It is often found in literature that self-harming patients presenting themselves at the accident and emergency departments, even if not for problems related to self-harm, are perceived negatively (Saunders et al., 2011). Saunders et al. (2011) add that the attitudes held by clinical staff towards individuals who self-harm, together with the knowledge about self-harm, tend to have an influence in their clinical practice, affecting the experiences and outcomes for the patient. The World Health Organisation (2011) reports that an estimate of 53 males and 2 females commit suicide in Malta annually.
Emerson (2010), carried out a literature review focusing on five nursing studies, namely:
Authors Date Research Design Location Comments
Tay et al., 2004 Quantitative Study Singapore Psychiatric Hospital Liggings and
Hatcher
2005 Qualitative Study New Zealand
McCann et al., 2006 Quantitative Australia A&E Department
Patterson et al., 2007 Quantitative UK General Nurses, Mental Health Nurses and Social Workers included in the study Anderson and
Standen
2007 Doctors and Nurses. Included A&E, Paediatric medicine and adolescent inpatient mental health services
Table 3.7. Studies included in the literature review by Emerson (2010)
In a critique of these five studies, Emerson (2010) identifies three themes. The first theme involves the exposure of nurses towards self-harm. It was found that the length of time on the nursing register correlates with a more positive attitude. Thus, one might assume that years of service or experience would have an influence on the nurses’ attitudes. This finding was highlighted in the study carried out by Tay et al. (2004).
The second theme to emerge from the review by Emerson (2010), described the stigma associated with self-harm and how applying a label of mental illness to persons who self-
harm can have a negative impact on the delivery of care. Liggins and Hatcher (2005) together with Anderson and Standen (2007) describe that stigma can be destructive and infringe on the person’s life. This would affect how they act and how they live their lives. It lowers a person’s self-esteem and might in turn also lead to dangerous health issues. The third theme to emerge from the work of Emerson (2010) identifies the need for health professionals to receive up-to-date training. Emerson (2010) reviews the findings of Patterson, Whittington and Bogg (2007), suggesting that there is no clear separation between nurses having negative or positive attitudes towards individuals who self-harm. It also shows there are different extents of attitudes that can be altered depending on the circumstances that the nurse is currently facing.
In another review by McHale and Felton (2010), 19 papers are discussed, 13 of which originated from the UK. All participants in these reviewed studies were adults over 18 years of age. These studies included:
Authors Date Design Sample Setting Location
Crawford et al., 1998 Questionnaire and notes reviewed before and after educational interventions
Convenience sample of 52 nurses and 15 junior medics
A&E department UK Harris 2000 Qualitative study Self-selected sample of six women UK Holdsworth et al., 2001 Questionnaires and
reflective diary
13 nurses A&E, minor injuries and medical assessment units
UK Hopkins 2002 Participant observation;
semi-structured interviews and reflective journal
Purposive sample of four from two medical wards
Medical wards UK Jeffery & Warm 2002 Questionnaire Opportunity sample of 96 including
professionals and people who self- harmed
UK McAllister et al., 2002 Questionnaires 352 nurses A&E department Australia Smith 2002 Unstructured Interviews
and semi-structured interviews
3 self-selected service users; 9 nurses; 3 occupational therapists, 2 psychotherapists and 1 psychiatrist
UK Warm et al., 2002 Questionnaires 243 Self-selected service users UK Lindgren et al., 2004 Interviews 9 self-selected females Community settings Sweden MacKay &
Barrowclough
2005 Convenience sample of 89 A&E nursing and medical staff
A & E department UK Friedman et al., 2006 Focus groups and
questionnaires
Focus groups six of eight people and questionnaires to 88 nurses and 29 doctors
UK McCann et al., 2007 Questionnaire Convenience sample of 43 A&E
nurses
A & E department Australia McCann et al., 2007 Exploratory Study Convenience sample of 43
registered nurses
Emergency Department
Australia O’Donavon 2007 Semi-structured interviews Convenience sample of 8 nurses 2 Inpatient settings Ireland Patterson et al., 2007 Quasi-experimental study
using questionnaires
Self-selecting sample of 69 healthcare professionals
UK Patterson et al., 2007 Quantitative Survey Self-selected sample – 153
respondents attending post registration education
UK Wilstrand et al., 2007 Narrative interviews Purposive sample of 6 psychiatric
nurses
Inpatient psychiatric ward
Sweden Hadfield et al., 2009 Semi- structured
interviews 5 qualified doctors A&E department UK McAllister et al., 2009 Qualitative interviews Purposive sample of 29 nurses A&E department Australia
