Experiences and attitudes of psychiatric nurses in caring for patients with repeated non-suicidal self-injury in China: a qualitative study

Abstract

Background

The incidence of non-suicidal self-injury (NSSI) is high and often occurs repeatedly. Psychiatric nurses play a vital role in the care and treatment of NSSI patients, as they have the most frequent contact with patients. The experiences and attitudes of nurses has a direct affect on the quality of care they provide to patients. Negative care experiences and attitudes of patient aversion on behalf of nurses may delay the observation and treatment of changes in the patient’s condition, leading to irreversible risks. Although cross-sectional studies have investigated the attitudes of medical staff toward NSSI patients, quantitative research results cannot comprehensively reflect the emotional experiences and complex psychological changes of the study subjects. A few studies have focused on the psychiatric nurses’ care experiences and attitudes toward patients with repeated NSSI.

Objective

This study aimed to explore psychiatric nurses’ care experiences and attitudes toward patients during repeated NSSI.

Methods

A thematic analysis qualitative study was used. Using purposive sampling, 18 psychiatric nurses were recruited from a mental health center in Chengdu, China. Semi-structured interviews were conducted and audio-recorded. Audio-recordings were transcribed verbatim and analyzed using six-phase thematic analysis.

Results

Four themes emerged from the analysis: psychiatric nurses’ care experiences, perceptions, care attitudes and coping style toward repeated NSSI patients. Psychiatric nurses have experienced negative care experiences and severe career burnout during the patient’s repeated NSSI. Nurses’ attitudes toward NSSI patients changed during repeated NSSI, from understanding to indifference to anger and resentment. At the same time, it was found that nurses’ coping style with NSSI patients could be divided into three stages, namely, active coping, neglect and perfunctory, and criticism and punishment.

Conclusions

The findings have implications for health care systems regarding interventions to improve nurses’ care experiences and attitudes toward repeated NSSI patients. These findings suggest that enhancing nurses’ understanding of NSSI, establishing standardized emergency response and intervention programs, guiding positive professional values and responsibility, and improving nurses’ caring attitudes can promote the early detection and timely intervention of NSSI.

Introduction

NSSI (non-suicidal self-injury) refers to the behavior of directly damaging one’s body tissue, such as self-harming, skin scratching, and self-burning [1]. NSSI usually starts in early adolescence with an estimated global prevalence of 17.6% in community samples [2], while it is as high as 40∼61% in clinical samples [2, 3]. NSSI often occurs repeatedly [4, 5]. A study with a community sample of Chinese adolescents, assessed every three months over two years with a self-report measure showed consistently NSSI of up to 69.2% [6]. Multiple episodes of NSSI can lead to serious health problems such as infection and even autoamputation of body tissues [7]. Additionally, the suicide risk of patients who engage in NSSI is hundreds of times higher than that of the general population [8]. This is concerning, as self-injury is the single most reliable predictor of suicidal ideation and attempts, with one-fourth of suicides preceded by acts of NSSI within the prior year [9]. NSSI has become an important issue affecting the health of adolescents. At present, NSSI has been included as an independent mental health issue in the 5th edition of the Diagnostic and Statistical Manual for Mental Disorders and is a major global public health issue [10].

A Canadian study with large sample (n = 2038) of hospitalized children and adolescents showed that about 29% attempted to self-injury even when under care in a mental health setting [11]. Research shows that more than half of people who have experienced NSSI often experience repeated self-injury [5]. However, from clinical practice, these data may be higher. Due to its high detection rate, high risk, and high repeatability, this behavior has become one of the most important public health problems in the world [10]. The effective treatment of NSSI remains a prominent research focus within the field of psychiatry. No specific pharmacological intervention has demonstrated consistent efficacy in addressing NSSI [12]. Consequently, the current consensus among researchers emphasizes the primacy of psychological interventions in the treatment of this condition [13]. A systematic review and meta-analysis identified potential benefits of Dialectical Behavior Therapy (DBT) [14] in reducing the occurrence of NSSI in adolescents. However, the extended duration of this therapeutic approach precludes its application as an immediate crisis intervention strategy for hospitalized patients facing acute emergencies. An effective crisis intervention methods for self-harm are developed and evaluated on individuals with borderline personality disorder (BPD), such as Patient-Initiated Brief Admissions(PIBA) [15, 16]. To date, no studies have been found on the application of PIBA to NSSI patients. The dearth of evidence-based practices for crisis intervention in NSSI cases is noteworthy. Healthcare professionals have expressed that they often feel powerless and helpless due to the lack of standardized, timely, and effective intervention programs for NSSI patients [17].

