1. Introduction
Suicide is defined as the act of deliberately ending one’s own life [1]. More than a million people worldwide die by suicide every year [2]. Suicidal behaviors and ideation are among the most common reasons for referral to the emergency department [3]. It is noteworthy that 36-39% of the individuals with suicide attempts or died by suicide were in contact with the emergency department 12 months prior to suicide [4]. Research results show that the risk of committing suicide in the medical community as well as other health care workers, especially nurses, is much higher than other occupations [5]. Despite the high rate of suicide in the nursing community, the number of studies conducted in this area is very limited [6].
A number of studies in several countries shown an increased risk of suicide attempts among nurses, but very little information is provided in relation to the causes of suicide attempts by nurses [7]. In a study on the factors related to suicide among doctors and nurses, it was observed that suicide attempt was higher among nurses than doctors and the general population. The reasons for this difference were reported as familiarity of nurses with various suicidal drugs, occupational stress, mental exhaustion as a result of heavy work, and depression due to the effects of work environment [8]. Osafo et al. (2018) investigated the attitudes of physicians and nurses towards suicide [9]. Hawton et al. (1999) compared the risk of suicide in medical groups and general population, and reported that the risk of suicide was higher in nurses [10].
Various reasons and perspectives are mentioned to explain suicidal behaviors. However, there are very few experimental and systematic studies on suicide. One of the reasons is the lack of a structured model to explain this behavior. To fill this gap, Joiner presented interpersonal-psychological theory of suicidal behavior. According to this theory, an individual will not die by suicide unless she/he has both the desire to die by suicide and the ability to do so. Regarding the desire to commit suicide, this theory states two inter-organizational constructs; Thwarted Belongingness (TB) and Perceived Burdensomeness (PB). TB is the experience that one is alienated from others, or sense of low belongingness to groups and to oneself.
Individuals with TB do not consider themselves as an integral part of a family, circle of friends, or other valued group. PB is the sense that one’s existence places a burden on family, friends, and/or society. This sense produces the idea that the person’s death is better for his/her family, friends, and society [11]. Ma et al. (2016) reported that of 12 studies on examining the effects of TB and PB on suicide ideation and attempt, eight studies showed their significant effect, and in four studies, the reported effect was not significant; of which only two studies showed effective results. Also, among 21 studies on testing correlation between acquired ability for suicide attempt and ideation, 12 were significant and nine were not significant [1].
The research background indicates the relationship of TB and PB with suicide attempt and ideation in different groups; but so far, no study is conducted to investigate the relationship between these variables in the nursing community. Another concept that attracts the attention of many researchers to predict suicide ideation is the concept of “Self-Efficacy”. This concept was introduced by Albert Bandura as the social-cognitive theory. According to him, it is one’s belief in one’s ability to organize and execute courses of action in order to achieve the desired goals. He also believed that Self-Efficacy was one of the most important factors regulating human behavior [12].
A study examined the moderating role of Self-Efficacy on Suicidal Ideation in Iran. According to this study, although depression is always emphasized as an important part in the underlying structure of Suicidal Ideation and attempt, Suicidal Ideation is much less likely experienced, even at the highest levels of depression, in individuals with high levels of Self-Efficacy [13]. In the study by Kobayashi et al. (2015) Self-Efficacy, depression, and demographic factors were reported as predictors of Suicidal Ideation [14]. Ammentorp et al. (2007) indicated the effect of training in communication skills on medical nurses’ Self-Efficacy [15].
Yang (2011) suggested a need to develop programs for nurses to increase Self-Efficacy [16]. In Iran, there are also some studies on the relationship of Self-Efficacy with clinical decision-making [17], social health [18], and conflict management strategies of nurses [19]. However, with regard to the confirmation of Self-Efficacy’s association with Suicidal Ideation in previous studies, a research is not yet conducted to examine the relationship between these two variables among nurses. The “Ego Strength” is another concept that its effect on Suicidal Ideation and behavior is less considered, and the scholars are less concerned about it in many psychological disorders and impulsive behaviors. In psychoanalytic theory, ego is one of the elements of personality, and when an individual experiences anxiety, if it becomes overwhelming, “ego” tries to control the situation by employing defense mechanisms.
Vaillant, as one of the theorists in the field of defense mechanisms, believes that compromised defenses are linked to physical health, life satisfaction, quality of friendship and mental health, and the greater the strength of ego, the more developed defense mechanisms are used by the person. In addition, Ego Strength can improve the individual’s flexibility in using defense mechanisms [20]. In this regard, and considering that with reduced Ego Strength the immature levels of defense mechanisms (e.g. denial, displacement, projection, and repression) are emerged, and according to previous studies such as that of Plutchik et al. (1995) (reporting a significant negative relationship between Ego Strength and the risk of suicide) [21].
Apter et al. (1997) (showing that the defense mechanisms of denial, displacement, and repression had correlation with suicidal behavior) [22], Yang (2015) (suggesting that an ego-resiliency and work environment have correlation with job satisfaction of nurses) [23], and Lee et al. (2015) (showing the effect of emotional intelligence and ego-resiliency on interpersonal relationship of nurses), it can be argued that suicide attempts and Suicidal Ideation are higher in nurses with lower Ego Strength. However, no study was found on the relationship between Ego Strength and Suicidal Ideation among nurses [24].
According to the World Health Organization (WHO) that included suicide as one of the leading causes of death in the world, and given that a number of studies reported the higher risk of suicide in health care workers including nurses, and due to the very limited studies worldwide, including Iran, regarding the factors influencing the Suicidal Ideation and attempt among nurses, further research is needed. Moreover, due to the lack of studies on examining the relationship of TB, BP, Self-Efficacy, and Ego Strength with Suicidal Ideation in nurses, there is a need for research in this area. More knowledge about the role of these variables in predicting Suicidal Ideation can help to improve the treatment used to reduce suicide attempts in nurses. The current study aimed at assessing the relationship of TB, BP, Self-Efficacy, and Ego Strength with Suicidal Ideation in nurses to examine which of them can predict Suicidal Ideation in nurses.

