Responses of persons at risk of suicide: A critical interpretive synthesis

Abstract Aim Several nursing studies focus on suicidal persons; yet, a synthesis of such research is unavailable. The aim of this review was to give an inclusive understanding of responses of persons at risk for suicide that guides clinical nursing practice and research. Design A reflexive and iterative study design was used in this study. Method A qualitative content analysis and a systematic review of literature guided the six‐phase Critical Interpretive Synthesis . A sample consisting of 24 nursing studies published during 1994–2017 were included in this study. Results Key concepts found were “Disengaged while fraught with affliction”; “Readiness to engage in life”; and “Engaging through caring and confirming humanity.” Contextually, there are gaps in global nursing knowledge. Conceptually, three key concepts can guide the nursing practice and give an impetus for the research. Methodologically, the Critical Interpretive Synthesis served as a helpful way to summarize and synthesize a small sample size into an aggregate body of knowledge. An evidenced‐based understanding of responses of persons at risk for suicide can guide nurses to ensure safety, promote hopeful recovery, and foster resilience.

"turning points,"; and "suicide and coping." A follow-up article (Lakeman, 2010) described how these five themes informed about nursing practice and empathic care. Of note is that the inclusion criteria for the Lakeman and Fitzgerald study (2008) was not solely nursing research; 16 of the 20 articles were authored by non-nurses. An aggregate study of evidencedbased nursing research on this topic is unavailable in published literature.
An updated inclusive view of this topic based on a synthesis of qualitative and quantitative nursing research could increase and enhance nursing's global evidenced-based knowledge, guide nursing practice while ensuring patient safety and serve as an impetus for future nursing research.

| AIM
The aim of this review was to give an inclusive understanding of responses of persons at risk for suicide based on the published nursing research. The intent was to guide nurses as they encounter persons at risk of suicide in clinical nursing practice and to inform future nursing research.

| ME THOD
A Critical Interpretive Synthesis (CIS) was conducted (Dixon-Woods, et al., 2006). This six-phase iterative, reflexive review approach consisted of formulating the review question, search the literature, sampling, determining quality, extracting data, and developing an interpretive synthesis. Such reviews guide selecting relevant, quality works from a large amount of available information and increasing clarity of current knowledge; systematic reviews can offer workable practice solutions (Sandelowski, 2008).

| Formulating the review question
The review question was: "What is a CIS of nursing research addressing responses of persons at risk for suicide?" The aim was to increase the understanding that would benefit nursing practice and give an impetus for future research. The review question was initially apparent to the researchers because they had previously conducted a CIS on nurses' experiences with suicidal patients (Talseth & Gilje, 2011).

| Searching the literature
The search strategy proceeded in several phases. To begin, we developed inclusion and exclusion criteria. Inclusion criteria were nursing research studies with at least one nurse as the author, published in peer-reviewed nursing journals and peer-reviewed healthcare journals between 1990 and 2007 in English language, and available in electronic databases. Content criteria for inclusion were studies that focused on patients' responses to being suicidal. Exclusion criteria were all studies in non-English languages, and those classified as reviews, published in books, and dissertations. Identification of records occurred though searching electronic databases CINAHL Medline, Ovid, Psychinfo, and PubMed using the following search terms for each database: CIS, experiences, nursing research, patients, suicide, suicidal. These terms were searched individually and collectively resulting in 86 studies. Eight additional studies identified through other sources (i.e., reference lists of the 86 studies) were also included for screening. The screening was carried out by examining titles and abstracts of the 94 studies. A total of 20 duplicate studies were found and were removed. With further screening, 37 of the 74 studies were excluded because they did not fit the inclusion criteria. The remaining 37 full-text studies were then assessed by both authors for eligibility based on relevancy to the aim of this study and the inclusion criteria. Of the 37 eligible studies, 13 were excluded based on sampling, authorship, secondary studies, or did not meet quality appraisal. Based on results of PRISMA, 24 nursing research studies were included in the sample (see Figure 1).

