ARTICLE IN PRESS

International Journal of Nursing Studies 43 (2006) 791802

www.elsevier.com/locate/ijnurstu

A modied grounded theory study of

how psychiatric nurses work with suicidal people
John R. Cutcliffea,, Chris Stevensonb, Sue Jacksonc, Paul Smithd
a

University of Tennessee (Knoxville), USA

b
Dublin City University, Ireland
c
Teeside University, UK
d
Sheffield Health Authority, UK

Received 19 March 2005; received in revised form 30 July 2005; accepted 10 September 2005

Abstract
Background: People with mental health problems continue to present a disproportionately high risk of suicide.
Despite the relevance of suicide to psychiatric/mental health (P/MH) nurses, there is a documented paucity of research
in this substantive area undertaken by or referring specically to P/MH nurses; there is currently no extant theory to
guide P/MH nursing care of the suicidal person.
Objectives: Accordingly, this paper reports on a study undertaken to determine if P/MH nurses provide meaningful
caring response to suicidal people, and if so how.
Design: The study used a modied grounded theory method and was conducted in keeping with the Glaserian tenets
of Grounded Theory.
Settings: The study was conducted in two geographical locations within the United Kingdom, one in the North and
the other in the Midlands; both locations contained large urban centres.
Participants: A total of 20 participants were selected across the locations by means of theoretical sampling. All the
participants were over 18 years old, had made a serious attempt on their lives or felt they were on the cusp of so doing
and had received crisis care from the emergency psychiatric services.
Methods: The study adhered to the principle features of Glaserian grounded theory namely(a) theory generation,
not theory verication; (b) theoretical sampling, (c) the constant comparative method of data analysis; and (d)
theoretical sensitivity (searching for/discovering the core variable, one which identied the key pychosocial process and
contains temporal dimensions stages). Further, the authors ensured that the study was concerned with generating
conceptual theory, not conceptual description.
Findings/Conclusion: The ndings indicate that this key psychosocial problem is addressed through the core variable,
re-connecting the person with humanity. This parsimonious theory describes and explains a three-stage healing
process consisting of the sub-core variables: reecting an image of humanity, guiding the individual back to humanity
and learning to live.
r 2005 Published by Elsevier Ltd.
Keywords: Psychiatric/mental health nurses; Suicide; Re-connecting with humanity; Grounded theory

Corresponding author. Visiting Professor of Nursing, University of Tennessee (Knoxville), College of Nursing, 1200 Volunteer
Blvd. Knoxville, TN 379964180, USA.
E-mail addresses: dr.johnr@shaw.ca, jcutcliffe@gwmail.utk.edu (J.R. Cutcliffe).

0020-7489/$ - see front matter r 2005 Published by Elsevier Ltd.

doi:10.1016/j.ijnurstu.2005.09.001

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792

What is already known about the topic?

 Psychiatric/mental


health (P/MH) nurses have a

major role to play in the care of the suicidal person.
The current care emphasis for this client group can
be described as defensive, observation led and
short term.

What this paper adds

 The key psychosocial processes involved in moving




the suicidal person from a death orientated position

to a life orientated position can be encapsulated by
the core variable, re-connecting the person with
humanity.
People in suicidality need a different form of care
than is currently being practiced in most mental
health units and within the community.
The participants in this study were clear in indicating
that they do not want to be treated mechanically, as
epitomised by being under observations, but prefer
to form a human, close relationship with the P/MH
nurse.

1. Introduction
Suicide remains as one of the most imposing
contemporary public-health issues facing many nations
of the world (Health Canada/Canadian Institutes of
Health Research (CIHR), 2003; World Health Organization, 2002). According to the WHO (2002), since 1950,
the global rate of suicide has continued to rise
exponentially. Neither Canada nor the UK is spared
from the devastating impact of (relatively) high rates of
suicide and the effects are both multi-dimensional and
widespread. Suicide is expensive, not only in terms of the
human cost in the form of suffering (Shneidman, 2004),
but also economically (Institute of Medicine, 2002,
2003), socially (CASP, 2004; Maris, 1997) and spiritually
(Jobes et al., 2000). Some recent success has been
documented in reducing suicide rates in the UK (DofH,
2005). This report indicates a downward trend in the
completed suicide rate per 100,000 of the population;
from 9.2 in 1995 to 8.6 in 2002/2003. However, the
number of completed suicides indicates that there is no
case for complacency. Additionally, the international
epidemiological data depict a very different representation. For example, the alarmingly signicant rates in the
former Eastern block countries notwithstanding, according to the rst national Canadian Blueprint for
Suicide Prevention Strategy (CASP, 2004) not only does
Canada have a higher suicide rate than many indus-

trialized countries, but the suicide rate has more than

tripled since 1950.
These epidemiological data further show that certain
sub-groups of the population pose a particularly high
risk of suicide; both the CASP Blueprint (2004) and the
ndings reported in the largest survey of suicide trends
in the UK, the National Condential Inquiry into
Suicide and Homicide by People with Mental Illness
(DofH, 2001) indicate that people with mental health
problems continue to be a particularly high risk
population. The latest summary issued by the UK
Department of Health (2005), published in the 2nd
Annual Report from the National Suicide Prevention
Strategy for England, continues to reiterate that people
with mental health problems remain a disproportionately high risk group (when compared to the general
population). In summary, suicide remains a major
public health concern across Canada and the UK, and
it is particularly pronounced in people with mental
health problems.

