This article reports on a quantitative study which investigated the impact of an educational intervention for paramedic students attending a university in the Thames Valley region in the south east of England on their perceptions of people who self-harm. It also looked at the implications of the intervention for the preregistration paramedic curricular programme.
Definition and reasons for self-harm
Several terms are used to describe self-harm, such as self-injury, self-mutilation, self-injurious behaviour, self-wounding and deliberate self-harm. There is no universal definition, resulting in diverse interpretations about the purpose of this self-inflicting injurious behaviour (Ramluggun, 2013; Shaw and Sandy, 2016). Self-harm refers to intentional self-poisoning or self-injury, irrespective of type of motive or the extent of suicidal intent (National Institute for Health and Care Excellence (NICE), 2011).
There are a plethora of social and psychological triggers for self-harm. While there are multiple reasons, these are predominantly related to the regulation of emotion from distressing thoughts and feelings (RCP, 2020). Common types of self-harm include cutting, burning, scratching, self-hitting, inserting objects in the skin or swallowing objects and drug overdose (Royal College of Psychiatrists, 2020), with cutting being the most common type used by adolescents (Gillies et al, 2018). A dissociative state, which is an altered state of consciousness where there is a disconnect in mental processes such as thoughts and feelings, has been reported to precede some acts of self-harm (Colle et al, 2020). Hence, self-harm is also used in an effort to end dissociative experiences such as emotional numbness and to stimulate emotional and physical sensations that make people feel real and alive again (Klonsky, 2007).
Self-harm has been observed in both non-clinical and clinical populations (Klonsky et al, 2003) and is generally held to be an interaction between personal vulnerabilities and situational factors (Nock, 2010). In the clinical population, it can be a response to symptoms from a spectrum of psychiatric disorders including psychotic experiences such as responding to auditory hallucinations (Koyanagi et al, 2015).
Generally, people who self-harm are not clinically mentally ill, but may have underlying symptoms of depression, anxiety and personality difficulties, and are highly emotionally distressed. They are usually aware of the harm they are causing to themselves but use self-harm as a coping mechanism to get some relief from an unbearable emotional pain.
Self-harm and suicide
It is important to differentiate self-harm from suicide as self-harm has also been referred to as parasuicide, which is an apparent suicidal attempt without intending to kill oneself (Marris, 2002). At times, it may appear that these individuals wanted to kill themselves when they were trying to survive their intolerable pain in comparison to a suicide act where the intention is clearly to end life (Muehlenkamp, 2014). However, self-harm has been recognised as a harbinger of completed suicide (Hawton et al, 2003), with a third of adolescents with a history of self-harm having attempted suicide (Nock et al, 2006).
For this study, self-harm is defined as:
‘Individuals who purposely and consciously engage in harming themselves by employing different methods but where the intended outcome is non-fatal, and the individuals understand the meaning and consequences of their actions’
Prevalence
Self-harm is a growing public health concern that has been reported to be on the increase in England (Clements et al, 2016) and is mostly prevalent in adolescents (Morgan et al, 2017). It is difficult to provide accurate statistics on self-harm as medical attention is not sought for all incidences, which are then underreported; this is further compounded by the usually secretive nature of this behaviour (DeAngelis, 2015). However, a 70% increase of self-harm incidents has been reported over 2011–2014 in girls aged 10–14 years (Griffin et al, 2018).
Health professionals' attitudes to self-harm
Attitude refers to a disposition to behave and cognise based on a complex set of emotions and beliefs formed as a result of the evaluation of a phenomenon, thing or person (Hogg and Vaughan, 2005). The positive or negative valence in the way it is expressed may change over time and with experience (Albarracín et al, 2005).
The inability to help individuals who persistently self-harm can be a daunting prospect for health professionals and evoke feelings of powerlessness and inadequacy (Patterson et al, 2007).
A few studies have reported that attitudes towards people who self-harm in health professionals were generally positive (Conlon and O'Tuathail, 2012) but most of the literature finds that attitudes are negative (Saunders et al, 2012; Karman et al, 2015). It is important to note that the negative responses vary depending on the clinical setting (Patterson et al, 2007), with more negativity observed in acute settings with busier workloads (Rees et al, 2014).