2. Materials and Methods
Study population and samples
The current study had a descriptive-correlational design. TB, BP, Self-Efficacy, and Ego Strength were considered as predictor variables and Suicidal Ideation as criterion variable. Study population consisted of all nurses working in hospitals located in Ardabil, Iran, in 2017 among which 120 were selected as the study samples using convenience sampling method. To analyze data, descriptive statistics (mean and standard deviation) and statistical tests (Pearson correlation and multiple regression analysis) were used with SPSS V. 23.

Data collection tools
Psychosocial Inventory of Ego Strengths (PIES)
This questionnaire was developed by Markstrom et al. (1997) [25]. It has 64 items measuring eight subscales of hope, will, purpose, competence, fidelity, love, care, and wisdom. Items are scored on a five-point Likert scale ranged from 5 (describes me very well) to 1 (does not describe me well). High scores indicate high Ego Strength. Its reliability using Cronbach’s alpha is reported 0.68. The reliability of its Persian version is reported 0.91 and its split-half reliability is 0.77 [26].

Interpersonal Needs Questionnaire (INQ)
It was developed by Van Orden (2009) and has 25 items measuring the two subscales of PB and TB. The items are scored based on a seven-point Likert scale [27]. The first 15 items assess PB and the other 10 are related to TB. This questionnaire has a good internal consistency with a Cronbach’s alpha of 0.88 [28]. For its Persian version, Cronbach’s alpha is reported 0.83 [29].

General Self-Efficacy (GSE)
This scale was developed by Sherer et al. (1982) It has 17 items measuring general Self-Efficacy of individuals and is scored based on a five-point Likert scale. Sherer et al. (1982) reported internal reliability of this instrument as α=0.76 [30].

Beck Scale for Suicide Ideation (BSSI)
It is a tool to examine suicidal intent in patients. It is a 19 item instrument developed by Beck in 1961 and is scored based on a three-point Likert scale from 0 to 2. The total score ranges from 0 to 38. This scale has high reliability. The reliability of the Persian version of BSSI is α=0.9 based on Cronbach’s alpha and 0.74 based on test-retest [31].

3. Results
Of the 120 subjects, 90 (75%) were female, and 30 (25%) male, with the mean age of 33.69 years. Regarding their education, 98 (81.7%) had bachelor’s degree and 22 (18.3%) master’s degree. Table 1 shows the mean and standard deviation of scores for the study variables. In order to test the normality of data distribution, the Kolmogorov-Smirnov est was used. According to Table 2, P>0.05; hence, the assumption of normality is met.
 

