The Journal of Emergency Medicine, Vol. 43, No. 6, pp. 1084–1090, 2012Copyright � 2012 Elsevier Inc.

Printed in the USA. All rights reserved0736-4679/$ - see front matter

doi:10.1016/j.jemermed.2012.01.049

1Meena O’ NeillIreland.

RECEIVED: 13 JuACCEPTED: 22 Ja

Education

FACTORS INFLUENCING PERCEIVED EFFECTIVENESS IN DEALING WITHSELF-HARMING PATIENTS IN A SAMPLE OF EMERGENCY DEPARTMENT STAFF

Rachel Egan, BA (HONS), MSC, D.PSYCH, SC. CLINICAL,* Kiran M. Sarma, BA, PHD,† and Meena O’Neill, BA, PHD*1

*Arbour Hill Prison, Dublin, Ireland and †National University of Ireland, Galway, Ireland

Reprint Address: Rachel Egan, BA (HONS), MSC, D.PSYCH, SC. CLINICAL, Clinical Psychologist, Arbour Hill Prison, Arbour Hill, Dublin 7, Ireland

, Abstract—Background: Past self-harming behavior isone of the most significant predictors of future suicide.Each year in Ireland there are approximately 11,000 presen-tations of self-harm to emergency departments (EDs) acrossthe country. Study Objectives: This study examines predic-tors of perceived personal effectiveness in dealing with self-harming patients as reported by ED staff. The predictors arederived from past research and are influenced by Bandura’sSocial Cognitive Theory. Method: One hundred twenty-fiveEDmedical staff (28 doctors and 97 nurses) from five EDs inthe West and South of Ireland completed a questionnaire.Predictor variables included in the design, and informedby past research, included knowledge of self-harm and sui-cidal behavior and confidence in dealing with incidents ofself-harm. Results: Standard multiple regression suggesteda statistically significant model fit between the two predic-tors and the criterion variable, accounting for 24% of totalvariance. Knowledge and Confidence were significant con-tributors to perceived personal effectiveness in dealingwith self-harming patients. Conclusions: Little is known re-garding specific factors that influence perceived effective-ness in dealing with self-harming patients in the EDsetting. These findings have implications for psycho-education and training content for staff. The findingssuggest that increasing knowledge of self-harm and confi-dence in dealing with self-harming patients can lead tomore positive perceived personal effectiveness in respondingto clients’ needs. � 2012 Elsevier Inc.

is now affiliated with Mayo PCCC, Co. Mayo,

ne 2011; FINAL SUBMISSION RECEIVED: 25 Augusnuary 2012

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, Keywords—self-harm; attitudes; emergency depart-ment; effectiveness

INTRODUCTION

Self-harm and suicidal behavior are significant publichealth issues in the Republic of Ireland. The overall pop-ulation rate of suicide is 11.6 per 100,000 individuals, andsuicides now account for 1.7% of all deaths in Ireland,compared to 0.8% in the early 1980s (1). Each year thereare approximately 11,000 presentations of self-harmto Irish hospitals, accounting for 0.9% of all emergencydepartment (ED) visits (2,3).

Self-harm is a significant predictor of future suicide,and for those who self-harm, the ED is often the first pointof contact with the health care system (3–9). Staff workingin EDs are at the forefront in suicide prevention, and it isimperative that they feel capable of responding effectivelyto thosewho present with self-harm and that they have theknowledge and attitudes to facilitate effective interven-tion. In a demanding environment such as the ED, inci-dents of repeat self-harm may cause significant distressand frustration for the ED staff member who is dealingwith the patient. This, in turn, can lead to ineffectivecare practices (5,7,8).

ED professionals’ attitudes may determine their eager-ness to provide care for self-harming individuals andtherefore influence the effectiveness of treatment(4–6,8,9). Although attitudes are multi-dimensional and

t 2011;

Perceived Effectiveness and Self-harming Patients 1085

often without conscious awareness, the recipient of a neg-ative attitudemay sense rejection through a staffmember’sdemeanor andmanner (10).A response of rejection or hos-tility may prompt further self-harming behavior.

The National Institute for Clinical Excellence UKguidelines report that the experiences of those who self-harm and who attend EDs is often unacceptable (11).Frontline staff are in a unique position to interrupt the on-going cyclical process of self-harm, provided there is ad-equate rapport between them and the self-harmingindividual (12). The intervention and care received byself-harming individuals may have an impact on the cycleof blame, shame, and worthlessness often associated withrepeat acts of self-harm (13–15).