| Sampling
From the systematic review of articles, the purpose sample comprised of 24 studies published from 1994 -May 2017. While our literature search started with the publication year 1990, the first published study found was dated 1994. Our rationale for including this study in the sample was: to focus on an inclusive perspective of the research topic of interest; the study's research question and results were relevant; and the study met inclusion criteria (Table 1).
Sixteen studies were published in peer-reviewed nursing journals. Four were published in refereed health-related journals (i.e.,

Gerontologist, Psychiatric Services, Suicide and Life-Threatening
Behavior and International Journal of Mental Health). Publication dates ranged from 1994 to May 2017; most were published since 2000.
Most study designs were qualitative (N = 23) and published after 1994. The only quantitative (N = 1) study was published prior to 2008. Most studies were reportedly situated in Europe and North America, and a few in Asia, United Kingdom, and Australia. Inpatient psychiatry was the most common setting; only some were in general and psychiatric settings. Other settings included emergency and psychiatric, nursing home, veterans' home, substance abuse treatment, and education. One study location was unreported ( Table 2).
The sample participants totalled 1,273. The majority (N = 849) of the participants were high school students; the remainder were mostly psychiatric patients. More than half (N = 18) of the study was conducted in psychiatric settings (inpatient, general and psychiatric, and emergency and psychiatric; Table 3).

| Determining quality
All studies met the inclusion criteria. Eighteen were published in nursing journals and two in medical-psychiatric journals. The one quantitative study was evaluated using the Jadad scale (Jadad, et al., 1996); the 23 qualitative studies were evaluated using a Critical Appraisal Skills Program (CASP) (2006). The Jadad scale was developed to evaluate the quality of reports of randomized trials. It is used in meta-analysis and systematic reviews. It involves a three-point questionnaire ranging from 0 to 3 assessing randomization, blinding, and withdrawals/dropouts.
Points are added if randomization and blinding are appropriately described. Critics of the scale have identified 10 flaws (Berger, 2006), noting it overemphasizes blinding and that inter-rater reliability needs to be further evaluated (Clark, Huët, Salmi, & Laupacis, 1999).
The authors agreed on including the Jaded scores which ranged from 1-3 points.
The CASP (2006) is a 10-item tool addressing the aim, method and design, sampling, data collection and analysis, ethical issues, validity, and relevance of results in qualitative studies. This tool calls for the rating of each of the 10 questions as "yes," "no," or "can't tell." The authors chose to rate responses as "yes" or "no" because they found that these were the most helpful responses. Of the 10 questions, 9 were rated as "yes" responses in all studies. The question about ethical issues lacked the most positive responses.
This question includes explaining the research to participants, adequately considering the researcher-participant relationship, discussing informed consent and confidentiality, and whether ethical committee approval had been sought. Eight of the studies had a CASP score of at least 8/10 because they did not report ethical standards. Reporting ethical standards is of concern because of its importance in all research (Lakeman & Fitzgerald, 2009) and most qualitative research views participants as co-researchers (Table 4).
As we examined the quality determinants, contemplated their variability and considered the historical evolution of nursing research, we concluded that all studies in the sample would add to an interpretive synthesis. For example, we were aware that eight of the 24 studies were published before 2000 when quality measures in nursing research were not emphasized. Over time, quality measures have become highlighted and commonly explicated in nursing research. Inherent in qualitative designs is interpretation; we acknowledge that qualitative findings are one of many interpretations. In view of these considerations, we came to a shared understanding to include all 24 studies in the CIS, weighing them equally as we synthesized them into a conceptual understanding of responses of persons at risk for suicide.

| Extracting data
Qualitative content analysis processes of organizing and summarizing data were used for extracting data (Granheim & Lundman, 2004 Further qualitative content analysis focused on condensing the extracted text into subthemes. Through the authors' dialogical conversations and in-depth reflections, consensus on themes emerged.
These themes were "Struggling desperately losing touch with self, others and the world; Grasping engagement releasing affliction; Pondering ways of being kept safe while moving from affliction toward the future; Contemplating meaningfulness of nurses' relating and care that fosters desire to live; Valuing support of nurses, family and systems" (Table 5). Through the unfolding and enfolding iterative and reflexive process, a CIS emerged.

