The development and piloting of an instrument to measure care staff attitudes towards child self-harm

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The development and piloting of aninstrument to measure care staffattitudes towards child self-harmJohn Christopher Harrison a , Charles Crosby a & Cor Jonker ba Applied Social and Community Studies , Liverpool, UKb School of Nursing , Liverpool John Moores University , Liverpool,UKPublished online: 06 Dec 2007.

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Vulnerable Children and Youth Studies, December 2007; 2(3): 232–245

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RVCH1745-01281745-0136Vulnerable Children and Youth Studies, Vol. 0, No. 0, Jun 2007: pp. 0–0Vulnerable Children and Youth StudiesThe development and piloting of an instrument to measure care staff attitudes towards child self-harm

Pilot instrument for measurement of care staff attitudes towards child self-harmJ. C. Harrison et al.JOHN CHRISTOPHER HARRISON1, CHARLES CROSBY1, & COR JONKER2

1Applied Social and Community Studies, 2School of Nursing, Liverpool John Moores University, Liverpool, UK

AbstractChild self-harm has been identified as an important issue within paediatric care, but the attitudes ofcare staff towards the topic have received limited investigation. The aim of this paper is the justificationand development of an instrument to measure care staff attitudes towards child self-harm. By identi-fying the salient features of the phenomenon and incorporating them into a means of data collection,it is hoped that a more realistic picture of the clinical environment emerges. The main elements of theinstrument are introduced in turn and its initial piloting is described. A questionnaire was developedbased on a series of hypothetical case vignettes and subjected to a number of tests. The results of thepilot test indicated that the instrument shows high levels of reliability and would therefore proveuseful in eliciting staff attitudes.

Keywords: Children, attitudes, vignettes, self-harm, pilot-work

Introduction

Recent years have seen an increase in official interest in suicide and self-harm, initially withthe resolution to reduce suicide rates in the document The health of the nation (Departmentof Health, 1992), continuing with Saving lives, our healthier nation (Department of Health,1999), which again aimed to reduce the number of fatalities caused by self-injury. Morerecently, further guidelines have been produced to help clinicians deal with self-harmingpatients (National Institute of Clinical Excellence, 2004). Alongside this official interest isthe growth in academic studies. Such work includes examination of the needs of suicidesurvivors (Van Dongen, 1990) and the fluctuating rates of self-harm among young people(Hawton et al., 1982).

The attitudes of care staff towards these patients have been examined in numerous studies(Hawton et al., 1981; McKie, 1994). However, examination of these texts shows that thetrend is to focus on variables associated with staff rather than those of the patient, such asSidley and Renton’s (1996) study of general nurses’ attitudes towards self-harmingpatients. Within such studies, role and environment are felt to affect attitude. Other worksidentified staff age and gender as influential (McLaughlin, 1994). However, factors such as

Correspondence: Dr John Christopher Harrison, Liverpool John Moores University, Applied Social and community Studies,Webster Street, Liverpool L3 3ET, UK. E-mail: [email protected]

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Pilot instrument for measurement of care staff attitudes towards child self-harm 233

gender have been discounted in later studies (Huband & Tantam, 2000). Those studiesthat examine patient variables do not do so in isolation, but use them in relation to establishedvariables such as clinical role (Ramon et al., 1975).

Within both types of study, assumptions proliferate. In some works, it is suggested thatstaff would have the same level of awareness of such issues as the lethality of the self-harmact. Other factors such as patient age and gender are often not considered, and when theyare, never in combination (Ramon et al., 1975). The aim of this research was to acknowledgethe multifaceted nature of self-harm and measure the attitudes of care staff towards it.

The development of the instrument

In keeping with previous studies (Ramon et al., 1975; Samuelsson et al., 1997) a series ofclinical vignettes were developed to ensure that the main aspects of the phenomenon (seeAppendix).

However, a number of difficulties in the use of vignettes have been observed. In theirexamination of the general publics’ attitudes towards mental illness, Barry and Greene(1992) note that issues of question and response format are as important as vignette content.Despite such reservations, they used seven hypothetical vignettes of case descriptions ofwhat they described as a ‘range of behaviours’ (Barry & Greene, 1992, p. 144). It should benoted that they concede that few empirical studies into the use of such methodologies havebeen undertaken.

Ramon et al. (1975) used vignettes in their investigation of Accident and Emergency(A&E) staff attitudes, while Samuelsson et al. (1997) focused on those of psychiatric staff.Within both studies, vignettes were used in tandem with other data collection techniques,namely questionnaires and structured interviews. However, the vignettes in both studiespresent with similar features. Of interest to this study is the small number of vignettes usedby both sides: ‘Four short descriptions’ (Ramon et al., 1975). Further difficulty can beidentified in the lack of justification for the vignettes employed. There are no formal selec-tion criteria in either study. If rigour was to be applied then it was important that a morestringent procedure be employed in vignette development. The variables listed below formthe basis of the instrument and the rationale for their inclusion is outlined.