Psychiatric nurses play a vital role in the care and treatment of NSSI patients, as they have the most frequent contact with patients. They play a crucial role in distinguishing whether patients have attempted self-injury, preventing self-injury, guiding patients in psychotherapy, or providing other assistance within their capabilities. The incidence of repeated NSSI is high, and only about 50% of NSSI adolescents have self-disclosure behavior [18], which is difficult to identify and prevent, and poses great risks to patient safety. This has become an increasingly difficult point in nursing safety management, causing great distress and pressure to psychiatric nurses [19]. Besides, the behavior of patients with NSSI—including manipulation, self-mutilation, aggression, and noncompliance with treatment recommendations can challenge the therapeutic relationship [16]. Such patient behavior can impede the efforts of psychiatric nurses and give rise to feelings of frustration and anger as they try to understand the destructive behavior and emotional outbursts of these patients [15]. Although psychiatric nurses expect to maintain professionalism and provide more support to patients, regardless of the emotional weight of this situation, nurses caring for NSSI patients face the risk of empathy fatigue and even a change in attitudes toward patients, which can have a negative impact on their empathy and thus affect the patients’ experiences with care [20].

Attitude can be defined as a response to a stimulus that involves cognitive, affective and behavioral components, extending to all aspects of intelligence and behavior [21]. This response is an interior disposition that affects the selection of an action or behavior to be adopted toward persons, events or objectives [21]. The Knowledge-Attitude-Behavior (KAB) model also explained that knowledge is the foundation of behavior change, and belief and attitude are the driving force of behavior change [22]. The attitude of nurses seems to have a positive or negative impact on the care provided to NSSI patients [23]. Studies have shown that negative attitudes toward self-injury are associated with a lack of preparation among professionals and may reinforce self-injury-related stigma and discrimination and decrease the level of care provided to patients who attempt self-injury [24]. Research reports that NSSI patients describe their experiences with healthcare professionals during hospitalization as judgmental, non-listening, and lacking sufficient knowledge [25]. Nurses’ negative attitudes toward NSSI patients, such as indifference and antipathy, are key factors that hinder patients from continuing treatment and seeking further help. Negative attitudes, which are reported to significantly influence outcomes and are even connected to adverse events such as patient falls and medication errors, are especially problematic [26]. Therefore, the negative care experiences and aversion attitudes of nurses may delay the observation and treatment of changes in the patient’s condition, which may lead to irreversible risks.

Although cross-sectional studies have investigated the attitudes of medical staff toward suicide or NSSI patients [27], quantitative research results cannot comprehensively reflect the emotional experiences of the study subjects, and psychological measurement scales have difficulty measuring complex psychological changes. Furthermore, the use of self-report questionnaire could produce overly optimistic scores because negative attitudes are not in accordance with nurses’ professional self-images and social expectations [28]. Previous qualitative studies have mostly focused on interviews with NSSI patients [29], parents [30], and teachers [31]. It is currently unclear how Chinese psychiatric nurses’ care experiences and attitudes toward repeated NSSI patients, as well as how they affect coping style toward repeated NSSI patients. Understanding the care experiences and attitudes of psychiatric nurses toward NSSI patients plays an important role in preventing and reducing repeated self-injury. This study explores the care experiences and attitudes of psychiatric nurses toward patients with repeated NSSI. The study is conducted in the context of Chinese culture using qualitative research methods, and analyzes the difficulties and challenges in nursing practice for NSSI patients. The goal is to provide a research basis for further improving and enhancing nurses’ care attitudes, coping style, and support systems toward NSSI patients and to provide a more theoretical basis for the management of NSSI patients.

Methods

Study design

This qualitative study took a thematic analysis, which attempts to understand human experience and uncover meanings [32]. This approach is an appropriate and powerful method to use when seeking to understand a set of experiences, thoughts, or behaviors across a data set [33].

Research setting

The study was conducted from March 2023 to June 2023 at the mental health center of a tertiary hospital in Chengdu, Sichuan Province, China. The tertiary hospital we chose is the largest regional medical center in the city, and approximately 600 NSSI patients were hospitalized each year in the last 3 years. The mental health center has 5 wards with a total of 300 beds and approximately 120 nurses. Patients with NSSI may be admitted to any of these wards where the participants were selected and interviewed.

Participants and recruitment

This study employed a purposive sampling method with a maximum variation strategy to ensure a diverse range of perspectives. Participants eligible for this study were nurses who (a) possessed a professional nursing qualification certificate; (b) were able to independently execute overall responsibility-based nursing care; (c) had a primary role as a staff nurse (bedside) position; (d) had at least 1 year of clinical experience in psychiatry; and (e) had cared for NSSI patients at least once in the past year. Nurses who were on sick leave, personal leave, maternity leave, rotation, and continuing education during the study period were excluded. The sampling criteria were carefully designed to capture a broad spectrum of experiences and backgrounds among psychiatric nurses. Specifically, we sought to include participants across the following dimensions: age (ranged from 22 to 55 years old), educational background (e.g., bachelor’s, master’s, and doctoral degrees in nursing or related fields), professional title (junior nurses, senior nurses, and nurse-in-charge to capture varying levels of expertise and responsibility). The sample size was based on the principle of saturation of interview information, and a total of 18 psychiatric nurses who had previous experience in handling NSSI cases were ultimately interviewed.

