International Emergency Nursing (2012) 20, 3– 13
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Measuring emergency department nurses’ attitudes towards deliberate self-harm using the Self-Harm Antipathy Scale Mary Conlon MHSc, H.Dip MH, RPN, Dip. Psych. (Advanced Nurse Practitioner Liaison Mental Health) a, Claire O’Tuathail RN, Diploma in Gerontology, PGCert. Teaching and Learning in Higher Education, MSc Advanced Clinical Practice (Lecturer, Director of Postgraduate Diploma in Nursing (Gerontology)) b,* a b
Mayo Mental Health Services, Mayo General Hospital, Castlebar, Co. Mayo, Ireland School of Nursing and Midwifery, Aras Moyola, National University of Ireland, Galway, Ireland
Received 5 July 2010; received in revised form 29 July 2010; accepted 7 August 2010
KEYWORDS Emergency department nursing; Self-harm; Nurses’ attitudes
Abstract The emergency department is an important gateway for the treatment of self-harm patients. Nurses’ attitudes towards patients who self-harm can be negative and often nurses experience frustration, helplessness, ambivalence and antipathy. Patients are often dissatisfied with the care provided, and meeting with positive or negative attitudes greatly influences whether they seek additional help. A quantitative design was utilised to measure emergency department nurses’ attitudes towards deliberate self-harm. The ‘Self-Harm Antipathy Scale’, a validated questionnaire, was administered to a random sample of nurses in four emergency departments in the Republic of Ireland. A total of 87 questionnaires were returned (87% response rate). Results reveal that nurses show slightly negative antipathy overall, indicating positive attitudes towards self-harming patients. Attitudes were significantly different in accordance with a nurse’s age. Education and social judgment also contribute to the way nurses view, interact and make moral decisions regarding self-harm patients. Evidence indicates there is need to improve the training, supervision and support of nurses caring for patients who self-harm, and that practical strategies should be implemented to manage the alienation process and inform practice.
ª 2010 Elsevier Ltd. All rights reserved. * Corresponding author. Tel.: +353 91495314. E-mail address:
[email protected] (C. O’Tuathail). 1755-599X/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ienj.2010.08.001
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Introduction Deliberate self-harm may be defined as a deliberate, selfharming behaviour not aimed at causing death and carried out in the knowledge that it is potentially harmful (Crawford et al., 2003). It includes all methods of self-injury such as cutting, burning, attempted drowning, attempted hanging, and self-poisoning. The National Strategy for Action on Suicide Prevention (HSE et al., 2005) emphasises that a history of engaging in self-harm is the strongest predictor of future suicidal behaviour. In 2005, there were 10,800 presentations of self-harm to hospitals in Ireland involving approximately 8600 individuals (National Suicide Research Foundation (NSRF), 2006). The NRSA (2006) identified that in 2005 the emergency department (ED) was the only treatment setting for 45% of all self-harming patients, highlighting the fact that repeat self-harm presentations to hospitals pose a significant problem in Ireland. They argue that service providers in Ireland face a major challenge to ensure that all self-harm patients receive comprehensive assessment and treatment, which begins in the ED. The ED is an important gateway for increasing numbers of mental health patients (Webster and Harrison, 2004) and the treatment of self-harm patients (NSRF, 2005). This presents particular diagnostic and management challenges for ED staff (Holdsworth et al., 2001). Inadequate assessment will result in failure to diagnose underlying treatable conditions such as depression and alcohol dependence (Lamb et al., 2006). This in turn leads to poor treatment plans, poor compliance with treatment and increased risk of repeated self-harm and suicidal behaviour (Kapur et al., 2002), as there is a strong relationship between those who self-harm and eventual suicide (Zahl and Hawton, 2004). In the ED, where the focus is on repairing physical injury, contact with self-harming patients is fleeting, with much less attention paid to the particularities of each patient’s experience (Moyle, 2003). These patients are viewed as manipulative, attention seeking or beyond the reach of help (Vivekananda, 2000), and are usually managed by staff who have little commitment to mental health care (Olfson et al., 2005). Achieving therapeutic engagement is complex and challenging, while at the same idea that the self-harm patient is manipulative and destructive (Gallop and O’Brien, 2003). Research has shown that attitudes are an important concept that relate to emotions, cognitions and behaviours (Ajzen, 1988). An attitude involves a tendency to react in a certain manner when confronted by specific stimuli (Oppenheim, 1992). Attitudes have a powerful influence on cognition, emotion and behaviour – the fundamental process by which we live our lives (Oppenheim, 1992). According to Crawford et al. (2003), assessments and follow up services may be influenced by initial attitudes. Furthermore, patients who do not receive or are not met with positive, empathetic and caring attitudes are less likely to remain in the ED for treatment (McAllister et al., 2002). What attitudes professionals hold towards individuals who self-harm and what may influence their attitudes is thus an important area in this field which warrants investigation.
