Assessment of Psychiatrists and Nurses’ Attitudes toward Suicide Behaviour ()
1. Introduction
Suicide is considered as an important public health concern worldwide and is identified as “an act of self-destruction, initiated and committed by a person fully aware of the fatal result” [1]. According to WHO, in 2019, close to 800.000 individuals died every year around the world. Also, WHO state that suicide is the third most important reason for death in 15-19-year-old and 79% of suicide emerge in low- and middle-income countries. Suicide lastly began to be regarded as being driven by a convoluted set of physical, psychological, and social issues in the 20th century [2].
Suicide attempters pose considerable strain and pressure on busy health care providers [3]. Attitudes of health care providers towards suicide and suicidal behaviour are thought to undesirably affect their encounter with suicidal behaviour patients [4]. Attitudes are theorized as consisting of three components: Behavioural component, affective component, and cognitive component. These components shape a person’s emotional responses, beliefs, knowledge, and behavioural in relation to the individual or a certain issue [5] [6].
Health care providers are anticipated to deter suicide behaviour, but their limited experience and relatively poor knowledge of suicidal attempts have influenced their perception [7]. Investigations have revealed that health care providers have felt incompetent and have been discouraged and unwilling to communicate with suicide attempters [1]. Moreover, [1] demonstrated significant relation between health care provider attitudes and the course of the suicidal behaviour treatment.
1.1. Background/Literature Review
A number of studies have begun to examine health care providers’ attitudes towards suicide and suicidal behaviour. These studies outline that most health care providers held negative and uncertain attitudes towards suicide. For instance, a Systematic review conducted by [7] demonstrated that a relatively large number of health care providers have negative attitudes towards suicide. Similarity, negative and uncertain attitudes amongst health care providers towards suicide and suicidal behaviour were indicated in the UK [8] [9]. In another instance, [10] revealed that mental health care providers in Uganda showed negative attitudes toward suicide behaviour. In contrast, two studies conducted in USA and Norway exhibited favourable attitudes among health care providers about suicide [11] [12]. Collectively, these studies outline a relatively negative attitude among health care providers toward the patient with a suicide attempts.
Other publications conducted in India and Japan [1] [13] [14] questioned the medical students’ attitudes towards patients with suicidal behaviour and showed that the attitudes of medical students range between negative and uncertain attitudes. In contrast, positive attitudes between medical students in Sweden toward suicide and suicidal behaviour [4]. These studies seemingly indicate that there is an uncertain and complex medical student’s attitude towards suicide and suicidal behaviour.
Attitudes of nursing students toward suicide have been investigated in India. The studies showed variations in nursing students’ attitudes toward suicide and suicidal behaviour. For example, Nebhinani et al. (2019) revealed that nursing students have favourable attitudes towards suicide. In contrast, uncertain attitudes toward suicide and suicide attempters amongst nursing students were detected [15]. In regard to nurses, a study conducted by [16], revealed that paediatric nurses have more favourable attitudes towards suicide and suicidal attempters compared with psychiatric nurses in the USA.
In the same context, [17] evaluated the attitudes of clinicians working in the emergency room. Demonstrated that emergency department (ED) providers in the USA held a positive attitude towards suicide. However, ED providers showed negative attitudes toward suicide behaviour and suicidal ideation [18]. Together, a different setting may predicate the variation of uncertain attitudes among ED providers. Moreover, the culture, environment, and health care system between India and USA may have an influence on the ED provider’s attitude.
On the other hand, a study conducted in China on 187 psychiatrists by Jiao et al. (2014) showed that psychiatrists have stigmatizing attitudes toward individuals involve in a suicidal attempts. In contrast, a positive and favourable attitude amongst general physicians, psychiatrists, and internists towards suicide attempters [19]. Collectively, the variations between results might be explained by different settings and health systems. Also, the result cannot be generalized because both studies were a cross-sectional related design.
Although the findings reviewed have found relatively negative and uncertain attitudes toward suicide and suicidal attempters amongst health care providers. In addition, there were only six studies that measured health care providers’ attitudes towards suicide. Furthermore, to our knowledge there was no study had been conducted in the Middle East or Saudi Arabia examining psychiatrists’ and nurses’ attitudes towards suicide and suicide attempters. However, there was no study assessed psychiatrists and nurses, and compared different specialties. Also, many of the scientific papers in the literature were considered moderate quality according to JBI critical appraisal instrument.