Indeed, research with self-harming patients has in-formed us that when an individual feels listened to andperceives genuine care in the ED setting, they reportmore positive outcomes and greater tendencies to attendfollow-up care. This, in turn, is linked to fewer incidentsof self-harm if the individual is receiving the appropriateaftercare and follow-up treatment (13–15).

According to Bandura, an individual’s attitudes, forexample, their perceived self-effectiveness, and theircognitive skills comprise their self-system (16). Self-effectiveness is the belief in one’s capability to organizeand execute specific courses of action that are requiredto manage certain situations. This self-system plays a sig-nificant role in how individuals view situations, espe-cially distressing or stressful situations, and how theysubsequently behave and respond in these situations.Bandura asserts that self-efficacy or self-effectivenessplays an essential part in the self-system, and behaviorsassociated with these beliefs become automatic overtime (16).

Bandura argued that an individual’s beliefs in theirability to succeed and to be effective in certain situationscan also strongly influence how they feel about the situa-tion (16). This self-system is particularly important dur-ing times of high stress and therefore, it is an importantfactor in understanding the responses of ED staff whenfaced with stressful and often repetitive behaviors suchas self-harming patients. Exploring an individual’s beliefand cognitions in their ability to be effective can shedsome light on what to target regarding improving behav-iors and care practices (4,7).

Literature in this area is of mixed utility in terms of un-derstanding ED staff perceptions of self-effectiveness indealing with self-harming patients. Studies have exploreddifferent aspects of the attitude-behavior nexus, but haveeither focused on ED allied-disciplines, or used diversesamples of ‘‘healthcare workers.’’ Few have focused onED staff alone and those that have, tended to take an athe-oretical approach or focused on the link between ‘‘knowl-edge’’ and general ‘‘attitudes’’ and failed to examine

specific beliefs in one’s ability to copewith such a difficultand vulnerable population of patients.

Studies exploring attitudes among clinicians towardsself-harming and suicidal individuals have reported mixedfindings. One study reported that general practitioners be-lieved self-harming patients to be ‘‘manipulative’’ and ‘‘at-tention seeking’’ (17). Conversely, another study found thatmedical students tended to view self-harming clients as notresponsible for their actions (18). This was in line witha study of UK health professionals who tended to reportlownegativity towards self-harmingpatients (19).Researchwould also tend to suggest that attitudes can differ withinthe medical professions, with one study reporting higherlevels of antipathy and hostility towards self-harming pa-tients among general nurses thanmental health nurses (20).

There have also been mixed findings with regard to therelationship between experience and attitudes among EDstaff. Two studies found positive relationships betweenthe number of years’ experience working in an ED andthe degree to which medical professionals felt angry to-wards self-harming patients (21,22). Staff with moreexperience reported feeling more inadequate and lessconfident in working with self-harming patients thanthose with less experience. They cited lack of appropriatetraining and sufficient time to de-brief on particularly dif-ficult cases as possible influences on their increased neg-ativity and anger towards self-harming patients.However, a separate study reported that ED nurses with10–15 years experience tended to endorse more positiveattitudes towards suicidal behavior than those with less(1–5 years) experience, although the reverse was truefor community mental health nurses (4).

Researchers argue that low confidence and a lack ofpsychological knowledge on self-harm may accentuatenegative attitudes of professionals towards self-harmingpatients (22,23). One study found that doctors reportedgreater knowledge and confidence in dealing withself-harming patients than nurses reported (23). The re-searchers suggest that low confidence leads to feelingsof frustration and burnout and a sense of powerlessnesswhen trying to cope with the strains of working with re-peat self-harming individuals in the ED. The researchersalso suggest that lack of appropriate knowledge of thepredisposing and precipitating factors that influence inci-dents of self-harm can leave staff feeling irritated and an-noyed with self-harming patients which, in-turn may leadto inappropriate care for these individuals (23).