2. The study of suicide: a brief historical overview

Even a cursory examination of the extant literature
will show that a substantial associated body of work
exists. The focused study of factors associated with
suicide has been well documented during the last 60
years. Not surprisingly, this has resulted in a body of
knowledge that is far from unied and unequivocal;
containing, as it does, many unresolved controversies
(Silverman, 1997). Encouragingly, two issues that
appear to have a very high degree of consensus within
the scientic academy of suicidology are,
(a) while our understanding of suicidology is signicant,
there is a great deal we do not yet know; there
remains much to yet be discovered, there are many
unanswered questions and much remains at issue
within the eld and,
(b) Suicide is a multi-dimensional, complex phenomenon; it needs to be recognized as such and interventions/strategies (and associated research activity)
should reect this (Health Canada/CIHR, 2003;
Maris, 1997; Taskforce on Suicide in Canada, 1994).
In addition, an examination of the extant literature
shows it is clear that the current emphasis to understanding suicide is on quantitative methods, clarifying
characteristic symptoms, symptom clusters, risk factors,
establishing causal links and identifying clinical phenomena associated with the presence of suicidal
behaviour (Silverman, 1997). While contemporary studies in this substantive area that use qualitative methods
are relatively sparse, signicant contributions have been

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made by studies and programs using qualitative

methods, including the earliest systematic works on the
subject. Durkheims 1897 qualitative study of suicide
(re-published in Durkheim, 1951) has long been
recognised for its seminal contribution and inuence,
and for some, is regarded as the beginning of formal
study of suicide. More recently, Jack Douglas helped to
create the research method of ethnomethodology in
sociology during his tenure at the renowned Los Angeles
Suicide Prevention Centre. His important contribution,
The Social Meanings of Suicide, questioned some of the
quantitative methodological trends that were dominant
at that time; he questioned founding the scientic study
of suicide on vital or ofcial statistics. Douglas, 1967
argued that we need to observe the subjective accounts
or situated meanings of actual suicidal individuals. He
made the case that the way to discover the meaning of
suicide is to observe the statements and behaviours of
individuals actively engaged in suicidal behaviours.
Following this work, Professor of Psychiatry, Ronald
Maris has produced a biopsychosocial perspective of
suicide (Maris, 1981, 1997). This model not only
articulates the need for methodological pluralism within
suicidology but also simultaneously advocates the need
for interdisciplinary study. He states,
Because suicide is not one kind of behaviour, the
explanation of suicide cannot be by a single factor or
the province solely of any one professional discipline
or specialty area (Maris, 1997, p. 53).
Notably, this need for multi-professional, collaborative research in suicidology was reiterated in the Health
Canada/CIHR (2003, p. 55) report on suicide-related
research in Canada. This paper pointed out key gaps in
the extant suicide research literature and stated,
Educational research and investigations about suicide from a nursing or social work perspective are
also rare, despite the relevance of suicide to these
professions.
Perhaps the most noted Suicidologist of his generation (and the creator of Suicidology as a discrete area of
study) Edwin Shneidman is convinced that suicide is a
state of mind and not necessarily a quantiable,
biological phenomenon (Shneidman, 1997, p. 24). He
makes persuasive arguments that suicide is a consequence of the failure of the individual (and society) to
address pain and frustrated psychological needs (the
psychache) of the suicidal individual. He concludes,
It means that our best route to understanding suicide
is not through the study of the structure of the brain,
or the study of social statistics, or the study of mental
diseases, but directly through the study of human
emotions described in plain English, in the words of
the suicidal person.

793

More recently, in Montreal, February 2003, the

Canadian Institutes for Health Research and Health
Canada organised and sponsored a Workshop on
Suicide-Related Research in Canada. The workshop
highlighted a number of key points regarding the
situation of the current suicide related research endeavours in Canada, and concluded that more emphasis
should be given to qualitative studies. Accordingly, it
can be seen that the contemporary argument advocating
the need for qualitative studies within suicidology, is
founded on well-established theoretical and empirical
arguments as well as a present-day methodological call.
It is important to note that qualitative studies would
provide an important complimentary approach to
quantitative analyses and, in combination with the
results from quantitative studies, will enable a more
comprehensive understanding of suicide.
In summary, the extant theory and existing literature
is clear in pointing out the need for more research in
suicide in order to ll some of the gaps in our
knowledge and there appears to be consensus that
studies which add to the multidimensional (biopsychosocial perspective) understanding appear to have signicant utility. Further, in spite of the well-documented
need for educational research and investigations about
suicide from a nursing perspective, such studies are
conspicuous by their absence. Accordingly, the authors
of this study responded to this call and decided to
undertake a qualitative study of how psychiatric/mental
health (P/MH) nurses worked with suicidal people. In
essence, we were concerned with deepening our understanding of how (if at all) P/MH nurses helped facilitate
the movement of a person from a death orientated
position to a life orientated position. We wanted to
induce the rst theory of its kind; a theory of meaningful
caring practice of suicidal people for P/MH nurses.

