hr. J. Nun. Stud. Vol. 14, pp. 29-35, Pergamon Press, 1977. Printed in Great Britain.
Attitudes of medical and nursing staff towards self-poisoning patients in a London hospital S.E.M. O’BRIEN, S.R.N., B.Sc., (Sot) and K. A. STOLL, B.Sc., M.Sc. Lecturer in Community Medicine, Westminster MedicalSchool, London.
Each year, there are about 100,000 admissions to hospitals in England and Wales following deliberate self-poisoning or self-injury (Bagley, 1971; Matthews, 1975). The rate of such parasuicides (Kreitman et al., 1969) would appear to be increasing annually (Alderson, 1974). Factors associated with the parasuicide have been widely studied (Buglass and McCullock, 1970; Buglass and Horton, 1974~; Kennedy and Kreitman, 1973; Paykel et al., 1975). Factors associated with repetition of the parasuicide act have also been reported by Buglass and Horton (19743). However, the quality of care received by the overdose patient (O.P.), both in hospital and subsequent to discharge has received little attention. Some studies have considered the effectiveness of psychiatric intervention in hospital (Greer and Bagley, 1971) and following discharge Paykel et al., 1974). But, as Greer and Bagley point out, not all patients are assessed by a psychiatrist during their stay in hospital. Despite the obvious importance of psychiatric intervention, the first individuals to meet the patient and respond to the powerful communication of the selfpoisoning act are other members of the hospital staff, namely nurses and somatic physicians (Ramon et al., 1975). Their attitudes are likely to be important in determining the consequences of such an act. Kennedy (1974) reported that the attitudes of hospital staff to O.P.‘s has traditionally been negative. He suggested that this could be due to internalised attitudes towards ‘deliberately induced illness’ and to the difficult practical problems presented by parasuicides. Ramon et al., (1975) attempted to quantify these attitudes by presenting hospital staff with idealised case histories in an attempt to elicit ratings for acceptability and understandability of the act, staff sympathy for and readiness to help the perpetrator .
Some underlying problems presented to nursing staff were shown to derive from the admission of the O.P. to a general ward. Apart from a study comparing mortality rates following intensive care compared with general ward care (Piper and Griner, 1974) the contribution of physical placement of this type of patient has received scant attention 29
30
S. E. M.
0'BRIENANDK.A.STOU
in the literature. The present study consisted of presenting a questionnaire to hospital staff to be returned anonymously. The questionnaire was designed to elicit information on their attitudes towards the O.P. and his care. Respondents were also asked to examine the case for a specialised ‘overdose’ ward. Methods
Sixty members of the staff of a central London hospital were asked to complete questionnaires. The number of parasuicides admitted to the hospital (approx 8OO/yr) reflects the catchment area, where there is a large proportion of young and highly mobile individuals. Due to the smaller number of medical staff compared with nursing staff at the hospital different sampling fractions were employed for each group (1:2 for physician staff; 1:4 for nursing staff). Details of the breakdown of the sample is presented in Table 1 below. Table 1. Subjects Nursing staff
Medical staff Consultants Registrars House Officers
Total
3 3 8
14
Sisters Staff Nurses Third year student nurses* State Enrolled nurses
17 12
Total
46
12 5
*Permission to circulate the questionnaire to first and second year student nurses was refused by the nursing administrator.
The sample was obtained by a process of systematic sampling, using a list supplied by the nursing administration. There were no refusals. The complete questionnaire is not appended to this paper due to space consideration. Questions were largely preceded with open ended follow up items to elicit further details and the reasons for selection from preceded alternatives. Respondents were also asked for any further relevant suggestions and comments. Questions were designed to elicit information about the attitudes of staff towards the O.P., e.g. ‘What is your initial reaction to the O.P. admission?‘; the care of the O.P., e.g. ‘Do you feel that the O.P. falls into the province of medical staff with psychiatric experience?‘; and consideration of the case for a specialised ward for 0.P.s. Results
(a) The attitudes of hospital stafftowards the overdose patient The large majority of staff distinguished 0.P.s from other patients. The reasons generally given for this differential attitude was that these patients were primarily considered as having psychiatric rather than medical problems. The O.P. was frequently described as difficult and requiring special care (Table 2).
ATTITUDES
TO WARDS SELF-POISONING
Table 2. Attitudes
towards
PATIENTS INA LONDON HOSPITAL
the overdose
-
Medical
and nursing
staff Doctors
1. 2. 3. 4.
