Four Nursing Questions of Interest

Introduction

The opportunity to ask questions of one’s own choosing as a student arises all too infrequently. So many professors seem to have pre-constructed answers in mind, or if not answers, then questions so specific as to be extremely limiting. Always there, a universal constant of the condition of the student, is the requirement that only “academic” questions are valid, only those quantifiable inquiries for which the answers can be found in scholarly journals. Yet just as important are the qualitative questions, the questions about what it is like to experience something, or how something makes a person feel. As a nursing student, I of course understand the value of scientific research, yet I would like to continue to strive toward balancing my logical inquiries with discussions of how disease makes people feel, so that I can bring my compassion as well as my intelligence to nursing—or, if the reader will, my heart as well as my head. Perhaps my head is indeed in a strange place as I write, for I find myself intrigued by the interactions of chronic pain and depression, of impulsiveness and suicide. These themes will form the basis for my four questions, one qualitative and one quantitative on fibromyalgia, and one qualitative, one quantitative on suicidal ideation. As best befits the nature of qualitative and quantitative questions, I strive to answer qualitative questions with colleague interviews and quantitative questions with references to scholarly research done on the topic.

Qualitative Question #1:

What is it like to have fibromyalgia?

To answer this question, I sought out my mother’s best friend from high school, who got me interested in nursing years ago as I heard her stories of using her status as a registered nurse to make house calls and provide in-home care to disabled adults. As with everyone to whom I spoke, I will use a pseudonym here to bridge the two equally important concerns of clarity and confidentiality. Let me call her Irene Johnson. Irene said she had taken care of three people with fibromyalgia over the years, all of them women in their thirties or forties, which she said, based on her own anecdotal experience, was the “stereotypical” fibromyalgia sufferer (personal conversation, November 3, 2013). Two of the women were essentially home bound, with family providing some care and Irene supplying what they could not when she came on her visits. The third did not experience quite as much pain, and, Irene said with a certain amount of anger in her voice, this had led to the United States social security office denying her benefits over and over. As Irene put it with a roll of the eyes, “She wasn’t disabled enough for them.” Fortunately, Irene said, the woman’s part-time business making customized rubber stamps actually did well enough for her to support herself working less than half-time, which helped pay for the expense of nurse visits to help monitor the woman’s condition (the woman was evidently also quite overweight and suffered type-two diabetes).

Still, the strangest request Irene had ever gotten was from one of the other two women, who said that being pinched quite hard in certain areas actually made her pain better, once she got past the initial rush of increased agony. Irene was willing to do this for her, but she said she never did understand it. The woman claimed it “released toxins,” according to Irene, but of course that idea does not at all fit with the scientific understanding of fibromyalgia, though Irene also pointed out that “we’re still in the dark on this one.” In the end, I feel satisfied with my greater understanding of living with this disease, though at the same time I know I was getting a biased sample in that anyone who both needed and was able to afford Irene’s help would not necessarily have been a typical sufferer of fibromyalgia. Since the topic came up as I spoke to Irene, maybe I will revise this question and ask now about what it is like to live with diabetes, instead.

Quantitative Question #2:

What do studies show about the relationship between fibromyalgia and depression?

After spending such a long time thinking about what Irene had said, I began to wonder about the flip side of things—I had anecdotal evidence that there was a link between chronic pain conditions, and fibromyalgia in particular, and depression, but would articles in peer-reviewed journals back this up? Yes indeed, it seemed, starting with Katz and Kravitz (1996), who state, “Fibromyalgia (FM) syndrome may be part of an ‘affective spectrum disorder.’ The diseases in this group have in common high rates of major depression in first degree relatives (FDR) and a response to antidepressant treatment” (p. 150). In fact, it is obvious that they have taken the relationship a step further, positing not just a correlation between fibromyalgia and depression, but even implying that fibromyalgia itself is a disease of affect, just like depression. This is certainly food for thought, for if there is truth in that idea, then perhaps mood alone can cause the typical tender points on the body associated with fibromyalgia. Still, as always, there is also an argument on the other side.