3. Research method and design: modied Grounded

Theory
The research team decided that a modied Grounded
Theory method would be the most appropriate method
for this study. This method was chosen as the most
appropriate for the study as a result of the following
reasons.

 It



is well documented that a qualitative method is

usually used when little is known about a phenomenon (Morse and Field, 1995).
Qualitative methods are particularly useful when
describing a phenomenon from the emic perspective
(i.e. from the natives or participants point of view).
The practice of providing care for the suicidal client
clearly involves at least two people and also occurs

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over a period of time. Thus, the research team needed

to select a research method that is concerned with
uncovering and understanding basic (psycho) social
processes between clients and formal carers. Thus, a
Grounded Theory method was indicated as the most
appropriate (Glaser, 1978, 2001).
3.1. Ethical considerations
Ethical issues in this study were addressed in keeping
with an approach that has been described as being more
tting for studies with an emergent design, namely the
ethics as process approach (Ramcharan and Cutcliffe,
2001; Cutcliffe and Ramcharan, 2002). Accordingly,
while ethical approval was obtained from both Local
Research Ethics Committees where the study was
undertaken, ethical issues were repeatedly revisited
throughout the duration of the study. Thus, consent
was re-visited and re-established with interviewees, a
safety net of services for interviewees was provided in
the unlikely event that they needed additional formal
healthcare support following the interview and relationship endings with participants were protracted rather
than sudden. Interestingly, no interviewee reported or
showed any evidence of being harmed by the interview
process.
3.2. Selection of the sample and data collection
The sample of twenty participants selected for this
study was obtained using the principles of theoretical
sampling. In keeping with Glaser and Strauss (1967)
directions for sample selection, the research team began
with individuals from the same substantive group. These
individuals were former clients who had received care
for a suicide crisis as community clients. Following
this, the emerging theory indicated that there might be
merit in increasing the differences in the sample.
Namely, the emerging theory indicated that the particular physical and social environment might have an
inuence on the person and that adjusting the environment to make it as stress free as possible could be a
therapeutic intervention. As a result, the research team
accessed former clients who had received care for their
suicidal crisis as in-patients. Following this, the emerging theory indicated that the research team needed to
sample formerly suicidal clients who had received care in
a Day Hospital or Day Unit setting, because there
may have been particular therapeutic value for suicidal
people in some of the activities that occurred on Day
Units. The emerging theory did not indicate any
theoretically relevant differences according to the
persons gender; neither did it indicate any theoretically
relevant differences according to theological backgrounds or beliefs. Neither did the emerging theory
indicate any theoretically relevant differences according

to race or culture. Thus, no such variations in the sample

were pursued. Also in accordance with Glaser and
Strauss (1967) directions, the research team sampled
individuals from several geographical locations, including the South Yorkshire and the Newcastle area.
Data were collected was by means of a semi-structured
interview, interviews taking place in a quiet room, most
often within the informants home. Each interview was
audiotaped, and transcribed verbatim. The interviews
lasted between 1 and 2 h and the research team began
with a very loose structure; as the tentative theory began
to emerge the interviews became more focused. Thus,
when entering interview one, the only written question
the researchers took into the interview was:
If we could begin by you telling me about your recent
experiences, perhaps you could say something about
what brought you into contact with the services?
This capacious question became more focused during
subsequent interviews. When entering later interviews,
the written questions/key issues, indicated by analysis of
the previous transcripts, the research team took with
them included:
How did the C.P.N.s make you feel secure, what did
they do?
Some of the previous people we have interviewed
have talked about perhaps having a nurse physically
close to you, and maybe even following you around.
Perhaps if they had decided that you were something
of a threat to yourself. Did you encounter any of that?
So what was it that Nurse X was doing at that time
for you?
So what was the difference with nurse Xs technique?
What was different about Nurse X that you did get
somewhere? Was it immediate?
Furthermore, in keeping with Glasers (2001) methodology, in earlier interviews the research team used
predominantly exploration questions. As the data were
subsequently analysed, and the theory began to emerge,
the research team used a combination of exploration
and conrmation questions. As the theoretical categories began to become more saturated in the later
interviews, the research team used predominantly
conrmation questions.

4. Data analysis
It is important to note, that given the process of the
constant comparison method within modied Grounded
Theory, the stages of data collection and data analysis

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do not occur in a linear sequence, they are cyclic in