Ethical considerations

This study was approved by the Ethics Review Committee of West China Hospital of Sichuan University. The research subjects all provided informed consent and voluntarily participated in this study. Participants were assured that their demographic data and interview responses would be confidential and anonymized. Addressing sensitive topics requires attention to the potential emotional impact the interview may have on the participant and the researcher [34]. During the interview, if participants have any discomfort (anxiety, irritability, etc.), they can terminate the interview at any time or even withdraw from the study. Additional measures included providing contact information for emotional and mental health resource follow-up.

Data collection

We conducted 18 one-on-one semi-structured interviews with participants in a psychotherapy room. Before the formal interview, the researcher first fully communicated with the participants, told them to record and record the conversation on the spot under the premise of protecting privacy, explained the purpose, method and content of the study in detail, and assured the participants that the interview contents were confidential and could be terminated at any time. The interview guide was developed based on our interests of study and research gaps identified from the literature review and was adjusted after analysis of the first three interviews. The interviews used open-ended questions and focused on 4 topics: (1) nurses’ responses and behaviors to patient NSSI; (2) nurses’ care experiences for repeated NSSI; (3) nurses’ perceptions about repeated NSSI; and (4) changes in nurses’ attitudes and behaviors during repeated NSSI. The interviews were semi-structured, following an interview guide (Table 1). Each interview lasted 30 to 45 min. No repeat interviews were conducted. Interviews were conducted in Mandarin or Sichuan dialect according to participants’ preferences.

Table 1 Interview questions and prompts

Data analysis

Two researchers transcribed the speech data into text, and confirmed the transcribed interview contents with the participants. Nvivo 11 [35] software was used for classification and coding analysis. Thematic analysis was used, following the six-phase process described by Kiger [36]. The approach is inductive without a prior coding frame or the authors’ “analytical preconceptions” [32]. From the transcript, a number of themes emerged, along with relevant quotations from the interviews, in an inductive process using a realist epistemological perspective. This perspective assumes that the truthful experiences and attitudes of psychiatric nurses in caring for patients with repeated non-suicidal self-injury can be obtained. Themes and subthemes were compared between cases to determine if they needed to be refined according to their supportive data. The research team, together with advisory experts read through all data, scrutinized coding, and defined and redefined themes until the scope and content of each theme could be clearly and succinctly described and consensus was reached.

Rigor

To ensure rigor and trustworthiness that the findings reflected participants’ words and perspectives, Lincoln and Guba’s criteria of credibility, dependability, confirmability and transferability were used in this study [37]. Strategies included two investigator discussions of coding decisions, maintaining field notes, and an audit trail (confirmability), participant checking and peer debriefing (credibility), an audit trail of coding decisions and theme development (dependability), and providing rich descriptions of participants, data collection process, and context (transferability) [38]. Considering the mental health counseling background of the two authors responsible for interviews, reflective journals were written for audit in order to reduce researcher bias.

Result

Characteristics of the 18 participants are shown in Table 2. 4 themes and 14 sub-themes emerged from the analysis (Table 3).

Table 2 Participant demographics

Table 3 Themes and sub-themes

Care experiences of repeated NSSI

This theme describes some of the negative experiences experienced by psychiatric nurses in the course of caring for patients with repeated NSSI, including: empathetic fatigue, excessive psychological pressure, struggling on caring them, feeling confused and helpless, deteriorating nurse patient relationship and career frustration and burnout.

Feeling powerless and helpless

The nurses in this study clearly show that caring for patients with NSSI is more challenging than caring for other patients. They all work very hard to help patients but often feel powerless and helpless due to a lack of understanding, team support, and standardized intervention protocols.

A10: “Without an exact theoretical model and standard intervention program to guide us on how to properly deal with such patients, we lack confidence in the intervention process, and the intervention effect is far from ideal.”

Respondents expressed the need for support from colleagues and leaders and wanted to talk with colleagues or leaders after patient incidents of self-injury. However; a lack of empathy from fellow staff members during these conversations made nurses feel even more isolated and criticized, causing them not to reach out and to distance themselves from potential sources of support, and thereby perpetuating the lack of emotional support.

A13: “When I reported this to colleagues and leaders or asked for help, I was often questioned or criticized by them, and thereafter I refused to report or communicate with them when no serious adverse events occurred.”

Excessive psychological pressure

Psychiatric nurses described high concealment of NSSI, that is, they were not able to predict when patients would commit NSSI, and the unpredictable consequences of NSSI, and nurses felt stressed during work. In addition, most of the nurses lost confidence in the potential for patients’ conditions to improve, and experienced feelings of pessimism and despair.

