Review
Attitudes of emergency care staff towards young people who self-harm: A scoping review

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Abstract

Aim

To determine whether reported attitudes towards patients who attend A&E following self-harm extend to young people.

Background

Historically A&E staff have displayed negative attitudes towards patients who self-harm, although more recent research suggests that attitudes have shifted. There is retrospective evidence of low satisfaction with A&E services by individuals who self-harmed as adolescents, with comparatively little research which has specifically examined attitudes towards adolescent self-harm available.

Method

A scoping review of papers published from 2000 to 2012 was undertaken, papers accessed through the following databases, British Nursing Index, CINAHL, Medline, Psychology and Behavioural Science Collection, and PsychINFO. Hawker et al.’s (2002) methodology for critical appraisal was adopted.

Results

Eleven papers derived from nine studies were located; three studies adopted qualitative methods, two mixed methods; the remainder were quantitative adopting a survey approach to measure attitudes. The studies revealed inconsistent findings, although the setting, patients’ characteristics and education and training all appear to have a bearing on attitudes towards young people who self-harm.

Conclusion

Further research is required which considers attitudes of emergency care practitioners within the context of emergency care work, and which investigates whether being a young person per se has an influence on attitudes.

Introduction

The number of patients (adult and adolescents) who access emergency services in England following self-harm increased by 11% between 2007 and 2010 (Fernandes, 2011). The increasing prevalence of adolescent self-harm and the association of self-harm with premature death (Bergen et al., 2012) means that young people with a history of self-harm are identified as a high-risk group in the UK’s suicide prevention strategy (H.M. Government, 2012). Adolescent self-harm, while sharing some commonality with self-harm in adults, has distinct features; there is an association with timing of self-harm and the school year, with exam stress and bullying evident as risk factors (Fox and Hawton, 2004). Difficult relationships with peers and family are also risk factors for young people (Evans et al., 2004), who are less likely to be serious in their suicide intent (Hawton and Harriss, 2008, Royal College of Psychiatrists, 2010).

Interest in attitudes of A&E staff towards self-harm has arisen as historically patients who overdose have been cited as ‘unpopular’, an observation made in Jeffery’s (1979) study and further conceptualised in a review by Cresswell and Karimova (2010), which draws attention to the discriminatory treatment of patients who self-harm in both in-patient psychiatric units and A&E departments. The National Institute Health and Clinical Effectiveness (NICE, 2004) acknowledged that the level of care provided in emergency services following an episode of self-harm was ‘often unacceptable’ (National Institute Health and Clinical Effectiveness, 2004, p. 7). Moreover, studies which have ascertained service users’ perspectives of their care as adolescents reveal less satisfaction with care received in A&E departments than in other services (Harris, 2000, Nada-Raja et al., 2003, Brophy, 2006), with a graphic account of the poor quality care as experienced by a young person in an A&E department evident in McDougall et al.’s book (2010, p. 175).

Nevertheless, recent research indicates that attitudes held by A&E practitioners towards patients who self-harm are now more benign (Sun et al., 2007, Suokas et al., 2008, McCarthy and Gijbels, 2010, Conlon and O’Tuathail, 2012), but while there has been a fairly substantive interest in attitudes towards self-harm, the extent to which these attitudes have been examined in relation to adolescent self-harm is comparatively minimal. As A&E departments fulfil a key role in the care of young people who self-harm and the concomitant prevention of suicide (H.M. Government, 2012), this scoping review aims to determine whether reported attitudes towards patients attending A&E services following an episode of self-harm extend to young people.

Section snippets

Design

An initial search of databases revealed that although there is a body of research that has examined attitudes of A&E practitioners towards self-harm, there is comparatively little research that has examined attitudes towards young people who self-harm, consequently a scoping review was the method adopted. The Centre for Reviews and Dissemination (2008) advise that a scoping review is appropriate to gauge the size and nature of the evidence base for a particular topic area with a view to

Methods

A search of the following databases was conducted, British Nursing Index, CINAHL, Medline, Psychology and Behavioural Science Collection, and PsychINFO. Google Scholar was also used to follow up on specific papers using the facility of ‘cited by’ and ‘related articles’. The search was limited to English language publications; no limits were placed on country of publication. In order to capture a range of papers, studies were included that had been published over a 12-year period (2000–2012);