Age

Studies that examined staff attitudes towards adult self-harm placed emphasis on staffrather than patient age (McLaughlin, 1994), although a recent study by Anderson et al.(2003) does identify the age of the patient as an issue. However, they do not differentiatepatients in terms of age. The individual is seen simply as a young person. Nevertheless,within child self-harm age has been identified as an important factor (Guoha et al., 1997).Within this study, age was divided into two areas: under 12 years and 12 years and over.

Kienhorst et al. (1987) noted the limited number of self-harm episodes committed bychildren aged less than 12 years, with a sharp increase in older children. Greene (1994)described the lack of willingness on the part of health professionals to accept that youngchildren would wish to harm themselves.

Gender

Gender differences abound within the literature that examines child self-harm (Gould et al.,1988). Of particular interest is the difference in suicide and parasuicide rates among male

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234 J. C. Harrison et al.

and female patients. DeRose and Page (1985) noted that females who engaged in self-harmwere less likely to kill themselves than males of the same age, an argument echoed by otherstudies (Dicker et al., 1997; Hawton et al., 1993; Kerfoot, 1988; Kienhorst et al., 1987).

This high repetition rate among young females was noted earlier by Hawton et al.(1996), who conceded that this could put pressure upon already overstretched services.Attitude studies that examine patient gender found that females who self-harm were viewedas more manipulative (Ramon et al., 1975).

Admission rate

A number of authors have noted that a large percentage of adolescents repeat self-harmbehaviours in a short period of time (Hill 1995; Lowe et al., 1999; McGaughy & Harrison,1995), and 10% will repeat the act within a year (Hawton et al., 1982). Studies that exam-ine staff attitudes towards patients who self-harm have noted a greater empathy for thosewho were perceived as genuinely suicidal (Samuelsson et al., 1997).

The format developed by Krietman and Casey (1988) formed the basis of this third inde-pendent variable. Within this variable three categories of patient were identified:

• First ever (no previous treatment for self-harm)• Minor repeaters (less than five previous admissions)• Major repeaters (five or more admissions for self-harm)

The use of such a categorization is a departure from the formats used in previous suicideattitude studies (Samuelsson et al., 1997). However, it acknowledges the issue of repetitiveself-harm as an important aspect of the phenomenon and thus a potential influence on staffattitudes.

Outcome variables

In order to regulate the measurement of these attitudes, the respondents were asked howthey perceived the child in terms of a number of variables. As with patient variables, thesewere based on the relevant literature.

The method of self-harm can be interpreted by staff in a number of ways. Feldman (1988)noted that patients self-harm in certain areas of the body, such as arms and legs, to elicit cer-tain responses from others. This is a factor identified further by Bunclark and Adcock (1996),who described the efforts made by patients to either reveal or hide their injuries.

A number of studies differentiate between patients in terms of the ‘incentive’ behindtheir self-harm (Anderson, 1997; Elliot et al., 1996). Those who were seen as manipulativein terms of their behaviour were seen as less acceptable to staff than the ‘genuine’ suicideattempt. Staff may view a method of self-harm, such as the ingestion of paracetamol infront of others, as communicative and thus of lower priority than one who harms in a covertnon-communicative manner.

Another outcome variable linked closely to method is intent. Its importance is evidentwithin the development of suicide intent scales, in which the amount of care a patientrequires is equated to the perceived seriousness of their intent (Beck et al., 1974). The linkbetween staff attitudes and the suicidal intent of the patient has been noted by a number ofstudies (Ramon et al., 1975; Samuelsson et al., 1997).

The perceived lethality of the self-harm act has been identified as an important factorwithin numerous attitude studies (Patel, 1975; Sidley & Renton, 1996). The lethality of theact as perceived by staff could possibly be influenced by all the independent factors.

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It is possible that a child with a large number of admissions for self-harm could have eachattempt viewed as less lethal than one who self-harms for the first time. Research by Andersonet al. (2003) has shown that the young person who self-harms can often frustrate clinicalstaff. It is possible that repeated acts of self-injury could result in negative attitudes on thepart of staff.

Questionnaire development

An item pool of 36 vignettes (three for each patient type) was developed from the relevantliterature and distributed to a group of psychiatrists. Each of the group had achieved col-lege membership and had experience in the treatment of young people who self-harm. Thepsychiatrists were then asked to identify which vignettes (of each category) they felt mostmirrored actual cases of child self-harm. From the initial list the most realistic 24 wereselected, and from this a second round produced the 12 used in the instrument.

