Self-harm is a considerable challenge for public health (Raynor et al., 2019).

The government
has acknowledged the need to improve the quality of patient care received by patients who
self-harm in hospitals (DOH, 2019). This ambition is shared by the NHS. The NHS Long
Term Plan makes a reduction in suicides a priority over the next ten years (NHS, 2019).
The issue of self-harm has been one that has received substantial attention in the academic
literature up to this point (Edmondson, Brennan & House, 2016; Witt et al., 2017;
John et al., 2018;…). Self-harm is a serious action in which an individual deliberately
damages or injures their own body and is typically a behavioural response to psychologically
overwhelming emotions (Skegg, 2005). A wide range of intentions and behaviours which
may include superficial cutting or scratching, to self-poisoning, ligatures, and burning oneself
(Hawton, Saunders & O’Connor, 2012). The attitudes to people who self-harm can be
significant in the manner that these individuals experience care (Pirmohamed et al., 2013;…)
and can be defined as the manner in which nurses think about, or express feelings towards
those in their care (McAllister, Creedy, Moyle & Farrugia, 2002).
When conducting any review of the literature, there must be a clear and justifiable rationale
behind it, in order to justify the amount of work spent on it, and to justify the reader’s interest
in examining what work has been conducted (Munn et al., 2018). Firstly, it is noteworthy
that the way in which self-harm is managed by hospital staff is an essential component
of suicide prevention (NCISH, 2018; Cully, Leahy, Shiely & Arensman 2019). What is of
concern is that patients who receive care following an episode of self-harm rate the
satisfaction with services as low. This not only has an impact on the perceived level of care
that patients, but also impacts upon future episodes in which they may need medical help.
(Cully et al., 2019). For example, a qualitative analysis conducted by Owens, Hansford,
Sharkey and Ford (2016) identified that previous poor experiences led to patients avoiding
seeking help prior to, or after DSH. This was the case both when experiencing poor care,
oneself, or even after hearing about the negative experiences of others (Owens et al., 2016).
There is often a sense of self-stigmatising and shame felt by those who DSH (Spillane,
Matvienko-Sikar, Larkin & Arensman, 2019), and this in itself can act as a barrier to seeking
help. However, when help is sought and these feelings of stigma are reinforced by the
pejorative or negative attitudes of staff attending to such patients, a vicious cycle of shame
and self-harm can follow (Rayner, Blackburn, Edward, Stephenson & Ousey, 2019). This not
only leads to decreased engagement with health services (Saunders, Hawton, Fortune &
Farrell, 2012), but also, as a knock on effect of this decrease engagement, raises the risk of
suicidal behaviour in the future (Roaldset, Linaker & Bjorkly, 2012).

As with many areas of mental health therefore, the engagement with nursing staff is key to
the experiences of patients accessing services (Hunter, Chantler, Kapur & Cooper, 2013).
This is vitally important to consider, for it is from such experiences that therapeutic alliance
can be forged (Dunster-Page, Haddock, Wainwright & Berry, 2017).
It is a therapeutic alliance that drives engagement with services, that can ultimately have a
positive impact on behaviours such as DSH (Bryan et al., 2012). It is therefore of vital
importance that the way in which nurses relate to such patients is understood.
This represents a large section of society, and points to the scale of the issue within current
society (McManus et al., 2016). Those who DSH typically engage in such behaviours as a
means of managing intense psychological distress (McAllister, 2003), and can hence be seen
as a functional response to distressing stimuli (Rayner, Blackburn, Edward, Stephenson &
Ousey, 2019), as opposed to a kind of attention seeking behaviour that those who DSH are
typically, pejoratively associated with (Cullen, Diana, Olfson & Marcus, 2019). This lack of
understanding about the functional nature of DSH often results in patients being unfairly
stigmatised by nursing staff (Gibson, Carson & Houghton, 2019), which in turn can lead to
such patients experiencing their care in a very negative manner (Long, 2018).
This leads to the core rationale behind the conduct of this current study. Firstly, it goes
against the NHS constitution for patients to be discriminated against or stigmatised, or to
receive substandard levels of care in this manner (DOH, 2015). Secondly, the National
Confidentiality Inquiry into Suicide and Safety in Mental Health (NCISH) links substandard
care provision of those who are at risk of DSH with an increased risk of suicidality (NCISH,
2018). Considering the prevalence of DSH within the UK population, and the likelihood that
many of these individuals will be accessing either physical or mental health services as a
result (Marchant et al., 2019), the way in which they are dealt with by staff may be crucial to
the way in which they engage with treatment and seek to change their behaviours (Cully,
Leahy, Shiely & Arensman, 2019).
Collaboration versus Control
Positive attitudes correlated with a mental health nurse whose collaborative, personal-centred,
empowering and recovery orientated approach decreased the risk of self-harm.