M. Conlon, C. O’Tuathail The word ‘‘antipathy’’ is the opposite of empathy, which is the cornerstone of an effective nurse-patient relationship and provides the foundation for important therapeutic work in nursing care (Evans, 2007). Exposure to ‘‘antipathy’’ (and being met with hostile cognitions and rejecting behaviour) can be considered an additional risk factor for self-harming patients, ‘‘as the attitude of others may be just as important as the psychopathology of the person who kills themselves’’ (Morgan and Priest, 1991, p. 373). In Ireland there has been minimal research on attitudes of staff towards patients who self-harm. Lamb et al. (2006) examined changes in attitudes, knowledge and confidence towards self-harming behaviour among 72, Emergency Department and Medical Assessment Unit (MAU) nurses before and after a training programme. Results found positive changes in confidence, attitudes and knowledge post training intervention. McCarthy and Gijbels (2010) examined the relationship between attitudes and factors such as age, academic achievements, experience and education using an amended version of the Attitude Towards Deliberate Self-Harm Questionnaire (McAllister et al., 2002). The study reported positive attitudes of ED nurses towards self-harming patients although older nurses and hospital trained nurses had less positive attitudes. Recommendations from these studies and the NSRF (2006) highlight the need for more research in this area. Following a review of the available literature it was decided to undertake a quantitative non-experimental descriptive survey approach utilising a self administered postal questionnaire. This decision was influenced at the conceptual phase by the following factors: – Discussions with key informants on the topic (ED nurses and service users). – Attendance at an international conference on suicide. – Finding a similar study undertaken in the UK by Patterson et al. (2007a). Patterson et al. (2007a) developed and used a psychometrically tested instrument for the assessment of attitudes towards people who self-harm derived from the emerging literature. Relatively few studies on staff attitudes have utilised standardised measures to investigate the underlying extent or scope of such attitudes (McAllister et al., 2002). Permission to use this instrument was obtained from Patterson et al. (2007a).
Aim of this study The aim of this study was to measure nurses’ attitudes towards deliberate self-harm using the Self-Harm Antipathy Scale (Patterson et al., 2007a). As attitudes influence cognition, emotion and behaviour, investigating nurses’ attitudes towards those who self-harm would provide information on how these patients are treated, the possible impact of the attitudes on the patients who self-harm, and the likelihood of them seeking further help (Eagley and Chaiken, 1993). Nurses also need to be aware that their beliefs, attitudes and resulting behaviours can have a profound effect on those they treat, not always
Measuring emergency department nurses’ attitudes towards deliberate self-harm in the way that they intend (MacKay and Barrowclough, 2005).
Literature review The relationship between self-harm and eventual suicide has been well documented (Appleby, 1997; Repper, 1999; Eastwick and Grant, 2004; Zahl and Hawton, 2004). About one quarter of suicides are preceded by acts of self-harm within the previous year (Owens et al., 2002) and Broadhurst and Gill (2007) argue this is compelling evidence for the need to improve delivery of care to self-harming patients. General nurses play a pivotal role in the detection and treatment of those who self-harm (Happell et al., 2003). Pearsall and Ryan (2004) argue that self-harm is one of the most frequent reasons for medical admissions in the United Kingdom (UK), with Morgan and Coleman (2000) suggesting that 60–70% of patients who present to the ED having deliberately self-harmed get a hospital bed. The recommendation that all patients attending EDs with self-harm should be offered adequate psychosocial assessment appears repeatedly in all recent strategy documents in Ireland and the UK (NICE, 2004; HSE et al., 2005; DoHC, 2006). Despite this, the ‘‘Report of the Regional Committee on Suicide’’ (2001), whilst emphasising crisis intervention, makes no reference to general nurses in EDs instead recommending liaison nurses. Nursing services are at the core of the ED and nurses are usually the first healthcare professionals with whom the patient comes into contact, providing triage, first aid and psychological support (Broadhurst and Gill, 2007). However, Perego (1999) found that the ED nurses were not confident enough to deal with the challenges associated with this vulnerable group. A significant factor which directly impacts the quality of nursing care delivered is that of nurses’ attitudes (Repper, 1999; McAllister et al., 2002). Attitudes significantly influence decision making in care judging by a National Institute for Health and Clinical Excellence (NICE, 2004) guideline on self-harm that states ‘‘analgesia should be offered to people who have self injured throughout the process of suturing or other painful treatments’’ (NICE, 2004, p. 6). It is a concern for professionals that this document, published only 6 years ago, felt it necessary to state this. In what appears to be one of the few international studies specifically focused on addressing the attitudes of ED nurses to self-harming patients, McAllister et al. (2002) undertook a survey of EDs in Queensland, Australia (public ED N = 23 and private ED N = 14). An analysis of the 353 questionnaires returned revealed four factors that reflected nurses’ attitudes towards these patients. These factors related to nurses’ perceived confidence in their assessment and referral skills, ability to cope effectively with the legal and hospital regulations which guide practice, the ability to deal effectively with patients and the extent of empathy. McAllister et al. (2002) conclude that although the attitude toward self-harming patients was generally negative, empathy increased with increased ED work experience. Eastwick and Grant (2004) stress the importance of acknowledging that the type of self-harming patients likely to receive treatment in the ED are those who are highly sensitive to criticism and negativity because of their own