| RE SULTS
Relating, reflecting, translating, and weaving subthemes with themes resulted in three interpreted, synthesized concepts which describe responses of persons at risk of suicide. These concepts are: "Disengaged while fraught with affliction"; "Readiness to engage in life"; and "Engaging through caring and confirming humanity.".

| Concept 1. Disengaged fraught with affliction
The concept 1 emerged from the theme "Losing touch with self, others and the world." This theme had five subthemes. The first subtheme describing persons at risk conveyed "deep struggles with turbulent disconnectedness with self and others." Disconnectedness was portrayed as, for example, psychological pain, inability to adjust, cognitive constriction (Valente, 1994). Disconnectedness with others happened through isolation from families, conflicts with family and coworkers, poor role models, death (Haight & Hendrix, 1998;Ku, Tsai, Lin, & Lin, 2009).
The second subtheme was "being alienated from self and others while striving to live." Alienation involved being controlled and being rebuffed by family instead of being connected to others while being caught between being responsible for family, yet responsible to strive to live for one's self (Tzeng, 2001). "Losing touch" with the world was another description that conveyed alienation (Vatne & Naden, 2012).
The third subtheme, "Being ashamed, consumed by shame and desperation," was related to an impulse to hide or escape from shame (Wicklander, Samuelsson, & Asberg, 2003).
Amidst struggling with disconnectedness, persons at risk reflected on "being perplexed about meaning in life," the fourth subtheme. This subtheme referred to questioning meaning. Questioning meaning related to psychache, powerlessness, and perceiving no one cared (Moore, 1997 (Biong & Ravndal, 2007) . The fifth subtheme, "Struggling to grasp self, self-responsibility and self-development," was involved searching for strength, seeking to be understood, refusing to be violated and being responsible for one's own safety (Holm & Severinsson, 2011). This concept addresses struggling desperately to connect yet being disconnected.

| Concept 2: Readiness to engage in dialogue
The concept 2 was synthesized from one theme and two subthemes.
These were "Pivoting from being disconnected to connected through self-worth, safety and hope" and "Opening up dialogue in the midst of becoming connected." Readiness was revealed as shifting from loss of support, loss of hope, lack of self-esteem, loneliness, abuse, searching for release, to trying to regain hope, and self-worth (Lin, Huang, Chen, & Shao, 2009

| Concept 3: Engaging through caring and being confirmed
The concept 3, "Engaging through caring and being confirmed," emerged from three subthemes. The first theme, "Ponder ways of being safe and connected," had two subthemes. The first subtheme was "Imaging a positive future through art." The use of art connected persons at risk with their emotions, rekindled their dreams, restored their identity and regained their control, imaging the future (Walsh & Minor-Schork, 1997). The second subtheme was "Reflecting on therapeutic and nontherapeutic ways of feeling safe and being supported in the midst of distress." This subtheme contrasted nontherapeutic (Cardell & Pitula, 1999;Pitula & Cardell, 1996) with therapeutic (Cardell & Pitula, 1999) aspects of constant observation.
The second theme in concept 3 was "Contemplating meaningfulness of nurses" relating three subthemes which formed the basis for the emergence of this theme. The first subtheme, "Considering importance of confirming-lack of confirming care from nurses," contrasted the presence and absence of confirming care. Confirming care was experienced when basic needs "being met" and one was seen, given time, conveyed hope and not judged while lack of confirming care dealt with unmet needs, not being seen, not provided time, lack of hope and being judged (Talseth, Lindseth, Jacobsson, & Norberg, 1999). Being confirmed was also sensed as being understood while noncaring evoked burdensome feelings, fostering risk of suicide (Samuelson, Wiklander, Asberg, & Saveman, 2000). The second subtheme pertaining to concept 3, theme 1, was "Meaningful caring as engagement, openness, trust and respect that re-connects with humanity and fosters learning to live." When psychosocial needs were met, engagement reconnected one with humanity as nurses reflected an image of humanity, guiding one back to humanity while learning to live (Cutcliffe, Stevenson, Jackson, & Smith, 2006).
The third subtheme for concept 3, theme 2, was "Sensing being understood through the presence of caring in health personnel who actively listened," focused on meaning and inspired hope. This subtheme addressed the therapeutic interaction with nurses that reduced, for example, isolation, loss of control, distress, and objectification (Lees, Proctor, & Fassett, 2014). Encounters with healthcare personnel were described as the presence or absence of openness and trust and being met or not being met by someone who acknowledged the topic of suicide and conveyed mutual respect (Vatne & Nåden, 2014). Caring encounters and caring cultures in an atmosphere of wisdom fostered resuming or assuming self-responsibility and inspired hope (Vatne & Nåden, 2016b).
The third theme embedded in concept 3, "Valuing support from nurses, family, health system and others," emerged from two subthemes. The first subtheme, "Desiring support from healthcare Condensed meaning units from key study findings about "Experiences of Persons at risk for suicide"