Unfortunately, there has not been any research to datethat has explored the relationship between perceivedeffectiveness in dealing with self-harming patients andactual effectiveness. Themain reason for this is the highlysensitive nature of this topic and the issue of informedconsent. To explore ED staff perceptions of their effec-tiveness in working with self-harming patients and its

Table 1. Overview of Descriptive Statistics

MeasurePossible Range

of Scores Mean SD Min Max

Knowledge 20–100 71.86 7.28 48 90Confidence 0–40 17.97 7.58 4 36Effectiveness 5–25 19.26 2.54 12 24Negativity 5–25 11.57 2.57 5 20

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relationship to actual effectiveness would require re-searchers to physically sit in and observe ED staff prac-tices when dealing with self-harming patients. Thisraises serious ethical questions, as the researcher wouldneed to ensure that they were obtaining informed consentfrom the patient, who is likely in a severely distressedstate. In addition, most EDs will not allow for this kindof intrusion and possible obstruction in their daily work.

However, a great deal of psychological literature in-forms us that attitudes and self-perceptions can influencebehavior, and this was the premise of looking at perceivedeffectiveness rather than actual effectiveness in the cur-rent study (24–27).

To date there has been no attempt to explore specificfactors that are linked to beliefs in perceived effectivenessin the ED setting, especially when dealing with self-harming patients. This research is set against a backdropof growing evidence that health care staff in Ireland havedeflated confidence and inadequate knowledge in the areaof working with self-harm (28). This is particularly wor-rying considering that rates of self-harm and suicide areon the increase in Ireland.

Thus, according to the literature and in keeping withAlbert Bandura’s Social Cognitive Theory, it is hypothe-sized that knowledge of self-harm and suicidal behaviorand confidence in dealing with such cases will predictlevels of perceived effectiveness in dealing with self-harming patients, in a sample of ED staff.

MATERIALS AND METHOD

Participants

The present sample consisted of ED staff members fromfive hospitals in the West and South of Ireland. A total of277 EDmedical staff (60 doctors and 217 nurses) work inthe five target hospitals. All staff were invited to take partin the study. One hundred twenty-five individuals com-pleted the questionnaires (45% response rate). The sam-ple consisted of 31 (25%) males and 94 (75%) females.The majority of participants (85%, n = 106) identifiedas ‘‘Irish.’’ In the sample, 28 (22%) participants were doc-tors by profession and 97 (78%) were nurses. The profileof the achieved sample was representative of ED staff na-tionally (2,29). The duration of participants’ experienceworking the ED sector varied from 1 month to 30 years(M = 7.7, SD = 6.5). The majority of participants (over75%) reported minimal or no training in dealing withself-harming patients.

Instrument

Participants were asked to complete a short questionnairethat consisted of four sections. Each section includeda specific measure. Section A included 10 questions

regarding participants’ demographic profiles. Section Bconsisted of ‘‘Knowledge of Self-Harm Scale’’ (30).Knowledge scores had a possible range of 20–100, withhigher scores indicative of greater knowledge.

Section C consisted of ‘‘Confidence in Dealing withSelf-Harming and Suicidal Patients Scale’’ (31). Confi-dence scores had a possible range from0 to 40,with higherscores indicative of greater perceived confidence. SectionD consisted of the Effectiveness measure taken from the‘‘Effectiveness in Dealing with Self-harm and SuicidalBehavior’’ subscale of the ‘‘Attitudes towards Self-HarmScale’’ (19). ‘‘Negativity’’ is also a sub-scale on this mea-sure and was included in the present study. Scores forEffectiveness and Negativity range from 5 to 25, withhigher scores indicative of greater perceived effectivenessand greater negativity towards those who self-harm (19).

The internal reliability of each measure in the ques-tionnaire was computed using Cronbach’s alpha. Cron-bach alpha for the Knowledge scale was 0.73, and 0.85for the Confidence scale. This was in keeping with earlierresearch (30). Cronbach alpha for the Effectiveness sub-scale was 0.64, which is not unexpected for self-reportmeasures of this nature and is in line with internal consis-tencies provided by those who designed the measure(19,32,33). Cronbach alpha for the Negativity sub-scalewas low at .57, however, this finding is also in line withthe research and could not be improved through factoranalysis (19,32).

Procedure

Questionnaire and information packs were distributed toeach of the participating hospitals by the primary re-searcher. Nurse Managers took responsibility for dissem-inating the questionnaires and arranging for their returnon completion. All data were collected anonymously.The data collection period took approximately 5 monthsto complete.

