Risk management in mental health settings is currently a hotly debated issue. This paper offers an insight into the issue of self-harm and negative attitudes amongst nursing staff. It is argued that change in staff conduct is unavoidable, if professional standards are to be maintained. Change can be achieved through a cognitive approach.
The Clinical Setting
The setting for this discourse is a 24-bed acute care ward in a local NHS psychiatric hospital. On average about 90 patients are admitted to this ward on a monthly basis. All patients are subject to an initial assessment immediately upon admission, during which various psychosocial data is collected. While a small minority of patients are transferred from other wards/hospitals, the vast majority of cases are admitted directly into the ward on the basis of GP referrals, or the recommendations of ambulance staff. Several primary nurses and midwifes have ultimate responsibility for supervising patient care (assessment, rehabilitation, etc), and manage a team of other nurses and ancillary staff. A team of consultant psychiatrists are principally responsible for diagnosis and treatment.
This paper considers risk from the point of view of the patient. Traditionally, risk management in mental health settings has focused on self-harm – patients deliberately or unknowingly causing injury to themselves, which in turn may result in severe pathology or even death (Johnstone, 1997). Suicide is perhaps the most extreme form of self-harm that mental health professionals have to deal with (Long et al, 1998). Other risks have also been considered including psychological issues such as loss of dignity, autonomy, authority, and self-esteem. Every patient admitted to this ward may be susceptible to one or more of these risks. However, the issue of self-harm is of particular interest in this paper.
The Nursing and Midwifery Council code of professional conduct (NMC, 2002) states that it is the responsibility of registered nurses and midwifes to identify and reduce risk to patients. Managers and staff have a professional duty of care, and must always consider the interests of the patient first when dealing with difficult situations involving self-harm. There are numerous personal, situational, and environmental factors that may increase a patients’ susceptibility to self-harm (DOH, 1999; Barr et al, 2005). Successful risk management requires an understanding of these issues. An important factor that may adversely affect the probability of self-harm is the attitude of nursing staff (Huband & Tantam, 2000). Negative attitudes may affect service delivery and/or be perceived by patients, increasing the patients sense of worthlessness, and hence the likelihood of self-harm.
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Nursing staff may encounter self-harm patients in primary care and emergency settings. Having to care for an individual who has intentionally tried to commit self-harm can induce strong and negative attitudes in the carer. According to social psychological theory attitudes are made up of three components – emotion, cognitive, and behaviour (Eagly & Chaiken, 1993). Thus, a nurse’s reaction to patients who attempt self-harm may be emotional (e.g. anger, fear, disgust, hate, contempt, dislike), cognitive (i.e. the individuals belief system – he/she may believe that self-harm is wrong, immoral, and self-fish), and behaviour (e.g. behaving differently towards the patient, for example in a hostile, indifferent, or denigrating fashion). According to cognitive-dissonance theory (Eagly & Chaiken, 1993), the respective components of an attitude are usually internally consistent, in other words, in agreement. This means that a nurse who has strong negative emotions and beliefs towards patients who self-harm is likely to treat such patients differently (i.e. negatively), perhaps further diminishing the patients sense of self-worth, and increasing the risk of further self-harm. This paper examines the issue of staff attitudes in risk management, and suggests a mechanism to help minimise the impact of such attitudes on patient’s susceptibility to self-harm.
There is some empirical research evaluating nurses attitudes towards patients who self-harm (e.g. Johnstone, 1997; Long et al, 1998; Hickey et al, 2001; McAllister et al, 2002; Barr et al, 2005). However, findings have been inconsistent. For example, while some studies suggest that mental health staff are more accepting of self-harm patients compared to staff working in emergency departments (e.g. Suokas & Lonnqvist, 1989) other studies report no differences between these groups (e.g. Anderson et al, 1997). Nevertheless, several studies have shown that most nurses hold negative attitudes towards self-harm, viewing such behaviour as a call for attention, waste of time, or quest for control. Many nurses indicate an unwillingness to work with such patients, have more trouble developing a rapport, and are sceptical that self-harm can be managed effectively (Huband & Tantam, 2000). However, these studies demonstrate that while nurses do indeed have negative views towards patients who self-harm, this forms only a small part of their overall attitude toward this issue. They are also concerned about the patient’s welfare and proficient service delivery (McAllister et al, 2002; Crawford et al, 2003). For example McAllister et al (2002) observed multiple attitude themes in nurses relating to ability, confidence, and empathy, albeit the last theme denoted negative attitudes.