Codes Subthemes Themes
Patterns of suicide were: unbearable psychological pain; dissatisfactory interpersonal relationships; inability to adjust; cognitive constriction; rejection-aggression; indirect expressions (Valente, 1994) Life stories concerned dysfunctional families of origin, poor role models, feeling isolated and being pessimistic (Haight & Hendrix, 1998) Suicide triggers were illness, pain, death of close relative or friends, family/friend/coworker conflicts/ disputes and difficulty adapting to institutional life (Ku et al., 2009) Losing touch with the world involved relating suicidal attempt to life history, struggling for death and life, seeing suicide as a way to relieve desperation, feeling shame and guilt (Vatne & Nåden, 2012) Being alienated instead of connected by being controlled and rebuffed by others while wanting to leave family versus striving to live for self, seeking company of others, being loved and being responsible for family (Tzeng, 2001) Shame reactions concerned feeling failure, being ashamed of self, struggling with impulses to hide or flea and experiencing trespassing (Wicklander et al., 2003) Questioning life's meaning while experiencing psych ache and powerlessness, and perceiving nobody cared (Biong et al., 2008;Moore, 1997 Finding meaning in being isolated, being close to the point of no return, yet still being on the edge (Biong et al., 2008) Struggling to assume responsibility for self and others (searching for strength, struggling to be understood, refusing to be violated) and struggling to stay alive by enhancing self-development (recovering being able to be safe and trusted) (Holm & Severinsson., 2011) Disconnected versus connected (N = 9) Struggling with turbulent disconnectedness with self and others (Haight & Hendrix, 1998;Ku et al., 2009;Valente, 1994) Being alienated from self and others while striving to live (Tzeng, 2001;Vatne & Nåden, 2012) Being ashamed and feeling consumed by shame and desperation (Wicklander et al., 2003) Being perplexed about meaning in life (Biong et al., 2008;Moore, 1997) Struggling to grasp self, self-responsibility and self-development (Holm & Severinsson., 2011) Losing touch with self, others. and the world Longing for closeness, desiring connectedness, struggling to open up inner dialogue, breaking into outer dialogue, liberating inner and outer dialogue and struggling to open up for consolation (Talseth et al., 2003) Moving from loss of support, loss of self-esteem, loss of hope, loneliness, suffering abuse and seeking salvation to regaining hope and self-worth  Wavering to grasp connectedness (N = 2) Opening up dialogue in the midst of becoming connected (Talseth et al., 2003) Pivoting from being disconnected to connected through self-worth, safety. and hope  Grasping for engagement Overlapping stages of art future images illustrated complaint irritation, identity searching, humour reappearing, rekindling dreams, regaining control and pleasant anticipation (Walsh & Minor-Schork, 1997) Constant observation was described as preservation of safety, restoration of hope and distressing incidents (Pitula & Cardell, 1996) Therapeutic observer interventions were: optimism, acknowledgement of the patient, use of distraction, emotional support, and protection. Nontherapeutic observer interventions were: lack of empathy, acknowledgement, information and privacy; invasion of personal space; and confinement. (Cardell & Pitula, 1999) Interventions Imaging a positive future through art (Walsh & Minor-Schork, 1997) Reflecting on therapeutic and nontherapeutic ways of feeling safe and being supported in the midst of distress (Cardell & Pitula, 1999;Pitula & Cardell, 1996) Pondering ways of being safe and connected (Continues) | 479 TALSETH And GILJE system and nurses," involved support of psychosocial needs, being loved, and esteemed by nurses and being in control of life (Carrigan, 1994). The second subtheme was "Support from family and someone who cares, the desire to live and connectedness alleviated suicide risk." Experiencing connectedness and someone who cared, awareness of one's desire to live (Vatne & Nåden, 2016a) along with family support, alleviated suicide risk (Sharaf, Thompson, & Walsh, 2008).

