Research Paper


E-ISSN No : 2454-9916 | Volume: 3 | Issue: 5 | May 2017


Ms. Mini Patiyal ‘| Mrs. Ranju. | Dr. Nageshwar V.

'M. Sc Nursing Final Year, Teerthanker Mahaveer College of Nursing, TMU, Moradabad, UP. * Assistant Professor, Teerthanker Mahaveer College of Nursing, TMU, Moradabad, U.P.


This review gives the useful results for the attitude of nurses towards self harming clients and present various factors that affect the attitude of nurses for self harming clients like work pressure, previous experience and any specialized training. The main aim of the study 1s to explore the attitude of nurses towards self harming clients. Method: The initial workout starts with the qualitative research review literature. The qualitative studies are suitable to explore the attitude of nurses towards self harming clients. A literature review was completed in which search done from PubMed, EBSCO, DELNET etc., using key words such as self-harm, experience, attitude of nurses. Those were focusing from 2000-2016 in which around 40 published articles investigating the experiences of nurses while caring for self harming clients. From these articles, 8 articles are selected which are included in the narrative review. The studies review found and narrative review was prepared.

THE RESULTS: The review identified the degree of attitude among nurses for self harmed clients. Mostly the nurses who had specific training in dealing with self harming clients have a positive attitude towards self harming clients then who don't have. This attitude is influenced by knowledge and years of experience with self harmed clients.

CONCLUSION: Attitude of the nurses towards self harming is variable and it completely depends upon on the factors, e.g. knowledge, specialized training, years of experience with these clients, work pressure. So all nurses need specific training to deal with these clients, so that they will be competent while these clients.

KEY WORDS: selfharm, deliberate selfharm, attitude of nurses, qualitative study.


An individual event of self-harm might be an attempt to end life. Self harm can be defined as the way of adjusting /coping with problems, but not in healthy way it's the unhealthy way in which the person has opted. The WHO estimates that, as of 2010, 880,000 deaths occur as a result of self-harm. This deliberate self harm is very common in developing countries. Self-harm is the top reason for adolescent or youth deaths in India causing close to 60,000 deaths annually in the age group of 15-24 years. And it became one of the biggest reasons for disability among youth. Self-harm become more common in the young peaking between the ages of 15 and 19 years in females and 20 and 24 years in males. Self-harm prevalent in all sections of the population but is more common among people who are dis- advantaged in socioeconomic terms and among those who are single or divorced, live alone, are single parents or have a severe lack of social support (Meltzer et al, 2002)

Self harm includes suicide, attempted suicide or any form of self-inflicted wounds. The findings of the study conducted by the institute for Health Metrics and Evaluation (IHME, 2013) The data shows self-harm has increased rapidly over the last two decades, indicating a rise in stress, mental disorders and chang- ing lifestyle and behavioral patterns. In 1990, self-harm caused a total of 37,630 deaths among youngsters between 15-24 years age.

The number of individuals who die by suicide each year in India alone is more than the total number of suicides in the four top ranked European countries com- bined (Gunnell et al, 2007). India is in 2nd place of self harm and suicide after the China. (Patel et al 2005). Much of the research evidence has indicated that the un- favorable attitudes among health care professionals like doctors and nurses influ- ences perceived by clients hitting more self harm.

1.1 Need for assessing attitudes of nurses towards self harming clients:

There are many studies which show that there is a need to assess the attitude of nurses towards self harming clients. There is a lack of evidence which support that attitude can be corrected with knowledge and particular strategies. The early foundation for building attitude is the cultures, beliefs and morals of the people or nurses. This article is based on a review of the literature. It includes articles that concern both general and mental health nurses who work in various health care settings e.g. acute inpatient wards, community mental health, medical admission units and emergency departments.

Taylor, Hawton, Fortune, & Kapur 2009 found the positive perceptions in nurses, but the people who self harmed themselves; felt that the staff attitude is negative and punitive to them.

C. Wilstrand, B.M. Lindgren et al 2007, seen that nurses have a negative attitude towards self harming clients with fear and anger. The nurses also had a lack of knowledge and understanding regarding the patient's problem and to care the cli-

ents. There is an intense need for qualitative studies to allowing the interpretation of the findings and generate and explore the existing attitude and the attitude which is to be corrected, like things can only be improved the time they are being noticed.