A4: “Since the behavior of NSSI patients is hidden and not easy to prevent, especially in the night shift, the manpower is relatively weak, and I always worry that NSSI patients will show NSSI behavior again when I am busy dealing with other things (which is always the case), which makes me feel particularly stressed and in a state of mental tension.”

A8: “My job is to give patients help and hope, but right now I’m the most desperate person on the ward.”

Empathetic fatigue

Almost all interviewees reported empathy fatigue after long-term care of patients with repeated NSSI. Psychiatric nurses described themselves have faced the pain and suffering of NSSI patients for a long time, may gradually lose their emotional empathy and care for them, and feel that their emotional resources are exhausted and emotionally exhausted. The nurses recounted spending a lot of time and energy to help NSSI patients solve problems or relieve painful emotions, while the patients’ self-injury behavior did not decrease, and even suffered from apathy and aggressive behavior. Over time, they felt that their sensory sensitivity gradually decreased, became numb to the patient’s pain or self-injury behavior, and felt that they became apathetic, and indifferent.

A1: “My child is 14 years old, which is similar to the age of these patients. At first, when I saw them hurt themselves, I would feel very distressed. I would patiently comfort and help them, just like helping my own children. However, not long after each incident, they will hurt themselves in different ways. I have become indifferent to them for a long time”.

A2: “Well, what’s the point? No matter how hard you try, she will still respond the same way, which is to continue NSSI.”

Struggling on caring them

Most participants mentioned that although after facing the patient’s long-term repeated self-injury, they lost confidence in the patient’s treatment and became numb and indifferent to self-injury behavior. But they had a responsibility to help patients get better, so they struggling on caring them.

A7: “I know I should actively respond to patients’ self-injury and needs, but I am struggling internally.”

A14: “I sometimes feel like I’m wasting my time dealing with repeated self-injury, but I still have to deal with it!”

Deteriorating nurse patient relationship

Some interviewed nurses stated that they were embarrassed to admit that they had difficulty establishing a collaborative relationship with NSSI patients. Others stated directly that their tolerance for repeated NSSI patients is low, and that they hold a moral critical attitude toward patients with repeated NSSI. They may blame the patients and are less willing to sympathize and understand them, which will distance the nurse from the patient. In addition, patients gave nurses feedback that they thought nurses did not understand why they hurt themselves, and even blamed and criticized them, which led to patients’ reluctance to maintain communication with nurses, resulting in increasingly distant nurse-patient relationship.

A9: “I know for sure that one’s patience is limited, even though I am a nurse (maintaining a high degree of professional responsibility). When I tried to help a NSSI patient, he still repeatedly demonstrated self-injury behavior. In anger I said to the patient: I am too disappointed in you! He could also sense that I was losing patience with him and began to distance himself from me.”

Career frustration and burnout

Respondents reported that when some repeated NSSI patients are admitted to the ward, they required too much time to prevent, control, and deal with their self-injury. However, even if nurses spent a lot of time and effort helping them, the results were often disappointing. Most respondents said that the long-term impact of patients’ unreasonable demands, destructive behavior, repeated NSSI, and repeated treatment led to a lack of confidence and frustration for nurses, resulting in more serious burnout.

A7: “In the face of NSSI patients, we tried everything we could think of, including the application of some psychological therapy techniques, but later, it was still to no avail, and I felt my energy was exhausted, and I gradually lost my passion for this job.”

Perceptions of repeated NSSI

Nurses have a vague perception of NSSI, meaning that nurses are not sure what the real reason and purpose behind each patient’s self-injury is. However, in clinical practice, they often treat NSSI as a way for patients to reduce mental distress and/or meet needs.

Coping strategy for reducing mental distress

A common feature of the interviews was that psychiatric nurse related NSSI to mental health and portrayed it as a maladaptive coping strategy for reducing mental distress.

A2: “Although I’m not sure why they hurt themselves, I have heard from patients who say that NSSI makes them feel better, or that the physical pain caused by NSSI drives away or relieves their mental pain.”

A17: “When adolescent patients are emotional or depressed, they may choose to relieve their emotions through self-injury, because they lack other coping methods.”

A way to meet a need

Some psychiatric nurses also see NSSI as a way or tool for adolescents to meet needs such as getting attention, eliciting sympathy, or manipulating caregivers (parents or medical staff). In the hospital, some adolescents commit self-injury when medical personnel refuse their request, and some NSSI become more serious or dangerous.

A6: “They threaten parents with self-harm at home, and they threaten staff in the same way at hospitals to meet their demands.”

A17: “It is common to encounter NSSI patients who ask to smoke, call their parents or even leave the hospital, and if their requests are not met, they will go to NSSI.”

Care attitudes of repeated NSSI

The care attitudes of psychiatric nurses toward NSSI patients changes with the recurrence of NSSI. The attitudes described by the nurses toward patients with NSSI fluctuated between understanding, sympathy, and anger. This change in attitude may stem from the experience of caring for patients with NSSI as well as perceptions of NSSI.