1.2. Theoretical Framework
The investigation was conducted and guided by the Theory of Reasoned Action (TRA), which describes and clarifies the association between attitudes, beliefs, behaviour, and intentions. This model hypothesizes individuals are rational and make decisions based on knowledge and information accessible and existing. TRA was modified and revised to the Theory of Planned Behavior TPB [20]. Related to TPB, study participants may have heightened awareness of their attitudes toward suicide.
1.3. Research Questions
The research paper aimed to address and focus on the following research question:
· Do Psychiatrists and nurses have negative attitudes toward suicide and suicide attempters?
· Is there a variation between Psychiatrists’ and Nurses’ attitudes towards suicide and suicide attempters?
1.4. Research Objectives
· Assess psychiatrist and nurse attitudes towards suicide behaivour.
· Identify factors that may affect psychiatrists’ and nurses’ attitudes toward patients who had a suicide attempt.
2. Methods
2.1. Design, Sample, and Setting
The researcher employed a cross sectional design survey. The study population included Psychiatrists and nurses working in psychiatric hospital. Questionnaires were distributed and collected in July 2021. These evaluations were carried out at Eradh Complex in Hail city. The current research utilized a convenience sampling method. The reasonable for selecting this sampling is to achieve large and representative contributors’ totals numbers. Using a sample calculation formula known as Andrew Fisher’s Formula and was appeared that the proper and suitable sample size was 130 participants. In the principle of maintaining clear inclusion and exclusion criteria in clinical research defines the characteristics of the study sample. For that specific reason, the sample criteria for this research paper are defined as follows
o Inclusion criteria
v Psychiatrists and Nurses are working in at Eradh Complex in Hail city.
v Male and female psychiatrists and nurses.
v Psychiatrists and nurses aged between 18-65 years old.
2.2. Outcome Measure
To assess psychiatrists’ and nurses’ attitudes toward suicide, we employed a Modified Suicide Opinion Questionnaire (SOQ) by [21]. The instrument comprised of five aspects, acceptability of suicide, professional role, work and care, morality and mental illness, communication, and attention, and finally beliefs. Objects were recorded on a 5-point Likert scale, from “strongly disagree” to “strongly agree.” The instrument’s internal consistency was evaluated by applying Cronbach’s α, with a total of 0.72 [22]. Apart from determining behaviour and feeling, actual items such as “>50% of suicidal individual sought medical assistance within the 180days preceding the suicide” were integrated to examine and evaluate knowledge of suicide behaviour [22]. Positively phrased statements (items 1, 3 - 8, and 10 - 21) were graded on a scale of five to one for “strongly agree” and “strongly disagree”. Negatively worded statements (items 2, 9 and 22) were scored in the opposite direction, with a range of one to five for “strongly agree” and “strongly disagree”. As a result, the scale’s possible score range was 22 - 110. Positive attitudes about suicide behaviour were reflected in high scores on the questionnaire.
Socio-demographic variables of the participants include age, sex, marital status, family type, level of education, religion, any exposure to suicide prevention training, nationality, personal history of suicide behaviour, family history of suicide behaviour, and history of suicide behaviour among close friends.
2.3. Ethical Consideration
IRB approval by the Research Ethics Committee at the Ministry of Health in Saudi Arabia was obtained. IRB approval number H-08-L-074. In terms of informed consent, informed consent is an essential principle to secure the rights of study participants while conducting a research paper [23]. For this research paper, the primary step in ensuring informed consent was to present an information poster prominently in particular clinical settings to advertise the research and its objectives. Additionally, the investigator approached psychiatrists and nurses and handed out information sheets along with a verbal description to deliver a full picture of the research. All research participants were able to contact the investigator openly utilizing his contact particulars offered on the information page. The psychiatrist and nurse have the right to withdraw from participation at any time without offering any justification or explanations. Participants were provided an appropriate time to think and confer and will provide a chance to question any queries prior to declaring their contribution. Also, Participant confidentiality was guaranteed by assigning contributors a number that would be utilized for all their information in the quantitative strand of the research. Ethical principles combine the avoidance of deception and confidentiality. Participants’ identification was not accessible during the research period (data assemblage, analysis or reporting research results), thus the participants’ information page stated obviously that the names of the participants would be treated confidentially. Furthermore, all data were stored and reserved securely and will be only accessible by the research group. In addition, participants were informed that their identities would not be uncovered in any research report or documents. The computer was also maintained in a protected filing cabinet and was not being employed by any individuals.
