Perceptions of service provision for clients who self-injure in the absence of expressed suicidal intent

A systematic review and mixed-methods synthesis of the experiences, perceptions and attitudes of prison staff regarding adult prisoners who self-harm

BACKGROUND

Self-harm, including suicide, is common among prisoners. Staff attitudes and perceptions regarding self-harm may affect quality of care and patient safety.

AIMS

To systematically review the experiences, perceptions and attitudes of staff in adult prisons regarding self-harm.

METHOD

Systematic searches of EMBASE, Medline, PsycINFO and CINAHL databases were conducted, and supplemented by hand-searching and grey literature review, to identify relevant English-language articles published since the year 2000. Articles were screened by two authors and evaluated with standardised quality appraisal tools. Qualitative data were analysed thematically, whereas quantitative data were narratively synthesised because of high study heterogeneity.

RESULTS

Two thousand articles were identified, of which 32 were included, involving 6389 participants from five countries. Most studies were moderate (n = 15) or poor (n = 10) quality, and seven were rated as good quality. Staff frequently witnessed self-harm and described multiple perceived risk factors and causes of this. Perceptions that self-harm is 'manipulative' or 'attention-seeking' were associated with hostility toward prisoners and lower quality of care. Perceived barriers to preventing and managing self-harm included low staffing levels, prison environments and culture, poor staff confidence and insufficient training. The importance of multidisciplinary teamwork and building staff-prisoner relationships were highlighted. Staff occasionally experienced intense psychological reactions to self-harm, which resulted in adaptive or maladaptive coping that influenced their capacity to care.

CONCLUSIONS

There are mixed attitudes and perceptions toward self-harm among prison staff. Further training, support and resources are required to protect staff's well-being and improve self-harm prevention and management in prisons.

Pediatric Nonsuicidal Self-Injury: A Call to Action for Inpatient Staff Training

The rising prevalence of nonsuicidal self-injury (NSSI) in pediatric populations along with the recent inclusion of NSSI as a condition for further study in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) have increased the focus on the assessment and treatment of NSSI among youth. Despite the frequent occurrence of NSSI in inpatient psychiatric treatment settings, there are no empirically based assessment protocols to guide clinical staff. This article presents findings from a needs assessment conducted with staff at a state-run child and adolescent inpatient treatment facility. The purpose was to assess the need for formalized NSSI training among staff. A questionnaire was developed to evaluate whether staff had received formal training in NSSI assessment and treatment as well as typical practice responses to patients engaging in NSSI behaviors. The questionnaire also evaluated staff comfort and confidence in their knowledge and skills concerning the assessment and treatment of NSSI among children and adolescents. Respondents were 126 clinical staff, most of whom were nursing staff. Only a minority of staff reported having received formal NSSI training, and a third of respondents indicated that they do not typically assess for NSSI at all. Although a substantial percentage of clinical staff self-reported comfort and confidence with assessing and treating NSSI, fewer than 10% demonstrated accurate skill. Formal training in NSSI is associated with positive outcomes for both patients and staff in general healthcare settings. These findings suggest that similar training for staff on pediatric inpatient psychiatric units will likely foster comfort, confidence, and accuracy, thereby improving outcomes for children and adolescents engaging in NSSI behaviors.

A qualitative study exploring female patients' experiences of self-harm in a medium secure unit

This study utilized a social constructivist model and reports upon interviews conducted with five female patients in a medium secure service. Their perception of self-harm is considered. Six themes emerged from the data, 'the traumatized individual', 'interrupted maturation process', 'the hidden experience', 'crossing the line', 'individual and systemic repercussions', 'nascent potential protection'. In addition to the six themes that emerged, we concluded that, although individual perceptions of self-harm varied, commonalities existed across accounts and that individual formulation may assist both patients and staff to gain a personalized understanding, thus, enabling less harmful ways of coping to be established.

Attitudes and knowledge of clinical staff regarding people who self-harm: a systematic review

BACKGROUND

The attitudes held by clinical staff towards people who harm themselves, together with their knowledge about self-harm, are likely to influence their clinical practice and hence the experiences and outcomes of patients. Our aim was to systematically review the nature of staff attitudes towards people who engage in self-harm, including the factors that influence them, and the impact of training on attitudes, knowledge and behaviour of staff.

METHODS AND FINDINGS

A comprehensive search for relevant studies was performed on six electronic databases. Two independent reviewers screened titles, abstracts and full reports of studies, extracted data and gave each paper a quality rating. Qualitative and quantitative studies published in English were included. A total of 74 studies were included. Attitudes of general hospital staff, especially doctors, were largely negative, particularly towards individuals who repeatedly self-harm. Self-harm patients were viewed more negatively than other patients, except those abusing alcohol or drugs. Psychiatric staff in community and hospital settings displayed more positive attitudes than general hospital staff. Negative attitudes were more common among doctors than nursing staff although this was only true of general hospital staff. Active training led to consistent improvements in attitude and knowledge in all groups.

CONCLUSIONS

Attitudes of general hospital staff towards self-harm patients are often negative, mirroring the experience of service users. Interventions can have a positive impact and improve the quality of patient care.