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lack of self-esteem. This is confirmed in feedback from service users of the ED who said their experience in the ED reinforced the negative feelings they held about themselves causing them to self-harm in the first place (Jeffery and Warm, 2002). The attitude, relationship and quality of the response of nurses to self-harming patients are very important ethical and professional issues in nursing (Patterson et al., 2007a). The Collins dictionary defines antipathy as ‘‘a strong or deep-seated aversion or dislike’’ and Patterson et al. (2007a) view antipathy as a negative attitude towards self-harming patients which the nurse takes from one relationship with a self-harming patient to the next. The patient is therefore seen not as an individual but as a member of a stereotypical group and, as an attitude, the nurse has negative emotional associations, hostile cognitions and rejecting behaviour when encountering the stereotyped patient. The word ‘antipathy’, therefore conveys the sense of a reaction, opposite to empathy, which is the fundamental component of an effective nurse-patient relationship involving the therapeutic use of self in the interests of patient care (Gallop and O’Brien, 2003). Antipathy for the self-harming patient and their care remains a significant barrier to improving care in the health care arena (Patterson et al., 2007a). There is a paucity of literature available regarding attitude change towards this vulnerable population (Herron et al., 2001) especially in Ireland.
Methods Introduction The four hospitals chosen as sites for this study provide services for approximately equal numbers of patients from both rural and urban backgrounds. One hundred and sixtyeight nurses are employed with varying ranges of experience and qualification in these EDs. The first author is an Acting Advanced Nurse Practitioner, Liaison Mental Health and felt that in order to work more effectively with the general nursing staff, it was necessary to determine their current attitudes to patients who present after single or multiple episodes of self-harm.
Ethics Ethical approval to conduct this research study was obtained from the four relevant hospital ethics committees.
Research design This study used an established, reliable and validated research tool developed by Patterson et al. (2007a) called the ‘Self-Harm Antipathy Scale’ (SHAS). The questionnaire was originally developed in the UK and was subsequently used to test the effectiveness of an educational intervention aimed at changing attitudes to self-harm (Patterson et al., 2007b) in the UK. The first author contacted Dr. Paul Patterson and received permission to use the questionnaire. Permission was also given to adapt the scale to suit the Irish context if necessary but no such changes were made. The SHAS consists of thirty statements about people who
6 self-harm and invites participants to indicate on a sevenpoint Likert Scale (‘strongly agree’ to ‘strongly disagree’ with an ‘undecided’ midpoint) their agreement or disagreement with each statement. Participants were asked to consider each item about people who self-harm (including single or multiple acts) by any means but are not considered to be making a direct attempt to kill themselves (an act with a non-fatal outcome). Seventeen of the statements were positively worded and thirteen negatively worded. Agreement with negatively phrased items indicating antipathy, such as ‘‘a self-harming patient is a complete waste of time’’, were scored positively, that is, yielded high scores. Agreement with items indicating positive evaluations of the patient group, such as ‘‘Self-harming individuals can learn new ways of coping’’, were reverse scored, that is, yielded low scores. The total scores range from 30 (low antipathy) to 210 (high antipathy). Patterson et al. (2007a) also included a brief additional questionnaire asking participants to record key personal and professional characteristics such as gender, age, qualification, year of registration, contact with self-harming patients, previous study of self-harm, and also afforded participants an opportunity to express their feelings and attitudes towards self-harming patients if they so wished. This too was utilised for the current study.
Pre-test The questionnaire pre-tested ten nurses who were representative of those who would be included in the study (Norwood, 2000), for review, feedback and its appropriateness in an Irish context. Their responses gave the researchers insight into whether all participants understood the questions in the same way, whether the format of the questions was suitable for this population, whether they understood the instructions, how relevant questions were and whether the length of the questionnaire and its structure were likely to affect responses (Parahoo, 1997). The pre-test participants were not used in the final study.
