants among the Study

Table 2 -
Comparative Analysis of Attitudinal Beliefs on Suicidal behavior among Emergency and Mental Health Professionals

Table 3 -
Results of Correlational Analysis between Moral Dimension of Suicide and Study Variables