nature. However, for the purposes of reporting the
research, the process of analysis is described in stages.
The rst stage involved transcribing each interview.
Following this, Glaser and Strauss (1967) process of
open coding was applied. This entails examining the text
line by line and identifying the processes in the data.
Each of these identied processes was then coded (often
on individual index cards) and these can be termed
labels or incidents or codes. This process of coding is
termed substantive coding since the labels codify the
substance of the data, often using the very words of the
participants themselves. Next, the research team attempted to discover the key psycho-social processes in
the social scene, from the point of view of the
participants, hence each label was then compared with
every other label and these were assigned to clusters or
categories according to obvious t. This allowed a
tentative conceptual framework to be generated from
the categorization of the data. Further, the research
team devised a tentative heading for each of the
categories. This was accomplished by examining common themes, concepts evident in each of the categories,
or alternatively by identifying if there was an underpinning process or theme. For example, in the context of
this research, several statements mentioned nally
getting the chance to talk, being listened to by the
nurse and feeling that someone was understanding the
participants point of view. Hence this tentative
category was termed Talking about ones experiences
and feeling understood.
The next stage of the analysis saw the development of
the tentative framework. This was achieved by using two
major steps to both expand and densify the emerging
theory, these are: reduction and selective sampling of the
data. The research team examined the tentative categories and perceived links; discovers umbrella terms
under which several categories t, as a result of
comparing each category with other categories to see
how they cluster or connect. The umbrella term can thus
be seen to encompass several initial tentative categories.
For example, several of the categories appeared to
contain, or allude to, a similar processnamely, a
process that suggests that the nurses would engage in
subtle, implicit challenging of the persons suicidal
constructs. Hence the sub core variable Implicitly
challenging suicidal constructs as a result of encountering contrary experiences was induced. Simultaneously,
further comparison with more data then helps the
renement of these concepts and variables. Additional
selective data is collected for the specic purpose of
developing the hypotheses and identifying the properties
of the main categories. The nal stage was dominated by
theoretical coding. Concepts are compared with more
highly developed concepts, and these are compared with
more data.

795

The procedure described was complicated, but also

enhanced, by having a team of researchers, each of
whom was involved in the data collection and analysis
(JC, CS, SJ and PS). It is important to set out the teams
approach as a means of establishing the delity to the
particular form of modied Grounded Theory chosen.
The rst interviews were substantively coded by JC. As
this occurred, the list of codes was shared with the rest of
the research team and this helped to orient further
interviewsin relation to what was asked of whom.
Thus, theoretical sampling was established. As the
interviewing progressed, the expanding codes were
circulated amongst team members and there was further
discussion regarding the coding itself and categorisation
of codes. Given the geographic distance between team
members, the discussions took place via video conferencing, e-mail and face-to-face meetings. The discussion
was fuelled by theoretical memos made by team
members and again, this directed the process of future
interviews. Nearing the point of data saturation, the
team devoted time to looking at every label, composition
of each category (in the interest of constant comparison), and description of each category and to teasing
out the processual dimensions of categories. This built
upon JCs initial conceptualisation of the temporal
dimensions of the theory. Every theoretical and analytic
choice was considered. Where there was disagreement
between the team, debate ensued until the analytical
choice with the most grab and t was arrived at. It
cannot be over stated that the aim was not to reach a
consensus that reected an absolute truth, in the spirit
of vericationism. That is to say, the categories were not
being validated through the agreement of team members, neither were the team members seeking nomothetic
generalisable truths arising out of the ndings. Rather,
the discussion tapped the creative imagination of the
team members. It threw up different interpretive/
conceptual possibilities, which allowed the development
of denser theory that could account for similarities and
differences. Hence, conceptual development was
achieved in part, as a result of these debates. The results
had immediate grab and t for the team members. As
the team rened categories, memoed and conceptualised it became apparent that data saturation had
occurred. However, three further interviews were conducted as a means of checking that no new processes
were identied by the participants. These processes
facilitated the elaboration of the core and sub core
variable and these are summarized in the next section.

5. Findings
Since the core variable has been described in detail
elsewhere (Cutcliffe and Stevenson, in press) this paper
contains a brief summary of the core variable and then

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focuses on the sub-core variables: reecting an image of

humanity (stage one), guiding the individual back to
humanity (stage two), and learning to live (stage
three).
Table 1
Sub-core variables category composition
Reflecting an image of humanity (stage one)
Experiencing intense, warm, care-based human to human
contact
Implicitly challenging suicidal constructs as a result of
encountering contrary experiences
Guiding the individual back to humanity (stage two)
Nurturing insight and understanding
Supporting and strengthening pre-suicidal beliefs
Encountering a novel interpersonal, helping relationship
Learning to live (stage three)
Accommodating an existential crisis, past, present and future
Going on in the context set by the existential relationship with
suicide

5.1. Core variablere-connecting the person with

humanity
The central or core variable of this theory is reconnecting the person with humanity. This parsimonious theoretical element is able to account for all other
codes and categories and so provides an explanatory
whole to all coding. Re-connecting the person with
humanity describes a 3-stage process of healing; each
has its own conceptual heading (see Table 1 and Fig. 1).
The key psychosocial process synonymous with care of
the suicidal person is re-connecting with humanity. This
is how the participants in this social setting resolved
their key problem. In order to move the suicidal person
from a death orientated position to a life orientated
position, it was necessary for the nurses to facilitate this
re-connection with humanity. They achieved this
through re-establishing the persons trust in humanity.
Through gaining trust in the nurse, the person is then reconnecting with a person; taking the rst tentative steps
towards re-connecting with the wider community of

RE-CONNECTING THE PERSON WITH HUMANITY

Core Variable

1st Phase Reflecting an

image of humanity

2nd Phase Guiding the

3rd Phase Learning to

individual

live

back to humanity

Categories

Categories

Experiencing intense, warm,

Nurturing insight

care-based human to

and understanding.

human contact.

Categories

Accommodating an
existential crisis, past,
present and future.

Implicitly challenging
suicidal constructs as a
result of encountering

Supporting and

Going on in the context

strengthening

set by the existential

pre-suicidal beliefs.

relationship with suicide

contrary experiences.