Data collection One hundred and sixty-eight registered general nurses in the four chosen study sites were used as a sampling frame for the research, of which one hundred (59.52%) were randomly selected and sent questionnaires. An envelope with the first author’s name and address was enclosed to allow for return and ensure participant anonymity. A 5 week period was allowed for data collection to facilitate staff shifts and annual leave patterns. A reminder notice was sent to the participating EDs at the end of week three. During the data collection the first author was available at any time to accept calls or emails from potential participants. A response rate of 87% (N = 87) was achieved. Each individual questionnaire returned was assigned an individual identity number to ensure accurate data input into Statistical Package for the Social Sciences (SPSS Version 12) and to ensure that all data could be rechecked.
M. Conlon, C. O’Tuathail most important to worst or least important some trait, attribute or characteristic she/he feels that most suits her/his response (Creswell, 2005). Therefore this study used a Likert Scale to collect the data. Each statement is rated along seven separate points from strongly disagree, disagree, tend to disagree, uncertain, tend to agree, agree to strongly agree. The higher the number (7 in this case) indicates that the participant has more of the property (antipathy) than the lower number. SPSS (Version 12) was utilised for data analysis as advised by Kelly et al. (2003). Data analysis was subsequently organised under the thirty variables on which the ED nurses were questioned as well as ten demographic questions. The total score for each participant was calculated and the descriptive statistics were explored. The higher the mean, the more positive the rating for antipathy. For example, a high mean for a variable indicated a more negative attitude towards self-harming patients. Each participant’s attitude was compared by age, gender, years qualified, number of self-harming patients nursed and previous study of selfharm. Inferential statistics were used to draw conclusions by analysing relationships among the variables and generalising to make inferences about the population as a whole (Pallant, 2001). Parametric statistics were utilised in the analysis of the data in this study.
Content analysis of open-ended question on questionnaire The transcription of the comments was subjected to content analysis using Burnard’s (1991) guidelines.
Results Eighty-seven completed questionnaires were returned with a response rate of 87%. All the nurses surveyed were general nurses, worked in the ED and all had cared for self-harming patients. Female participants, 95% (n = 83) vastly outnumbered males 4% (n = 3). The ages of the participants can be seen in Fig. 1. With regard to the number of years registered, 26% (n = 23) were registered less than 10 years, with 41% (n = 36) registered between 11 and 20 years and 29% (n = 25) registered more than 21 years (see Fig. 1).
Data analysis Attitudinal measures imply an ordinal scale which provides response options in which participants rate from best or
Fig. 1
Age group of participants.
Measuring emergency department nurses’ attitudes towards deliberate self-harm A range of responses given related to qualifications with 34% (n = 30) having a higher diploma in nursing, 29% (n = 25) having a certificate in nursing, 27% (n = 23) having either a Diploma or Degree in nursing, 3% (n = 3) having a Masters and 2% (n = 2) specified ‘other’. While 49% (n = 43) of the participants were involved in nursing self-harming patients for less than 10 years, the remaining participants 29% (n = 25) were nursing this patient group for more than 11 years. Twenty-two percent did not answer this question. In the last 12 months, the majority 40% (n = 35) of the participants had nursed between 1 and 25 self-harming patients, with 28% (n = 24) having nursed between 26 and 50, while 17% (n = 15) nursed more than 51 patients (see Fig. 2). Almost a third 32% (n = 28) of participants indicated that they had received no self-harm education (see Fig. 3). The remainder 68% (n = 59) received the following education: 28% (n = 22) participated in short workshops, 17% (n = 13) in a single study day, 19% (n = 15) in private self-directed study, and 13% (n = 10) having attended courses.
Positive attitudinal statements Mean scores for individual positively worded attitudinal statements are shown in Table 1. There are 17 statements with their overall mean score equating to 3.42 located in the slightly positive range. The response options are: strongly disagree, disagree, tend to disagree, uncertain, tend to agree, agree, and strongly agree. There was a particularly positive response to the statements ‘an individual has the right to self-harm’ (5.01) and ‘people should be allowed to self-harm in a safe environment’ (6.16). A below average mean score of 2.19, (negative response for antipathy) was recorded for the statement ‘a self-harming client deserves the highest standards of care on every occasion’. The statement ‘I can really help self-harming clients’ recorded the largest score 37.9% (n = 33) for the category ‘uncertain’ seen in the entire questionnaire.
Negative attitudinal statements There are 13 negatively worded attitudinal statements and these were subjected to reverse scoring. Results are shown in Table 2. The frequencies present raw data and the mean score takes into account reverse scoring. An overall mean
Fig. 3 harm.