| Contextual views
The context for most of the sample studies was Europe and North America. According to the World Health Organization (2016), the America's Region estimated suicide rates are, in general, lower than other WHO regions while the South East Asian Region has the highest estimated global suicide rate and the European Region has above the global average. However, published nursing research-based studies from regions with high as well as low suicide rates is very sparse. Throughout history, the topic of suicide has been taboo in many areas of the world.
Currently, the topics of suicide and suicidal persons are multidimensional with cultural attitudes and contexts having an impact on research.
Of importance is that much more research is needed in various contexts-geographical distributions and in variety of clinical settings.
In this CIS, 18 of the 24 studies were reportedly conducted in psychiatric settings. However, suicide risks also occur in nonpsychiatric settings, including medical-surgical units (Neville & Roan, 2013).

Condensed meaning units from key study findings about "Experiences of Persons at risk for suicide" Codes Subthemes Themes
Care received from nurses was confirming (e.g., meeting basic needs; being seen; given time; patience, being open and nonjudgemental; conveying hope) or lack of confirming care, (i.e., unmet needs; not seen, given time or conveyed hope; and being judged) (Talseth et al., 1999) Being well cared occurred when suicidal patients received understanding and confirmation. Lack of confirmation contributed to feeling burdensome, demanding discharge and risking suicide (Samuelson et al., 2000) A key psychosocial need was "re-connecting with humanity," occurring through nurses "reflecting an image of humanity," guiding one back to humanity and "learning to live."  Therapeutic interpersonal engagement with nurses that helped reduce isolation, loss of control, distress and objectification of the delivery of potentially objectifying common interventions was central to quality of care (Lees et al., 2014) Encounters with healthcare personnel were identified as: the presence or absence or openness and trust; being met and not being met by someone who addressed the topic of suicide; and being met on equal terms instead of being humiliated (Vatne & Nåden, 2014) Inspiring hope though encounters with healthcare personnel within caring cultures and an atmosphere of wisdom and resuming responsibilities (Vatne & Naden, 2016b) Meaningful caring and relating (N = 6) Considering importance of confirming lack of confirming care from nurses (Samuelson et al., 2000;Talseth et al., 1999) Meaningful caring as engagement, openness, trust, and respect that re-connects with humanity and fosters learning to live  Sensing being understood through the presence of caring in health personnel who actively listened and focused on meaning, inspiring hope (Lees et al., 2014;Vatne & Nåden, 2014, 2016b Contemplating meaningfulness of nurses' relating Support and psychosocial needs unmet by healthcare system and nurses were being loved, esteemed, and in control of life (Carrigan, 1994) Family support affected self-esteem, impacting suicide risk (Sharf et al., 2009) Recovery from suicide risk occurred through becoming aware of one's desire to live, experiencing connectedness and someone who cared (Vatne & Naden, 2016a)

Support (N = 3)
Desiring support from healthcare system and nurses (Carrigan, 1994) Support from family and someone who cares, the desire to live and connectedness alleviated suicide risk (Sharf et al., 2009;Vatne & Naden, 2016a) Valuing support of nurses, family, health systems, and others