Self-harm is generally frowned upon. What is debatable is the effect that negative attitudes among staff have on service delivery, and more importantly patient susceptibility to further self-harm. It is more comforting to believe that most nurses, myself included, do not allow their personal opinions to adversely affect their professional conduct or the behaviour of patients. Nursing care is supposedly regulated by professional and ethical standards that prescribe appropriate care protocols for self-harm patients (Long et al, 1998; DOH, 1999; NICE, 2004). However the reality may be very different. The problem is that negative attitudes can be very difficult to suppress, and moreover can influence nursing care and patient susceptibility in ways that may not be immediately obvious to the carer. Thus, while I have never actually observed a situation in which attitudes clearly had adverse effects on a patient, this view is entirely subjective and probably inaccurate. Indeed, my general impressions are consistent with research findings showing that nurses attitudes towards self-harm are multidimensional, and negative opinions are mixed with genuine concerns about patients welfare and proficiency in care delivery (McAllister et al, 2002).
Risk management entails the development of an approach to contain and reduce the level of risk in an organisation to which staff and/or clients may be exposed. Risk management in clinical settings is usually conceptualised within the domain of clinical governance (Huntington et al, 2000).
Negative staff attitudes and any adverse impact they have on patients’ susceptibility to self-harm will violate multiple ethical standards outlined by the Nursing & Midwifery Council (NMC, 2002). Nurses and midwifes are expected to respect the patient/client as an individual, maintain their professional knowledge and competence in care delivery, and above all try to identify and reduce patients vulnerability to self-inflicted injury (Lockwood, 1985; Downie & Calman, 1987; Long et al, 1998). Thus, it should be a major priority of clinical governance leaders to maintain the quality of patient care, by identifying staff attitudes and behaviours that may harm patients (Ayres et al, 1999; Pratt et al, 1999; Huntington et al, 2000). The Nursing & Midwifery Council (NMC, 2002) also requires staff to be aware of relevant legislation that protects the rights of patients/clients with regard to health and safety.
Need for Change According to the National Service Framework for Mental Health (DOH, 1999, p.77), suicide accounts for up to 400,000 deaths prior to the age of 75. More crucially though, at least one percent of patients who receive care in hospital after committing self-harm go on to commit suicide within a year, and up to 1 in 20 kill themselves within a decade. Clearly, staff attitudes form part of the hospital milieu that may precipitate self-harm. For example, a nurse who dislikes self-harm patients may fail to determine a patient’s physical risk and mental state in a respectful and understanding manner, refuse to take adequate account of their emotional distress, delay psychosocial assessment until medical treatment has been given, or decline to offer adequate advice and support, believing that such patients are “incurable”, or a “waste of time”. Thus, there is an urgent need to change any negative attitudes that may negate adherence to professional standards and clinical guidelines on self-harm, as set out by the National Institute for Clinical Excellence (NICE, 2004) and The Nursing & Midwifery Council (NMC, 2002). McPhail (1997) reviews literature indicating that nurses need to be amenable to change, and learn to manage it effectively. Despite the uncertainty and inconvenience, change can often lead to real innovation in care delivery, providing an occasion to improve patient care in ways that may be alien to the status quo, but yet highly beneficial for patient recovery. Failure to accept change means that patients in care will continue to be susceptible to self-harm.