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Number who previously studied approaches to self-
score of 2.83 was recorded for all the negatively worded statements indicating attitudes in the slightly negative range. Two particularly positive participant replies (for antipathy) were noted in the statements ‘when individuals selfharm it is often to manipulate their carers’ with a mean score of 3.81 and ‘people who self-harm are usually trying to get sympathy from others’ (3.69). This is suggestive of a favorable attitude towards this cohort. The statement ‘a self-harming client is a complete waste of time’ had a below average mean score of 1.93 and also recorded the smallest score, 1.1% (n = 1) for the category ‘uncertain’, with 85% (n = 74) of nurses responding with strongly disagree/disagree. This statement appears to contradict statement 29 in the positive attitudinal statements in which 63 participants strongly disagreed/disagreed that ‘a self-harming patient deserves the highest standard of care on every occasion’.
Factors (subscales) of Self-Harm Antipathy Scale Factor analysis indicated that there are six underlying factors or subscales making up the Self-Harm Antipathy Scale (Patterson et al., 2007a). If factor analysis demonstrates scale dimensions that are compatible with the conceptual definition on which the scale is based, then evidence has been gained for the instrument’s construct validity (Norwood, 2000). The overall mean score for the six factors (see Table 3) are within a similar range to that presented in Patterson et al. (2007a). However there is a difference in factor 5 – ‘‘Rights and Responsibilities’’ – which had a mean score of 7.02. This higher mean value in this factor indicates a greater belief that self-harm is more frequently judged as morally wrong, with critical judgment upon patient behaviour being often expressed and experienced in practice.
Comparison of sub-groups
Fig. 2 Number of self-harming patients nursed in the last 12 months.
The data was recoded in SPSS to facilitate analysis. Parametric statistics were utilised in the analysis of the data. The only statistically significant difference to emerge in overall antipathy was in regard to the participant’s age. The mean responses for the age group 21–40 were 98.45 (SD 21.23) and for the age group 41–60 was 89.91 (SD 16.70). This difference is statistically significant (t(85) = 2.21, p = .02, p < 0.05).
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M. Conlon, C. O’Tuathail Table 1
Participants’ level of positive attitudes towards patients who self-harm. Mean score
12. People should be allowed to self-harm in a safe environment (n = 87) 13. A rational person can self-harm (n = 87) 18. An individual has the right to self-harm (n = 87) 22. Self-harm may be a form of reassurance for the individual that they are real, alive and human (n = 87) 23. Self-harming individuals can learn new ways of coping (n = 87) 24. Acts of self-harm are a form of communication to their situation (n = 87) 27. For some individuals self-harm can be a way of relieving tension (n = 87) 28. Self-harm clients have a great need for acceptance and understanding (n = 87) 29. A self-harming client deserves the highest standards of care on every occasion (n = 87) 30. I listen fully to self-harming clients problems and experiences (n = 87) 31. I feel concern for the self-harming patient (n = 87) 33. I demonstrate warmth and understanding to self-harming clients in my care (n = 87) 34. I help self-harming clients feel positive about themselves (n = 87) 36. I acknowledge each self-harming clients qualities (n = 87) 37. I find it rewarding to care for self-harming clients (n = 87) 38. I can really help self-harming clients (n = 87) 40. I am highly supportive to clients who repeatedly self-harm (n = 87)
Table 2
11. 14. 15. 16. 17. 19. 20. 21. 25. 26. 32. 35. 39.
SD
D
TD
U
TA
A
SA
6.16
2
1
1
8
3
22
50
3.73 5.01
7 4
23 5
13 10
10 14
15 8
12 24
6 21
3.79
3
14
25
23
7
8
7
2.51
14
43
18
5
1
3
3
2.46
13
39
25
6
1
2
1
2.87
6
32
31
10
2
5
1
2.87
9
24
36
10
3
5
2.19
30
33
14
3
1
2
3
2.72
11
37
21
7
7
2
2
2.55
13
40
22
4
2
5
1
2.90
10
27
27
10
8
4
3.15
8
23
23
14
11
4
3.08
7
28
20
18
8
5
4.22
1
11
14
29
12
14
6
4.21 3.83
1 4
9 13
13 23
33 17
12 15
17 11
2 3
1
Participants’ level of negative attitudes towards patients who self-harm.