Studies on the experience of professional care for those who self-harm have indicated the importance of good contact with health professionals for successful engagement, continued care and support for these patients (Lindgren et al, 2018). Unhelpful, prejudicial and stigmatising care experienced by these patients who do not feel they were heard and supported by accident and emergency hospital staff have been well documented (Rayner et al, 2019). Therefore, the perceptions that paramedic staff hold towards people who self-harm—given that this may be these patients' first encounter with them as health professionals—is of paramount importance.
Rees et al (2018), who explored paramedics' views on self-harm, identified negative feelings towards these patients because their understanding of self-harm was limited and the lack of support to assess and manage patients who self-harm was amplified by the intensity of paramedics' workload.
Legal and ethical tensions were also noted in this study because paramedics lacked confidence in interpreting and applying the relevant legal framework to assess patients at risk under the Mental Capacity Act 2005.
Self-harm training and education
Numerous studies have reported that some health professionals lack an adequate understanding of patients who self-harm and the confidence to effectively engage with them (McCarthy and Gijbels, 2010).
This limited understanding has been attributed to a lack of education and training in caring for patients who self-harm (McHale and Felton, 2010). However, research on preregistration paramedic students' attitudes to patients who self-harm is lacking.
A study examining paramedic students' views on frequently stigmatised medical conditions indicated that students have a less empathetic disposition to patients with these conditions during their education and training (Williams et al, 2015). Rees et al (2018) emphasised the need for education for paramedics on how to care for patients who self-harm, including revised legislation and the implementation of appropriate pathways to address clinical challenges in paramedic practice on this issue.
The role of paramedics in the care of individuals who self-harm has received attention, with guidance on general principles of care for health and social care professionals from NICE (2011) endorsed by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) in the JRCALC 2016 guidelines updated in 2019 (Association of Ambulance Chief Executives, 2019). However, despite the relevance of paramedics' role and the prevalence of self-harm, empirical studies on paramedics' readiness to meet the complex and challenging needs of patients who self-harm and who have other mental health issues are limited (Ford-Jones and Chaufan, 2017). A lack of necessary skills is further evidenced by a survey from the College of Paramedics, which found that 98% (609) of respondents believed that more education and training in this area would be of great benefit and value (Berry, 2014).
The university in which this study was undertaken incorporates a standalone module on mental health in the BSc paramedic programme, which is delivered in the second year. The self-harm workshop was first introduced as a component of the module, and is discussed in the present study.
There is no nationally agreed consensus on teaching about self-harm in paramedic undergraduate programmes. Indeed, standalone modules on other contemporary health issues that paramedics frequently come across in practice such as mental health conditions are also not compulsory in these programmes. Although all programmes are validated and scrutinised by the Health and Care Professions Council and College of Paramedics, the format and make-up of such programmes are not standardised and are generally influenced and guided by Health Education England and local healthcare requirements.
Aim
The overarching aim of the current study was to observe the immediate and sustained changes in paramedic students' perceptions about self-harm following a focused educational intervention. This intervention was designed to elicit authentic and direct opinions from the students on self-harm without fear of judgment. The format allowed for reflection and discussion within a safe environment, where all views could be scrutinised and challenged. The secondary aim of the study was potentially to deliver additional educational content to further support paramedic students in caring for people who self-harm.
Methodology
Design
Students' perceptions regarding self-harm were measured using a validated 7-point Likert self-harm antipathy scale (SHAS) questionnaire and comparing SHAS scores at three intervals. A quasi-experimental design was used to collect SHAS scores with non-randomised groups of paramedic students immediately before (time 1: T1) and after (time 2: T2) the educational intervention; these were then used to make a primary comparison of SHAS scores. The secondary comparison of SHAS scores was carried out using scores 10 months later (time 3: T3) to find out whether any positive changes that had occurred in perceptions at T2 had been sustained.
Settings and participants
A cohort of students (n=30) in the second year of their preregistration paramedic BSc programme at the university were invited to attend the half-day educational intervention workshop, which was titled ‘Understanding Self-Harm’.
