Pre-hospital care to the individual with suicidal behavior: an integrative review

The purpose of this study is to identify the actions performed by nursing professionals during the pre-hospital care to the individual with suicidal behavior. Integrative review research, which used the Cooper Method. Data collection was performed in the following databases: LILACS, BDENF, MEDLINE, SciELO and BIREME. 4765 articles were obtained, of which 190 met the inclusion criteria, 21 answered the guiding question, 18 were repeated, and three were used in this study. 32 taken nursing actions were found. Therefore, it is considered important that the nursing staff, managers and society focus on the suicidal behavior theme in order to improve the care and understanding of the death wish.


Introduction
Suicidal behavior is an expression that covers several suicide linked phenomena, according to its manifestations (1) .This term is used to describe the thoughts and actions that indicate suicidal ideation, its risk, its planning, and the suicide attempt itself (2)(3) .The epidemiological relevance of this behavior became the object of attention in health (3) .
Brazil is among the ten countries with the highest absolute number of suicides, with 7,987 cases in 2004 (4) .In 2010 the death rate from suicide in the country was 9.4/100.000people (5) .
To accommodate the demand for suicidal behavior, health services are organized in distributed devices at different levels of care.Among the equipment existing in the network of mental health care for suicidal behavior, are the hospital emergencies and the resources provided by pre-hospital care, the focus of this study.The pre-hospital devices considered in this research were the Mobile Emergency Service (SAMU), the Emergency Care Units (APU), the Psychiatric Emergency Medical Service and Primary Health Care.
Pre-hospital care (PHC) is any assistance provided, directly or indirectly, outside the hospital environment, using means and methods available for the care of patients in life-threatening situation (13) .Victims of trauma, clinical and obstetric complications and psychiatric disorders are assisted, and the goal of the care is to initiate the necessary care actions for the patient's stabilization (4) .
In 2002, the Ministry of Health approved the Technical Regulation (RT) of the State Urgency and Emergency Systems, which standardizes the prehospital care (PHC) through Ordinance 2048/02 (14) .In accordance with RT by the PHC is divided into fixed and mobile services.The mobile pre-hospital in Brazil is performed by SUS through the Mobile Emergency Service -SAMU -and private companies of assistance (14) .Mobile PHC's mission is the immediate assistance to the victims, which are forwarded to the fixed pre-hospital care or to hospital care (13) .
The fixed PHC is the care provided outside the hospital environment.This service is carried out in basic health units, from Family Health, health community agents teams, specialized outpatient clinics, diagnostic and therapy services, and emergency medical service (4,14) .
It is highlighted the relevance of nursing work in providing care to individuals with suicide risk in prehospital care (PHC), which is present both in mobile PHC units and in fixed PHC.In general, the first service provided to the individual presenting suicidal behavior is carried out by the nursing staff.The Federal Council of Nursing (COFEN) introduced resolutions in order to legally protect the role of professionals in the PHC, in accordance with Resolution No. 225/2000 (15) , which provides for nursing action through tele-prescription.
an average incidence of 10.2/100.000people in the period from 1980-1999 (6) .Index that that has remained stable, whereas in 2011 the suicide rate was 9.6/100.000people (7).
Porto Alegre presented in 2011, in absolute numbers, 82 cases of suicide, being surpassed in the metropolitan area, by the municipality of Alvorada which had 202 deaths from this external cause (7) .
Durkhein, a sociologist, and Freud, a psychoanalyst, were precursors to formulate theories that focused on suicide motivated by various reasons, each within their area of expertise (3) .The causes identified for suicide involve social factors such as the inability of a person to integrate into society (8) , while the struggle between two instinctual impulses, life impulse and death impulse, results in suicidal behavior, representing the product of the conflict between the desire to live or die (9) .
Among the factors that influence suicidal behavior it is included the environmental, psychological and biological factors, each with a specific weight, however, separately, none of them may be sufficient to explain such an action (10) .
Suicidal ideation is expressed by thoughts of death that lead to the risk of life, even if the fatal action is not performed (3) .A study shows that suicide conception was more frequent among women, adults from 30-44 years old, people living alone, among spiritists and those with higher income (2) .Planning occurs when a person has mentally organized strategies on the way with which they will take their own life (3) .
The suicide attempt is the non-fatal suicidal behavior, representing the time when a person performs an action that can threaten their life (3) , having the same phenomenological characteristics of suicide (1) .Previous suicide attempts indicate an action repetition (11) and therefore should be properly assessed.In accordance with the report of the World Health Organization 10 to 20 million people in the world try to commit suicide (12) .
The word suicide has the meaning of the action which leads to voluntary death (3) .Suicide represents the attempt to solve a problem that is causing intense suffering, associated with unfulfilled needs, feelings of hopelessness and helplessness, conflict between survival and unbearable stress, narrowing of alternatives and search for escape, thus presenting the suicidal person signs of distress. (11).Thus, suicidal behavior is a time of crisis, characterized Silva SL, Kohlrausch E.
With this in mind, this study was developed from the guiding question: What are the nursing actions performed in the pre-hospital care to the person presenting suicidal behavior found in the scientific literature?
This guiding question was built in order to meet this study's purpose: identifying the actions performed by nursing professionals during the pre-hospital care to the individual presenting suicidal behavior found in the scientific literature.