RESULTS

An overview of descriptive statistics for each measure isprovided in Table 1. Nine percent of participants (n = 11)reported having somewhat poor knowledge of self-harm,with the remainder having good (82%, n = 103) or very

Table 2. Bivariate Correlations

Variable* Knowledge Confidence Effectiveness Negativity

KnowledgeConfidence .032Effectiveness .200** .453***Negativity �.298*** .081 �.252***

* All two-tailed analyses.** p < 0.05.*** p < 0.01.

Table 3. Standard Multiple Regression Statistics

Variable B SE B b 95% CI

Constant 11.91 2.03 7.87–15.93Knowledge 0.07 0.03 .19* 0.01–0.12Confidence 0.15 0.03 .45** 0.10–0.20

CI = confidence interval.R2 = .24; DR2 = .23; *p < 0.05; **p < 0.001.

Perceived Effectiveness and Self-harming Patients 1087

good knowledge of self-harm (9%, n = 11). When askedabout confidence in their ability to respond to self-harming behavior, the majority of participants felt some-what confident (74%, n = 93) or very confident (10%,n = 13) in dealing with self-harming patients. Fifteen per-cent (n = 19) reported that they were ‘‘not at all confi-dent’’ in their ability to respond to self-harming patients.

Almost half the sample (46.4%, n = 58) reported feel-ing somewhat effective when working with self-harmingpatients, with the remaining half reporting feeling veryeffective in working with self-harming patients (53.6%,n = 67). Thirty-six percent of participants (n = 45) re-ported feeling not at all negative towards individualswho self-harm. However, a greater majority of partici-pants (63.2%, n = 79) reported feeling somewhat negativetowards self-harming patients, with only one participant0.8% (n = 1) reporting feeling very negative.

Table 2 contains bivariate correlations between thevariables included in the design. Statistically significantcorrelations with Effectiveness emerged for Knowledge,Confidence, and Negativity. There was a small positiverelationship between Knowledge and Effectiveness(r = .20, p < 0.05). As knowledge increased, effectivenessalso increased. There was a medium positive relationshipbetween Confidence and Effectiveness (r = .45, p < 0.01).As confidence increased, effectiveness also increased.Effectiveness was significantly related to Negativity(r =�.25, p < 0.01). As effectiveness increased, negativ-ity decreased. Of note, there was a medium negative rela-tionship between Knowledge and Negativity (r =�.30,p < 0.01). As knowledge increased, negativity decreased.

A standard multiple regression was conducted to ex-plore the predictive utility of Knowledge and Confidencein predicting Effectiveness. Negativity was omitted fromthe model due to its relatively poor internal consistency.The results suggested a statistically significant model fitbetween the two predictors and the criterion variable[R2 = .24, F(2, 122) = 19.25, p < 0.0005]. The modelaccounted for 24% of the variance in perceived Effective-ness (Table 3).

Confidence (b = .45, t = 5.67, p < 0.0005) and Knowl-edge (b = .19, t = 2.36, p = 0.02) were significant contrib-utors to the model, with the standardized beta weightssuggesting that Confidence was the largest contributor

to the model. The direction of the standardized beta coef-ficients suggest that as confidence in dealing with self-harm and suicidal behavior increased, and knowledgeof self-harm and suicidal behavior increased, so too didperceived effectiveness in working with self-harmingpatients.

DISCUSSION

The findings of the present study showed that knowledgeof self-harm and confidence in dealing with self-harmingpatients were significant predictors of perceived effec-tiveness in a sample of Irish ED staff. As knowledgeand confidence increased for staff, so too did perceivedeffectiveness in dealing with self-harming patients. Thisfinding is consistent with international literature(23,34,35). There was also a significant negativerelationship between knowledge of self-harm and sui-cidal behavior and feelings of negativity towards self-harming patients. Thus, an important implication fromthese findings suggests that knowledge can enhance staffmembers’ perceived competencies in their work role inaddition to decreasing negative biases and cognitionstowards certain patients. This is likely to impact on carepractices for self-harming patients and the overall experi-ence in the ED for both staff member and patient.