People who self-harm are usually trying to get sympathy from others (n = 87) Self-harming clients do not respond to care (n = 87) When individuals self-harm it is often to manipulate their carers (n = 87) People who self-harm are typically trying to get even with someone (n = 87) A self-harming client is a complete waste of time (n = 87) Self-harm is a very serious moral wrong doing (n = 87) There is no way of reducing self-harming behaviors (n = 87) People who self-harm lack solid religious convictions (n = 87) A self-harming client is a person who is usually only trying to get attention (n = 87) Self-harming clients have only themselves to blame for their situation (n = 87) I feel critical towards self-harming clients (n = 87) I feel to blame when my clients self-harm (n = 87) I would feel ashamed if a member of my family engaged in self harm (n = 87)
It can be seen from Table 4 that the participants who were registered less than 15 years (98.60, SD 23.86) had
Mean score
SD
D
TD
U
TA
A
SA
3.69 2.60 3.81 2.85 1.93 3.06 2.23 2.28 3.28 2.33 3.19 2.17 3.36
2 17 3 11 40 12 24 32 10 25 10 30 8
1 38 15 30 34 29 42 29 19 30 21 32 26
1 13 16 19 6 19 8 13 20 22 26 14 15
8 8 21 18 1 9 7 6 19 5 9 4 14
3 6 23 6 2 8
22 3 8 3
50 2
1 14 1 12 2 13
7 3 2 4 1 8 3 7
4 3 2 4 1 3 1 3
more positive antipathy than those who were registered more than 15 years (91.41, SD 16.95). The participants
Measuring emergency department nurses’ attitudes towards deliberate self-harm Table 3
Table 5
Overall mean scores for the six factors.
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Main themes and sub-themes.
Factor
Mean
SD
Main theme
Sub-themes
Competence appraisal Care futility Client intent manipulation Acceptance and understanding Rights and responsibilities Needs function
22.40 12.15 13.70 8.02 11.03 6.25
7.24 5.35 4.56 3.17 2.82 2.09
1. Lack of education
ED staff not qualified More education and training Psychological care versus physical care Lack of resources Motivation Social judgment
who had experience working with self-harm patients for less than 10 years (95.42, SD 22.21) also had more positive antipathy than those who had more than 10 years (93.84, SD 17.52) experience. Despite the fact that these differences did not reach a statistically significant level, this result suggests that ED nurses with more experience may have lower antipathy towards self-harming patients.
Content analysis of open-ended question in questionnaire Patterson’s et al. (2007a) questionnaire allowed participants an opportunity to express their feelings and attitudes towards self-harming patients. While 24% (n = 21) of participants in this study chose not to make a comment, the other 76% (n = 66) did and were transcribed verbatim. Transcripts were analyzed using a thematic framework outlined by Burnard (1991). Table 5 shows three core themes were identified after combining a range of sub-themes. 1. Lack of education: Nurses in this study reported a deficit in mental health knowledge and little or no opportunities to develop skills on both self-harm and the wider mental health issues. Moreover, many ED nurses expressed the view that they are not adequately equipped to deal with the challenges of this patient group. Many nurses believed that they lack the necessary skills to care for self-harming patients and need education and training to enhance communication and care. Moreover, the nurses felt that more training would enable them to be confident and more aware of a self-harming patient’s needs and distress. Table 4
2. ED is an unsuitable environment 3. Empathy/antipathy
2. ED is an Unsuitable Environment: Nurses reported that they tend to focus largely on medical rather than psychological assessment and intervention, and the care they provide focuses primarily on the patient’s physical needs. The nurses acknowledged that the ED is not a suitable environment to care for this patient group owing to lack of privacy, overcrowding and a general lack of resources. They also reported a lack of collegial support, and this, coupled with the ‘lack of time’, impairs their ability to provide good care. Once medical care is provided the nurses point out that the patient is referred or transferred on to psychiatry as a priority. They do acknowledge support from liaison psychiatry, but feel that the psychiatric services are the most appropriate people to care for this patient group. 3. Empathy and antipathy: The nurses reported that patients who repeatedly presented as a result of selfharm evoked feelings of frustration and powerlessness in some of the nurses and that self-harming patients looking for attention and help are often ignored or marginalised by nurses. In addition some nurses perceive manipulation and wasting of staff time, and find it difficult to be helpful or compassionate. The nurses indicate a widely held belief that self-harm is more frequently judged as morally wrong, with critical judgment upon the self-harming patient’s behaviour being expressed and experienced in practice. These views nurses have of patients cause them to interact in a substantially different way and this plays a part in how decisions are made and the outcomes of care. Nurses make judgments regarding the reasons or genuineness of the self-harming patient, as is suggested in the following comment,
Subgroup means (SD) for total SHAS.