| Conceptual views
Conceptually, this CIS contributes to a more inclusive understanding about of responses of persons at risk for suicide. The three concepts, which are not linear, but rather interwoven, can guide and direct nurses' understandings, assisting persons at risk of suicide to survive suicide risk, and go on living.
"Disengaged fraught with affliction," reflects persons at risk desperate struggle losing touch with self, others, and the world.
This is experienced as being alienated, consumed in shame, trying to grasp a sense of self and self-responsibility while suffering with psychache. Psychache is extreme psychological pain (Sperber, 2011). Losing touch with the world alienates, experienced as "being rebuffed" by others (Tzeng, 2001), being estranged from nature, others, and self' (Sperber, 2011) and a way of "not being-in the world" (Heidegger, 1972). Alienation encompasses loneliness and despair. It can be understood as being cut-off from one's existence, perplexed with meaning in life. Shame is a mortifying experience involving one's own self-evaluation of one's actions or feelings. Shame can be understood as unworthiness of the whole self (Kalafat & Lester, 2011) accompanied by a desire to flee (Tzeng, 2001;Vatne & Nåden, 2012) and extreme withdraw from the situation. Suicide becomes the ultimate withdrawal (Kalafat & Lester, 2011). When experiencing shame, we lose touch with our existence (Vatne & Naden, 2012); we fear losing the world, others and our self.
Self-responsibility includes self-control, being in control of life (Carrigan, 1994). For those at risk of suicide, control is about struggling with self to maintain control or to grasp regaining control (Crocker et al., 2006). Control involves being more or less connected.
"Grasping engagement releasing affliction" reveals persons at risk shifting from extreme disconnectedness to connectedness. Afflicted with shame and low self-worth disconnects one from self and others. As self-worth increases and shame decreases, dialogue opens up for connecting through engagement. As engagement evolves, persons at risk begin to see themselves in the light of another person. Engagement, then, can relieve shame and foster attaching value to one's existence (c.f. Valente, 1994;Ku et al., 2009).
Feeling safe from suicidal thoughts and impulse safe in encounters with others involves "connection, protection and control," essential to recovery from suicidal crises (Berg, Rørtveit, & Aase, 2017). It is evident that connection is important for safety. Similarly, control is important for safely. While safety includes but is more than a technical, physical intervention, of importance, safety is also about regaining emotional balance (Berglund et al., 2016) as well as engagement (c.f. Berg et al., 2017;Cutcliffe & Baker, 2002).
While grasping for engagement, hope wavers. Hope can waver to and fro; it can be very temporary. It needs repeating over and over while grasping connectedness (Berglund et al., 2016;Cutcliffe, 2007).
Hope diminishes alienation, affirms self-worth, fosters safety, evokes a sense of engagement, opens up for dialogue, releasing affliction.
"Engaging through receiving meaningful care and being confirmed inspires hope" is about meeting needs and being understood, esteemed and supported. These responses confirm one's humanity and inspire a desire to move into the future (Cutcliffe & Baker, 2002).
Engaging meaningfully with self and others echo a kind of "being at home-or at homeness" (Zingmark, Norberg, & Sandman, 1995).
"Being at home" confirms one's humanity. Persons afflicted with suicide risk are "not at home"; they need to become ready for "being at home." Being at home is about being in relationship, engaging meaningfully, and experiencing being confirmed. Being confirmed is a most significant aspect of life (Cissna & Sieburg, 1981, p. 259), fostering a desire to live and fostering hope. Experiencing hope gives way to strength to manage problems and can bring forth self-control/self-responsibility (Berglund et al., 2016).
As persons at risk engage meaningfully with nurses, they can begin to feel "at home" and self-worth can emerge. Self-worth emerges from experiencing confirmation. Confirmation means giving the other person the following messages: "To me, you exist! -We are relating! -To me, you are significant! -Your way of experiencing your world is valid" (Cissna & Sieburg, 1981, p. 259). All human beings want to be confirmed for what they are and even for what they can become (Buber 1957, pp. 102-103). Making the other present means imagining what he/she perceives, feels and wishes in the moment. (Cissna & Sieburg, 1981, p. 258;Buber, 1957,. p. 102-103).
The desire to live, to be hopeful, is essential for those at suicide risk.
Hope and caring are processes integrally woven together. These processes involve a human-to-human relationship, unconditional acceptance and tolerance, being heard, being understood, and feeling that one's life has value (Cutcliffe & Baker, 2002). Hope is also connected to confirming care experienced through being given time, being acknowledged, not judged yet sensing hope (Talseth et al., 1999). Similarly, being confirmed is being understood (Samuelson et al., 2000). During the processes of being cared for and being confirmed, at-risk persons can be guided back to humanity and learn to live (Cutcliffe & Barker, 2002). From these processes, hope can emerge, revealing readiness for consolation (Talseth, Gilje & Norberg, 2003, Vatne & Nåden, 2012. Readiness for consolation emerges from opening up to move into the future. This is facilitated through examining ways for hopeful recovery. Recovery is a process that involves opening up to others to be consoled (Lakeman & Fitzgerald, 2008  The CIS approach (Dixon-Woods et al., 2006), along with qualitative content analysis (Granheim & Lundman, 2004) and systematic review of literature (Sandelowski, 2008), provided orderly ways to sort and arrange data through extraction-condensation processes.