The workshop was not mandatory, and all attendees agreed to take part in the study. The SHAS questionnaires were distributed to the attendees to complete on the day before and at the end of the workshop. Each participant was assigned a code which they were asked to keep so their completed SHAS questionnaires could be identified at the three time points.
Measuring tool
The SHAS (Patterson et al, 2007) is a 30-item scale ranging from 30 (low antipathy) to 210 (high antipathy). It is designed to elicit respondents' views on their own attitudes to self-harm. It is a well-appraised tool that has been widely used in the UK and other countries such as Sweden (Lantto et al, 2020) to measure healthcare staff antipathy/empathy, emotions, beliefs and attitudes towards self-harm. The SHAS questions are clustered into six factors and each factor as described by Paterson et al (2007) is outlined in Table 1. The six factors encapsulate the three attitudinal components of the participants' thoughts (cognitive), feelings (affective) and actions (behaviour) towards patients who self-harm.
| Factors | Meaning | |
|---|---|---|
| 1 | Competence appraisal | Being empathetic: positively appraised the value of care given |
| 2 | Care futility | Being apathetic: seeing no value in providing care to those who self-harm |
| 3 | Client intent manipulation | View self-harm as a manipulation tool |
| 4 | Acceptance and understanding | Being empathetic: recognises the purpose of self-harm |
| 5 | Rights and responsibilities | Debates whether to stop patients self-harming |
| 6 | Needs function | Acknowledges the ‘unconscious function’ that self-harm serves for the patient |
Analysis
The baseline SHAS scores before and after the workshop were analysed by generating descriptive statistics for the total SHAS score at the three time-point intervals (T1, T2 and T3). The pre- and post-test SHAS scores at T1, T2 and T3 were analysed but fewer participants (n=18) completed the questionnaire at T3, which was in their final year of study. SPSS (v. 26 for Windows) was used to perform a paired sample t-test to compare the differences in the SHAS scores at T1, T2 and T3.
Learning content and strategies
The workshop was delivered by the first author, who has considerable expertise in the topic of self-harm including the delivery of educational interventions in this subject area. The intervention was based on a constructivist approach to learning (Piaget, 1950), drawing from learners' existing knowledge and experiences, which have shaped their understanding of self-harm.
This approach provided an opportunity to garner the meaning students attached to self-harm and enabled them to explore their perceptions in an open, non-threatening forum. Any myths and assumptions that arose were constructively challenged in the workshop using vignettes of the experiences of people who self-harm and the students' experiences within clinical practice. Vignettes are effective reflective tools used in education to explore contentious and sensitive topics (Hughes and Hubby, 2002).
The educational intervention reflected recommended areas from the literature on building knowledge of self-harm, such as explaining the reasons and causes for self-harm and its functions, the therapeutic responses in its assessment and management, and challenging issues relating to practice (Rayner et al, 2019).
The content reflected some of the factors discussed by Rees et al (2018) in relation to decision-making for patients who self-harm (Figure 1). These include: the frustration of managing frequent callers within a heavy workload; an apparent lack of supportand integrated pathways for referring these patients to other services; a limited understanding of self-harm; and the application of the legal framework for assessing these patients' mental state and their capacity.
Although the efficacy of educational interventions is widely reported in promoting positive attitudes to self-harm, the strategies for delivering these interventions are not well documented. In this study, a social-constructivist approach was adopted and used as a general framework for the intervention. This progressive approach to education is supported by John Dewey's work, which implies that knowledge is socially situated and developed through open and guided interactions with others (Hickman et al, 2009). The participants' personal views and experiences that had informed their understanding of self-harm were elicited and scrutinised in a non-judgmental way.
To create a positive connection with the participants, the facilitator of the workshop, through active dialogue, shared his initial preconceived thoughts on self-harm and his experiential knowledge in caring for such patients. This approach, based on Elias and Merriam's (2005: 3) school of thought that ‘theory without practice leads to empty idealism’, encouraged participants to critically examine and reflect on their personal and professional perspectives vis-à-vis evidence-based information that included anecdotal evidence using vignettes of patients’ real-life stories. To address the potential negative attitudes to a complex phenomenon such as self-harm, the vignettes encompassed the cognitive, affective and behavioural attitudinal dimensions to self-harm. The vignettes were intended to enable thoughtful and contextualised reflections in recognition of the well-documented challenges paramedics face in their practice, as identified by Rees et al (2018) (Figure 1).