Variable
Category
n
Mean (SD)
Independent samples t test
p value
Previous study of self-harm
Yes No < than 10 yrs 11 or more 0–15 yrs 16+ yrs Female Male 21–40 yrs 41–60 yrs 1–25 26+
59 28 43 25 31 35 83 3 49 28 35 39
95.78 92.14 95.42 93.84 98.60 91.41 95.19 82.50 98.45 89.91 97.46 92.60
t(85) = .842
p = 0.40
t(66) = .917
p = 0.36
t(82) = 1.605
p = 0.11
t(84) =
1.19
p = 0.23
t(85) = 2.217
p = 0.02
t(73) = 1.157
p = 0.25
Length of experience with self-harm patients No of years registered Gender Age No. of self-harm patients nursed in the last year
(22.50) (15.21) (22.21) (17.52) (23.86) (16.95) (20.68) (9.94) (21.23) (16.70) (24.25) (17.44)
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M. Conlon, C. O’Tuathail ‘‘I have more tolerance for genuine people with genuine reasons’’
Some nurses were willing to invest time with the patient if their circumstances were perceived to be authentic, ‘‘if a patient is genuinely depressed I have sympathy for them’’.
Discussion The results of this study show that generally the participants scored slightly negative antipathy overall indicating positive attitudes towards self-harming patients. These findings concur with the recent study undertaken by McCarthy and Gijbels (2010). The overall mean score in this study is higher than that obtained by Patterson et al. (2007a). This (slightly) negative antipathy score indicating positive attitudes towards self-harming patients was a particularly positive element of the study findings, and the themes identified reflect and compliment other research identified in the literature (Keogh et al., 2007; Patterson et al., 2007a; Lamb et al., 2006; Anderson, 1997; McLaughlin, 1994). There is good evidence in this study that attitudes toward self-harming behaviour have a direct impact on the relationship nurses have with these patients and the quality of care they provide (McDonough et al., 2004). Despite the overall negative antipathy score, a positive antipathy response was discovered in relation to judgmental attitudes and manipulation in the self-harming behaviour. Nurses were also frustrated with these patients frequently returning to hospital. Moreover, the results of this study show that the nurses do not feel adequately trained to respond, and many have doubts about the degree of support that may be available to them in this area. They also feel that self-harm is the responsibility of the mental health services, and consequently it will indeed be difficult to shift the major responsibility for responding to self-harm patients to generic hospital-based staff. In the group of nurses reported on in this study, it is clear that their experience working with self-harm patients is strongly influenced by their age, length of experience, and to a lesser extent education and social judgment. This study, serves to emphasise those findings presented in McCann et al. (2006) which argues that retention of older, experienced staff in the ED, especially those who have received training in self-harm, leads to increased empathy and positive attitudes, all of which can only benefit the outcomes of care for this population. The nurses in this study reported a deficit in mental health knowledge and skills. However, it can be seen that nurses who had previously studied approaches to self-harm reported lower antipathy than those who did not. Some nurses genuinely believe that they cannot help self-harming patients as they lack the necessary skills. McAllister et al. (2002) argue that these identified deficits could account for the fact that nurses sometimes distance themselves from self-harming patients, and view them as attention seeking, manipulative or beyond the reach of help (Vivekananda, 2000). This perceived lack of clinical skills was found
to be one of the main barriers to communicating with this patient group (Crowley, 2000). Kerrison and Chapman (2007) argue that it is, therefore, essential that any education initiatives incorporate effective communication and assertiveness training. The nurses in this study highlighted the need for strengthening educational preparation and support (Friedman et al., 2006; McCann et al., 2006). Holdsworth et al. (2001) found that this education and training in self-harm led to reduced stress and strain on nurses as professionals, which resulted in improved care for self-harming patients. Empathy and tolerance towards self-harming patients can be achieved after a mental health training programme (Commons Treloar and Lewis, 2008). Where antipathy is present, even at low levels, in nurses or more widely within teams, it is vital to help staff view the self-harming patient in a different way (Patterson et al., 2007a). This can be achieved through reflection, education and clinical supervision (Patterson et al., 2007b; Sun et al., 2007; Keogh et al., 2007), where the relationship between intuition, expertise and self-awareness will be enhanced. Critical attitudes on self-harming patients’ behaviour would then be less frequently seen in practice, leading to improvement in the overall experience of care in the ED (Patterson et al., 2007a). As this study supports the view that self-harm is more frequently judged as morally wrong, it therefore implies that critical judgment upon the self-harming patients’ behaviour is often expressed and experienced in practice. The views people have of others cause them to interact in a substantially different way with them (Johnson and Webb, 1995), and this plays a part in how decisions are made (Dowding, 2003), and the outcome of care (Carveth, 1995). Johnson and Webb (1995) further explain that most of the nurses in their study were aware of their judgmental attitudes and approach to their patients, and felt guilty for both labelling the patient and modelling lower standards of care than they would really like to maintain. However, evidence also indicates that the context within which they worked made this behaviour a necessary part of social relations within the department (Morton-Cooper and Palmer, 2000), irrespective