Methodological Approach
This research was structured from an integrative review of scientific literature on studies that identify the actions performed by nursing professionals during the pre-hospital care to the person presenting suicidal behavior.
The integrative review (RI) of scientific literature is a technique that aims at gathering and analyzing data from primary research on the same subject, in order to develop a more comprehensive explanation of a particular phenomenon (16) , in this case the care to the individual presenting suicidal behavior.This method allows to synthesize multiple studies, enabling general conclusions about a given topic (17) .
The construction of this research came from the investigation of nursing actions in the pre-hospital care to the individual presenting suicidal behavior in scientific literature in Portuguese and Spanish.The steps for the preparation of this integrative review were: formulating the research question, data collection, collected data evaluation, analysis and interpretation of results and presentation of results (16) .
The guiding question of a study aims at searching for evidence in the scientific literature.Thus, the question built for this research was: What are the nursing actions performed in the pre-hospital care to the individual presenting suicidal behavior found in the scientific literature?
Data collection was done through direct research in the Virtual Library on Nursing Health (BVS), having as source the following databases: LILACS (Latin American Literature on Health Sciences), BDENF (Bibliographic Database Specialized in Brazil's Nursing Area), SciELO (Scientific Electronic Library On-line), BIREME (Latin American and Caribbean Center of Information of Health Sciences) and

MEDLINE (Medical Literature Analysis and Retrieval System Online).
The research's data gathering occurred in November 2013, and it systematized publications in the period from January/1990 to August/2013.Descriptors (DeCS) were: emergency care, mental health, psychiatric nursing, health services, prehospital care, primary care, basic care, pre-hospital emergency care, emergency room, suicidal ideation, suicide attempt and suicide.
It was defined as inclusion criteria studies indexed in the selected databases, research presenting the term suicidal behavior not indexed in the BVS, included for addressing the entire gradation of suicide risk.Works comprising the actions of nursing professionals held in pre-hospital care to the individual presenting suicidal behavior were also included.National and international publications published in Portuguese and Spanish; complete full texts available online and of open access; quantitative, qualitative research, theoretical reflection; systematic review, integrative, bibliographic and case report.
The exclusion criteria established were: publications that match editorials, conferences' summaries, historical records, opinions and comments and research that relate to other locations other than Emergency Care Units (UPA), Psychiatric Emergency Medical Service, Primary Care and the Mobile Emergency Service (SAMU).Three instruments were developed to systematize and refine data collection.The first was the data collection strategy table, where the suicidal behavior, suicidal ideation, suicide attempts and suicide descriptors were associated with others, through the Boolean connective and, occurring selection of items answering the guiding question.The second instrument had as its function extracting from the articles the following information: article number, title, authors, authors' background, year, periodic, place of publication, objectives, methodologies, results, final considerations/ conclusions and observations.The last instrument was used to analyze and interpret the results obtained in the previous stage.
In accordance with the Copyright Law, this Integrative Review respected the authenticity of ideas, concepts and definitions of the researched authors (18) .

Results and discussion
Data collection on the databases resulted in obtaining 4765 articles, among such 190 answered the inclusion criteria.Of these, 21 articles were selected answering the guiding question, 18 were excluded for being repeated.For the final composition of this Integrative Review three articles were used, and the reading of these made it possible to select the contents related to nursing actions undertaken in the service to the individual presenting suicidal behavior.
Figure 1 shows the titles of the selected studies with their respective authors.The study code was set by year of publication of the periodicals, from the most recent to the oldest.

Figure 1-Articles Title
In relation to the authors of these studies, there are two Doctors in Nursing, four are licensed (Two in Nursing, one in Economy, one in Psychology) and two are Undergraduate in Nursing.Research in Nursing, along with development of the human sciences, provides the innovation and improvement of this area of knowledge (19) .Two studies were published in Cuba, in 1998 and 2000, the Cuban Journal of Nursing, and one in Brazil, in 2008, in the periodical Science, Care and Health.
The objectives of the three publications contemplated the look about the service to suicidal behavior in primary care.The studies have objectives elaborated clearly and directly.
In the methodology of these studies two descriptive quantitative researches and one qualitative exploratory research were found.Data collection was conducted through semi-structured interviews, information systems review and observation of patients and professionals.Only study number three described the period of data collection (20) .
We found in this RI 32 nursing interventions in the care of individual presenting suicidal behavior, and the Cuban studies showed 23 nursing actions, and the Brazilian, 19. .Articles defend the concept that nursing actions in the care of suicidal behavior should aim at the full attention of the user.The actions of prevention, the listening, orientation to family and home visits are included in articles of this review.A study found that patients who were treated in an emergency were given care to their clinical improvement, and no care for their psychiatric problem, with no action taken related to the care to suicidal behavior (21) .In this sense, effective forwarding to the health team is necessary, the family and social support, considering that previous attempts of suicide are risk indicators for the consummation of suicide (22) .
Listening is as important as the physical examination of the patient (23) .Listening means being committed, interested and linked to the person, with all its complexity and vicissitude (24) .In accordance with the analyzed authors, it is believed that one must move with regard to qualified listening and communication.Regarding the care of the individual presenting suicidal behavior, it is necessary not only to listen to them, but also to listen to the family.This idea is supported in a study that claims that the family needs to be looked at, listened to, welcomed and oriented, so that it can provide support to those who tried to commit suicide (22) .
Home visits (VD) were mentioned in the three articles as one of the care devices to the individual presenting suicidal behavior.The VD is an action that facilitates the approximation of the team, users and their families and this technique helps to understand the family dynamics with a focus on improving the user (25) .
The publications of this Integrative Review claim that primary care is organized to take care of the health needs of the population, including suicidal behavior.The nursing team plays an important role in the care of these patients.The authors concluded, then, that increased knowledge about suicidal behavior, its manifestations, warning signs, risk factors, together with effective preventive intervention would bring a Silva SL, Kohlrausch E. significant contribution to reducing the impact of this health problem in the population.Some nursing actions were identified such as forwarding, reporting, analysis and planning of action with patient, family and community, education for health, love, security and non-judgment, which should be considered by the nurse in the organization of the working process of their team to meet the individual presenting suicidal behavior in Pre-Hospital Care.Empathy is included as a nursing action, in care to the individual presenting this behavior, but it was not mentioned in the articles researched for this study, both for the integrative review and to the reference used for the theoretical discussion