Encountering a novel
interpersonal,
helping relationship.
Fig. 1. Re-connecting the person with humanity.

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humanity. Following this, the person is further guided

back to humanity through the nurses nurturing of
additional insight and understanding in him/her;
through supporting and strengthening the persons
pre-suicidal beliefs and as a result of experiencing the
additional sense of security offered within the novel
relationship, which allowed feelings, previously kept
internalised by the person, to be discussed freely.
Following this, the re-connection with humanity was
also brought about by the person gaining understanding
of, and beginning to make sense of his/her suicidality.
The continued presence of the P/MH nurse, albeit in
different guises, represents a longitudinal re-connection;
a thread that pulls the person back to the land of the
living from the land of the dead, and offers a hand-hold
on the path to the future. In other words, the
professional is the bridge that helps the person reconnect with humanity. This re-connection with humanity was also brought about by the person becoming more
condent about the meaning of the suicide attempt and
how it ts into her/his past, present and future life
trajectory. This understanding helps to give the person
power over the suicidality, whereas before the persons
sense of being and the suicidality were collapsed
together. Putting the suicide in its place allows more
space for re-connection. Consequently, it becomes
possible to begin to make plans and set goals, which
serve to help the person feel reconnected and hopeful.
Without hope, the person can simply not be bothered to
stay connected to her/his world.

6. Stage one: relecting an image of humanity

This sub core variable explains how the rst stage of
meaningful, transformative care for the suicidal person
is actualized through a combination of two key
processes, and these are captured in the conceptually
robust categoriesexperiencing intense, warm, carebased human to human contact and implicitly challenging suicidal constructs as a result of encountering
contrary experiences.
6.1. Experiencing intense, warm, care-based human to
human contact
The P/MH nurses in this study were concerned with a
communicating that they cared about the suicidal
person; they communicated a sense that the individual
mattered. As a result, the participants in this study
reported how experiencing this sense that they actually
did matter, that another human being was concerned
about and interested in them, had a profound effect on
them. Such feelings and experiences had a direct
countering action on their perspectives and on the
constricted thoughts of their suicidal ideation. These

797

feelings and experiences helped the participants sense

that they were not alone; that perhaps they were not as
disconnected from humanity as they believed. Participants made clear reference to their feelings stimulated
when they experienced the nurses interest in and
concern for their well-being. For example:
It is important that the nurses spent time with me;
demonstrated that I was important, showed that I
matter. (Int. S2)
There were these two women who sat on the edge of
the bed dragging me back, mentally, intellectually
and emotionally by making me engage with them.
(Int. N5)
It helped me not commit suicide, even though I was
thinking about it, because now I knew there were
people (the Community Assessment Team) who were
bothered about me and didnt want me to. (Int. N7)
It is marvellous when someone cares; to know that
someone in that eld (mental health care) knows
what you are feeling (Int. S3)
The therapeutic value of compassion, understanding
and someone who was prepared to listen to the
participants was also made clear. Being able to talk
about their feelings, thoughts and experiences without
any sense of judgment was a liberating and emancipatory experience. Further as this occurred in a very
specic interpersonal atmosphere, one exemplied by
human warmth, the participants found they were able to
re-form their rst tenuous links with humanity. They
began to engage and subsequently connect with their
nurse(s). Participants reported how their sense of feeling
cared about and for; their sense of the (holistic) warm
presence of the nurse acts as a draw, and drew them
back to humanity. Re-connecting with all their former
human connections at this point in their recovery was
to ask too much of the person, however, re-connecting
with one (or two) people was distinctly possible. In
essence, the P/MH nurse becomes a representative or
emissary for humanity. Re-connecting with the P/MH
nurse is this way helps the person begin to internalise
that he/she can still engage and connect with humanity.
The P/MH nurses attitudes, demeanor and behavior
provides a way back; an opportunity to re-connect.
This was described by the participants in the following
ways:
It is very important to feel that someone understands
what I am feeling. (Int. S3)
I had come to the conclusion that nobody cared. So
what I needed was a sense that somebody did and
that was provided by the Psychiatric Emergency
Team. (Int. S1)
Just to see a face, to tell them (the nurses) about my
problem and feel that they understood was brilliant
(Int. S4)

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I just wanted and needed someone to talk to as I felt

so alone. (Int. N5)
I wanted and needed that human thing. (Int. N1)
The human warmth was crucial. They didnt come in
and get their stuff out. They looked me in the eye;
they listened. Just chatting, even if it was going off at
a tangent, was valuable. You know, when I say
something, they didnt just move onto the next
question. (Int. N5)
6.2. Implicitly challenging suicidal constructs as a result
of encountering contrary experiences
Suicidal people experience and interpret the world in a
particular way and, as Shneidman (2004) notes, form
distinctly constricted constructs. According to Beck et
al. (1990) the suicidal person can Systematically
misconstrue his or her experience in a negative way.
Accordingly, the emerging theory reported in this study
indicates that a key process in working with suicidal
people was the way in which P/MH nurses implicitly
challenged these constructs; mostly as a result of what
the nurse is and what they did rather than what they
said. Importantly, the P/MH nurses were also very
careful not to engage in too much challenge early on;
recognizing as they did, that explicit challenge early in
the recovery process only added to the persons sense
of psychological pressure. Gentle challenge then was
purposefully left implicit. The rst step in this process
however, was to recognize and acknowledge that
these suicidal constructs existed and for the participants,
these constructs had powerful feelings attached to them.
This was described by the participants in the following
ways:
I felt like my feelings were trivial (Int. S3)
I felt as if everyone was against me. I couldnt trust
my own family (Int. N1)
I felt like I had died anyway (Int. N2)
Yet, the P/MH nurses were aware that these
constructs were still only thatnamely, constructs.
They were interpretations of ones experiences; interpretations of ones place and value in the world; they
were not necessarily the truth. Given that the
constructs most often contained a sense that the person
felt disconnected from humanity, the P/MH nurses
would engage and communicate with the person in a
way that provided the opposite experience and this
served as an implicit gentle challenge of the suicidal
(disconnected from humanity) construct. This subtle and
gentle reection provided the opportunity for participants to begin to re-consider some of their constricted
beliefs and assumptions. When the participants were
able to internalize that many of their constricted beliefs
about past failures, present limitations and future