Risk has dominated the mode of nursing practice to self-harm and defined how nurses have
understood and treated patients who were perceived as objects of risk (Felton, Repper, &
Avis, 2018) both to themselves and to others (Higgins et al., 2016;…). Furthermore, the
emphasis on risk can mean that patients loss their independence unnecessary (Clarke and
Mantle, 2016). As a result, the practice of a nurse in preventing self-harm and suicide is often
defensive (Manuel, Crowe, Inder, & Henaghan, 2018), fails to value therapeutic engagement,
individualised care (Morrissey, Doyle, & Higgins 2018) and is disproportionately focused on
patient inadequacies (Felton, Repper, & Avis, 2018). There has been calls by some for risk
management to include the patient (DOH, 2009) in order to manage risk in a much more safer
way (Deering, Pawson, Summers & Williams (2019).
In a patient-centred and collaborative relationship nurses should share power allowing
patients to play an active role in directing the course of their own safety (Reid, Escott, and
Isobel 2018). Joint discussions between a nurse and patient could include issues such as their
personal care and safety which are key components of a recovery‐oriented approach (Higgins
et al., 2016;…) These discussions can include matters relating to strategies for managing risk,
identifying triggers that increase risk, protective factors as well as positive risk‐taking
opportunities (Higgins et al., 2015;…). Discussions centred around thoughts relating to self-
harm and suicide ideation are not only a critical component of suicide prevention (Dazzi,
Gribble, Wessely, & Fear, 2014) but the act of listening is an important way to validate the
patient (Morrissey, Doyle, & Higgins 2018). Therefore, a person-centred, recovery orientated
approach compared to a prevention and controlling approach uses interpersonal skills such as
talking, listening and understanding to reduce the risk without disempowering the patient.
A positive nursing attitude has been linked with effective suicide prevention and as a result
there has been more success in meeting health care service objectives (Wadey et al., 2013).
It was evident in two of the qualitative studies that mental health nurses collaborated with
patients who self-harmed and used a person-centered, empowering, solution focused and
recovery orientated approach (Tofhagen et al., 2014; Hagen et al., 2017). Tofhagen et al.
(2014) found mental health nurses formed a therapeutic alliance with the patient and then
used a reflective, non-judgmental dialogue in order to explore internal and external triggers
and help patients better articulate their feelings when they feel the urge to self-harm. Mental
health nurses taught patients alternative strategies to self-harm by encouraging and involving
patients in the use of intervention and prevention strategies that distanced the patient from
their suffering. Another finding was that reflective dialogue enabled nurses to increase their
level of compassion to the patient who self-harms. Several of the mental health nurses also
used the concept of hope to support the patient to believe in the possibility of recovery and
the prospective of a better future. Person-centred practice and the concept of hope were also
found in Hagen et al. (2017) study where several of the mental health nurses' described their
interactions with suicidal patients in terms of inspiring hope through a shared understanding
of the patient’s suicidal behaviour and helping the patient to be more directed toward life
rather as opposed to death. However, while a caring and understanding attitude was found
overall there was some negative attitudes. Several mental health nurses in Tofghagen et al.
(2014) stated they felt it was unpleasant to be in relationship with a patient who self-harms
and four of the mental health nurses in Hagen et al., (2017) experienced feelings of anger and
frustration when a patient repeatedly engaged in an attempted suicide.
In contrast to the above studies the predominant approach of mental health nurses in Murphy
et al. (2019) study was involved the use of restrictive practice to maintain safety. Several of
the mental health nurses reported that episodes of self-harm were by ended by prevention and
control methods such as removing dangerous items, physical restraint, close monitoring,
seclusion, and medication.
Murphy et al. (2019) found nearly all mental health nurses expressed feeling uncomfortable
and dissatisfied with restrictive practice believing that the methods lacked therapeutic value.
In the opinion of one nurse prevention method are not a long-term solution since in their
experience many of the patients had self-harmed for 20 years. In comparison to the previous
two studies Murphy et al. (2019) also found several nurses had adopted, to a lesser degree, a
person-centred and empowerment approach. Nurses involved patients in decision making,
supported patients to develop coping strategies, educated patients about self-harm and
encouraged them to take responsibility for their own actions. Several mental health nurses
identified an alternative method but only considered the harm reduction approach in terms of
its potential to manage self-harm. In contrast, several of the mental health nurses in Tofhagen
et al. (2014) study expressed diverse attitudes toward the management of self-harm. While
there was support for restrictive practice these nurses said they permitted the use of a harm
reduction approach as a way of maintaining the safety of a patient. Patients, while under
supervision, could harm themselves to a mild or moderate degree. This was summed up in a
quote by a nurse who stated, ‘We do not stop it because for some it is important to see blood’