Jo McHale explores attitudes and perceptions to self-harm.
My article on self-harm was reported on the Nursing Times site a couple of weeks ago. My research involved looking at healthcare professionals’ attitudes towards people who had self-harmed. From the literature reviewed I found that a main focus was on a lack of training. It wasn’t so much the topic of self-harm that intrigued me, moreover why it evoked such a reaction from staff. The response to this report has not changed that intrigue.
Some of the readers comments made in response to the report confirmed for me that negative attitudes are not a rarity; people make these statements suggesting that people are not worthy of care and appear to be fairly certain that others will follow suit. Being non-judgemental is a key requirement of being a nurse and is clearly stated in the NMC code of professional conduct. We are taught within our nursing education and practice placements that the care we offer has to reflect diversity and equality and yet it appears to me that people who have self-harmed are excluded from this.
The literature review looked at 19 research papers and following analysis we found 6 key themes: education and training needs; role expectation and clinical need;perception of health need; dissatisfaction with care; education and training use and knowledge of self harm. Of these, 4 are related to education and training - the main message from this review. Where training has been provided, healthcare professionals are reporting greater knowledge and understanding, which they believe has improved their own attitudes towards the profession. The recording of people’s attitudes is difficult, as a social desirability factor may determine the nature of responses to research - an attempt to improve how they themselves are viewed. However, as I previously mentioned, the comments made in response to the report suggest that discussing a negative attitude towards self-harm is seen as acceptable.
The people who have received treatment following self-harm report dissatisfaction with the care they received; in fact, in my search there were no reports concluding service-user satisfaction. Although, worth noting is the result from one internet based study that found 50% of patients did not report dissatisfaction or worse; although as an outcome I hope we as healthcare professionals are seeking more than this.
The level of dissatisfaction felt by some respondents in the research covered has meant that some would not return for treatment in the future. When this is considered alongside the fact that people who have been seen in hospital settings are 66 times more likely to commit suicide in the year following, it does not offer a reassuring insight into care provision. What I found particularly intriguing in the litearature search was how little service-user evaluations of care had been consulted.
For me, it seems difficult to meet expectations of care when these are not actively identified. However, the hurdle that is ‘ethical approval’ may mean this is a difficult area to research - although service audits and evaluation may offer an alternative. Where service-users expectations have been mentioned, these have been skills or practice that nurses will consider fundamental - being listened to and being able to provide adequate pain relief. This does not feel a lot to offer people who have been in distress.
Role expectation and clinical culture was the final theme identified, which in particular related to differences between expected roles and actual roles. Both mental health and general nurses felt that their clinical areas were not set up for dealing with people who had self-harmed. Both branches felt that the care they wanted to provide - and had been taught to provide - was limited, due to the constraints of clinical areas and policis such as ‘risk assessment’ being viewed as paramount. The common reaction to dissatisfaction with self-harm care is the integration of branches to one nursing programme, along with the introduction of mental health workers into A&E departments. However, from the literature reviewed this would not resolve the issue, as it is not a stand-alone issue that only RGN’s are facing.
Self-harm is not only a mental health or an A&E issue. Whether we are general nurses, mental health nurses, children’s nurses, learning disability nurses or any other healthcare professional, we will face the issues that surround self-harm. And if we will encounter them then we need to be prepared, which brings us back round to training and education: it should be mandatory and it should be for all.