2.4. Quantitative Data Analysis
Information and statistics obtained from contributors were numerically coded and analysed employing the SPSS for Windows, version 21. Descriptive statistics are used to summaries baseline characteristics, comprising socio-demographic and participant data. For the sake of the current research paper, attitudes are categorized into groups as follows (group one: negative), (group two: uncertain), and (group three: positive). In terms of multi-comparison tests to protect against wrongly rejecting a null hypothesis and type 1 error, the modification level of significance will be presented. The varying degree of significance is set at baseline for all statistical examinations, thus determined at the 1% level (ρ < 0.05) [24] [25].
3. Results
3.1. Socio-Demographic Data of the Psychiatrists and Nurses
Sociodemographic characteristics of psychiatrists and nurses are summarized in Table 1. The investigator distributed 150 papers and we received 135 responses; three from the responses did not complete the questionnaire; this suggests the response rate was 88%. The study included 132 psychiatrists and nurses from Eradh Complex at Hail. The results showed that 59.1% of the participants were between 30-39 years category. Also, the majority of the study participants are male psychiatrists and nurses (62.9%). In addition, most of the participants were held Saudi nationality (75%), compared with 14.4% holding Egyptian nationality and 10.6 were from Filipin country.
Six to eleven years were the experience of 71 of the participants in the study, 31 experienced below five years and 30 were more than eleven years of providing and serving patients. Many of the psychiatrists and nurses were Muslim (92.4%), Christian was 6.8%, and only one participant held Buddhism religion. Moreover, 107 of the participants were nurses, compared with 25 psychiatrists.
In terms of the level of education, the findings suggest that the vast majority of participants have Bachelor (63.35%), Diploma (24.2%), and Master level (12.1%). However, only 1.5% of the participants had a personal history of suicide. Furthermore, 48 participants had exposure to suicide training, compared to 84 of psychiatrists and nurses who did not expose to such training about suicide.
It can be seen from Table 1 that slight proportion of participants (1.5%) had a family history of suicide. As well, the findings obtained from the preliminary analysis revealed that the only ten participants had a friend who committed or attempted suicide.
3.2. Attitudes Scoring for Suicidal Patients and Attempters by Category
The overall score of psychiatrists’ and nurses’ attitudes towards patients who had suicide behaviour on a five points scale was 77.04 (4.82) for psychiatrists and 74.01 (4.45) for nurses, showing that the participants held favourable attitudes towards individuals who had attempted suicide. Five of the 22 items scoring more than four points indicated that participants perceived that: 1) individuals
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Table 1. Demographic characteristics of respondents (n = 132).
*Indicates the highest percent.
who attempted suicide previously and live should be required to undertake thereby to know their inner drive (4.55 ± 0.77); 2) if somebody intents to commit suicide, it is their right and we should not interfere (4.39 ± 0.88); 3) suicidal behaviour in younger individuals is unacceptable (4.38 ± 0.96); 4) it is the professional responsibility of the nurse to stop and prevent any suicidal patient from dying (4.31 ± 0.96); 5) suicidal behaviour is fundamentally a way of crying out for help (4.02 ± 0.96). Participants who scored more than four points exhibited higher positive sentiments toward these statements, according to the findings.
The most surprising aspect of the data is that one of the 22 items obtained a mean score of fewer than two points demonstrating psychiatrists and nurses did not perceived that: suicide act is an agreeable way to stop an incurable illness (1.55 ± 0.88). Turning to items scoring less than three and above two revealed that participants disagreed with the following items. They were, 1) Potentially, every one of us can be a suicide victim (2.55 ± 0.92); 2) Suicide is a selfish behaviour (2.25 ± 1.25). On the statements scale, a score of fewer than two points indicated negative opinions regarding these specific items.
As can be seen from Table 2, the percentage of the psychiatrists and nurses who agreed with the following statements showed that 87 (65.9%) of the participants agreed that suicidal behaviour could be irritating. Also, 82 (62.1%) of the participants agreed that people with suicide attempt who use public places (bridges or buildings) are more concerned about getting attention. Further, psychiatrists and nurses agreed that the probability of the suicide attempters trying again is not minimal (3.52 ± 1.30). According to the above remarks, psychiatrists and nurses had favorable sentiments toward these particular statments.