Understanding and sympathy

Some respondents said that for NSSI patients, self-injury is not only a way to express bad feelings but also a strategy to cope with negative feelings, which is why they choose hospitalization. Patients who commit NSSI have also told nurses that it made them feel better or that the physical pain caused by NSSI drove away or lessened their mental pain. Psychiatric nurses express empathy for the patients’ self-injury, and actively try to help patients.

A1: “When I saw their wounds, I was very shocked by how much pain they must have in their hearts to cause them to treat themselves in such a way, it was painful to watch.”

A15: “At the moment of their self-injury, they may be very desperate and uncomfortable.”

Apathy and escape

Most respondents mentioned that they have the responsibility to help patients cope with adverse emotions or meet their reasonable requirements, but with the increasing frequency of repeated NSSI or the increasing severity of NSSI results, nurses gradually lose confidence and patience in the treatment of patients and become numb and indifferent to their self-injury.

A11: “When I tried to stop them from hurting themselves, they spoke harshly to me and even attacked me. At this time, I would feel very sad because good intentions would not be rewarded. So that in the later stage, I would ask my colleagues to deal with it, as I did not want to face such patients.”

A16: “I know it was not a suicide attempt. Otherwise, the scratch would not be so shallow. I do not even want to care why she continues to do this.”

Antipathy and resentment

Some interviewed nurses described that their tolerance for repeated NSSI patients is low, and that they hold a moral critical attitude toward patients with repeated NSSI. They may blame the patients and are less willing to sympathize and understand them, which can play a role in recurrent attacks or lack of improvement in the patient’s condition. At the same time, interviewed nurses believe that repeated NSSI behavior is a manifestation of intentional manipulation or excessive dependence, causing a serious loss of empathy for patients and resentment among medical staff.

A7: “There are plenty of alternative ways in our ward to help her relieve her mood, but she still repeatedly took the way we forbid, which made me very unacceptable and feel frustrated and even caused me to show antipathy.”

A10: “They threaten their parents with NSSI at home, and they threaten their staff in the same way at the hospital. This behavior and motivation make me very resentful.”

Psychiatric nurses stated that NSSI seems to demonstrate a phenomenon of human-to-human transmission. This may be related to the tendency of teenagers to accept negative information that promotes NSSI and imitates others’ NSSI behavior [39]. In addition, it is not difficult to find in clinical practice that patients with long-term repeated NSSI often try to persuade more adolescents to participate in self-injury. Nurses resents these types of initiators because they make it difficult to manage the entire ward.

A6: “When there is a repeatedly hospitalized NSSI patient in the ward, a group of new NSSI patients will emerge at this time. I will be very angry when I find out through tracking that the NSSI behavior of the newly admitted patients is learned from the veteran NSSI patients.”

Coping style of repeated NSSI

Through interviews, we found that psychiatric nurses’ responses to repeated NSSI can be divided into three stages: actively respond, neglect and perfunctory, criticism and discipline. Behind the variations in coping styles at each stage are changes in nurses’ cognition and attitudes toward NSSI patients.

Actively respond

Some interviewed nurses believe that for teenagers, NSSI is not only a way to express negative emotions but also a strategy to deal with negative emotions. Psychiatric nurses express understanding of their behavior, actively explore alternative ways to help alleviate negative emotions, and provide suggestions on how to deal with triggering factors.

A11: “I will ask them about their feelings and reasons behind NSSI, express concerns about potential health issues that may arise later, and provide advice on how to respond to negative emotions and alternative approaches, as well as how to deal with triggering factors.”

A9: “Although I sometimes feel disappointed and resentful about patients’ long-term and repeated NSSI behaviors, my responsibility is still to actively handle patients’ problems.”

Neglect and perfunctory

Most respondents mentioned that with the increasing frequency of repeated NSSI or the increasing severity of NSSI results, they gradually lose confidence and patience in the treatment of patients and become numb and indifferent to their self-injury, and sometimes ignored and perfunctory NSSI behaviors of patients. Besides, when nurses believe that NSSI is a way for teenagers to meet their needs or receive attention, and think that NSSI are not causing serious health problems, they will choose to ignore the patient’s self-injurious behavior and believe that reducing attention can help the regression of NSSI.

A2: “I expressed my powerlessness and helplessness toward his performance, and I have become emotionally numb. Sometimes when I hear NSSI patients calling for help, I delay the response.”

A15: “I believe that any method is not helpful in preventing NSSI. In contrast, excessive attention will only reinforce their self-injury.”

Criticism and punishment

Almost all respondents mentioned that repeated NSSI of patients results in a serious loss of empathy among psychiatric nurses toward patients, and causes aversion and resentment among psychiatric nurses. When nurses believe that teenagers’ NSSI is intentional, they may try other approaches to preventing teenagers from engaging in NSSI. One approach is criticism, and the other is punishment. Criticizing and punishing this behavior is to prevent it from happening again. In traditional Chinese culture, criticism and punishment are also very common and practical educational methods.