of how guilty it made the nurses feel. According to this study, nurses’ experience when working with self-harming patients includes a range of feelings which include powerlessness, futility, moral judgment and empathy. It is evident from this study that there are a range of contextual factors that affect nurses’ behaviour. For example, how the self-harming patient behaves towards the ED staff, alcohol and illicit drug use, the functionality of the self-harm, nurses’ interpretation of selfharm acts, and the ED nurses’ focus on medical assessment and management of the patient. However, it can also be seen from this study and the literature (Arbon, 2004; MacKay and Barrowclough, 2005; Patterson et al., 2007a,b) that attitudes to self-harm are not simply negative or positive but are instead influenced by individual personal characteristics and situational factors and are the result of personal history as opposed to professional background (McElroy and Sheppard, 1999). Different dimensions of attitude are therefore likely to vary in different ways in individuals, with resulting implications for behaviour (Ajzen,
Measuring emergency department nurses’ attitudes towards deliberate self-harm 2001) which need to be more fully explored and understood. It is important not to judge nurses with high levels of antipathy as ‘bad nurses’ (Patterson et al., 2007a). While these study participants made generalisations in their attitudes towards self-harming patients and their care, Patterson et al. (2007a) urges caution in assuming that antipathy is invariably experienced in practice and reflected in nurses’ behaviour towards all self-harming patients, regardless of the patients’ behaviour and individual characteristics. The extent to which a nurse’s attitude reflects the team attitude and vice versa also needs to be considered. Anderson and Standen (2007) argue that this complexity of attitudes among professionals to self-harm needs to be taken into account when challenging or changing these attitudes.
Limitations The results provide important insight into nurses’ attitudes towards self-harming patients. The response rate of 87% was considered representative of the ED nurses in the Republic of Ireland and is generalisable to the ED population at large, as Doyle et al. (2007) argue that most EDs in the Republic of Ireland now have a dedicated mental health liaison nursing service. However, limitations of the study design include: –– The questionnaire lacks a question on the utilisation of the mental health liaison nursing service. The impact their modelling of positive behaviour on attitudes, while assessing self-harming patients, has on ED nurses may have affected the study results. While the response rate appears impressive it is not known if the nurses who did not respond were the really negative ones. –– The reliance on self-report data to examine a sensitive topic poses the risk for nurses of self-incrimination. Antipathy scores may be reduced if nurses feel that such views clash with their professional self-image and/or are socially desirable, although anonymity may have reduced this effect. –– The relationship between attitudes and actual nursing care was not examined in this study. There is need for further research measuring nurses’ actual caring behaviour towards those presenting with self-harm in the ED.
Implications for practice The care and treatment provided to self-harming patients is likely to be dependant on how nurses regard these patients. An understanding of the way nurses intend to behave towards self-harming patients and the attitudes which give rise to these intentions is, therefore, very important (McKinlay et al., 2001). Furthermore, the care provided to self-harming patients may be improved through the delivery of educational curricula, at both undergraduate and postgraduate level. This education must emphasise the potentially emotionally satisfying and job-enriching nature of work with these patients (McKinlay et al., 2001), and have a greater focus on the influence of social judgment and attitudes on the quality of care and treatment they receive.
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Conclusion Despite the aforementioned limitations, this study has provided valuable data of ED nurses’ attitudes towards selfharming patients, using the Self-Harm Antipathy Scale (Patterson et al., 2007a), and contributes to the work of Patterson et al. (2007b) and McCarthy and Gijbels (2010). Generally the nurses in this study showed slightly negative antipathy overall indicating positive attitudes towards self-harming patients. Older nurses reported statistically significant lower antipathy, and a more positive attitude towards this patient group. Education and judgment also contributed to the way nurses view, interact and make moral decisions for and with patients. Identification of antipathy, on its own, is not sufficient to improve the care experience for the self-harming patient in the ED (Patterson et al., 2007a). Specific steps, for example clinical supervision, have to be taken to encourage and enable nurses to look at their attitudes and strengthen awareness to self-harm in a non-threatening environment. The retention of older, experienced staff, especially those who have received training in self-harm is vital to benefit the outcomes of care for this population. Improved training and educational opportunities would lead to less judgment and a greater understanding of the problems and needs of the self-harming patient. The result should be a more appropriate experience for self-harming patients in the ED and a reduction in the self-harm and suicide rate. Further and more comprehensive research should be conducted in this area to establish a greater evidence base. This could involve an experimental before–after design study conducted into the effectiveness of an educational intervention aimed at improving nurses’ attitudes, knowledge and confidence in caring for patients who self-harm.
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