restrictions are based on unrealistic constructs and

inaccurate self perceptions, and these constructs are all
heavily inuenced by their current state of hopelessness,
then they were able to begin to deconstruct these
constructs. For example, some of the participants
described their constructs of being totally alone and
a feeling that no-one cares. Accordingly, the intensive,
warm, regular and compassionate contact, coupled with
the P/MH nurses unwillingness to collude with the
participants sense of hopelessness, began this gentle
process of implicit challenging. This was described by
the participants in the following ways:
You feel that you are not alone because they (the
nurses) are caring for you. (Int. S3)
I felt as though (now) there were other people
thinking about me; other people helping me. (Int. S8)
They just changed my life in three days because they
were so loving and kind (Int. S7)
The company, the presence of another who demonstrated care and concern, was crucial (Int. S4)
What I got from the nurses was a bit of compassion;
somebody to listen to; a bit of understanding and
somebody trying to helpand it did help (Int. N9)

7. Stage two: guiding the individual back to humanity

This sub core variable explains how the second stage
of meaningful, transformative care for the suicidal
person is actualized through a combination of three
key processes, and these are captured in the conceptually
robust categoriesNurturing insight and understanding, Supporting and strengthening pre-suicidal beliefs,
and Encountering a novel interpersonal, helping relationship. Furthermore, it is important to note that while
the rst stage had a distinct sense of stillness rather than
overt doing on behalf of the person, this second is one
characterized by a more active nursing role (and
associated interventions).
7.1. Nurturing insight and understanding
Concerned as they were with guiding the person back
to humanity, in this second stage the P/MH nurses
attempted to nurture insight and understanding; particularly a renewed insight and understanding vis-a`-vis
control. The participants in this study were very clear
that an increased sense of control over their suicidal
thoughts feelings rather then the suicidal thoughts
feelings having control over them, was not only
extremely important but further, it was indicative of
re-connecting with humanity. In gaining or re-gaining
insight into and understanding of his/her experiences
and situation, the person begins to see that he/she is not
as irremediably disconnected from humanity as he/she

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once thought; there is still a way back. Furthermore, the

increased insight and understanding was concerned with
a new awareness of the persons increased need for help;
in some cases a recognition that the person needed to
reach out to humanity, reach out to the nurses as a
means of helping the person overcome their suicidal
ideation. This was described by the participants in the
following ways:
It was so helpful to realise that I had an internal
conict going on, and through talking about it I
could identify what was going on for me. (Int. N3)
I thought to myself, I am going to ght this. (Int. S3)
I was ready to accept help (from the nurses) when it
was offered. (Int. N2)
Talking about my son and what I could have done
to him had a big effect on me not taking my life.
(Int. N1)
7.2. Supporting and strengthening pre-suicidal beliefs
As stated previously, suicidal people experience and
interpret the world in a particular way (Shneidman,
2004) and inevitably, this constricted way of thinking/
experiencing was different to the persons pre-suicidal
patterns of thinking, feeling and behaving. The participants described how their pre-suicidal beliefs were
inevitably, more hopeful, indicative of the fact that they
felt life was worth living and importantly, indicative of
the persons sense of feeling connected to or part of,
humanity. Accordingly, this category is concerned with
the nurses attempts to help guide the person back to
these more hopeful, more connected, beliefs; supporting
and encouraging the person in re-framing his/her
constricted thoughts. Helping the person re-construct a
more connected and hopeful construct of the world and
his/her place in it. This was described by the participants
in the following ways:
The PET helped change my thoughts, helped me see
that people were not against me. (Int. S1)
They tried to help me think differently about myself
and my circumstances. (Int. S4)
Because my nurse stirred up different feelings, helped
me change my perspective and I found this so helpful.
(Int. N2)
I used to draw on my Christian beliefs, but even that
left me when I got ill. (Int. S1)

