Hrev_master [page 44] [Emergency Care Journal 2023; 19:11220] Emergency Care Journal 2023; volume 19:11220 Abstract Nurses have an important role in caring for patients with inten- tional self-poisoning. This study attempted to explore the emergen- cy department nurses’ perception of caring for patients with inten- tional self-poisoning. The present qualitative study was performed using the phenomenological method. This study was done on 14 emergency department nurses with experience in caring for patients with intentional self-poisoning. Data were collected through semi-structured interviews and transcribed verbatim. Data were analyzed using Colaizzi’s method. Following data analysis, two themes and five sub-themes were extracted, which included being reluctant to provide care (discomfort in providing care, and lack of desire to care) and comprehensive patient support (provid- ing complete care and emotional support). Given that emergency department nurses are the first medical staff who face intentional self-poisoning patients and play an important role in the care and treatment of these patients, it is necessary to improve their under- standing of caring for these patients. In addition, their comprehen- sive support for these patients should be strengthened. Psychological support for nurses and training them on how to com- municate with intentional self-poisoning patients and their families are also recommended. Introduction Poisoning is one of the most common reasons for patients’ admission to the hospital emergency department.1 It is a global problem that has become an epidemic in developing countries over the past few years and has turned into one of the leading causes of death in these countries.2,3 One type of poisoning is intentional self-poisoning. Irrespective of its intent and motive, intentional self-poisoning is potentially life-threatening and can sometimes lead to death.4 Intentional self-poisoning is defined as the inten- tional use of a substance or in excess of the prescribed dose of any drug for the purpose of self-harm.5 It is one of the most common methods of suicide in the world.6 Statistics show that over a ten-year period, more than 75,000 cases of self-poisoning were admitted to Canadian hospitals,7 and 64,000 cases of self-harm were admitted to UK hospitals over a three-month period.8 The rate of intentional self-poisoning in Asian countries is approximately 20 to 30% higher than that in Europe.9,10 In Iran, the rate of intentional self-poisoning growth is more than the rate of population growth, so that, in a six-year period, more than 108,000 patients were admitted to Loghman Hospital in Tehran, Iran, with a diagnosis of poisoning, of whom more than 2,000 died.11 During one year, 280 deaths due to poisoning were registered in a teaching hospital in Tehran, 29% of which had a his- Correspondence: Sina Valiee, Faculty of Nursing and Midwifery, Kurdistan University of Medical Sciences, Pasdaran St., 66177-13446, Sanandaj, Iran. Tel.: +98.9188734619 - Fax: +98.8733660092. E-mail: valiee@muk.ac.ir Key words: perception; nurse; emergency department; care; poisoning. Acknowledgments: we want to thank the emergency Department’s nurs- es at Tohid Hospital affiliated with Kurdistan University of Medical Sciences, Sanandaj, Iran. Contributions: SS, conception and design, data collection, analysis and interpretation, writing the manuscript, critical revision of the manu- script; SV, conception and design, data collection, analysis and interpre- tation, writing the manuscript, critical revision of the manuscript. Conflict of interest: the authors declare no potential conflict of interest. Funding: this study was supported by the research fund of the Kurdistan University of Medical Sciences (No. IR.MUK.REC.1397. 277). Ethics approval and consent to participate: the present study was approved by the Research Council of the Clinical Care Research Center (No. IR.MUK.REC.1397.277) and by the Ethics Committee of Kurdistan University of Medical Sciences (code IR.MUK.REC. 1397.277). Availability of data and materials: all data underlying the findings are fully available. Consent for publication: the objectives of the study were explained to the participants and written informed consent was obtained from all the participants of the study. The participants were assured about the confi- dentiality of their information and that their audio files would be deleted after being transcribed. Participants were free to leave the study at any stage of the research. Received for publication: 27 January 2023. Revision received: 27 February 2023. Accepted for publication: 27 February 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Emergency Care Journal 2023; 19:11220 doi:10.4081/ecj.2023.11220 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organiza- tions, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its man- ufacturer is not guaranteed or endorsed by the publisher. Emergency department nurses’ perceptions of caring for patients with intentional self-poisoning: a qualitative study Salar Sharifi,1 Sina Valiee2,3 1Tohid Hospital, Kurdistan University of Medical Sciences, Sanandaj; 2Clinical Care Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj; 3Faculty of Nursing and Midwifery, Kurdistan University of Medical Sciences, Sanandaj, Iran Non -co mmerc ial us e o nly tory of unsuccessful suicide.12 In addition, more than 5,000 cases of poisoning were admitted to a hospital in Mashhad for a period of one year.1 The number of intentional self-poisoning cases in west- ern Iran was estimated at 331.7 per 100,000 people in 2015.13 Poisonings impose irreparable economic and physical-mental health damages on society and the family.1,7,14 One of the