1.2 Aim: The aim of this review is to identify the attitude of nurses towards self- harming clients.

1.3 Objective: ¢ Toexplore the attitude of staff nurses towards self-harming clients.


2.1 Search strategy method:

An electronic search of 40 published articles in the PUBMED, DELNET and EBSCO. Most of the studies selected for this review are qualitative studies. The search was restricted to English language only. By using these sources 40 studies are selected. From these 40 studies 9 are removed because of duplicity and the other 19 articles are not full text. After removing the articles, left 12 articles are screened. 4 full text articles are removed because of not fulfilling the criteria. The eligibility criteria for including studies dealt with these: 1) Nurses who had expe- rience with self harmed clients 2) Nurses attitude towards self harming clients 3) Health care professional attitude towards self harm.

2.1.1 Types of studies: Qualitative studies with these designs: (Interpretive phenomenological, descrip- tive and exploratory, cross-sectional design).

2.1.2 Type of participants: Staffnurses, psychologist, doctors and student nurses.

2.1.3 Settings: Hospitals and academic institutions

Copyright© 2016, IERJ. This open-access article is published under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License which permits Share (copy and redistribute the material in any medium or format) and Adapt (remix, transform, and build upon the material) under the Attribution-NonCommercial terms.

International Education & Research Journal [[ERJ]

Research Paper


3.2 Table no. 1: Data extraction table

Design Title/ Place & year Variables Tools | Duration Outcomes Conclusion Problem statement| of research (Minutes)

Experiences of | Narrative

Sl. No & author name

1. C. Wilstrand, B.M. Lindgren, F. Giljs & B.Olofsson

2. Andrew R. Thompson, Jane-Powls, Angela Carradice.

3. Margaret McAllister,

1. Wendy Moyle,

2. Stephen Billett, 3. Melanie Zimmer- Gembeck.

4. Randi Tofthagen, Anne-Grethe Talseth, and Lisbeth Fagerstrém.

Records are identified through database searching



Records after duplicate remove


Records screened


Full text articles are assessed for eligibility


Studies are included in narrative review



Qualitative | A qualitative study | Sweden, 2007 of nurses' experiences caring for Patients who self-harm.

the nurses with self harmed clients.

Experience of the community psychiatry nurses to self

Experiences Sutton hospital of Community and | of U.K., 2007 psychiatric nurses' working with people who engaged in self-harm.


Qualitative study on| 3/April .2009 the emergency nurses who are caring for self harm clients.

Emergency nurses attitude for self harm clients.

Qualitative study. Mixed

method pretest —postest group design was used.

Mental Health Nurses' Experiences of Caring for Patients who self- Harmed

Qualitative Norway, 2012 | Experience of exploratory and descriptive



harming clients.

nurse caring for | structured

E-ISSN No : 2454-9916 | Volume: 3 | Issue: 5 | May 2017

Identified records through other sources

(n= 0)

Record excluded (not full text article) (n=19)

Full text articles are removed


Nurses are pille up | Education and training of with the feelings of | nurses is important not frustration working | only for nurses but for along with self- improving the care harming clients. concerns of the clients. Nurses managing |This will make the nurses their personal and |more competent and skill professional full for dealing with self boundaries between harm clients. self and patient.


It was analyzed that, | Nurses are caring for self for nurses, it was very} harming clients and they difficult to maintain |didn't show any degree of the professional attitude towards these boundaries. They are | patients. But nurses are using variety of been challenged to copying mechanism provide care to such to perform their work clients. towards these clients.

semi- structured interview

The results shown nurses are having positive attitude or they are developing

Emergency nurses are caring for self harming clients. And learning how to deal with these clients.

positive attitude. And there is increase in Nurses striving to their knowledge about understands about self] caring for such clients. harm. Nurses are having positive attitude to influence such clients so another attempt will be prohibited.


Semi- for caring these be at the place of clients. Its difficult to | promotion, rehabilitation maintain nurse- of health of the patients patient relationship. and that has to be Nurses promoting reflected in the care of their self esteem by the client. promoting the well- being.