LIMITATIONS

Included only English language publications.

Self-harm and attempted suicide within inpatient psychiatric services: a review of the literature

Self harm is a major public health concern, yet there are considerable challenges in providing support for those who self harm within psychiatric inpatient services. This paper presents the first review of research into self harm within inpatient settings. Searches of the main electronic databases were conducted using key words for self harm and inpatient care. There was substantial variation in the rates of self-harm and attempted suicide between studies, but rates were highest on forensic wards. There was no evidence of differences in prevalence of self-harm between men and women; women, however, were at increased risk of attempting suicide. People were more likely to self-harm in private areas of the ward and in the evening hours, and often self-harmed in response to psychological distress, or elements of nursing care that restricted their freedom. Wards used a variety of strategies to prevent self-harm; however, there is little research into their effectiveness.

'They don't understand…you cut yourself in order to live.' Interpretative repertoires jointly constructing interactions between adult women who self-harm and professional caregivers

The aim of the study was to illuminate interpretative repertoires that jointly construct the interaction between adult women who self-harm and professional caregivers in psychiatric inpatient care. Participant observations and informal interviews were conducted among six women who self-harm and their professional caregivers in two psychiatric inpatient wards, and analysed using the concept of interpretative repertoires from the discipline of discursive psychology. The analysis revealed four interpretative repertoires that jointly constructed the interaction. The professional caregivers used a “fostering repertoire” and a “supportive repertoire” and the women who self-harmed used a “victim repertoire” and an “expert repertoire.” The women and the caregivers were positioned and positioned themselves and people around them within and among these interpretative repertoires to make sense of their experiences of the interaction. It was necessary to consider each woman's own life chances and knowledge about herself and her needs. The participants made it clear that it was essential for them to be met with respect as individuals. Professional caregivers need to work in partnership with individuals who self-harm—experts by profession collaborating with experts by experience. Caregivers need to look beyond behavioural symptoms and recognise each individual's possibilities for agency.

Self-harm: what's the problem? A literature review of the factors affecting attitudes towards self-harm

People who have experienced self-harm report dissatisfaction with the care provided by statutory services. This review provides a critical exploration of the evidence examining the attitudes of healthcare professionals across both mental health and medical settings towards people who self-harm. It also explored in detail service users perceptions of care. A literature search conducted via electronic databases and cross-matching reference lists produced 19 papers that met the inclusion criteria. A thematic analysis of the literature indicated six key areas which contributed to the development of attitudes defined as positive or negative towards people who self-harm. Negative attitudes and experiences of care were associated with lack of education and training, the impact of differences in perceptions of health professionals' role and the influence of clinical culture as well as how self-harm was perceived as a health need. More positive attitudes were associated with a greater understanding of experiences of self-harm and improved training. However, the nature of care reported by service users indicates that there are still significant improvements needed to the attitudes in health settings to ensure they receive a high-quality service.

Held to ransom: Parents of self-harming adults describe their lived experience of professional care and caregivers

The aim of the study was to discover and describe lived experiences of professional care and caregivers among parents of adults who self-harm. Narrative interviews were conducted with six parents of daughters with self-harming behaviours and analysed using a phenomenological hermeneutic approach. The meanings of the parents' narratives of their lived experiences of professional care and caregivers were interpreted as their being involved in 'limit situations' comparable to hostage dramas. Several meaningful themes contributed to this interpretation: being trapped in a situation with no escape; being in the prisoner's dock; groping in the dark; and finding glimmers of hope. Parents of daughters who were in care because of self-harming often felt obliged to pay an emotional ransom, which included feelings of being accused, being 'broken', being confused, and feeling lost. Moments of peace occurred as welcome breaks offering a short time of rest for the parents. Situations that were understood by the parents and solved in a peaceful way were experienced as a respite and inspired parents with hope for their daughters' recovery.

Attitudes towards clinical services among people who self-harm: systematic review

BACKGROUND

Self-harm is increasingly common in many countries, is often repeated and may have other negative outcomes.

AIMS

To systematically review people's attitudes towards clinical services following self-harm in order to inform service design and improvement.

METHOD

A search of electronic databases was conducted and experts in the field were contacted in order to identify relevant worldwide qualitative or quantitative studies. Data were extracted independently by two reviewers with more weight given to studies of greater quality and relevance.

RESULTS

Thirty-one studies met the inclusion criteria. Despite variations in healthcare systems and setting, participants' experiences were remarkably similar. Poor communication between patients and staff and a perceived lack of staff knowledge with regard to self-harm were common themes. Many participants suggested that psychosocial assessments and access to after-care needed to be improved.

CONCLUSIONS

Specific aspects of care that might increase service user satisfaction and treatment adherence include staff knowledge, communication and better after-care arrangements. A standard protocol could aid regular audits of users' experiences of services.