799

7.3. Encountering a novel interpersonal, helping

relationship
Participants in this study were clear that they gained a
sense of relief by being able to talk about their feelings,
thoughts and experiences. Interestingly though, there
was something qualitatively different about the relationship with the nurse, as opposed to the persons
relationship with his/her family and friends, that allowed
for freedom to express, to talk frankly, and as a result,
experience a sense of emancipation. According to the
participants in this study, this freedom to reect and talk
with an experienced professional, in a non-judgmental
atmosphere, was experienced as giving a sense of feeling
very secure; the nurse has faced such situations before,
knows what to do and has helped resolve similar
situations previously. Thus, the relationship, though
different to that in stage two, is still very important to
the process and the guiding back towards humanity still
occurs within the context of this relationship. The
participants were also abundantly clear that, at times,
they were extremely reluctant to share any of their
thoughts and feelings with family or friends, as they
feared that this would somehow harm their signicant
other. Feelings are expressed sparingly within the family
for fear of causing pain or risking alienation. Accordingly, the novel relationship with the nurse enabled the
participants to express feelings and thoughts without
risking damage to their human contacts, because the
nurses have been through similar before and survived,
they would not be harmed (and thus neither would the
persons connection with humanity). This was described
by the participants in the following ways:
When you try to talk to family or friends, there is
always a kickback, so you need a professional. (Int.
N3)
I can tell the nurse things without him getting all
emotional and I couldnt do that with my family and
yet I needed that. (Int. S1)
I needed something different from Pull yourself
together! which is what I was getting from my
family. (Int. N2)
As a result of the input from the team, they made me
feel secure, and I felt as though I didnt have to rely
on my family. (Int. S3)

8. Stage three: learning to live

This sub-core variable explains how the third stage of
meaningful, transformative care for the suicidal person
is actualized through a combination of two key

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processes, and these are captured in the conceptually

robust categoriesaccommodating an existential crisis,
past, present and future and going on in the context set
by the existential relationship with suicide.
8.1. Accommodating an existential crisis, past, present
and future
This sub-core variable is concerned with the participants beginning to pick up the threads of their life and
in essence, how they learn to live again. According to
participants, this included the important process of
making sense of their suicidality; this shifted the sense
of the existential crisis from what do I have to live for
to how do I go on living in the context of surviving a
suicide attempt? Participants referred to how rather
than dismissing the suicidality, it had to be made sense
of, and to the various processes involved in this
endeavor. Interestingly, none of the participants in this
study referred to this process of sense making in the
past tense or as something they had completed. It was
clear that, for these participants, this was going to be a
lengthy and complex process. Additionally, it was
evident that a number of inter and intra-personal
processes were involved; not least the continued support
from and involvement of (in this instance) the mental
health nurses and fellow travelers on the recovery
path. Existential crises by their nature involve facing up
to the realities of living and dying and the reality of ones
mortality. The post-suicidal person has a new element to
come to terms with, the purposeful attempt to end ones
life prematurely; in other words, life will never be the
same again. However, in making sense of their
experience of suicidality, the participants were able to
feel more connected with humanity. Not only because
some of this sense making occurred within the strengthening and developing interpersonal relationship between
person/nurse, but even the intra-personal work entered
into occurred within the safety net of continued virtual
support from the P/MH nurse. Furthermore, trying
to make sense of these events was fundamentally a
very human thing to do; the very fact that it mattered
to the participants was an indication that their connections with humanity were strengthening. To be disconnected with humanity was synonymous with not
caring, with apathy and ambivalence regarding living or
dying. This was described by the participants in the
following ways:
The feeling (suicidal feelings) never goes away; it is
there at the back of my head all the time. (Int. N8)
Every minute I was there, they were bringing me back
to the land of the livingnot the land of the dead.
(Int. S3)
It is the fact that I am not the only one. I am not on
my own; that there are other people like me. (Int. N4)

Talking to my CPN helped me gain a different

perspective on the signicant events. Instead of
seeing the bad and feeling disconnected from my
family, I was able to see the good, feel compassion,
and feel more connected with her (daughter).
(Int. S7)
It was like feeling a bit more in line with society
again. I felt a bit more in line with the usual. This
made me feel a lot better. (Int. S8)

8.2. Going on in the context set by the existential

relationship with suicide
A further key process inherent in learning to live again
is that of going on; re-engaging in life, but now within
the new context of the relationship with suicide.
According to participants, discovering more and more
that life could still be worth living involved re-visiting
many factors. For example, re-working previous constructs (e.g. nobody would miss me or care if I died, or
I cant do anything right. Accordingly, re-investing in
the ordinariness of their pre-suicide life was an
immensely powerful process. In so doing, the reconnection with humanity occurs, since living out an
ordinary life was regarded as ultimately, a human
activity. The participants described a further process,
one concerned with nding balance in life once more,
and this balance was manifest in a number of ways. The
participants needed to balance the emotional hard work
of making sense of their suicide attempt with the
practical requirements of day-to-day, moment-to-moment living. To a great extent, practically living life
appeared to be helpful in accommodating the existential
crisis. A further process of balancing was that between
re-connecting with family, friends and signicant
others and disconnecting gradually from the formal
healthcare services (their nurse). Understandably, the
participants needed to go on with their relationships, but
each of these had to in some way, to come to terms with
what had happened and thus re-dene their own
context. This process was one further way in which the
formerly suicidal person re-connected with humanity.
This was described by the participants in the following
ways:
Just progress in the small things, like putting some
smart clothes on, boosted me up (Int. S4).
I started talking some positive steps, tried to reconnect, like sending a letter (Int. N2).
It was so helpful in being able to recognize that I had
an internal conict going on, and through talking
about it I could identify what was going on for me
(Int. N3).
Regaining my previous activities and abilities gave
me some hope (Int. S3)