International Education & Research Journal [IERJ]


Research Paper

5. Dr.Peter Thomas | Phenomin- | Attitudes of Mental

Sandy and Dr. ological Health Nurses to

David G Shaw study. Self-Harm in Secure Forensic Settings.

North India in May 2012.

Cross- sectional design.

6. Mamta Nebhinani, Naresh Nebhinani, L. Tamphasana, and AchlaD. Gaikwad

Nursing students' attitude towards suicide attempters.


Interpretive | Nurses attitudes and Dr.Murali, Krishna, |phenomeno-} beliefs to attempted |Southern India, |beliefs of nurses] structured

suicide in Southern India.

Dr Raj gopal, Paul Keenan.


8. Claudia Obando Medina, Gunnar Kullgren,Kjerstin Dahlblom.

Qualitative | Primary health care Leon, professional's Nicaragua perceptions of At 3 PHC, mental health, 2014

suicidal problems

and help-seeking among young



This review is completely focused on the attitude of nurses towards self harming clients. So it’s been found that there is the presence of certain degree of attitude. Few studies support that nurses are having positive attitude due to their knowl- edge and years of experience while dealing with such clients. Especially the nurses who are having any specialized training in dealing with such clients have soft corner and empathetic behaviour towards such clients.

And a few studies showed that nurses are having a negative attitude towards self harming clients. After analysis the data are divided into three categories:


Emergency nurses are caring for self harmed clients and their knowledge is increased while caring for them. They have shown a positive attitude towards self harming clients (Margaret McAllister, Wendy Moyle, Stephen Billett, Melanie Zimmer-Gembeck 2009). Whereas few studies are shown nurses have- n’t certain degree of attitude, but they are challenged to provide care self- harming clients (Andrew R. Thompson, Jane-Powis, Angela Carradice 2007).


Few studies supported that the staff is having the negative attitude towards self harming clients and putting the clients on risk to attempt self harm again (Mamta Nebhinani, Naresh Nebhinani, L. Tamphasana, and AchlaD. Gaikwad 2012). Health professionals are having certain degree of attitude and mostly they are neg- ative attitudes (Dr.Peter Thomas Sandy and Dr. David G Shaw 2012).

CHALLENGED WHILE DEALING WITH SELF-HARMING CLIENTS Nurse’s are afraid of patient’s life threatening actions or burdened with emotions and they are managing with their personal and professional boundaries (C. Wilstrand, B.M. lindgren , F. gilj C. B .Olofsson 2007). Nurses haven’t shown degree of attitude but they are challenged to provide care self harming clients (An- drew R. Thompson, Jane-Powis, Angela Carradice 2007). The health care per-

International Education & Research Journal [IERJ]

Nursing students attitude towards suicide/

self harming.

Attitude and

towards suicide |interviews

Professional's Un-

Perception of | structured

mental health |observatio suicidal problem. semi-

E-ISSN No : 2454-9916 | Volume: 3 | Issue: 5 | May 2017

Attitude of mental health |interviews nurses towards

self harm.

Indepth This study has The attitude of nurse may evolved with many of |persuade the self harming the findings. Positive | behaviour. So nurses has

as well as negative to be equipped with

also. enough amount of e.g of positive attitude] knowledge and should be are feeling of aware approaching way acceptance, readiness, to client. need for training etc. negative attitude like rigid approach,

blanket approach etc.

According to students} Suicide is unpredictable onlt those people behavior, and reflects, attempt self-harm | many health problems in

who had problems in | patient. Self-harming relationship, love | clients are challenge for

failures or suffering | the health system. This from depression. challenge to health care These patients are | professionals make them impulsive and self- to exhibit negative punitive. Self- attitude towards self- harming patients don't harming clients. find hope in living life.

The nurse's care is directly influenced by their religious practice

and culture. So this study more focuses on educational qualification and competency which are to be gained by the nurses.

In this study the care of the client is influenced by the nurse's culture and their religious factors.

Nurses and doctors are reluctant for caring adolescents. Many difficulties and problems are faced by them and they are not interested for caring conducted them in any aspect in urban like physically and

PHC. spiritually.