A17: “If a patient attempts to manipulate us using NSSI (such as requesting discharge), I will tell them which approach is incorrect and express my anger. In addition, warn them that if similar behavior occurs again, I will restrain them.”

Some participants also expressed that when they learned that the patient had experienced NSSI again, they found it difficult to control their emotions and expressed anger toward the patient, as they had invested a lot of energy and emotions in exchange for repeated NSSI and aggressive behavior.

A3: “Do you know? After spending a lot of time and energy guiding her on how to deal with negative emotions, shortly after the conversation ended, she hurt herself again, which made me very angry. I blamed and criticized her behavior.”

Some interviewed nurses feel strongly that punishment is a very effective way of discipline. From the perspective of immediately stopping bad behavior, punishment is often effective. For psychiatric nurses, ensuring patient safety is the primary task of their work. Protective restraint is a coping method that can have an immediate effect on preventing patients from engaging in NSSI. Another reason why psychiatric nurses use punitive measures is that they are concerned that not punishing them will only pamper adolescent patients and cause them to worry about losing control of the patients. Moreover, punishment is easy and often a “reactive” response.

A9: “When my patients engage in NSSI, I will intervene with protective restraints because they are violating the basic principles of mutual respect and trust. “.

A18: “I know that adopting protective renstraints on patients with repeated NSSI is often a disguised punishment. However, when faced with patients’ bad behavior, I still fall into the old habit of punishment.”

Punishment is often effective at stopping bad behavior in the short term, but the problem is that the nurses are not aware of the long-term effects of punishment. Nevertheless, the primary reason psychiatric nurses insist on using punitive measures is that they do not know what else to do.

A12: “I do not think restraints are a very effective intervention measure, but we have tried various ways and methods, but still have not effectively solved the problem of NSSI, and I do not know how to deal with it.”

Discussion

It is necessary to discuss the experiences and attitude of psychiatric nurses who care for patients with repeated NSSI, because the nurse’s attitude toward patients seems to have an impact (positive or negative) on the quality of patient care. For the first time, this study explored the care experience and attitude of Chinese psychiatric nurses toward repeated NSSI patients through qualitative research methods. Four themes were identified through interviews: care experience, perceptions, care attitude and coping style toward repeated NSSI. Six kinds of care experience were identified as: feeling powerless and helpless, excessive psychological pressure, empathetic fatigue, struggling on caring them, deteriorating nurse patient relationship and career frustration and burnout.

In this study, we found that psychiatric nurse felt excessive psychological pressure in the face of NSSI. Hadfield et al. [40] similarly show that doctors view treating people with self-injury as a futile task that causes feelings of despair and frustration. In recent years, the proportion of NSSI patients within psychiatric inpatient populations has been increasing [41]. However, due to the incidence of repeated NSSI is high, and only about 50% of NSSI adolescents have self-disclosure behavior [18] which is difficult to identify and prevent, and poses great distress and pressure to psychiatric nurses, and strong negative emotions such as anxiety and despair. These outcomes have been widely reported in the literature [42, 43]. In addition, although many of the nurses in this study had cared for a large number of NSSI patients, they indicated that they did not have an in-depth understanding of NSSI and sometimes had to improvise patient guidance and interventions based on their own experience, with little effect. Nurses make it clear that they work very hard to help NSSI patients but often feel powerless and helpless by the lack of standardized, timely and effective intervention programs. Without a theoretical model to guide this work, the effect of the intervention is very limited, similarly to reports by Kickan [43]. To address this issue, a novel intervention known as patient-initiated brief admission (PIBA) has been developed. PIBA is a psychiatric nursing intervention on the basis of the theoretical concepts of patient participation, shared decision-making and patient autonomy [15, 44]. The aim of PIBA is to promote constructive coping strategies when increased anxiety and thoughts of self-harm become unmanageable [45]. At present, PIBA is mainly used in BPD patients with emotional instability and self-injury, and the effect is significant [46]. Furthermore, a study suggested that BA may reduce work-related stress experienced by nurses while caring for persons with emotional instability and self-harm [46]. Therefore, future studies can be combined with PIBA to provide a constructive crisis management approach for NSSI. During a crisis, this easily accessible care option has the potential to prevent harm to patients and reduce the stress on nurses caring for patients with NSSI patients.