 

Table 3 shows the Pearson correlation test results. As can be observed, Suicidal Ideation has a significant positive relationship with TB (r=0.49) and PB (r=0.59), and a significant negative relationship with Self-Efficacy (r=-0.44) and Ego Strength (r=-0.37) (P<0.001). Multiple regression analysis results showed that TB, BP, Self-Efficacy, and Ego Strength variables had the ability to predict 46% of changes in Suicidal Ideation, whereas PB was the most powerful predictor of Suicidal Ideation (Table 4).

4. Discussion
The current study aimed at examining the role of TB, BP, Self-Efficacy, and Ego Strength in predicting Suicidal Ideation of nurses. The obtained results indicated that Suicidal Ideation of nurses had significant positive relationship with TB and BP. The results were consistent with those of the Rashid et al. (2016) [1], Bryan (2011) [32], O’Keefe et al. (2014) [33], and Hill and Pettit (2012) [34].
The current study results also showed that PB was the strongest predictor of Suicidal Ideation in nurses, which was in agreement with the results of Rashid et al. (2016) where scholars reported that PB was a strong predictor of suicidal behavior [1]. In this regard, it can be claimed that interpersonal-psychological theory of suicidal behavior presented appropriate explanation for the causes and interpersonal factors of suicidal thoughts and behavior, and the theory could predict the tendency of nurses to commit suicide.

 

 

 

 

Results of the current study also showed that Suicidal Ideation of nurses had a significant negative correlation with Self-Efficacy and Ego Strength; regarding Self-Efficacy variable, the result was consistent with the findings of Kobayashi et al. (2015) [14], Nabavi et al. (2017) [35], and Valois et al. (2015) [36]. The high level of Self-Efficacy has a positive effect on mental health and its low level negatively affects self-esteem, and also, it is effective on the severity of depression and anxiety; and on the other hand, depression, anxiety, and low self-esteem can increase Suicidal Ideation; therefore, it can be concluded that low levels of Self-Efficacy can increase suicidal thoughts.
Regarding Ego Strength variable, the result was consistent with the findings of Plutchik et al. (1995), and Apter et al. (1997) [21, 22]. According to the fact that by increased Ego Strength, people use more mature defense mechanisms, and with its reduction, people use immature defense mechanisms such as denial, displacement, projection, and repression, and considering that previous studies reported positive correlation between immature defense mechanisms and suicide [22], the relationship between Ego Strength and suicide can be deduced.
The current study had a correlational design. Thus, there was limitation for intergroup comparison and generalization of results to other communities or other cities data. According to previous reports regarding high rate of suicide attempt among nurses in comparison with other occupations, and based on the findings of the current study, it is suggested that nursing authorities should plan for early intervention to prevent Suicidal Ideation and subsequently suicidal attempts as an emergency for critical occupations, and prevent the development of suicidal thoughts and behaviors in at-risk nurses using psychological and educational intervention programs and holding workshops in order to reduce the underlying factors such as TB and PB and increasing their Self-Efficacy and Ego Strength.
It is recommended that with regard to the difficult conditions of the nursing career, which needs high responsibility, and considering the emphasis and strategy of the WHO in utilizing counseling and psychological services to strengthen personal relationships and beliefs, and learning positive coping skills, nurses should reduce TB and PB senses and improve Self-Efficacy and Ego Strength in themselves. Furthermore, longitudinal studies are recommended on other populations and using other techniques to achieve more accurate results.

5. Conclusion
According to the reports of previous studies on the high rate of suicide among nurses on one hand, and limited number of international studies on the factors associated with the formation of suicidal thoughts and behavior in nurses, and the lack of a national study in this area, the current study aimed at investigating interpersonal (TB and PB) and intrapersonal (Self-Efficacy and Ego Strength) factors of this behavior in order to raise awareness, and thus identifying several factors associated with this irreparable phenomenon, and thereby reducing its incidence rate among nurses.
Since suicide is one of the key issues in the psychology of the crisis and the first step in crisis management is preparation, the current study tried to help specialists in crisis intervention to educate and prevent suicide attempts and make psychological readiness for exposure before occurrence by identifying a number of suicide-related factors among nurses. It was concluded that both interpersonal and intrapersonal factors had considerable role in Suicidal Ideation. Therefore, in order to prevent and treat this behavior, both interpersonal and interpersonal problems should be considered.

Ethical Considerations
Compliance with ethical guidelines
Participants were not obliged to complete the questionnaires, and they were assured of the confidentiality of their information.

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors contributions
All authors contributed in preparing this article.

Conflict of interest
The authors declared no conflict of interest.




References