Nurses should always be trained in a way so that they are aware how to discuss the sensitive issue and they will be giving the way of acceptance to client.

n and

structured interviews

sonnel’s are lacking in taking care of self harming clients and also want change in policies of taking care of the clients (Claudia Obando Medina,Gunnar Kullgren, Kjerstin Dahlblom 2014). Nurses are working in so challenging situation and pro- moting their health but also effected emotionally (Randi Tofthagen, Anne- Grethe Talseth, and Lisbeth Fagerstr6m 2012).


Self harm or deliberate self harm is the way of harming self in order to copying with stress which can be attempted in many ways (cutting self, withdrawing blood from the body, strangulations on the body, head banging etc) which may lead to suicide also. Nurses who are having special training in taking care of self harmed clients have positive attitude than the nurses who don’t have. And at a level nurses did not shown any attitude instead of they are challenged and emo- tionally burdened to provide care to self harmed clients.

In summary findings shows that the nurses are having degree of attitude towards self harming clients. And it is been proven with many studies that mostly nurses are reluctant to provide care to self harming clients. Nurses are emotionally pile up and also challenged to take care of the self harmed clients. To improve the atti- tude and care given by nurses, special training has to be provided and policies need to form for self harming clients.


The studies on the attitude of the nurses towards self harming clients, 60 % nurses are reluctant to deal with such clients and have degree of attitude neither negative nor positive. Because they are not specialized in dealing with self harm clients and they are not confident enough to manage self and clients. So they need spe- cialized training to care self harming clients so that they are able to manage per- sonal and professional boundaries and not feel challenged while caring for these clients. This training will help the nurses to convey the degree of acceptance and positivity in a way like (empathetic, engagement, optimism and readiness to take

the responsibility.

Research Paper





Dey,Sushmi. (May 10,2016). Self-harm causing most youth deaths in India. Times of India.

Daniel Zahl, Hawton. K, Rosamund (2003). Suicide following deliberate self harm:long term follow up patients who presented to a general hospital, British journal of psychiatry, 182(6),532-542.

Danivas, V., Bharmal, M., Keenan, P., Jones, S., Karat, S. C., Kalyanaraman, K.,& Krishna, M. (2016). An interpretative phenomenological analysis (IPA) of coercion towards community dwelling older adults with dementia: findings from Mysore stud- ies of natal effects on ageing and health (MYNAH). Social psychiatry and psychiatric epidemiology, 51(12), 1659-1664.

Evans .E, Hawton. K, Rodham k., wheather all R.(2002). Deliberate self harm in ado- lescent: self report survey in schools of England. British journal of psychiatry (7374), 1207-1211.

Emerson, L. E. (1913), "The case of Miss A: A preliminary report of a psychoanalysis study and treatment of a case of self-mutilation", Psychoanalytic Review, William A. White, MD & Smith Ely Jelliffe, MD, pp. 41-54, retrieved 2009-06-15.

Fortune, S., Sinclair, J., & Hawton, K. (2008). Help-seeking before and after episodes of self-harm: a descriptive study in school pupils in England. BMC Public Health, 8(1), 1

GVU’s WWW user survey. (n.d) retrieved from harm/ user surveys/survey.

GVU’s WWW user survey. (n.d) retrieved from http// / wiki/ index.php/self mutilation.

GVU’s WWW user survey. (n.d) retrieved from Self- harm.

GVU’s WWW user survey. (n.d) retrieved from https:// www. ncbi. nlm.nih .gov/books/NBK126787/

Gualberto, A. (1991), An Overview of the Maya World, Production Editorial Dante, pp. 207-208, ISBN 968-7232-19-6.

Gopal Rajendra Raj, Krishna Murali, Keenan Paul, jones steven. (2014). Nurses atti- tudes to attempted suicide in Southern India. Pdf. retrived from

O'Brien, A., Women and Parasuicide: a Literature Review, Women's Health Council, archived from the original on April 28, 2008, retrieved 2008-05-26.

Wilstrand C. Gilje F, Lindgren BM , Olofsson B, 2007) Being burdened and balancing boundaries: a qualitative study of nurses' experiences caring for patients who self- harm, 14(1):72-80.

E-ISSN No : 2454-9916 | Volume: 3 | Issue: 5 | May 2017

International Education & Research Journal [IERJ]