factors that have a great impact on the care and risk of suicidal behaviors in patients with intentional self-poisoning is the knowledge and attitude of healthcare workers toward these patients.15 Healthcare workers, especially nurses, have an important role in caring for patients with intentional self-poisoning.16 Nurses’ negative attitude affects the quality of care provided to patients with intentional self- poisoning.16,17 Moreover, emergency department patients’ experi- ences affect their decision to stay in the hospital and continue treat- ment, so that inappropriate experiences can lead to the recurrence of suicide in the patient.17,18 Negative attitudes of nurses towards patients with intentional self-poisoning can also lead to inappropri- ate behaviors such as anger, lack of proper care provision, and pun- ishment of patients.16-18 The main concerns of patients with inten- tional self-poisoning are fear of being labeled by emergency department staff, the unwillingness of emergency department staff to care for them, and lack of respect for their privacy.18 Therefore, exploring nurses’ perceptions toward caring for intentional self-poisoning patients can help improve the care pro- cess. Although studies have been conducted on the perceptions of nurses and other members of the treatment team toward providing care for patients with intentional self-poisoning, these studies have been performed quantitatively and with a range of questions, and few in-depth studies have been done on nurses’ perspectives. Qualitative studies with an in-depth explanation of phenomena from the perspective of participants can help clarify the status of the phenomenon. A phenomenology is a qualitative approach that runs to explore the essence of a phenomenon from the perspective of participants who have experienced it. The phenomenology goal is to describe what and how was experienced.19,20 Therefore, the aim of this study was to explore emergency department nurses’ perceptions of caring for patients with intentional self-poisoning. Materials and Methods Design The present descriptive qualitative study explored the emer- gency department nurses’ perception of caring for patients with intentional self-poisoning using the phenomenological method. The phenomenology method examines an experience as it is sub- jectively lived by experiencers, and new meanings and understand- ings can be developed about that experience.19,20 Participants The study was performed on 14 emergency department nurses (10 male nurses and 4 female nurses). Inclusion criteria were being a nurse in the emergency department, willingness to participate in the research, having one year of work experience in the emergency department and caring for patients with intentional self-poisoning. Exclusion criteria were unwillingness to continue the study or record the interview. The interviews continued until data saturation was achieved. In this study, data saturation emphasized on data collection used. This method regards the degree to which new data repeats what represents in previous data.21 Therefore, interviews followed until new content was not added to the previous partici- pants’ interviews, and the data were repeated. Data collection Data were collected through semi-structured interviews, per- formed face to face. The interviews were conducted and recorded by the author after obtaining the participants’ consent. Data were collected between October 2019 and April 2020. The interviews, 30 to 45 minutes in length, were carried out in a separate and quiet room of the emergency department during non-working hours. At first, a few trial interviews were conducted by the main researcher with nurses not participating in the study to develop an interview guide. In order to properly guide the interview and extract the par- ticipants’ experiences, an interview guide was used. The interview started with some demographic questions and then moved on to open-ended questions. The interview guide included the following items: i) please describe your experience of caring for a patient with intentional self-poisoning; ii) how do you feel about caring for intentional self-poisoning patients; iii) how important are patients with inten- tional self-poisoning to you, and are you willing to care for them; iv) what does care for self-poisoning patients look like to you? Data analysis Data were analyzed using Colaizzi’s descriptive seven-step method.22 The interviews were conducted in Kurdish and tran- scribed and analyzed in Persian and only translated into English for the final report. After each interview, the audio recording of the interview was transcribed verbatim by the researcher. Then, signif- icant statements related to the investigated phenomenon were extracted from each interview and coded. Next, the underlying meaning of each of the significant statements was extracted and written under the title of formulated meaning, and the formulated meaning was organized into specific thematic categories. Rigor To ensure the rigor of the study, some strategies were used,23 including written transcription, member checking, reviewing texts, and using participants’ own words,24 overseeing transcriptions, audio recordings, interviews, coding, and extracting themes and sub-themes,24,25 and using patients’ direct quotations to support the findings. Ethical considerations The present study was approved by the Research Council of the Clinical Care Research Center (No. 277.1397) and by the Ethics Committee of Kurdistan University of Medical Sciences (code IR.MUK.REC.1397.277). The objectives of the study were explained to the participants and written informed consent was obtained from all the participants of the study. The participants were