As with any good question asked by someone studying science, I was prepared for my idea of depression and fibromyalgia being connected to be proven false. Indeed, as put forth by Okifuji, Turk, and Sherman (2000), when they explain, “Pain severity, numbers of positive tender points, and pain intensity of tender points and control points did not differentiate the depressed and nondepressed patients” (p. 217). That is, in a sense, “more fibromyalgia” did not lead to more depression. Instead, “Discriminant analysis revealed that living status, the perception of functional limitations, maladaptive thoughts, and physical therapy treatment together identified diagnoses of depressive disorders for 78% of the patients” (p. 217). This is contradictory to the idea that fibromyalgia and depression go hand in hand, for it suggests that the state of the disease does not predict depression as well as other, mainly unrelated factors. There is room for much more investigation on this topic, so I will keep this question as-is for now. Later, I may want to simply ask if there is a relationship at all between fibromyalgia and depression, or I may want to broaden the condition to discuss chronic pain in general and not just fibromyalgia, but that can wait until I have a better grasp of the answers to the original question.

Qualitative Question #3:

Why do people attempt suicide?

Perhaps such a question seems almost infantile, and yet I have always been fundamentally unable to understand what would cause someone to go through painful, violent means to end their life prematurely. I did not even think about the matter much one way or the other until my friend, pseudonym Gloria Miller, also a nursing student, but farther along in her studies than I am in mine, related to me her experience on her required visit helping out in the emergency department (personal communication, September 13, 2013). She spoke of having to help hold down a man who came in with a self-inflicted gash across his throat practically from ear to ear, the skin cut all the way through. Apparently, the wound was not bleeding at that point, which Gloria said only made the damage more obvious, and the man was trying to get his hands up to his face to take off the respiration mask. I did not say a single word listening to her story, because I was too flabbergasted that someone would actually do such a thing to himself on purpose. Gloria even said one of the nurses who worked in the emergency department made some sort of joke about the man being a “frequent flyer”—so he had done this before. It was then that I realized that if I wanted to work in the field of nursing, I had to come to terms with self-inflicted injuries and the motives behind them. I also need to be able to identify suicidal patients. If I choose to work in an emergency department, I may even have to re-encounter again and again the same “frequent flyers” and learn how to cope with the idea that even after all the time that mentally ill person spent in the psychiatric parts of the hospital last time, the person still suffers from depression bad enough to perform acts of self-harm.

The answer to my question appears to be that people who are extremely depressed simply function differently in ways people who have never been seriously depressed cannot understand. At least, that is what one of my former teachers, pseudonym Nick Stone, conveyed to me (personal communication, November 9, 2013) when I interviewed him about his experience as a psychiatric nurse before he became a teacher. As I told him about how though I am not religious, I do always have a lot of hope, he nodded vigorously and replied, as I recall it, “Yes, that’s very similar to me. I was like you once; I couldn’t understand it. But then one young lady I was treating was telling me about how when she was depressed, she literally saw the physical world differently.” Nick went on to describe what the young woman had said about how the world looked three-dimensional to her normally, but she always knew she was getting depressed because everything turned flat, like driving a car in a video game and watching the world go by without being able to interact with it. That seemed very strange to me, but in a way, I could understand more easily why a person might do “crazy” things if that person’s brain was in such an altered state that even vision became altered. To me, it sounded almost as if a major depressive episode is similar to how people describe a bad “trip” on a recreational drug, except that of course no one would ever choose to take a drug that did nothing except give the user depression.

After relating to these various anecdotal experiences, I became more at peace with the fact that sometimes people just “lose it” and develop a need to start doing self-harm. I no longer feel answering this question as a burning need inside me, and at this point I consider it answered, resolved. At some later point, I might consider revising the question to have a more positive focus, such as how to be compassionate when confronted by the difficult circumstance of being around others’ serious depression. However, for now, I have a sense that I am still digesting what I have learned on this topic, and it is too soon to make a firm decision where to go next with this second of my qualitative questions. Nonetheless, the related quantitative question still hangs in the air.

Quantitative Question #4:

What does the literature show about surprising factors that might be correlated with increased risk of suicide?