Regard O.P. in the same light as other patients Initial ‘irritated’ reaction to the O.P. admission Feel that some O.P. are more justified than others Feel that some/most O.P. seriously want to kill themselves N
31
Nurses
0 8 12 9
a* 151 23. 31
14
46
*Significant difference between doctor and nurse response. P-C 0.05 (Fisher Exact Probability Test).
Although Table 2 reveals a significant difference between medical and nursing staff in their initial reaction to the overdose, more detailed examination of the data revealed that the difference is even more marked at junior physician level. Senior physicians consistently reported feeling neutral towards the O.P. This group, consultants and senior registrars, see only a minority of overdose admissions since many of these patients are discharged within 24 hr. All housemen and most of the sisters reported feeling irritated. The attitude of this latter group may be explained by the fact that with a shortage of staff, they are often faced with difficult problems of priorities. Third year student nurses tended to feel more sympathetic towards the O.P., possibly because they find it easier to identify with them. This is also reflected in response to the suggestion that some overdoses are more justified in their action than others. The staff nurse group reported feeling that all attempts were similarly unjustifiable. (b) Care of the patient and the case for a specialised ward No significant difference between medical and nursing staff response was recorded (Table 3). Table 3. Care of the overdose
patient
-
Attitudes
of medical
and nursing
staff
Doctors 1. Feel that O.P. fall into the province psychiatric experience 2. Feel that talking
of medical
staff with
to the O.P. is very important/important
Nurses
a
28
13
41
3. Feel that they can spend as much time with O.P. as is needed
2
4. Feel that, the service to the O.P. at this hospital
6
3 18
12
44
14
46
5. Feel that patients general ward
should be treated
is adequate
in a specialised
rather N
than a
Nurses, in particular, complained that they lacked adequate psychiatric training to deal with the O’.P. Most staff felt that they should be the responsibility of staff with psychiatric experience - complementing the evidence that 0.P.s were considered different to other patients. Perhaps, some staff may use this rationale for their unwillingness to come to terms with patients who would appear to be ‘.. . . . unmanageable and irritating’. Further analysis of the responses demonstrated that staff - physicians and nursing - who had psychiatric experience shared different attitudes towards the O.P. and his care. These staff were more likely to feel that some overdoses were more justified
S. E. M. O’BRIENAND
32
K. A. STOLL
than others (P
Attitudes of medical and nursing staff towards self-poisoning patients in a London hospital S.E.M. O’BRIEN, S.R.N., B.Sc., (Sot) and K. A. STOLL, B.Sc., M.Sc. Lecturer in Community Medicine, Westminster MedicalSchool, London.
Each year, there are about 100,000 admissions to hospitals in England and Wales following deliberate self-poisoning or self-injury (Bagley, 1971; Matthews, 1975). The rate of such parasuicides (Kreitman et al., 1969) would appear to be increasing annually (Alderson, 1974). Factors associated with the parasuicide have been widely studied (Buglass and McCullock, 1970; Buglass and Horton, 1974~; Kennedy and Kreitman, 1973; Paykel et al., 1975). Factors associated with repetition of the parasuicide act have also been reported by Buglass and Horton (19743). However, the quality of care received by the overdose patient (O.P.), both in hospital and subsequent to discharge has received little attention. Some studies have considered the effectiveness of psychiatric intervention in hospital (Greer and Bagley, 1971) and following discharge Paykel et al., 1974). But, as Greer and Bagley point out, not all patients are assessed by a psychiatrist during their stay in hospital. Despite the obvious importance of psychiatric intervention, the first individuals to meet the patient and respond to the powerful communication of the selfpoisoning act are other members of the hospital staff, namely nurses and somatic physicians (Ramon et al., 1975). Their attitudes are likely to be important in determining the consequences of such an act. Kennedy (1974) reported that the attitudes of hospital staff to O.P.‘s has traditionally been negative. He suggested that this could be due to internalised attitudes towards ‘deliberately induced illness’ and to the difficult practical problems presented by parasuicides. Ramon et al., (1975) attempted to quantify these attitudes by presenting hospital staff with idealised case histories in an attempt to elicit ratings for acceptability and understandability of the act, staff sympathy for and readiness to help the perpetrator .