assured about the confidentiality of their information and that their audio files would be deleted after being transcribed. Participants were free to leave the study at any stage of the research. Results Participants were 14 nurses (10 male and 4 female nurses) with a mean age of 28.28±3.62, mean work experience of 5.14±2.79, and mean work experience at the emergency department of 2.92±1.63. Regarding marital status, 5 were single, and 9 were married. In terms of educational level, 13 had a bachelor’s degree and 1 had a master’s degree. Following data analysis, 196 primary codes, 16 primary categories, 5 sub-themes, and 2 main themes were extracted. Data analysis revealed two main themes, namely Article [Emergency Care Journal 2023; 19:11220] [page 45] Non -co mmerc ial us e o nly being reluctant to provide care (discomfort in providing care, and lack of desire to care for these patients) and comprehensive patient support (providing complete care and emotional support) for nurs- es’ perceptions toward caring for patients with intentional self-poi- soning (Table 1). Being reluctant to provide care The first theme was being reluctant to provide care, which included three sub-themes, namely discomfort in providing care, psychological roots of patient’s problems, and lack of desire to care for these patients. To summarize, emergency department nurs- es had little willingness to care for patients with intentional self- poisoning, and they preferred caring for other patients. Discomfort in providing care One of the reasons for nurses’ reluctance to provide care to patients with intentional self-poisoning was feeling upset when caring for this group of patients. “...I get very upset with the patient. When he committed sui- cide again, it means that his life is not important to him, so why should I care for him?...” (p. 1) “...One day they brought a girl whose mother had told her to bring some tea. She had taken two packs of pills. At that moment, I wanted to punish that girl. I got angry and told her: your mother does not have the right to ask you to do something for her??” (p. 3) “...In general, I feel sick about intentional self-poisoning patients, and I do not like caring for them...” (p. 5) Along with getting angry, the nurses got upset to see the patient’s condition. “...One day, one of the emergency medical personnel was brought to the emergency department. He had taken rice pills and died a few days later. I got very sad and upset...” (p. 14) Finally, nurses felt compassion for the patient with intentional self-poisoning. “...I myself feel more sorry for the poor families whose chil- dren have attempted intentional self-poisoning.” (p. 9) Lack of desire to care Another sub-theme of being reluctant to care was nurses’ lack of desire to care for intentional self-poisoning patients so that emergency department nurses had a negative perception towards patients with intentional self-poisoning. “...I have a negative attitude towards patients with intentional self-poisoning. Whenever I was in charge of the shift, I allocated the worst bed to patients with intentional self-poisoning, even if they were critically ill because I do not like to allocate a suitable bed to these patients...” (p. 4) “...because patients with intentional self-poisoning do this knowingly, all of my colleagues do not have a good view of them and our attitude is negative...” (p. 3) In addition, the nurses felt their effort in care remained ungrateful to patients. “...I have no special feelings, but I feel I am doing something useless for them and these patients are not important to me...” (p. 7) “...If we have a few patients and one is critically ill, I choose the critically ill patient, not the patient with intentional self-poison- ing who do not value his/her life.” (p. 11) Comprehensive patient support Despite nurses’ reluctance to provide care to patients with intentional self-poisoning, they provided comprehensive support to these patients. They provided complete care to these patients and provided them with emotional support. Providing complete care One of the sub-themes of comprehensive patient support was the provision of complete care, and nurses stated that care should be provided to patients with intentional self-poisoning based on job descriptions. “...It does not matter to me what the patient’s problem is, although I may be angry with the patient because of the crowded- ness of the ward, but I do my job completely and provide all nec- essary patient care” (p. 9) “...Patients with intentional self-poisoning are sick like the rest of the patients, and it makes no difference. Each of them definitely had problems that did intentional self-poisoning. I personally will do whatever is necessary for them...” (p. 4) Article [page 46] [Emergency Care Journal 2023; 19:11220] Table 1. The main themes and sub-themes. Main themes Sub- themes Primary categories Being reluctant to provide care Discomfort in providing care Feeling upset due to patient’s condition Feeling anger due to patient’s readmission Feeling compassion Lack of desire to care Having negative attitude towards the patient Ungrateful of care Comprehensive patient support Providing complete care Providing care based on job descriptions Explaining the care and treatment process Comprehensive patient needs Following up the patient’s condition Emotional support Investigating the cause of suicide/self-harm Communicate Recommending the follow-up of the patient’s mental condition Supporting the patient Non -co mmerc ial us e o nly From the participants’ point of view, the care and treatment process should be explained to patients with intentional self-poi- soning. “...I explain to the patient the type of medicine and injectable