Further analysis revealed that the mean score of the participants is above three points indicating favourable attitudes towards the next statements. They were, 1) >50% of suicidal individuals sought medical aid within the 6 months prior to the suicide attempt (3.50 ± 0.96); 2) individual with suicide attempt are less religious than others (3.37 ± 1.20); 3) individuals should not have the right to end their own lives (3.36 ± 1.37); 4) training of interpersonal skills would be of benefit when providing care for suicidal attempter (3.34 ± 1.14); 5) individuals who attempt suicide behaviour are typically attempting to get sympathy from others (3.30 ± 1.02); 6) individuals who have poor family relationship are more likely to attempts suicide (3.28 ± 0.98).
Respondents of the study demonstrated relatively neutral attitudes towards four statements. They were, 1) suicidal behaviour among younger individuals is particularly perplexing as they have everything to live for (3.50 ± 0.96); 2) suicidal individuals are attempting to make somebody else sorry (3.10 ± 1.07); 3) it is problematic to deal with suicidal behaviour and requires specialist care (3.05 ± 1.20); 4) persons who talk about suicide usually commit suicide (2.95 ± 1.24). These prior items elicited indecisive and neutral responses from nurses and psychiatrists.
With an average mean score of 3.64 ± 0.47 for the psychiatrist and nurses’ attitudes held favourable attitudes towards their professional function and their work with and care for suicidal patients. Further, participants perceived that individuals who attempt suicide are seeking to communicate their ache and seek attention for aid with average score of 3.57 ± 0.66. in addition, the psychiatrists and nurses’ attitudes towards mental illness and morality received a mean of 3.47 ± 0.49. Moreover, with regard to participants believe about suicide patients received a mean of 3.28 ± 0.71 meaning that they held positive attitudes. Finally,
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Table 2. Ranking Psychiatrists and nurses’ attitudes toward suicide and suicide attempters.
the participants’ acceptability of suicide behaviour received an average mean of 3.02 ± 0.36. See Table 3.
3.3. Psychiatrists and Nurses’ Personal Data and Their Attitudes towards Suicide
On the question of psychiatrists’ and nurses’ age and their attitudes towards suicide, participants in this investigation were classified into three different categories. An ANOVA test revealed significant differences between psychiatrists’ and nurses’ age and their attitudes towards suicide behaviour (=17.02, ρ = 0.0001). The results from Table 4 indicate that participants who had higher age achieved higher score on the positive attitudes toward suicide attempters.
Regarding psychiatrists and nurses as different occupation. Results demonstrate that there were statistically significant between psychiatrists’ and nurses’ attitudes toward suicide behaviour (ρ = 0.003). Table 5 shows that the psychiatrists held more positive attitudes towards suicide attempters than nurses. In addition, ANOVA statistical process was utilized to examine the relationship between level of education and participants attitudes towards suicide. As shown in Table 4, there was a significant variation between psychiatrists’ level of education and their attitudes towards suicide (ρ = 0.0001). Meaning that participants
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Table 3. Attiude scoring for suicidal patients by category.
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Table 4. ANOVA test of age, level of education, and years of experience of participants and their attitudes towards suicidal behaviour.
Values are given as Mean (SD). *p > 0.05.
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Table 5. T-test of psychiatrists and nurses’ personal history and speciality and their attitudes towards suicidal behaviour.
Values are given as Mean (SD). *p > 0.05.
who hold higher level of education record higher scores on the positive attitudes scale.
Moreover, there were five different categories of participants’ years of experience providing care and treatment to patients. Thus, the ANOVA statistical method applied to calculate whether there was statistically significant difference between participants’ attitudes towards suicide and count of years of experience in providing health care. The result from ANOVA reveals that there was statistically significant difference between respondents’ attitudes toward suicide behaviour and their years of experience (=28.78, ρ = 0.000). As shown in Table 4, psychiatrists and nurses who served more years providing health care to patients had higher score on the positive attitudes scale toward suicide and suicide attempters.