Evidence & Reflection
Given the empirical research indicating that nurses may hold negative attitudes towards self-harm (e.g. Huband & Tantam, 2000; McAllister et al, 2002; Crawford et al, 2003), what is the best way to manage patient’s susceptibility to self-harm? Negative attitudes can be difficult to change, especially when the attitude object entails harm, injury, and even suicide. Nevertheless, I feel that change is paramount whatever the difficulties or costs. The negative opinion of staff is quite understandable, given the nature of self-harm (most people who observe a suicide of act of laceration will react negatively), but there is a lot that can be done to alter rejecting attitudes, so patient care is not compromised in any way. So, what action can be taken? Cognitive-based interventions may be useful in implementing change (Lima-Basto, 1995), and such an approach can be adapted to bring about change in attitudes related specifically to self-harm.
Attitude as indicated earlier is a multidimensional construct incorporating emotion, thoughts, and behaviour (Eagly & Chaiken, 1993). The primary aim of the intervention would be to target all three elements. McAllister et al (2002) identified specific negative attitudes in nurses that could be targeted for modification. These include the notions that patients who self-harm are necessarily a waste of the health care professionals time, attention seekers, “clogging up the system”, have a problem that cannot be “cured”, or use poor and ineffective coping strategies for dealing with their problems. Lima-Basto (1995; also see Watson, 1988; Erickson, 1989) delineates specific “caring” behaviours that could be targeted for improvement. These comprise verbal therapeutic communication (e.g. active listening, reflective questions, seeking clarification), non-verbal therapeutic communication (e.g. touch, eye contact, and physical proximity), social communication (e.g. think aloud, making general statements), respecting the patient’s privacy (e.g. drawing curtains), noting the patient’s problems (e.g., date identified, date terminated), and recording the patients own observations.
Implementation The cognitive-based intervention described by Lima-Basto (1995) will be implemented. Implementation will require the approval or management, and an ethics committee. Further staff will have to be notified in advance, with clear delineation of goals and targets. The intervention itself entails organising group sessions, individual supervision, and individual feedback. Instructions will be issued through a combination of lectures, discussions, handouts, role-play sessions, and pocket aid documents). Target attitudes and behaviours have been outlined above. A full account of the intervention is presented by Lima-Basto (1995, pp.483-484.)
RECOMMENDATIONS Reducing the Risk – Kurt Lewin’s (1951) model
It seems evident that the attitudes and professional conduct of nurses affect patients’ susceptibility to self-harm (Johnstone, 1997; Hickey et al, 2001; Barr et al, 2005), irrespective of the patients’ own personal problems (e.g. alcohol/drug abuse, social problems, etc). Thus, changing staff attitudes and professional behaviours is a logical first step for clinical governance leaders. But how can risk be managed effectively in this context? How can change in staff attitudes be achieved? Answering these questions requires an understanding of how change occurs in organisational settings. Kurt Lewin (1951) proposed that change entails a three-stage process (see Figure 1). The first stage is described as “unfreezing”, and involves dismantling the current way of thinking or doing things status quo and surmounting inertia. Human behaviour is assumed to be held in a state of “quasi stationary” equilibrium by a substantial field force of personal and situational driving and restraining forces. Driving forces include customer care, improved corporate image, increased patient/client focus, and winning (e.g. adhering to professional code of conduct). Restraining forces comprise not wanting to hurt nurses’ feelings, increase their workload, introduce yet another change (especially after a long series of reforms), confuse patients, or challenge the old school (i.e. the established mindset). Change can be achieved primarily by removing restraints albeit this is difficult since these factors are mostly unpalatable psychological defences or social norms that are difficult to quantify or target. Stage two is when “change” occurs, and is characterised by chaos, uncertainty, and ambiguity, as the old paradigm is replaced by the new. This phases entails a painful process of “cognitive restructuring” whereby the learner takes in new information that redefines and broadens concepts, and establishes new standards of judgement and comparison. The final stage is called “refreezing”, whereby the new order becomes established. Regardless of the type of intervention, changing nurses attitudes towards self-harm will first involve overcoming the current mindset. An important feature in refreezing is that change in attitude must be in harmony with other attitudinal or personality characteristics of the learner, otherwise resistance to change will magnify, hence reversing any progress made. For example, attempting to change negative attitudes using a cognitive intervention will be pointless if nursing staff then return to a clinical setting in which hostile care practices (e.g. failing to collect samples, delaying psychosocial assessment) are the norm when dealing with self-harm clients.