This multi-site study offers unique insight into factorsthat influence perceived effectiveness in dealing withself-harm and suicidal behavior among ED staff inIreland. The model fit of 24% is based on a limited num-ber of predictors being entered in the equation. It is inter-esting to note that although past research would tend tosuggest that demographic variables such as gender, age,occupation, and length of time in service might have util-ity in such a model, in our study they did not improve onthe basic model presented here. Nor did measures of post-qualification training (17,19,36–40).

The generalizability of the findings is enhanced by thefact that the sample was drawn from five hospitals nation-wide and that the achieved sample was representative ofthe ED staff population. However, due to concerns ex-pressed by staff that individuals could be identifiablebased on their responses to specific demographic ques-tions, ‘‘site’’ was not coded and we are unable to ruleout the possibility that there may have been differences

1088 R. Egan et al.

across the sites. This is an important consideration for fu-ture research, as there is strong evidence to suggest thatrates of self-harm can vary from urban to rural areas (1,3).

Limitations of the Study

Self-reported attitudes can be difficult to assess due totheir complex and multi-faceted nature and however hon-estly they are expressed, their validity and predictive abil-ity is never fully clear (20). Indeed, these self-reportmeasuresmay not predict actual behavior and this is a lim-itation of the current study because the research exploresperceived effectiveness and not actual effectiveness.When investigating a sensitive topic such as self-harmit is difficult to consider how to measure specific behav-iors such as ED staff interactions and effectiveness inworking with this patient group. A task for future researchwould be to look at perceived effectiveness and attempt tocorrelate this with specific behavioral outcomes.

Another potential limitation of the current study in-cludes difficulties associatedwith probing sensitive topicsthatmay elicit self-critical evaluation, such as experiencesof self-harm and suicide. Although it is impossible tomeasure the impact of this, it may potentially lead to re-sponse bias where those with specific attitudinal or expe-riential profiles (e.g., low confidence, knowledge, andexperience) are less likely to participate in the research.One ED site refused to participate in this research dueto concerns that negative findings could expose individualrespondents to litigation should an individual presentingwith self-harming behavior subsequently die by suicide.

CONCLUSION

The picture emerging from the present research is thatknowledge of self-harm and suicidal behavior and confi-dence in having the ability to respond to such patients,collectively predict almost a quarter (24%) of the varia-tion in self-reported effectiveness in working in thisarea. Although cause-effect relationships were not ex-plored in this design, realistically it is likely thatpsycho-education targeting knowledge and confidencewill lead to improved perceived effectiveness in the EDsetting and possibly decrease negativity towards self-harming patients. This does not necessarily mean thatthe association between education and perceived effec-tiveness would improve actual care, however, it is possi-ble that if perceptions of self-effectiveness are increasedand negativity is decreased, then the likelihood is that ac-tual practices would improve. This specific link is an areafor further investigation.

The majority of participants in the present study re-ported minimal or no previous training in self-harm andsuicidal behavior. Training in this area could develop

skills and confidence in working with self-harming pa-tients (8). This, in turn, would likely improve care prac-tices and the experiences of these patients in the ED.Training does not have to be extensive or time-consuming. Brief targeted training has been shown toimprove knowledge and confidence, and thus promotepositive attitudes (41).

One study that looked at the effectiveness of a brief ed-ucational intervention aimed at changing attitudes to-wards self-harm found that antipathy was significantlylower after specific training, and this finding was main-tained at 18-month follow-up (41). Another study foundthat nurses reported increased knowledge and perceivedability (i.e., effectiveness) in working with self-harmingindividuals post-training (42). In a similar study, nursesreported increased knowledge and confidence in theirabilities to deal with self-harming patients following atargeted training program (42).

The present study adds important information to theknowledge base on factors that influence perceived effec-tiveness in working with self-harming and suicidal pa-tients in EDs in Ireland. The emergence of ‘‘knowledge’’as a principle predictor of perceived effectiveness is con-sistent with international literature, as is the relationshipbetween ‘‘confidence’’ and ‘‘effectiveness’’ (23,34,35).

Effective and quality care practices often begin in theED setting (11). Attitudes and feelings towards individ-uals who self-harm and their emotional suffering do nothave to remain shrouded in fear and frustration, leavingED staff feeling helpless in knowing how to respond. Itis proposed here that with appropriate training, ED staffcan gain the knowledge and confidence required to beginthe healing process for individuals who are experiencingsevere and life-threatening states of emotional distress.