A noteworthy finding of this study was that psychiatric nurses experienced empathy fatigue and career burnout in the process of caring for repeated NSSI patients. Psychiatric nurses recurrently witness repeated self-injury, unreasonable demands, destructive behaviors and repeated hospitalization of NSSI patients. In response, nurses gradually lose patience with patients, become frustrated, and lack confidence in their ability to treat patients. Psychiatric nurses recounted spending a lot of time and energy to help NSSI patients solve problems or relieve painful emotions, while the patients’ self-injury behavior did not decrease, and even suffered from apathy and aggressive behavior [47]. Such patient behavior can impede the efforts of the nurses and give rise to feelings of frustration and anger in psychiatric nurses who try to understand the destructive behavior and emotional outbursts of such patients [15]. This enormous and lasting psychological gap leads to the empathy fatigue of nurses for patients. A meta-analysis shows that mental health nurses face a sense of low value, heavy pressure and hopelessness for a long time, which can easily lead to career burnout [48]. Burnout not only deteriorates nurses’ work performance but also adversely influences their health and well-being [49]. Therefore, it is suggested that clinical managers should introduce effective strategies and courses(such as mindfulness-based stress reduction [50])to reduce nurse burnout while paying attention to staff mental health and stress management. In addition, support for nurses is essential because nurses often encounter distressing situations when caring for NSSI patients. It is recommended that nurses have access to mental health training, mental health liaison teams in acute trusts, and managerial support [51].

Research has also shown that although psychiatric nurses expect and strive to maintain professionalism and provide as much support as possible to patients, the specific experiences (empathy fatigue, anxiety, hopelessness, etc.) of nurses working in high-stress environments for NSSI patients negatively affects their empathy and willingness to care. However, driven by responsibility and leadership, so they struggling on caring repeated NSSI patients. However, it is worth noting that most participants mentioned that although after facing the patient’s long-term repeated self-injury, they lost confidence in the patient’s treatment and became numb and indifferent to self-injury behavior. In other words, psychiatric nurses are at risk of reduced or lack of sense of responsibility when caring for patients with repeated NSSI. Responsibility guides nurses to pay attention to patients’ emotional changes, seek information, prioritize care, and develop responses [52]. Reduced or absent accountability can delay the observation and recognition of changes in a patient’s condition, with serious consequences [53]. People who self-harm present at healthcare services during times of crisis, with the potential intention of suicide. It is, therefore, imperative that services for this vulnerable group are delivered with compassion and in a non-judgmental manner. This is an ethical issue in nursing practice, particularly as maintaining a non-judgmental and positive attitude is a core nursing value [54]. This finding highlights the need to support the development of nurses’ professional values and sense of responsibility throughout their education and career.

Psychiatric nurses have a vague perception of NSSI, meaning that nurses are not sure what the real reason and purpose behind each patient’s self-injury is. However, in clinical practice, they often treat NSSI as a way for patients to reduce mental distress and/or meet needs (such as getting attention, eliciting sympathy, or manipulating caregivers). This is in line with multiple studies and theories on NSSI [40, 42, 43]. One of the things we must note is that when psychiatric nurses also see NSSI as a way or tool for adolescents to meet needs, it appears to label patients. Labels can carry harmful, implicit biases that negatively affect clinical outcomes for the people they describe [55, 56]. For example, our study found some psychiatric nurses will choose to ignore the patient’s self-injury and believe that reducing attention can help the regression of NSSI when they believe that NSSI is a way to meet needs or get attention. Similarly, a previous study found that medical staff see NSSI as an attention-seeking behaviors in emergency department, which is why they refrained from giving too much attention to NSSI patients [40]. Owens et al. [57] study found that when care providers withheld sufficient attention to self-injuries patients, it can lead to a tendency to avoid seeking help in the future. Refusing to seek help may miss the best time to receive psychological intervention, with irreversible consequences. In some cases, hold a moral critical attitude toward NSSI among nurse may delayed NSSI patients for proper treatment. Therefore, improving psychiatric nurses’ understanding of NSSI may avoid labeling patients and reduce biased statements.

The study found that the nurse-patient relationship gradually deteriorated in the process of patients with repeated NSSI. The nurses in this study stated that their tolerance for repeated NSSI patients is low, and that they hold a moral critical attitude toward patients with repeated NSSI. They may blame the patients and are less willing to sympathize and understand them, which will distance the nurse from the patient. Research reports that NSSI patients describe their experiences with healthcare professionals during hospitalization as judgmental, non-listening, and lacking sufficient knowledge [25]. In fact, the relationship between psychiatric care providers and patients is often described as challenging [17]. Psychiatric nurses often encounter patients experiencing acute crises, a phase in which patients may express anger, self-harm, and have suicidal ideations. In response to such conflict-prone situations, coercive measures such as physical restraint, forced medication, and seclusion are often applied against the patient’s will to ensure the safety of both patients and staff [58]. However, the use of coercive measures may make patients hostile to nurses and destroy the nurse-patient relationship. From this, we can infer that the reason for the gradual deterioration of the nurse-patient relationship is that the negative feelings and misunderstandings toward each other remain from both sides. Therefore, the authors of this study suggest that future quantitative studies could be used to investigate how common this phenomenon is and to explore how to develop a more collaborative nurse-patient relationship.