Some underlying problems presented to nursing staff were shown to derive from the admission of the O.P. to a general ward. Apart from a study comparing mortality rates following intensive care compared with general ward care (Piper and Griner, 1974) the contribution of physical placement of this type of patient has received scant attention 29
30
S. E. M.
0'BRIENANDK.A.STOU
in the literature. The present study consisted of presenting a questionnaire to hospital staff to be returned anonymously. The questionnaire was designed to elicit information on their attitudes towards the O.P. and his care. Respondents were also asked to examine the case for a specialised ‘overdose’ ward. Methods
Sixty members of the staff of a central London hospital were asked to complete questionnaires. The number of parasuicides admitted to the hospital (approx 8OO/yr) reflects the catchment area, where there is a large proportion of young and highly mobile individuals. Due to the smaller number of medical staff compared with nursing staff at the hospital different sampling fractions were employed for each group (1:2 for physician staff; 1:4 for nursing staff). Details of the breakdown of the sample is presented in Table 1 below. Table 1. Subjects Nursing staff
Medical staff Consultants Registrars House Officers
Total
3 3 8
14
Sisters Staff Nurses Third year student nurses* State Enrolled nurses
17 12
Total
46
12 5
*Permission to circulate the questionnaire to first and second year student nurses was refused by the nursing administrator.
The sample was obtained by a process of systematic sampling, using a list supplied by the nursing administration. There were no refusals. The complete questionnaire is not appended to this paper due to space consideration. Questions were largely preceded with open ended follow up items to elicit further details and the reasons for selection from preceded alternatives. Respondents were also asked for any further relevant suggestions and comments. Questions were designed to elicit information about the attitudes of staff towards the O.P., e.g. ‘What is your initial reaction to the O.P. admission?‘; the care of the O.P., e.g. ‘Do you feel that the O.P. falls into the province of medical staff with psychiatric experience?‘; and consideration of the case for a specialised ward for 0.P.s. Results
(a) The attitudes of hospital stafftowards the overdose patient The large majority of staff distinguished 0.P.s from other patients. The reasons generally given for this differential attitude was that these patients were primarily considered as having psychiatric rather than medical problems. The O.P. was frequently described as difficult and requiring special care (Table 2).
ATTITUDES
TO WARDS SELF-POISONING
Table 2. Attitudes
towards
PATIENTS INA LONDON HOSPITAL
the overdose
-
Medical
and nursing
staff Doctors
1. 2. 3. 4.
Regard O.P. in the same light as other patients Initial ‘irritated’ reaction to the O.P. admission Feel that some O.P. are more justified than others Feel that some/most O.P. seriously want to kill themselves N
31
Nurses
0 8 12 9
a* 151 23. 31
14
46
*Significant difference between doctor and nurse response. P-C 0.05 (Fisher Exact Probability Test).
Although Table 2 reveals a significant difference between medical and nursing staff in their initial reaction to the overdose, more detailed examination of the data revealed that the difference is even more marked at junior physician level. Senior physicians consistently reported feeling neutral towards the O.P. This group, consultants and senior registrars, see only a minority of overdose admissions since many of these patients are discharged within 24 hr. All housemen and most of the sisters reported feeling irritated. The attitude of this latter group may be explained by the fact that with a shortage of staff, they are often faced with difficult problems of priorities. Third year student nurses tended to feel more sympathetic towards the O.P., possibly because they find it easier to identify with them. This is also reflected in response to the suggestion that some overdoses are more justified in their action than others. The staff nurse group reported feeling that all attempts were similarly unjustifiable. (b) Care of the patient and the case for a specialised ward No significant difference between medical and nursing staff response was recorded (Table 3). Table 3. Care of the overdose
patient
-
Attitudes
of medical
and nursing
staff
Doctors 1. Feel that O.P. fall into the province psychiatric experience 2. Feel that talking
of medical
staff with
to the O.P. is very important/important
Nurses
a
28
13
41
3. Feel that they can spend as much time with O.P. as is needed
2
4. Feel that, the service to the O.P. at this hospital
6
3 18
12
44
14
46
5. Feel that patients general ward
should be treated
is adequate
in a specialised
rather N
than a
Nurses, in particular, complained that they lacked adequate psychiatric training to deal with the O’.P. Most staff felt that they should be the responsibility of staff with psychiatric experience - complementing the evidence that 0.P.s were considered different to other patients. Perhaps, some staff may use this rationale for their unwillingness to come to terms with patients who would appear to be ‘.. . . . unmanageable and irritating’. Further analysis of the responses demonstrated that staff - physicians and nursing - who had psychiatric experience shared different attitudes towards the O.P. and his care. These staff were more likely to feel that some overdoses were more justified
S. E. M. O’BRIENAND
32
K. A. STOLL
than others (P
