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'Self -harm training and education should be for all'


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. 


Readers' comments (3)

  • To Jo and other interested readers

    Please do not take this the wrong way, I am just nit-picking but you state in your opening paragraph that it is not self-harm that intrigues you but rather the reaction of nurses. This suggests that you may also disdain this group of patients, although I do not think you would have carried out this research if you did.

    "..the comments made in response to the report suggest that discussing a negative attitude towards self-harm is seen as acceptable."

    Although I haven't counted, I note that many of those making the comments expressing negative attitudes following your article and mine, entitled "The stress increases until you think you will burst" 16 October 2010, used the option of anonyimity which perhaps makes it appear more acceptable, and which I have also for my article!

    I am pleased you have published these two intersting articles which highlight a vital point about the lack of training of nurses in self-harm. I believe absence of knowledge of this¨problem and comorbid mental health disorders leads to their lack of understanding and empathy, fear and sometimes disgust.

    I have seen patients in this area who have received very poor or non-existant treatment and have been very shocked at the reactions of some of the nursing and medical staff. this is also reflected, as you point out, in important feedback from patients. However, as I omitted in my article, and somebody kindly pointed out in the comments which followed, patients who self-harm often have other comorbid mh disorders and can be very difficult to treat and can be aggressive or adopt various other difficult to cope with attitudes. They are not always able to accept help very easily which they sometimes percive as interference or a threat and may fail to recognise that help is intended. Although they may present to A&E themselves, they are often brought in on the insistence of somebody else such as a relative, paramedics or the police, and sometimes by force, so that they can receive treatment and protection from further harm to themselves. This treatment resistence needs to be recognised and acknowledged and addressed and indicates that a very high level of skill and training is required to approach them with the right attitude in order to identify and deliver the specific care that they need.

    Your article inspired mine as my initial comment became too long to submit following your article. I suggested that nurses with negative attitudes put themselves in the shoes of their patients and presented them with a set of questions. My original title was 'Put yourself in their shoes'. Unfortunately, editorial licence permitted NT to change this to their own existing title which I do not agree with as it is too much of a 'jingle', for want of a better word, and does not reflect the purpose of my article. They took the title from one minor phrase in my own text!

    I have written an article, yet to be published, along similar lines on the poor reception of patients with personality disorders by general nurses in medical services. I also perceived this was due to a lack of education and training in the psychopathology of patients with this group of disorders who also present freqently for self harm and a high incidence of attempted suicide. They tend to go from service to service seeking attention as they often fail to get the treatment they need.

    Kind regards, Anonymous RGN!

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  • Brilliant and far reaching comments-so often we can be didactic and it is these very patients who either self harm or have MH problems who need us to take a step back and say'what can we do for you that we have not done before'-I find this works very well

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  • As an RN (Child) and parent of teenagers, I come to this subject from 2 perspectives; as a professional and a parent. I also have a dear friend whose children have suffered with mh problems that have lead to (sometimes serious) self-harming issues. My own daughter harmed herself for 18 months, but never seriously enough to warrent hospital care. The most diffucult aspect to deal with was her total unwillingness to talk to us, her parents, or any other adults in the family. This difficult time gave me very valuable insight into the mindset of these troubled youngsters, and has helped me enormously in my nursing practice. My friends problems have been much more severe and her experiences of nursing care have been mixed. She is herself an experienced professional in the area of mh and has been saddened and troubled by the attitudes of A/E staff to these patients. I defy anyone to not confess to feeling at the end of their tether at times. For one person that may result in drinking too much and suffering the effects of a hangover. For others, more vulnerable to self-doubt and lack of self esteem, their actions take the form of harming themselves in a more permanent way. These people need help and not the derision of those health professionals in a position to assess their problems objectively and, if possible, facilitate the path to recovery.

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