In terms of attribution, this study showed that the caring attitude of psychiatric nurses toward NSSI patients changes with the recurrence of NSSI. As NSSI repeats more frequently or NSSI results become increasingly severe, the attitude of nurses toward NSSI patients changes from understanding to indifference to anger and resentment. However; in previous studies, the dynamic changes and depth of this care attitude may have been masked [27]. After the nurses invested a great deal of emotion in exchange for the patient’s repeated self-injury, they consumed the nurse’s patience and compassion, accompanied by a change in attitude. Although nurses acknowledge that ‘understanding can generate empathy’ and describe the importance of understanding patients to gain more empathy, they also acknowledge that it is difficult to truly understand NSSI because they do not easily accept this coping style. In clinical practice, nurses’ capacity for empathy is also easily affected by patients’ negative emotions and aggressive behaviors, resulting in antipathy and aversion toward patients [59]. Although nurses are well aware that NSSI is a disorder that requires psychological assistance, many staff members may inadvertently revert to indifference, anger, or resentment when they encounter repeated NSSI if they do not fully understand the patterns and mechanisms of repeated NSSI. Therefore, this finding emphasizes the importance and urgency of studying the mechanism of NSSI and the pattern of repeated NSSI. Further research on the educational intervention that are most effective in improving the attitudes of psychiatric nurses towards patients with NSSI would be valuable.

Our study also highlights that how nurses respond to NSSI patients is not simply determined by perceptions of NSSI, and that nurses’ attitudes towards patients are another strong predictor. An attitude is not specifically a behavior but instead an inclination toward actions, modes or ways to address, react or face a situation or problem in a variety of circumstances [21]. The KAB model elaborates that a person’s knowledge directly affects their attitude and indirectly affects their behavior through their attitude [22]. With this model, it can be assumed that the knowledge of psychiatric nurses about NSSI affects their attitudes toward it, and that their attitudes affect the actions (behaviors) they take. In this study, nurses who understood and sympathized with patients’ self-injurious behavior in the past were more likely to mediate, avoid conflict, and cooperate with patients. Nurses who had expressed indifference and resentment to patients’ self-injurious behavior in the past were more likely to deny, be perfunctory, or criticize and punish them. Social psychology believes that attitude is the most important breakthrough point in influencing strategies [60]. The ultimate goal of social influence may be behavioral change, but reaching this ultimate goal requires a complex channel of attitude. Only by mobilizing a person’s real and implicit attitude and exerting his subjective initiative can he affect his behavior [61]. Therefore, relying solely on training and guidelines might prove inadequate in enhancing the care provided to individuals with NSSI. Ideally, comprehensive competence development should encompass not only the acquisition of skills but also the cultivation of awareness regarding attitudes and the promotion of reflection on the nurses’ influence on the patients’ trajectory.

Strengths and limitations

This is the first qualitative study to explore the experiences and attitudes of psychiatric nurses in caring for patients with repeated NSSI in China. Despite the promising findings of this study, there were several limitations. As with all qualitative research, the findings are limited by self-reporting and are subjected to social desirability bias. This was a relatively small local study; therefore, the findings are not necessarily representative of a broader cross section of psychiatric nurses. The findings may not be transferable to nurses working in other types of hospitals, cultures or countries. In addition, this study explored nurses’ caregiving experiences and attitudes towards repeated NSSI patients from the perspective of nurses, and did not explore other factors that might affect nurses’ caregiving experience and attitude towards patients, such as their own personality traits and coping styles. One limitation of this study is that nurses’ caregiving experiences and attitudes toward NSSI patients with different diagnoses and characteristics were not separately discussed. It is hoped that future studies can make up for the above limitations. Despite this, the recurring nature of key phrases and words lends weight to the strength and credibility of the findings. Several factors add to the trustworthiness of the study’s findings. The investigators used an established method of data analysis and several strategies (included two investigator discussions of coding decisions, maintaining field notes, and an audit trail, participant checking and peer debriefing, an audit trail of coding decisions and theme development, and providing rich descriptions of participants, data collection process, and context) to enhance the trustworthiness of the findings. Data collection continued until saturation was reached and confirmed by two investigators. Analysis of the findings was validated by three investigators and by several participants of the study.

Conclusions

Through interviews with psychiatric nurses, this study found that psychiatric nurses have experienced negative care experiences and severe career burnout during the patient’s repeated NSSI. It is of concern that psychiatric nurses are not sure what the real reason and purpose behind each patient’s self-injury is. Nurses’ attitudes toward NSSI patients changed during repeated NSSI, from understanding to indifference to anger and resentment. At the same time, it was found that psychiatric nurses’ coping style with NSSI patients could be divided into three stages. Behind the changes in coping style at each stage were the changes in nurses’ attitudes toward repeated NSSI patients. These findings suggest that enhancing nurses’ understanding of NSSI behavior, establishing standardized emergency response and intervention programs, guiding positive professional values and responsibility, and improving nurses’ caring attitudes can promote the early detection and timely intervention of NSSI.