antidotes...” (p. 2) Another aspect of providing complete care was the follow-up of patients with intentional self-poisoning who had acute condi- tions. “...I always follow up patients with intentional self-poisoning to see whether they get well, have problems, and are discharged or not. I would like to understand what their outcome is...” (p. 10) “...Patients do not stay long in the emergency department, so we do not think about them or get worried to see what happens to them, but I myself follow up for intentional self-poisoning patients with rice tablet to see whether they survive or not...” (p. 9) Emotional support An important sub-them of comprehensive patient support was emotional support. The nurses communicated with the patients and their companions and reminded the necessary recommendations for the follow-up of the medical treatment and the mental condi- tion of the patient, and provided their support to the patients with intentional self-poisoning. “We had a self-poisoned case with medications. He attempted self-poisoning after not being accepted in the entrance exam. He was saying that I would do the same next year if I won’t be accept- ed. I talked to him and comforted him and recommended his fam- ily take him to a psychiatrist because he had suicidal thoughts.” (p. 10) “...I myself have a close relationship with intentional self-poi- soning patients and often ask their reason for attempting self-poi- soning. I advised them and did my best to convince them not to hurt themselves again.” (p. 2) “...For example, an old man in his seventies attempted self-poi- soning with medicine. At first, he was not conscious, and after a while he regained consciousness; I asked him what did you take? Why did you do this? I talked to him as much as I could and sup- ported him. I really wondered why he did that at this age” (p. 5) “...Patients and companions should be supported, and the nec- essary training should be given to companions by nurses...” (p. 7) Discussion Being reluctant to provide care The findings of this study showed that the emergency depart- ment nurses were reluctant to provide care for patients with inten- tional self-poisoning. Providing equal and non-discriminatory care to patients is one of the ethical and professional principles of nurs- ing.26 The behavior and attitude of nurses in relation to patients with intentional self-poisoning are ethically and professionally important.27 In a study by Rutto et al., (2012), nurses reported that they sometimes felt angry when caring for patients with intentional self-poisoning.28 In another study by Ouzouni and Nakakis (2013), nurses, in addition to feeling responsible, felt angry about caring for suicidal patients and the mean of their attitude toward suicide was unfavorable.29 In general, nurses’ unfavorable attitude toward caring for patients with intentional self-poisoning causes a feeling of inadequacy and hopelessness in them.16 Emergency department nurses in Australia (2014) provided care to all patients without judgment and regardless of the cause of their admission, although some nurses reported low levels of knowledge and confidence in caring for intentional self-poisoning patients and requested a relat- ed training program.30 Patients with intentional self-poisoning are vulnerable and must be admitted as patients and receive the neces- sary care and support.31 In this regard, educational programs should be established to educate nurses regarding the care of patients with intentional self-poisoning.27 Due to the fact that the inconvenience imposed on nurses in the care of patients with inten- tional self-poisoning reduced their willingness to provide care, provision of professional and emotional support to nurses in emer- gency departments and preferably assigning a new nurse to re- admitted patients are recommended. Despite being angry with intentional self-poisoning patients, the nurses felt compassion for them. Emergency department nurses in Australia (2014) felt com- passion for patients with intentional self-poisoning and believed that the attempt of these patients for self-poisoning was to attract others’ attention.30 Various studies revealed that nurses did not con- sider the emergency department as a suitable place to provide care for patients with intentional self-poisoning.30-33 Overcrowding in the emergency department can adversely affect the quality of care provided to patients with intentional self-poisoning.34 Most nurses attributed overcrowding in the emergency department, lack of ade- quate time to care, and the increased workload caused by self-poi- soned patients to feel angry with patients with intentional self-poi- soning. Therefore, the emergency department and the balance between nurses and patients need proper management to reduce nursing workload so that nurses can provide quality care with calm and patience to patients with intentional self-poisoning. The results of a study by Chapman and Martin (2014) showed that emergency department nurses provided equal care to patients with intentional self-poisoning and they had a sense of empathy and compassion for these patients, although many of them did not have the neces- sary skills and confidence to care for these patients.33 Emergency department nurses in Beaver’s study in South Carolina stated that they were indifferent to patients with intentional self-poisoning and were reluctant to communicate with them. In the study men- tioned before, the training of emergency department nurses in rela- tion to intentional self-poisoning patients led to an improvement in the quality of care provided to these patients.32 Therefore, strength- ening nurses’ sense of empathy and compassion can be effective in caring for patients