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Putting my life into a different perspective, seeing

things in a different, more positive way, really made a
big difference (Int. N2)
My thread was not wanting my kids to be
traumatized by my suicide (Int. N3).
I had to re-establish a connection with my daughter
and her family after talking with the nurse (Int. N2)

9. Discussion
Given that nursing is a practice-based or practiceorientated discipline, a hallmark of high-quality nursing
research then would be implications for practice that
arise from the study ndings (Cutcliffe and Ward, 2003).
Accordingly, we have identied seven distinct practice
implications and these are summarized in Cutcliffe et al.
(2003). However, as a result of word/space limits, we
have decided to focus on the rst of these namely, any
nurses who wish to work with suicidal people will need
to be comfortable with co-presencing, be able to hold
back from being too instrumental and need to be
comfortable with death; talking about suicide. Normative approaches to discussions of research results require
the researchers to compare the ndings with existing
empirical work; most often to indicate supporting
evidence. However, we have adopted a Popperian
(1963) approach in the sense that we attempt to refute
our ndings through comparison with the extant
empirical literature. Popper (1963) asserts that if
researchers cannot disprove their theory then this adds
substantially to its credibility and authenticity. However, it should be noted that the authors are hindered in
this endeavor since the width and depth of the extant
literature is hardly extensive.
Sun et al. (2005) describe a simplistic process of care
for suicidal Taiwanese psychiatric in-patients. They
outline a four-stage model: holistic assessment, provides
protection, provides basic and advanced care. While
they do not appear to explain how, for example,
restraining or secluding suicidal people helps address
suicidal ideation or suicidality per se; their emerging
theory emphasizes a more custodial driven approach to
caring for suicidal people than that described in the
present study. Interestingly, Sun et al. (2005, p. 281)
conclude,
The emergent ndings yindicated that psychiatric
nurses should have the skills and qualities required to
provide advanced care for suicidal patients, the
compassionate art of nursing was generated as the
overarching principley
Talseth et al.s insightful (1997, 1999) work does not
refute the ndings in the current study. Talseth et al.
(1997, 1999) report the following processes and experi-

801

ences in the care of suicidal people in Scandinavia. P/

MH nurses who cared for suicidal clients conrmed,
rather than criticized the clients emotions and feelings;
the P/MH accepted suicidal clients feelings, were open
to these people and had time for them. Further, P/MH
nurses ensured they listened to the clients; emphasized
the value of listening without prejudice. The authors of
this current study will not belabor the obvious parallels
of Talseth et al.s (1997, 1999) ndings with our own;
especially the value of co-presencing (and all the microskills and qualities that such a phrase captures) in care of
the suicidal person. Thus, it is difcult to refute our
current ndings through comparison with the extant
literature; though it should be acknowledged that the
limited width and depth of this literature makes any
comparison problematic.
One nal point that emerges from this position
warrants more attention. Our emerging Grounded
Theory indicates that P/MH nurses need to be able to
sit with both the patients and their own emotions that
surround the near experience of death. To do so, they
need to have personally come to terms with their own
mortality and not be afraid to discuss matters of death/
suicide. In order for nurses to be able to co-presence
with a suicidal person, in order for the nurses to be able
to adopt the appropriate and most helpful role at that
time, the nurse must be comfortable with talking about
death and suicide. The existing evidence, such as it is,
indicates that despite the nature of P/MH nursing, many
are uncomfortable with emotionally charged interpersonal interactions and some construct elaborate defense
mechanisms in order to avoid doing this. We believe that
this skill is rarely spelled out in the theoretical or
empirical literature. To be able to spend relatively long
periods of time, concentrating on the person as he/she
informs the nurse (often in great detail) about wanting
to die, is no easy task. Yet such willingness appeared to
be a pre-requisite for the nurses in this study.

10. Conclusions
The ndings of the study indicate that the key
psychosocial processes involved in moving the suicidal
person from a death orientated position to a life
orientated position can be encapsulated by the core
variable, re-connecting the person with humanity. This
re-connection is brought about through a three-stage
process comprised of the sub-core variables: Reecting
an image of humanity; guiding the individual back to
humanity; and learning to live. The ndings further
indicate that people in suicidality need a different form
of care than is currently being practiced in most mental
health units and within the community. The participants
in this study were clear in indicating that they do not
want to be treated mechanically, as epitomized by being

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under observations, but prefer to form a human, close

relationship with the P/MH nurse (perhaps captured by
the phrase co-presencing). Given the nature of the
research method and study design, we would not
purport any nomothetic generalizability of these ndings. Having said that, it also needs to be acknowledged
that P/MH nursing, irrespective of what country it
occurs in, inevitably has a high degree of idiographic
generalizability; where in this refers to generalizations
about and drawn from cases (Sandelowski, 1998).
Denzin and Lincoln (1994, p. 201) make this point very
clear when they state,
Every instance of a case or process bears the general
class of phenomenon it belongs to. Accordingly, every
instance, case or process drawn from the substantive
area of care of the suicidal person bears the general class
of this substantive area and can be similarly experienced
by groups of P/MH nurses in other settings.

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