REFERENCES

1. National Office for Suicide Prevention. Annual report 2007. Avail-able at: http://www.dohc.ie/publications/pdf/nosp_report2007.pdf.Accessed September 30, 2008.

2. Health Service Executive. A&E survey report, 2007. Availableat: http://www.hse.ie/en/AEActivity/FiletoUpload,6933,en.pdf.Accessed February 13, 2008.

3. National Registry of Deliberate Self-Harm. Annual report 2005.Cork, Ireland: National Suicide Research Foundation; 2006.

4. Anderson M. Nurses’ attitudes towards suicidal behavior—acomparative study of community mental health nurses and nursesworking in an accidents and emergency department. J Adv Nurs1997;25:1283–91.

5. Corcoran P, Keeley HS, O’Sullivan M, Perry IJ. The incidence andrepetition of attempted suicide in Ireland. Eur J Public Health 2004;14:19–23.

6. Hawton K, Zahl D, Weatherall R. Suicide following deliberate self-harm: long-term follow-up of patients who presented to a generalhospital. Br J Psychiatry 2003;182:537–42.

7. McAllister M. Multiple meanings of self-harm: a critical review. IntJ Ment Health Nurs 2003;12:177–85.

8. McAllister M, Creedy D, Moyle W, Farrugia C. Nurses attitudestowards clients who self-harm. J Adv Nurs 2002;40:578–86.

Perceived Effectiveness and Self-harming Patients 1089

9. Platt S, Salter D. A comparison of health workers attitudes towardsparasuicide. Soc Psychiatry 1987;22:202–8.

10. Hemmings A. Attitudes to deliberate self-harm among staff in anaccident and emergency team. Ment Health Care 1999;2:300–3.

11. National Institute for Clinical Excellence (NICE). Self-harm. Theshort term physical and psychological management and secondaryprevention of self-harm in primary and secondary care [2004].Available at: http://www.nice.org.uk/nicemedia/pdf/CH016NICEguideline.pdf. Accessed January 4, 2008.

12. Berlim MT, Perizzolo J, Lejderman F, Fleck MP, Joiner TE. Doesa brief training on suicide prevention among general hospital per-sonnel impact their baseline attitudes towards suicidal behaviour?J Affect Disord 2006;100:233–9.

13. Lindgren BM, Wilstrand C, Gilge F, Olofsson B. Struggling forhopefulness: a qualitative study of Swedish women who self-harm. J Psychiatr Ment Health Nurs 2004;11:284–91.

14. Talseth AG, Lindseth A, Jacobsson L, Norberg A. The meaning ofpsychiatric in-patients’ experiences of being cared for by mentalhealth nurses. J Adv Nurs 1999;29:1034–41.

15. WarmA,Murray C. Fox, J.Who helps? Supporting peoplewho self-harm. J Ment Health 2002;11:121–30.

16. Bandura A. Self-efficacy in changing societies. Cambridge, UK:Cambridge University Press; 1995.

17. Zadravec T, Grad O, So�can G. Expert and lay explanations ofsuicidal behavior: comparison of the general population’s, suicideattempters’, general practitioners’, and psychiatrists’ views. Int JSoc Psychiatry 2006;52:535–51.

18. Wallin U, Runeson B. Attitudes towards suicide and suicidal pa-tients among medical students. Eur Psychiatry 2003;18:329–33.

19. Crawford T, Geraghty W, Street K, Simonoff E. Staff knowledgeand attitudes towards deliberate self-harm in adolescents. J Adolesc2003;26:619–29.

20. Patterson P, Whittington R, Bogg J. Measuring nurse attitudes to-wards deliberate self-harm: the self-harm antipathy scale (SHAS).J Psychiatr Ment Health Nurs 2007;14:438–45.

21. Friedman T, Newton C, Coggan C, et al. Predictors of A&E staff at-titudes to self-harm patients who use self-laceration: influence ofprevious training and experience. J Psychosom Res 2006;60:273–7.

22. Anderson M, Standen PJ, Nazir S, Noon JP. Nurses’ and doctors’attitudes towards suicidal behavior in young people. Int J NursStud 2000;37:1–11.

23. McCann TV, Clark E, McConnachie S, Harvey I. Deliberateself-harm: emergency department nurses’ attitudes, triage, andcare intentions. J Clin Nurs 2007;16:1704–11.