with intentional self-poisoning. In this study, emergency department nurses were found to care for patients with intentional self-poisoning ungrateful and were reluctant to provide care to them. In most studies, emergency department nurses had an unfavorable attitude toward patients with intentional self-poisoning.29,30,35 Emergency department nurses in Denmark had a positive attitude towards patients with intentional self-poisoning.6 In a study by Rutto et al., (2012), most emergency department nurses had a positive attitude toward patients with acute self-poisoning.28 Various studies revealed that a negative atti- tude adversely affected the quality of care provided to patients with intentional self-poisoning.16,17 Negative attitudes of nurses toward intentional self-poisoning patients can lead to inappropriate behav- iors such as feeling angry with these patients, patients’ punishment, indifference toward patients, and lack of providing proper care.6,17 Holding workshops and educational programs related to intention- Article [Emergency Care Journal 2023; 19:11220] [page 47] Non -co mmerc ial us e o nly al self-poisoning and psychological conditions of these patients by nursing managers can increase the quality of nursing care. Improving the desire of emergency department nurses to provide care for these patients using various incentives is recommended. Comprehensive patient support Nurses in this study provided comprehensive support to inten- tional self-poisoning patients through complete care and emotional support. Complete care, from the nurses’ point of view, includes performing care based on job descriptions, giving sufficient expla- nations to the patient, paying attention to all the patient’s needs, and following up with the patient. Providing complete care for intentional self-poisoning patients is one of the principles of nurs- ing that these nurses were aware of and demanded care based on their job descriptions and informing the patients and their families about the relevant care, which was sometimes done incompletely. Patient support should be comprehensive and multidimensional. One aspect of the comprehensive care program is communicating with the patient and the patient’s family.36 Receiving complete care is one of the patients’ basic rights.26 Given that comprehensive and holistic care of patients is one of the principles of nursing care, so emergency department nurses should try to provide the most com- plete care to patients with intentional self-poisoning by consider- ing other aspects as well. Using the experience of more experi- enced nurses can also be helpful in this regard. Patients’ emotional support is also one of the principles of comprehensive patient sup- port and nurses who participated in this study perceived the impor- tance of caring for these patients by communicating with them and investigating the cause of patients’ intentional self-poisoning. Nurses were more concerned with the physical condition of patients with intentional self-poisoning, who had more critical con- ditions. The relationship between nurse and patient can have a direct effect on the quality of care.37 Patients expect a sense of empathy from nurses.18 Nurses should be able to communicate and empathize with intentional self-poisoning patients and help pre- vent re-committing and resolving the patient’s mental illness.38 Patients with intentional self-poisoning should receive the same care as other patients.34 In various studies, it was seen that nurses did not have sufficient and satisfactory knowledge about poisoning and managing intentional self-poisoning patients and needed train- ing programs.34,38,39 Nurses who have been trained in relation to patients with intentional self-poisoning have a positive attitude and empathy towards these patients.6 The nurses who participated in this study believed that recommendations to follow up on the patient’s mental status and thoroughly investigate the causes of suicide were needed. According to the results of a study by Finkelstein (2015), in which significant cases of intentional self- poisoning patients had a history of previous intentional self-poi- soning and committed suicide after being discharged from the hos- pital,40 the need for a comprehensive psychiatric examination of these patients is felt more. Therefore, it is necessary to pay atten- tion to educating nurses to increase their ability to provide compre- hensive care and emotional support according to the conditions of patients with intentional self-poisoning. In addition to emotional support, emergency department nurses should be familiar with the correct methods of this type of support and provide the right emo- tional support that strengthens the positive aspects of patients’ per- sonalities. Limitations and suggestions The present study was performed in an emergency department and on a small number of nurses. Therefore, conducting a study with a larger sample size in the same and different contexts is rec- ommended. It is also recommended to design-related tools and extensively examine nurses’ perceptions about intentional self-poi- soning. This study was conducted on emergency department nurs- es only, therefore exploring the experiences of other healthcare providers was recommended. Studying the perception of nurses working in other departments about caring for these patients is also recommended. Conclusions The results of this study showed that the emergency depart- ment nurses were reluctant to care for patients with intentional self-poisoning. Despite the negative perception, the participants considered it necessary to provide comprehensive support and complete care to these patients. 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