The teaching on self-harm was delivered using a formal and non-formal format, which allowed for discussion, assimilation of knowledge and new learning (Eraut and Hirsh, 2007). The social constructivist element allowed the students to formulate and agree their own learning and conclusions by providing them with a safe space within a structured time to critically reflect on their personal views of their care experiences for these patients.
Ethics
The study was approved by the university's research ethics committee (UREC 171106). Students were informed of the study via the university's Moodle online learning platform. An invitation letter was emailed to the students detailing the purpose of the study, which included that participation was voluntary, an assurance of anonymity in completing the questionnaire and a consent form.
Results
All 30 participants completing the SHAS questionnaire had heard about self-harm and all of them had come across someone who had self-harmed. Only 16% (n=5) of the participants had previously attended a training event on self-harm. Their pre- and post-test SHAS scores at T1, T2 and T3 (only 18 participants completed the questionnaire at T3) are presented in Table 2.
| Participants | T1* | T2* | T3* |
|---|---|---|---|
| 1 | 51 | 37 | 56 |
| 2 | 69 | 52 | 59 |
| 3 ** | 61 | 54 | 51 |
| 4 | 59 | 52 | |
| 5 ** | 58 | 41 | |
| 6 | 69 | 61 | 53 |
| 7 | 97 | 86 | 61 |
| 8 | 32 | 33 | |
| 9 | 52 | 46 | 48 |
| 10 ** | 59 | 49 | 59 |
| 11 | 70 | 63 | 61 |
| 12 | 66 | 59 | |
| 13 | 61 | 68 | |
| 14 ** | 46 | 50 | 41 |
| 15 | 51 | 41 | |
| 16 | 69 | 58 | |
| 17 | 73 | 54 | 65 |
| 18 ** | 73 | 54 | 43 |
| 19 | 52 | 45 | 65 |
| 20 | 47 | 42 | |
| 21 | 82 | 68 | |
| 22 | 46 | 42 | |
| 23 | 71 | 60 | 65 |
| 24 | 42 | 39 | 36 |
| 25 | 98 | 92 | |
| 26 | 72 | 51 | |
| 27 | 49 | 37 | 33 |
| 28 | 45 | 36 | 41 |
| 29 | 45 | 52 | 64 |
| 30 | 40 | 28 | 37 |
With the significance threshold set at 0.05, a significant statistical difference in SHAS scores was noted between: T1 and T2 (P=0.011), and T1 and T3 (P=0.035) for the 18 participants (Table 3).
| SHAS scores | Mean | n | SD | P value |
|---|---|---|---|---|
| T1: before the intervention | 60.57 | 30 | 15.18 | 0.011 |
| T2 immediately after | 51.67 | 30 | 14.36 | |
| T1 | 59.11 | 18 | 14.91 | 0.035 |
| T3: 10 months later | 52.11 | 18 | 11.14 |
Discussion
This study indicated that antipathy to self-harm was broadly on the lower end of the spectrum, with the highest antipathy scores being under 100, compared to a maximum possible score of 210.
A significantly lower feeling of aversion to people who self-harm was identified following the workshop, which was sustained after a period of 10 months. Mean SHAS scores recorded after a period of 10 months were marginally higher than immediately after the workshop (0.44 point), which could indicate a very moderate return to the baseline SHAS scores. Therefore, it can be assumed that the improvement in the SHAS scores has remained relatively stable 10 months after the workshop.
The apparent increase in positive perceptions of people who self-harm following the workshop is generally comparable to that found in other studies (Patterson et al, 2007; Kool et al, 2014; Manning et al, 2017), which have reported improvements in attitudes to people who self-harm following educational interventions. Nevertheless, the results at T3 are based on a lower response rate (n=18) than at T1 and T2 (n=30), so the long-term impact of the education intervention needs to be interpreted with caution.