| Methodological views
The extracted data were formulated into condensed meaning units, codes, subthemes, and themes. Reflection and clarification of the themes led to formation of three key concepts that address the aim of the CIS. We thoughtfully considered quality determinants of the data which varied yet decided on the sample of 24 studies realizing each contributed to the aggregate findings.

| LI M ITATI O N S
As described above, the sample size was small and most studies were conducted in Europe and North America. Yet, the size was sufficient to address the research question and generate collective understandings of the topic. Of note is that suicide is a complex topic imbued with diverse cultural values and interpretations. Both authors are experienced psychiatric mental health nurse educators and qualitative researchers familiar with responses of suicidal patients.
One author is from Norway and the other author is from the United States. While we view our backgrounds as both strengths and limitations to our interpretive lenses, we acknowledge the interpretations in this study are one of many (Ricoeur, 1976).

| CON CLUS ION
This paper presents a CIS of nursing research studies (N = 24) published from 1994 to 2017 on responses of persons at risk for suicide, a very vulnerable population whose safety is paramount. This understanding, based on a small sample of accumulated research-based from nursing literature, expands contextual, conceptual, and methodological views of this topic.
Contextually, gaps are apparent in international research. Most studies were conducted in Europe and North America, and in psychiatric settings. Of note is that the context of research influences understandings of this culturally situated, sensitive topic of suicide.
Conceptually, the three key concepts (i.e., Disengaged fraught with affliction; Readiness to engage in dialogue; and Engaging through caring and being confirmed) reveals a way of understanding responses of persons at risk for suicide. These concepts can guide nurses in clinical practice as well as research.
Methodologically, the systematic review of literature and qualitative content analysis served as reasonable ways to organize data.
The results can direct researchers in diverse areas of the world to further investigate responses of persons at risk for suicide. Of importance is that nurses address suicide as a preventable public health problem.

| RELE VAN CE TO CLINI C AL PR AC TI CE
Many nurses will encounter vulnerable persons at risk for suicide (Lakeman, 2010). Regardless of the setting, nurses should realize that most suicidal persons can survive and go on to live. Hence, understanding ways of engaging through caring and confirming humanity can prevent suicide. Accessing and using evidenced-informed knowledge and evidenced-based nursing knowledge to meet the challenges of encountering these at-risk persons, can guide nurses to facilitate hopeful recovery. Of importance is nurses' reflection on their hopefulness in working with persons at risk (Cutcliffe, 2006).
Hopeful recovery emerges from meaningful connections, caring, being confirmed as a human being. Hopeful recovery can build resilience. Nursing research on the complex unfolding processes of resilience related to depression and suicide is emerging.
Depression is a known risk factor of suicide. Of note is that from 2005 to 2015, the total estimated number of people living with depression worldwide increased 18.4% (World Health Organization, 2017). Resilience is a known protective factor for depression; it is highly correlated with low depression and anxiety (Edward, 2005;Wagnild & Gantnar, 2011). Lakeman and Fitzgerald (2008) implicitly described resilience when they asserted that persons at risk for suicide can quickly turn their lives around through experiencing gaining or regaining connection with others. Hopeful recovery, a way to not give up, can potentially build resilience (Edward & Warlow, 2005). As nurses' foster resilience in those at risk for suicide, lives can turnaround and risk of suicide can be overcome, thus addressing the important work of suicide prevention in the world.