It appears that in the studies reviewed by McHale and Felton (2010), there is a general agreement that nurses and health care professionals perceive individuals who self-harm negatively. Key factors contributing to this negativity include the necessity of more education and training on the subject, staff confidence and poor knowledge on self-harm. There is a general agreement within all the studies reviewed that education, more specifically the lack of it, is considered the primary rational for negative attitudes. Education is considered to promote quality of care through positive attitudes as this helps to better understand the presenting situation, in this case, self-harm (McHale and Felton, 2010). Of note are the findings of Patterson, Whittington and Bogg (2007) that mental health nurses were less likely to have negative attitudes compared to medical nurses. Several hypotheses are given to illustrate these results. Patterson, Whittington and Bogg (2007) feel that this might be due to the difference in the pre-registration education. McHale and Felton (2010) add that this might also be explained by the demand characteristics of the specialised area. Another suggestion might be due to the amount of contact with this specific client group. This places mental health nurses in a position to be more knowledgeable on the subject, due to their training, work in an environment that provides specific care to this client group thus being more exposed to self-harming individuals.
Although Emerson’s (2010) review of the literature only focused on 5 studies as opposed by the 19 studies reviewed by McHale and Felton (2010) the conclusions are very similar. Both researchers have reviewed international studies. This provides the opportunity to compare results globally as well as consider any cultural influences.
In another systematic review on the attitudes and knowledge of clinical staff regarding people who self-harm, 73 studies were reviewed (Saunders et al., (2011). These studies were published between 1971 and 2009. All studies were in the English Language and originated from various countries. The majority (36) originated from the UK. Of note is that a study included in this review originated from Malta (Ghodse et al., 1986). Titles, abstracts, then followed by full text, were screened by two members of the research team independently. Quality ratings were given using a combination of the Critical Appraisal Skills Programme (CASP, 2002) and the Social Care Institute for Excellence’s quality assessment tool (SCIE, 2006). Six common themes emerged from this review which include, general attitudes, relationship between staff characteristics and attitudes, influence
of characteristics of people who harm themselves on staff attitudes, knowledge and understanding of why people self-harm, effects of training on staff attitudes and knowledge and lastly suggestions for improving attitudes and services. Saunders et al. (2011) suggest that it is unclear whether the age of the staff influences attitudes but experience and the extent of exposure to individuals who self-harm appears to have a greater impact. They add that in a Psychiatric setting experience was found to be associated with improvements in attitude whilst this was seen as the complete opposite in the general hospital setting. This review also illustrates that the working environment might also play a key factor on the attitudes of nurses, as it was found that negative attitudes towards individuals who self- harm is associated with higher levels of burnout and low personal accomplishment. Although no studies compared different professions whilst controlling for gender, the authors describe that female staff had more positive attitudes than males (Anderson et al., 2000; Ghodse, 1978; Samuelsson, Asberg and Gustavsson, 1997).
More negative attitudes were expressed towards individuals who repeatedly self-harm. This was reported in all three reviews (Emerson 2010; McHale and Felton, 2010; Saunders
et al., 2011). General hospital staff viewed self-harming behaviour as attention seeking
behaviour whilst psychiatric staff were more interested in understanding why individuals resorted to self-harm. Of note is that McHale and Felton (2010) identify that general medical staff hold more negative attitudes than nurses. This might be due to the greater opportunities that nurses have to build a therapeutic relationship with the patients and also can spend more time with them. A limitation of these reviews (Emerson, 2010; McHale and Felton 2010; Saunders et al., 2011), is that only studies carried out in the English language were considered, limiting the inclusion of non-westernised countries. Although, the inclusion of both qualitative and quantitative research designs allowed for the inclusion of a wide range of studies, this limits the ability to make detailed comparisons of findings beyond general themes.
3.10 Attitudes of Nurses towards individuals suffering from Schizophrenia and Major