It is noteworthy that an attitude is a complex internal construct, widely believed to be mostly determined by affective, behavioural and cognitive components, which can be acquired through direct or indirect experiences and social knowledge about the object (Hogg and Vaughan, 2005). As these attitudinal dispositions are evaluations, they can be assessed, usually through self-reported measures (Lavrakas, 2008).
Although the SHAS questionnaire addresses the three attitudinal components, it is a self-report method and the behaviour of the participants in practice has not been observed. Therefore, the decrease in aversion to people who self-harm observed in this study needs to be interpreted accordingly. As shown in this study, self-harm was not a new phenomenon to the participants; all of them had knowledge and experience of someone who had self-harmed. Their existing knowledge and encounters with individuals who had self-harmed may have shaped their understanding and predispositions to this condition.
In addition to classroom knowledge on self-harm, experiential knowledge has been associated with positive attributes in the treatment of patients who self-harm (McCarthy and Gijbels, 2010). However, it is important to note that greater experience of working with patients does not always result in positive attitudes. For example, there is documented evidence relating to the nursing profession, where it was found that a proportion of more experienced emergency care nurses in busy clinical settings still harboured some resentment towards patients presenting with self-harm (Friedman et al, 2006). These findings underlined the prevailing challenges when making therapeutic connections with these patients in a highly pressured working environment (Rayner et al, 2019).
Although there is some indication that the participants in this study were becoming more empathetic regarding self-harm, certain perspectives and subjectivity on self-harm may have been retained. As reported by Rees et al (2018), paramedics struggled at times to understand why these patients self-harmed and found making decisions on treatment difficult in the absence of clear care management guidelines and collaborative working pathways with other healthcare services. These problems were identified by Rees et al (2018) among the heightened factors that can limit the ability to manage these patients effectively. Using taught knowledge and implementing it in practice can prove to be difficult if these limiting factors are present (Rees et al, 2018).
In addition to self-harm, paramedic students frequently come across patients with diverse and complex care needs who require treatment and support. Therefore, the ability to master the increasingly complex paramedic role is an ongoing challenge (Freeman-May, 2012).
Although it did not exclusively focus on self-harm, a study examining empathetic attitudes of undergraduate paramedic students towards frequently stereotyped medical conditions, including attempted suicide, reported a drop in empathy between the second and third years of their programme (Williams et al, 2015). A possible explanation for this reduced empathy is emotional distancing of paramedic students as a way of coping with emotionally taxing conditions (Regehr et al, 2002). Wills and Asbury (2019) reported a considerable level of anxiety by paramedic students in all year groups pertaining to the stress of trying to manage workloads and the practical element of their programme.
Anecdotal evidence at the authors' university indicates a rise in stress and anxiety in paramedic students during the programme, with an increase in referrals to counselling services as they progress from year 2 to year 3. The higher stress levels observed in paramedic students in their final year and registration have been attributed to the anxiety of making a wrong clinical decision, as well as a lack of preparation and targeted support for their mental wellbeing to meet the demands of the programme. (Holmes et al, 2017).
Resilience
Patients who self-harm can be very distressing and difficult for students to manage effectively from an emotional and physiological perspective.
Once qualified, paramedic practitioners are expected to independently manage patients presenting with traumatic and other distressing conditions, such as self-harm. The cumulative effects of such events on qualified paramedics and students alike can result in the development of mental health issues (Holmes et al, 2017). The emotional exhaustion of paramedics attending frequent self-harm incidents (Sterud et al, 2006) can lead to suboptimal care (Druss et al, 2010).
Hence, in addition to developing these students' understanding of self-harm, further self-harm workshops could focus on key components for developing resilience such as critical introspection and reflexivity (Bracken-Scally et al, 2014) to strengthen their self-belief and confidence (Barody, 2016).
Strengths and limitations
This is the first study to examine changes in attitudes around self-harm by preregistration paramedic students using a focused educational intervention to allow them to openly express their thoughts, feelings and beliefs in a safe forum. It also highlights the possibility for revisiting this subject at a later point in the paramedic programme and could provide the initial catalyst for a larger national study.
