The emergency care of young people who self-harm: an exploration of attitudes towards young people who self-harm and the care they receive from practitioners working in pre-hospital and hospital based emergency services
Aim: Using a mixed methods approach, this thesis seeks to explore the attitudes of emergency care staff towards young people (aged 12− 18 years) who self-harm and to gain an understanding of the basis of attitudes that exist. Background: This thesis has drawn on Strauss et al’s (1964), concept of the hospital as a negotiated order, a perspective that has latterly been applied to the organisation of hospital A&E services (Sbaih1997a&b 1998a&b, 2001, 2002). As the fundamental premise of emergency care work is the rapid assessment of patients’ needs, categorisation is an essential element of this work. This thesis therefore also draws on the sociological theories which have examined the categorisation of patients as ‘good’ or ‘bad’, as earlier sociological work has clearly demonstrated that practitioners working in emergency services judge patients based on their reasons for accessing the service (Roth 1972, Jeffery 1979, Dingwall & Murray 1983); patients who self-harm are amongst those adversely judged. However the extent to which these categorisations extend to young people was not wholly clear. Findings from earlier research that had considered this were inconclusive and inconsistent (Dingwall & Murray 1983, White 2002). Methods: A mixed methods approach, using a triangulation convergent design was employed. Staff employed in four emergency departments in South East London and five London Ambulance complexes that served these departments were surveyed; data from 143 questionnaires were analysed using SPSS. Qualitative data were obtained through semi-structured interviews with 12 practitioners, seven nurses and five paramedics, with thematic analysis undertaken. The two data sets were integrated and analysed to identify where the two data sets were consistent and whether/where discrepancies existed. Results: Findings from this study indicate that age, i.e. being a young person, does influence attitudes towards self-harm. Young people are less adversely judged as their self-harm is seen as symptom of distress, a coping mechanism or response to a stressor out with a young person’s control, thus as a consequence, attitudes towards young people who self-harm are benign. The findings lend support to previous research which has indicated that as an occupation, nurses have less positive attitudes than their peers working in emergency services. Although not statistically significant, the nurses surveyed in this study obtained lower scores on the scale used to measure attitudes than their medical and paramedical colleagues. The data from the interviews illustrated the difficulties and frustration the nurses faced in managing the care of young people who self-harm, which centred on the pressure to ‘move young people on’, pressures that were exacerbated by the need to do this within four hours. The paramedics interviewed did not face these challenges. Nurses faced considerable difficulty in securing admission to a children’s ward; the accounts of the nurse interviewees suggested that their ward colleagues expected and anticipated that young people who had self-harmed would be challenging in terms of their behaviours, whereas no such expectation existed with other adolescent patients. To this end the diagnostic label of self-harm had negative connotations Conclusions: The findings from this study have extended existing knowledge in relation to practitioners’ attitudes towards young people who self-harm, providing as they do an insight into how young peoples’ immaturity and diminished agency, contribute to the framing of young people as vulnerable, thus their self-harming behaviour is less adversely judged. A negotiated order perspective remains a relevant lens through which to analyse and explore the organisation of hospital services and specifically the work of the A&E department; the findings of the research presented in this thesis have revealed how young people who self-harm, through both their actual and perceived behaviours, disrupt the organisation of children’s accident and emergency care, thereby distorting its ‘shape’. The ambiguity of adolescence as a life-stage is reflected in the attitudes and perceptions of the study participants and is also reflected in health policy and guidelines, which is particularly exemplified by inconsistency in how the emergency care needs of young people between the ages of 16– 18 years generally, and young people who self-harm specifically, are addressed. This inconsistency and ambiguity in turn serves to impede young people’s progress through emergency services following an episode of self-harm.
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