Moreover, attempts to change staff attitudes will be unproductive without an understanding of nurses’ preparedness for change, and the clinical barriers that may hamper change. Moulding et al (1999) proposed a conceptual framework for managing change in clinical settings, which can be subsumed within Lewin’s (1951) model. Firstly, there must be an assessment of nurse’s state of preparedness to change. Many nurses may be unwilling to change, and/or believe the change will be difficult to achieve (McPhail, 1997).
Figure 1 An interpretation of Lewin’s (1951) model of change in relation to nurses attitudes towards self-harm
This initial resistance will need to be overcome. Next is an evaluation of barriers to change that are specific to this target group and setting. It is difficult to make people feel more positive towards acts that clearly entail injury and possibly death. Moreover, workload constraints may hamper participation in the intervention, and there may be other factors in the “field” that help sustain negative attitudes. Step three involves determining where to “pitch” the intervention. Is it more relevant to junior or student nurses? Or should more experienced staff also participate? Should the intervention be presented as an elementary scheme merely designed to alter a few beliefs, or a comprehensive programme designed to “overhaul” the current mindset? Next, the intervention is designed and implemented, and finally, in stage five, outcomes of the intervention are evaluated. The first three stages can be viewed part of the “unfreezing” phase of Lewin’s model, while stages four and five may occur during the “change” and “refreezing” phases, respectively.
Change in nurse attitudes is inescapable if professional standards are to be upheld (Repper, 1999). This has multiple implications for clinical practice. Firstly, clinical governance leaders should view nurse attitudes as a broad mindset of which negative opinions are just a small part: nurses are also genuinely remain concerned about patient welfare and good service delivery. This is important because as Kurt Lewin’s (1951) field theory contends, the whole milieu has to be accounted for, otherwise a distorted picture may develop, and inappropriate elements may be targeted for change. Intervention should be based on a cognitive approach, and separately target negative emotions (e.g. contempt), beliefs (e.g. self-harm patients are a waste of time), and behaviours (e.g. failing to do a proper assessment) – the three dimensions that make up an attitude. Attempting to alter just one or two aspects will be unproductive because people seek harmony in their feelings, thoughts, and actions, and hence will resist change that threatens to create dissonance. Nurses need to be prepared for any intervention (management will need to give notice of their intentions to implement an intervention, and details of what may be involved). Specific barriers to change need to be identified and addressed (e.g. increased workload, hurting staff feelings, lack of motivation) – every clinical setting is unique, and hence will have its own peculiar set of hindrances. Overall management will have to show leadership, anticipate resistance, communicate openly with staff about the proposed changes, and time the intervention correctly.
CONCLUSION What have I learned from this discourse? There appear to be several key issues. Firstly, the presence of professional standards, codes of conduct, ethics, and other guidelines for best practice does not prevent nurses from holding undesirable attitudes that may diminish the quality of care that self-harm patients receive. This is an important inference because the public typically regards nurses as health experts who work to strict professional standards. Thus, it may be quite debilitating for a vulnerable patient with a history of self-harm to suddenly sense hostility and other negative reactions from their nurse. Secondly, the fact that self-harm, and in particular suicide, still occurs in patients after they have “received” nursing care justifies any attempts to improve staff attitudes towards self-harm. Finally, it is the responsibility of clinical governance leaders to implement what ever changes are required to maintain the quality of patient care, even if such measures may be difficult to implement, as is the case in trying to change people’s attitudes (Eagly & Chaiken, 1993). Still, evidence indicating a link between staff attitudes and patients self-harm is limited, and there is a need for randomised clinical trials that can establish a causal link.
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