My interest in this question began a couple years back when I first learned about the reason acetaminophen is packaged only in small quantities in the United Kingdom. As I learned the story, apparently some people commit “impulsive suicide,” wherein even the simple five-minute delay of having to open more packages of acetaminophen in order to attempt an overdose causes the person to have a change of heart. I was later able to corroborate this remembered story with a paper by Hughes et al. (2003), who state their results thus: “Prior to legislation, an average of 360 people a year were admitted to UHB [University Hospitals, Birmingham]. However, following the [1998] change in legislation the number of admissions has fallen to an average of 250 people per year. This represents a reduction of 31%” (p. 309). Thirty-one percent is indeed a striking drop in the apparent suicide rate. I wanted to learn more about these bizarre connections between various factors related to suicide.

As I began to investigate my rather open-ended second qualitative question a little further, it became apparent that quite a few researchers are interested in the relationship between religiosity and suicidal ideation. In Breault and Barkey (2005), “Linear and nonlinear multiple regression analysis showed that the relationships between religious integration and suicide and between political integration and suicide are inverse exponential functions of the form Y = aebX, while the relationship between family integration and suicide is linear” (p. 329). As I understand this, aided by the graphs, the inverse exponential functions feature a steeper drop-off initially than the linear functions, so that with religiosity, even a small bit causes suicide risk to drop dramatically, whereas for family integration, the drop in suicide risk is more gradual as family integration increases. Those relationships do make a certain sort of intuitive sense; in my discussions of suicide with my colleagues, the term religion came up over and over again (G. Miller, personal communication, September 13, 2013; N. Stone, personal communication, November 9, 2013). Perhaps the connection between religion and suicidal ideation is as simple as it at first appears.

However, it may be that I am merely biased in my thinking on this topic, and that a more cross-cultural examination would reveal something different. Zhang and Jin (1996), though, suggest a cultural aspect might also be at play in the relationship between suicide and religiosity: “As expected, for the US sample, religiosity is negatively correlated with suicide ideation, depression, and prosuicide attitudes. Surprisingly, however, Chinese [students’] religiosity is positively correlated with suicide ideation, depression, and prosuicide attitudes” (p. 454). I suspect that one would have to know a great deal more than I do about Chinese culture and religion to untangle why being more religious made the youth more suicidal, but for me as a nurse, the important lesson here is that I also need to be aware of my assumptions so that I do not project my own ideas onto my patients who might come from other cultures. All in all, a great deal more could be said on this question with a greater allotment of time and space. I am happy to keep this as one of my top questions going forward.

Overall, my understanding of fibromyalgia, depression, and suicidal ideation increased greatly over the course of this project. I find it good to know that with a little research, both personal and academic, I really can access some of what it is like to struggle with diseases that I do not necessarily understand myself. If I continue to proceed in this way, enlightening myself whenever a topic related to nursing comes into my life and makes me aware of how different and individual each person’s experience can be, ultimately, I will become both a more compassionate and a better-read nurse for my patients. Though I still have some time yet before I will be out in the real world doing real nursing, I know that the preparations I take now will help me be the best nurse I can be. 

References

Breault, K. D. and Barkey, K. (1982), A comparative analysis of Durkheim's theory of egoistic suicide. The Sociological Quarterly, 23(3), 321–331.

Hughes, B., Durran, A., Langford, N. J. & Mutimer, D. (2003). Paracetamol poisoning: Impact of pack size restrictions. Journal of Clinical Pharmacy and Therapeutics, 28(4), 307-310.

Katz, R. S., & Kravitz, H. M. (1996). Fibromyalgia, depression, and alcoholism: A family history study. The Journal of Rheumatology, 23(1), 149-154.

Okifuji, A., Turk, D. C., & Sherman, J. J. (2000). Evaluation of the relationship between depression and fibromyalgia syndrome: Why aren't all patients depressed? The Journal of Rheumatology, 27(1), 212-219.

Zhang, J. & Jin, S. (1996). Determinants of suicide ideation: A comparison of Chinese and American college students. Adolescence 31(122), 451-457.