Search results

Having excluded duplication across the searches, 302 abstracts were reviewed; nine papers met the inclusion criteria. A further two papers were located by following up references on these papers. Following critical appraisal 11 papers, derived from nine studies were included in the analysis (Anderson et al., 2000, Anderson et al., 2003, Anderson et al., 2005, Crawford et al., 2003, Anderson and Standen, 2007, Dickinson et al., 2009, Law et al., 2009, Wheatley and Austin-Payne, 2009, Dickinson

A note on terminology – suicide, attempted suicide and self-harm

Scholars working in the field of suicide have for over 50 years been trying to gain consensus on satisfactory terminology to describe various suicidal behaviours (Skegg, 2005). This is evident in the papers reviewed which variously used ‘self-mutilation’ (Rissanen et al., 2011), ‘suicidal behaviours’ (Anderson et al., 2000, Anderson et al., 2003, Anderson et al., 2005) ‘deliberate self-harm’ (Crawford et al., 2003) and ‘self-harm’ (Dickinson et al., 2009, Law et al., 2009, Wheatley and

Methodological considerations

With the exception of four studies, (Anderson et al., 2000, Anderson et al., 2003, Anderson et al., 2005, Rissanen et al., 2011), all the studies drew on quantitative methodology using a survey approach. Two studies adopted a mixed methods approach (Anderson et al., 2000, Dickinson et al., 2009); Dickinson and Hurley’s (2011) subsequent paper reported only on the quantitative components of their data set. The qualitative studies undertaken by Anderson et al., 2003, Anderson et al., 2005 reports

Overview of findings

Overall the studies revealed inconsistent findings in relation to the influence of gender, occupation and length of experience (see Table 1). Two studies examined whether there was a relationship between practitioners’ age and attitudes, with no association found (Anderson et al., 2000 Dickinson and Hurley, 2011).

In terms of education and occupation, doctors were more knowledgeable in Crawford et al.’s (2003) study, with psychiatric doctors demonstrating highest level of knowledge. It is

Themes

Following thematic analysis, three themes were identified, the ‘setting/service’, ‘patient characteristics’ and ‘education makes a difference’. Table 2 provides a tabular summary.

Discussion

Eleven papers derived from nine studies provided the basis for this review; each study adopted a different approach to the measurement and analysis of attitudes, thus a definitive picture of attitudes towards young people who self-harm has not been possible to ascertain at this stage. Moreover, only five of the papers included practitioners working in accident and emergency care within their study population. Nevertheless as per the remit of a scoping review, gaps in the literature are

Conclusion

Studies that have examined attitudes towards young people who self-harm are to date limited in scope, and thus it is unclear as to whether the more benign attitudes reported in recently published studies (Sun et al., 2007, Suokas et al., 2008, McCarthy and Gijbels, 2010, Conlon and O’Tuathail, 2012) extend to young people. Given the limited number of studies specific to emergency care, further research is required which considers attitudes towards young people who self-harm within the context

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      Recent studies reported more positive attitudes from emergency staff which contrasts with a recent systematic review [22], and studies investigating the patients' perspective [10,12,21,39]. A recent scoping review of attitudes of emergency care staff towards young people who self harm [39] recognised benign attitudes towards self harm in recently published studies which reflects the mixed picture of our findings. The findings of more positive attitudes towards self harm from emergency staff is unclear, it may demonstrate the influence of education, policy, guidelines or media reporting, but this has yet to be examined.

    • A mixed method study to determine the attitude of Australian emergency health professionals towards patients who present with deliberate self-poisoning

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      In addition, a negative emergency department experience may participate in the inducement of the cyclic behaviour of self-harm for this population (NICE:CG16, 2004). As DSH has been associated with premature death including future suicide (Gairin et al., 2003; Cooper et al., 2005; Bergen et al., 2012; Cleaver, 2014), then the attitude of emergency staff, towards a person who deliberately self-harms, plays an important part in the treatment and care of these patient’s (Sun et al., 2007). Studies investigating health care worker’s attitudes toward patients who deliberately self-harm have shown conflicting results.

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