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

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Abstract

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.

Introduction

The improved management of patients who engage in self-harm is highlighted in most suicide prevention strategies (Department of Health, 2002, Health Service Executive et al., 2005, Ministry of Health New Zealand, 2006). It is also the subject of clinical guidelines such as the NICE guideline on self-harm (National Collaborating Centre for Mental Health, 2004). This document highlights standards of care and notes the often negative experiences of self-harm patients of current services, which were the subject of a recent systematic review (Taylor et al., 2009).

The attitudes held by clinical staff towards people who harm themselves, together with their knowledge about self-harm, are likely to be important influences on their clinical practice and hence on the experiences and outcomes of those they treat (Pompili and Girardi, 2005). We have conducted a systematic review of the international literature on staff attitudes towards patients who present to hospital following an episode of self-harm. Our aim was to summarise current knowledge about staff attitudes and knowledge of clinical staff regarding people who self-harm to inform the design of clinical services, particularly with regard to training staff.

Section snippets

Method

We sought to include both quantitative and qualitative studies of staff attitudes towards, and knowledge about, people who engage in self-harm where staff were involved in the provision of services to them. We searched Electronic databases (AMED, British Nursing Index, CINAHL, International Bibliography of Social Sciences, MEDLINE and PsychInfo) for any relevant literature up to the first week of July 2011. The search strategy is shown in Appendix 1. References from identified studies were

Results

The studies included in the review are summarised in Table 1. Six main themes were identified: (i) general attitudes, (ii) relationship between staff characteristics and attitudes, (iii) influence of characteristics of people who harm themselves on staff attitudes, (iv) knowledge and understanding of why people self-harm, (v) effects of training on staff attitudes and knowledge, and (vi) suggestions for improving attitudes and services.

Discussion

The results of this review highlight the extent to which medical and nursing staff in general medical settings tend to view those who self-harm in a negative way. This was found in several countries. There was little difference between newer and older studies, despite the dramatic increases in awareness, guidance and publicity regarding the prevalence, risk factors and management following of people following an episode of self-harm. On the other hand, rates of self-harm have steadily increased

Role of funding source

There was no specific funding for this review. KH is supported by Oxfordshire and Buckinghamshire NHS Foundation Trust. KH is also supported by the National Institute for Health Research (NIHR) and is an NIHR Senior Investigator. KS and SH are supported by the Oxford University Clinical Academic Graduate School. The sponsor had no role in the development, design, data collection, analysis or interpretation.

Conflict of interest

KS, KH, SF and SM have no relationships with companies that might have an interest in the submitted work in the previous 3 years; their spouses, partners, or children have no financial relationships that may be relevant to the submitted work; and KS, KH, SF and SM have no non-financial interests that may be relevant to the submitted work.

Acknowledgements

This review builds on earlier work by Allan House and Judith Horrocks who kindly gave us access to their collection of papers. We thank Louise Harris and Lesley Sutton for assistance in screening abstracts and papers and Judy Hodgson for helping retrieve reports.

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