Final Considerations
The purpose of this study was to identify the actions performed by nursing professionals during the pre-hospital care to the individual presenting suicidal behavior, from the development of an integrative review.
The integrative review is a research method that allows to systematize information found on a particular subject in the scientific literature.It is believed that for the chosen subject, the method presented limitations, since its rigorous selection of items, included as a data source, excluded others that discussed the subject of nursing actions in care to suicidal behavior, but that did not meet the other criteria chosen for this study.Possibly, an exploratory qualitative approach could bring subjective clarification on suicidal behavior and its care.
Suicidal behavior covers gradations of the intention to suicide, transiting from the ideation, planning, reaching the suicide itself.There are signs of this behavior that can be observed in the individual, in which the timely intervention, it is believed, can avoid death.The risk of suicide is an emergency, for the individual's life is threatened.
Suicide is a public health problem, epidemiologically relevant and complex, for which there is no single cause or a single reason.It results from an intricate interaction of biological, genetic, psychological, social, cultural and environmental factors.So it is difficult to explain why some people decide to commit suicide while others in a similar or worse situation do not.
Various health services are responsible for assisting the individual presenting suicidal behavior.
In this study we chose to find the care provided in the pre-hospital care.Among PHC health professionals we highlight the relevance of nursing work in providing such care.
In this integrative review, in relation to care, 32 nursing interventions were found in the care of the individual presenting suicidal behavior, their family and community.Among the actions listed in the selected studies, there was convergence on the three regarding the prevention, listening, orientation to family and home visits.These actions include different ways of acting during the act of care to individuals presenting suicidal behavior, it being relevant to the maintenance and preservation of life.
The forwarding of the individual presenting suicidal behavior to other health professionals is fundamental for the patient to receive comprehensive care in different areas of knowledge, both from health and human sciences, and social work and psychology.Thus, through the integration of actions and multidisciplinary care are founded the care basis, making the person to feel more protected in their life context.
We defend the necessity for improvement of notifications of suicide attempts and confirmed suicides, because it may contribute to qualify the record in information systems.Public policies for the prevention of suicidal behavior may be reevaluated from data efficiently supplied, accurately demonstrating the reality of statistics on suicidal behavior.
Planning actions with the individual, family and community does not mean the scope of its full implementation, yet this nursing intervention can come to help the care since the professional can imagine the possible scenarios for intervention to prevent suicidal behavior of those involved in this context.
The health education can be a tool to guide health care, especially for the persons involved in the care of the individual presenting suicidal behavior.Educating the individual and their partners, family, friends and others close to them to recognize how the dynamics of suicidal behavior is, can provide means so that they can assist in the care actions.
The attitude of understanding and no judgment exercised by nursing professionals with individuals suffering from some psychological suffering, and within it is included suicidal behavior, generates a security relationship and trust between the nurse-SMAD, Rev. Eletrônica Saúde Mental Álcool Drog.apr.-jun.2016;12(2):108-15 patient-family, qualifying the service, adding value to the care.
Thus, a change of professional conduct may come to influence the treatment and rehabilitation of people presenting suicidal behavior.Permanent education actions provide for the nursing staff moments of group reflection on suicidal behavior and finitude, which could improve service to individuals in psychological distress, in this case with a death wish.
This study provided theoretical information on the actions taken in the pre-hospital care to the individual presenting suicidal behavior.However it is necessary to move forward and obtain empirical data from the practice field with the professionals who perform this care.In this direction, approval is expected of a project that proposes to investigate the vision of mobile prehospital care nursing professionals on the actions taken in compliance with the individual presenting suicidal behavior.

3
Identification of suicidal indicators in the population by the nursing of Primary HealthCare.