Perspectives of mental health professionals and patients on self-injury in psychiatry: a literature review

Professionals in psychiatry often encounter patients who injure themselves. To explore the perspectives of mental health professionals and patients on self-injurious behavior and treatment, the authors carried out a literature review. The reviewers found little documented data that elucidated or discussed any shared understanding about self-injurious behavior between patients and professionals or between professionals themselves. Many of the problems experienced in relation to self-injury may be due to this lack of a common view. There were few evidence-based strategies for managing self-injury that received any attention in the literature. Future studies should focus on the development and testing of preventative interventions, putting particular emphasis on effective communication between professionals and patients.

Community psychiatric nurses' experience of working with people who engage in deliberate self-harm

This paper reports on a study that explored community psychiatric nurses' experiences of working with people who self-harm. Interpretative Phenomenological Analysis was used with eight experienced community psychiatric nurses who participated in semi-structured interviews. Established quality control procedures were utilized including audit of the analysis process and validating the results with participants. The participants described struggling to conceptualize self-harm behaviour and generally reported finding working with people who self-harm stressful particularly in terms of managing the emotional impact upon themselves and the boundaries of their professional responsibilities in relation to managing risk. The therapeutic relationship was viewed as crucial and a variety of coping methods to manage the impact of the work, which had largely developed through 'on the job', experience were described. The results highlight the potential difficulties faced by community staff and can be translated into clear recommendations for training and support.

Service user views and expectations of UK-registered mental health nurses: A systematic review of empirical research

OBJECTIVES

To review national (UK) literature in order to (i) examine service user and carer views of UK-registered mental health nurses; (ii) identify the diversity of populations from which these views have been collected; (iii) assess the methodological rigour of the current knowledge base and (iv) evaluate the extent to which service users and carers have been involved in the development and execution of this work. This paper reports only on service users' views.

DESIGN

Systematic review.

DATA SOURCES

Electronic and evidence-based databases, reference checking and hand searching of key academic journals, national policy and user/carer organisational websites.

REVIEW METHODS

Two reviewers independently undertook study eligibility judgements and data extraction. Eligible studies were sub-classified according to service setting (inpatient/residential, community/non-residential or mixed/unspecified). Each study was assessed against key quality criteria. Data were synthesised in a narrative format.

RESULTS

One hundred and thirty two studies were included in the review. The majority were small-scale academic studies biased towards white, adult service users. Few studies provided evidence of user collaboration. Service users regard mental health nursing as a multi-faceted role delivering practical and social support alongside more formal psychological therapies. Service users report inadequate information provision, poor inter-professional communication and a lack of opportunities for collaborative care. Service users perceive inpatient mental health nurses as particularly inaccessible.

CONCLUSIONS

UK-registered mental health nurses should be equipped with both therapeutic clinical skills and generic skills associated with relationship building, engagement and communication. Future research should be conducted in collaboration with service users and include clear and effective mechanisms for the dissemination and implementation of research findings. In particular, the views of children and adolescents, the elderly and black and minority ethnic groups, currently under-represented in research, should be examined.

Guilt and shame: experiences of parents of self-harming adolescents

This paper reports the findings of a qualitative study that used a hermeneutic phenomenological methodology to develop insights into the experience of parents of young people who engage in self-harming behaviour. Six mothers (and one father who accompanied his wife) participated in the study. Findings reveal that mothers experienced guilt and shame, and that these feelings shaped their reactions and responses. These mothers described experiencing emotional dilemmas, such as the degree to which they could be responsible, uncertainty about how to understand self harm, and the best course of action to take with their child. They also encountered difficulties in combating the negative emotional effects for themselves and other family members. Findings provide insights that can help nurses and family health workers to understand and assist parents with greater effectiveness; by maintaining a non-judgemental stance, acknowledging the difficulties of their experiences, encouraging confidence in their parenting abilities, and promoting effective stress management strategies.

Pragmatism rules: the intervention and prevention strategies used by psychiatric nurses working with non-suicidal self-harming individuals

Self harm in the absence of expressed suicidal intent is an under explored area in psychiatric nursing research. This paper reports on findings of a study undertaken in two acute psychiatric inpatient units in Ireland. The purpose of the study was to gain an understanding of the practices of psychiatric nurses in relation to people who self harm, but who are not considered suicidal. Semi structured interviews were held with eight psychiatric nurses. Content analysis revealed several themes. For the purpose of this paper the prevention and intervention strategies psychiatric nurses engage in when working with non-suicidal self harming individuals are presented. Recommendations for further research are offered.

Understanding psychiatric nursing care with nonsuicidal self-harming patients in acute psychiatric admission units: the views of psychiatric nurses

Self-harm in the absence of suicidal intent is an underexplored area in psychiatric nursing research. This article reports on findings of a study undertaken in two acute psychiatric admission units in Ireland. The purpose of this study was to gain an understanding of the practices of psychiatric nurses in relation to people who self-harm but who are not considered suicidal. Semistructured interviews were held with eight psychiatric nurses. Content analysis revealed several themes, some of which will be presented and discussed in this article, namely, the participants' understanding of self-harm, their approach to care, and factors in the acute psychiatric admission setting, which impacted on their care. Recommendations for further research are offered.