Further statistical T-test revealed a statistically significant relationship between psychiatrists’ and nurses’ positive attitudes and their personal history of suicide behaviour (ρ = 0.000). As can be seen from Table 5, illustrate that participants who had suicide attempt previously had more positive attitudes toward suicide behaviour, compared with other participants who did not have a history of suicide (ρ = 0.000).
4. Discussion
4.1. Interpretation of the Study Findings: Links to Existing Research
An initial objective of the project was to assess psychiatrists’ and nurses’ attitudes towards suicide in Hail region. As far as the researcher is aware, this is the first-time psychiatrists and nurses were exclusively determined on their attitudes toward suicide behaviour.
The results demonstrate that the mean score of psychiatrists’ and nurse’ attitudes towards suicide behaviour on five-point scale was 3.39, which shows that psychiatrist and nurses in Hail district held positive attitudes towards suicide and patient who had suicide behaviour. This finding is consistent with that of [21] who indicate that casualty nurses in the middle of Taiwan held favourable attitudes towards suicide on the scale of SOQ. Also, current study support evidence from previous observations revealing positive among health care providers towards suicide behaviour [8] [12] [16]. For instance, [8] demonstrate that nurses and doctors held positive attitudes towards patient who had attempted suicide. Another instance, positive attitudes towards suicide among psychiatrists, general practitioners, and internists [19]. Further instance, Glodsteinet al. (2018) indicate that psychiatric and paediatric APRNs had positive attitudes towards suicidal behaviour in the 15-24 years-old populations.
In contrast, positive attitudes among psychiatrists and nurses toward suicide have not previously been described on some studies in the literature. For example, health care providers held negative attitudes towards suicide attempters [7] [10]. Moreover, [18] demonstrates that clinicians in emergency room had negative attitudes toward suicide behaviour. However, this inconsistency may be due to many explanations. For instance, previous studies that they indicate negative attitudes towards suicide were actually on health care providers which included psychologists, social workers, and clinicians working in the emergency room. Another possible reason is that method of teaching in the country, sociocultural circumstances have an influence on changing the participants’ attitudes toward suicide behaviour.
The results of these studies showed that psychiatrists and nurses held favourable attitudes toward suicide in the categories of professional role, beliefs, and communication and seeking attention. There is a similarity between attitudes expressed by psychiatrists and nurses in this study and those described by [21] which suggests that casualty nurses have positive attitudes towards seeking attention, professional role, and beliefs categories about suicidal behaviour.
With regard to psychiatrists’ and nurses’ attitudes towards acceptability of patient who had suicide behaviour, the results of the current study indicate that respondents expressed average attitudes of the acceptability of suicidal patient. This result is different from that of [21] who found that respondents expressed positive attitude towards acceptability of patient who has a history of personal suicide. In addition, on the question of assessing the participants’ attitudes towards morality and mental illness about patient with suicidal behaviour. [21] showed that nurses received an average score when they investigated their attitudes toward suicide on the morality and mental illness category. This differs from the results presented in current investigation which indicate positive attitudes among psychiatrists and nurses toward suicide on the category of morality and mental illness. However, since these differences have not been found elsewhere it is probably due to different targeted sample in the studies. Moreover, the different country and cultural between current study and [21] study. For example, [21] was conducted in the middle of Taiwan, while current study initiated in the north of Saudi Arabia.
In this study, another important finding was that participants who had higher age achieved higher score on the positive attitudes towards suicide. These results seem to be inconsistent with the other research which found no significant differences in the nurses’ and doctors’ attitudes towards suicidal and their age [8]. However, these differences may be explained in part by that [8] study was restricted their sample to nurses and physicians working with children and young patients only, while current study was focused on psychiatrists and nurses practicing in psychiatric hospital.
The evidence that emerged from the current study demonstrates that psychiatrists expressed more positive attitudes toward suicidal behaviour than nursing staff. However, this finding has not been previously described. Also, these results differ from [7] who suggested that more negative attitudes were observed in medical than nursing staff in general hospitals. Furthermore, [8] indicate that no difference was found between nurses and doctors regarding their attitudes toward self-harm and suicide behaviour. These contrary results may be clarified by the fact that the sample of both studies was nurses and doctors providing health care to their patients in general hospitals, while in current study we participated psychiatrists and nurses working in psychiatric hospital. In supporting this suggestion, previous studies have demonstrated that psychiatrists expressed more positive attitudes toward suicidal behaviour, comparing with other specialists in medicine [26] [27] [28]. Another possible explanation may be the difference occurred because of different country and region. For example, Anderson & Standen, (2007) were conducted in the UK. Also, the majority of the studies that included in the systematic review of Saunders et al. (2012) were from Europe and South America.