24. Ajzen J. From intentions to actions: a theory of planned behaviour.In: Kuhl J, Beckmannn J, eds. Action control: from cognition tobehaviour. New York: Springer-Verlag; 1985:11–39.

25. Eagly AH, Chaiken S. The psychology of attitudes. Orlando, FL:Harcourt Brace and Company; 1993.

26. Glasman LR, Albarracin D. Forming attitudes that predict futurebehaviour: a meta-analysis of the attitude behaviour relation. Psy-chol Bull 2006;132:778–822.

27. Kraus SJ. Attitudes and the prediction of behaviour: a meta-analysisof the empirical literature. Pers Soc Psychol Bull 1995;21:58–75.

28. Lamb S, Arensman E, Mullally B. Accident and emergency nursingassessment of deliberate self-harm. Cork, Ireland: National SuicideResearch Foundation; 2006.

29. McCarthy L, Gijbels H. An examination of emergency departmentnurses’ attitudes towards deliberate self-harm in an Irish teachinghospital. Int Emerg Med 2010;18:29–35.

30. Jeffery D, Warm A. A study of service providers’ understanding ofself-harm. J Ment Health 2002;11:295–303.

31. Morriss R, Gask L, Battersby L, Francheschini A, Robson M.Teaching front-line health and voluntary workers to assess andmanage suicidal patients. J Affect Disord 1999;52:77–83.

32. Field A. Regression. In: Discovering statistics using SPSS. 2nd edn.London: Sage Publications Ltd.; 2005:143–218.

33. Kline P. The handbook of psychological testing. 2nd edn. London:Routledge; 1999.

34. McLaughlin C. An exploration of psychiatric nurses’ and patients’opinions regarding in-patient care for suicidal patients. J Adv Nurs1999;29:1042–51.

35. Sidley G, Renton J. General nurses’ attitudes to patients who self-harm. Nurs Stand 1996;10:32–6.

36. Beautrais AL, Horwood LJ, Fergusson DM. Knowledge and atti-tudes about suicide in 25-year-olds. Aust N Z J Psychiatry 2004;38:260–5.

37. Domino G, Leenaars A. Attitudes towards suicide among Englishspeaking urban Canadians. Death Stud 1995;19:489–500.

38. Domino G, Perrone L. Attitudes toward suicide: Italian and UnitedStates physicians. Omega 1993;27:195–206.

39. Renberg ES, Jacobsson L. Development of a questionnaire onattitudes towards suicide (ATTS) and its application in a Swedishpopulation. Suicide Life Threat Behav 2003;33:52–64.

40. Segal DL, Mincic MS, Coolidge FL, O Reilly A. Attitudes towardssuicide and suicidal risk among younger and older persons. DeathStud 2004;28:671–8.

41. Patterson P, Whittington R, Bogg J. Testing the effectiveness of aneducational intervention aimed at changing attitudes to self-harm.J Psychiatr Ment Health Nurs 2007;14:100–5.

42. Holdsworth N, Belshaw D, Murray S. Developing A&E nursing re-sponses to people who deliberately self-harm: the provision andevaluation of a series of reflective workshops. J Psychiatr MentHealth Nurs 2001;8:449–58.

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ARTICLE SUMMARY

1. Why is this topic important?Past self-harming behavior is a key predictor of future

suicide. It is vital that we explore emergency department(ED) staff attitudes towards self-harming patients to im-prove care practices for these patients.2. What does this study attempt to show?

This study explores some predictors of perceived per-sonal effectiveness in dealing with self-harming patientsas reported by ED staff.3. What are the key findings?

Key findings showed that knowledge and confidencewere significant contributors to perceived personal effec-tiveness in dealing with self-harming patients. As knowl-edge and confidence increased, so too did personaleffectiveness in dealing with self-harming patients. Find-ings also showed that as knowledge of self-harmingbehavior increased, negativity towards these patientsdecreased.4. How is patient care impacted?

Effective care practices begin in the ED setting, espe-cially for those who have engaged in serious self-harmand suicidal behavior. Attitudes and feelings towards indi-viduals who self-harm are often cloaked in fear and frus-tration, leaving ED staff feeling helpless when dealingwith these patients. With appropriate training, ED staffcan gain the knowledge and confidence required toprovide effective care practices that may reduce futuresuicide.