It is worth pointing out that, in experimental design, a control group would usually be used to determine whether behavioural and/or cognitive changes can be attributed to the intervention by comparing the outcomes of the intervention against the control group (Sullivan, 2011). However, this study adopted a quasi-experimental design using baseline attitude measures from a validated and approved questionnaire with the same group of students. Ethical approval was not received for the use of a control group.
In terms of internal validity, the participants were typical in that they were second-year preregistration paramedic students, they had all heard of self-harm and most of them had not previously attended a training event on self-harm. Although the range of the participants' SHAS scores indicates how antipathy to self-harm can vary, most of their baseline SHAS scores were relatively moderate, including among the five participants who had previously attended a training event on self-harm.
The findings may not be generalisable given national differences in programme content and structure.
The self-reported data presented indicate that the students' perceptions and the accuracy of this data depend on their authentic thoughts, feelings and intentions around patients who self-harm. It is conceivable that the positive effect of the workshop may be subject to some bias if participants have not accurately reflected their true thoughts and feelings to self-harm in answering the SHAS questionnaire.
It is also possible that those who attended the workshop may have been more inclined to change their attitudes to self-harm. A qualitative study may provide further means of exploring nuances to the responses that were not fully identified in this study.
Implications and recommendations
The study indicated a level of antipathy towards self-harm in preregistration paramedic students and has highlighted the potential contribution of an educational intervention to address this in the undergraduate paramedic programme. The BSc paramedic programme is designed to create autonomous, critical and independent thinking practitioners who are also self-aware, compassionate and empathetic to their patients. Classroom-based education needs to be consolidated by clinical mentors as role models in students' placements to potentially translate this knowledge into practice. How this acquired knowledge is translated into practice needs further attention.
Education on a sensitive topic with associated contentious views such as self-harm requires a focused, considered approach to allow both facilitator and students to elicit genuine views while allowing for examination and reflection on any potential negative attitudes. The findings of the present study highlighted the importance of delivering a structured workshop for paramedic students with pre-existing views and moderate antipathy to self-harm.
Being often the first contact for patients who self-harm, paramedics are uniquely placed to make a positive difference to the care of these patients. Hence, it is imperative to address any negative views on self-harm and the related knowledge and skills gap in the training of paramedics. Further research looking at better outcomes for these patients at the time of consultation with paramedics, as well as its impact on the care received and subsequent engagement with other healthcare workers, would be beneficial.
Ambulance services and health education providers could agree some consensus over a nationally agreed curriculum incorporating mental health topics, including self-harm. The introduction of self-harm content in year 1, with follow-ups during years 2 and 3 is worth considering. This should also include supportive interventions, designed to reduce the well known and documented stresses, and managing them more effectively to develop confidence and strengthen students' resilience to the challenging aspects of their practice (Anderson et al, 2017).
Conclusion
Paramedics frequently encounter people who self-harm, so their timely assessment and therapeutic response as the first contact with these patients can positively influence their subsequent care interaction with other healthcare workers.
Caring for individuals who self-harm can be a challenging endeavour for healthcare workers including paramedics. This can result in antipathy to such patients, which can create a barrier to the desired compassionate and individualised care. Therefore, it is important to understand how negative views towards self-harm can arise and be addressed in the preregistration paramedic students' programme to better prepare them as qualified paramedics to effectively care for individuals who self-harm. The students who participated in the study seemed to benefit from the educational intervention by improving their understanding of self-harm, which has subsequently positively influenced their attitudes towards those who self-harm.
This study adds to the growing body of knowledge about self-harm and how educational interventions can influence and change negative attitudes to it. It raises questions and considerations for addressing attitudes towards self-harm in the preparation of future paramedics to care for these patients.
Two significant areas relating to paramedic education arose from this study. First, education is needed to fill the knowledge and skills gap for self-harm, which considers these patients' experience as well as attending to their physical injuries. Second, effective approaches to deliver educational interventions on complex and challenging issues to promote a more compassionate and competent paramedic need to be considered.