In terms of the impact of the level of education on participant attitudes toward suicide behaviour. It was indicated in current study that psychiatrists and nurses who have a higher level of education recorded higher scores on the positive attitudes scale towards suicidal behaviour. These results are in accord with Sun et al. (2007) study which indicates a positive correlation between nurses’ attitudes towards suicide and their level of education. In contrast, [29] showed no differences based on psychiatrists educational degree and their attitudes toward suicide. This inconsistency may be due to that Jiao et al. (2014) study was recruited only psychiatrists, while Sun et al. (2007) and current study participated nurses and psychiatrists. Further possible explanations for this might be those differences between countries and cultures in their suicide rates and the impact of culture in shaping attitudes toward a patient who has suicide attempt [13].
The most obvious finding to emerge from the analysis is that psychiatrist and nurses who have more years providing health care to patient with suicide behaviour have a higher score on the positive attitudes scale. There is a similarity between the attitudes expressed by psychiatrist and nurse in current study and those described by Saunders et al. (2012) who demonstrate that psychiatric clinical staff who have more experience was shown to be associated with an enhancement in their attitudes toward self-harm and suicidal behaviour.
In reviewing the literature, no data was found on the association between psychiatrist and nurse attitudes toward suicide behaviour and their personal history of suicide attempt. However, the statistical t-test indicate that psychiatrist and nurse who have a personal history of suicide have more positive attitudes toward suicide.
4.2. Strengths and Limitations
To the best of our knowledge, the findings from this study make many contributions to the current literature. Primarily, this is the first scientific paper that has assessed psychiatrists and nurses’ attitudes toward suicide behaviour in Saudi Arabia. Secondly, the study has employed valid and reliable instruments to a measured psychiatrists’ and nurses’ attitude toward suicide. Finally, the majority of the investigations were initiated out in the West, only a limited nation was represented from the developing world.
The generalizability of these findings is subject to certain limitations. Primarily, the psychiatrist and nurse were chosen from only one hospital and the results may not be generalizable to all psychiatric hospitals in worldwide. Secondly, as the investigation is cross sectional in design, identifying and spot which variable influenced the other in cross sectional design it is complicated. Thirdly, convenience sampling was particularly selected, and it made it difficult to generalize the results. Some of the psychiatrists and nurses in the study might be unrepresentative of the whole population and that’s the convenience sampling difficulty [30]. Finally, the participants’ response might influence by social desirability because the questionnaires were distributed by the author who at the same time held a nursing supervisor position in the hospital.
4.3. Relevance to Clinical Practice
In terms of implications for future research, this study has raised more than questions in need of further search. The evidence from this study suggests that psychiatric and nurses have positive attitudes toward suicide. Although these findings are encouraging, they may not be generalizable to other scientific papers in Middle East, as it has been assumed that such variables effects psychiatric and nurse’ attitudes (i.e., age, years of experience and level of education).
With regarding implications for clinical practice, health care organizations need to provide support to professionals. For instance, exposing them to suicide prevention programs and was expected to improve and enhance the attitudes toward suicidal behaviour. Psychiatrist and nurses when they are aware of their opinions and attitudes about suicide behaviour, can help their patients through the expression of their own thoughts and fears, which can lead to increased communication and trust.
5. Conclusion
The attitudes towards suicide among psychiatrists and nurses were generally positive. The findings of these studies demonstrate that psychiatrists and nurses held positive attitudes toward suicide in the categories of professional role, beliefs, communication and seeking attention. Also, the evidence revealed in the current paper demonstrates that psychiatrists expressed more positive attitudes toward suicidal behaviour than nursing staff. Moreover, it was noticed in the present study that psychiatrists and nurses who have a higher level of education got higher scores on the positive attitudes scale towards suicidal behaviour. Finally, psychiatrists and nurses who have a personal history of suicide have more positive attitudes toward suicide.
List of Abbreviations
SOQ: Suicide Opinion Questionnaire Scale.
WHO: World Health Organization.
ED: Emergency Department.
TRA: Theory of Reasoned Action