Litwin (1995) states that this process of expert review helps to ensure the content validityof the instrument. While this is not a scientific measure of validity it can be seen as a strongindicator of vignette relevance, with face validity also assured by this process. If the psychi-atrists were able to identify the vignettes as depicting acts of child self-harm accurately it isreasonable to assume that a sample population will do the same: an important issue if thestudy were to achieve a high return rate.

The psychiatrists were recruited as the expert group for a number of reasons. First, theywere a convenience sample, the researcher having access to a group of psychiatrists in thelocal area. Secondly, experienced health professionals had all had extensive experienceworking with the subject group and, importantly, this experience had been accrued for themost part within the A&E environment, often the first point of entry for treatment byyoung people engaged in self-harm.

The use of clinicians also ensured that the degree of ‘relative understanding’ (Peterson,2000) within the sample population would be high. The administration of a questionnairethat was incomprehensible to the respondents would obviously result in a low return rate.Indeed, there were a number of inherent issues within the instrument that could influencelevels of response.

The use of closed questions within the instrument is also seen as beneficial, given theemotive topic under investigation. Open-ended responses may result in the sample popula-tion giving what they see as the correct answer. By limiting the range of potential responses,it is hoped that a truer picture of the phenomenon is uncovered. The possibility of ‘balloteffect’ (Peterson, 2000), in which busy respondents simply complete the questions in thequickest time, is another factor in selecting closed questions. Nevertheless, whatever formatis selected the utility of the instrument can be confirmed only through the piloting process.

Pilot study

Once the instrument had been developed and the format of the vignettes confirmed, it waspossible to undertake piloting. The importance of pilot work within the research processhas been highlighted by numerous authors. Oppenheim (1992) saw the pilot study stage asa process for the revision, refinement and adaptation of the data collection instrument; thisis supported by Mitchell and Jolly (1996), who see pilot work as a confirmation that theinstrument measures the potential range of scores for which it was developed.

Even when a previously validated instrument is used, pilot work is still seen as a necessaryphase of the research process. Given this study’s use of a newly developed questionnaire,

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issues of layout and instrument reliability are of increased importance. Based on thispremise, the purpose of the pilot phase in this study is to ensure that the questionnaire iscapable of eliciting the attitudes of care staff towards child self-harm.

Pilot study population

A convenience sample of nursing students within the university was selected. The use ofthe university as the environment to complete the pilot work was beneficial for a number ofreasons. First, the researcher could be present to answer any questions posed by therespondents. Secondly, the length of time taken to complete the instrument could also bemeasured; this is important if the sample is to be comprised of busy clinicians.

Two tutorial groups on a research methods course were selected: one would completethe questionnaire that contained case studies of paracetamol ingestion, the other cases ofwounding (see Appendix).

The purpose of the study was outlined and the respondents asked if they had any objec-tion to taking part. The questionnaire was distributed to the students, who were timed bythe researcher as they completed it. Once the questionnaires were collected it was possibleto commence with data analysis.

Duxbury (2003) suggests that the piloting of a questionnaire can help to establish its valid-ity and reliability. The process of establishing reliability can be undertaken by measuring theinternal consistency of the instrument (MacInnes, 2003). If an instrument is to measure anunderlying theme (in this case attitudes towards child self-harm), then the items that makeit up should have a strong relationship with each other. Internal consistency exists if theitems correlate highly; the higher the internal consistency of an instrument, the lower thechance of error and the greater its reliability (Oppenheim, 1992).

Examination of the literature suggests the use of Cronbach’s alpha as the most suitablemeans of measuring internal consistency, and thus reliability. Another benefit of usingCronbach’s alpha within this study lies in the test’s suitability in measuring an instrumentthat does not have binary scores (Black, 1999). An alpha score of 0.7 is considered anaccepted level of internal consistency by MacInnes (2003), while Bland and Altman (1997)suggest that a coefficient of 0.75 or greater is needed to confirm reliability. If this latterscore is taken as the benchmark within this study, then any score greater than the abovewill indicate the instrument’s suitability for use in this study.

A total of 25 respondents completed the questionnaire. Eight completed the instrumentthat dealt with paracetamol ingestion, 17 with self-wounding. The data from all 25 ques-tionnaires were encoded with the use of the SPSS statistical package. The answers for allquestions from each respondent were given the following values:

From this, the percentage response for each vignette could be assessed. The calculationof these ‘scores’ allowed the internal consistency of the instrument to be measured. Eachgroup response was measured initially, then both combined, and the overall alpha scoreobtained.

The scores obtained indicated a high level of internal consistency and thus reliabilitywithin the questionnaire. However, the establishment of reliability was not the only issuewithin the pilot study process.

(Low) Communicative=0.00 (High) Communicative=1.00Intent=0:00 Intent=1:00Lethality=0.00 Lethality=1.00

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Completion time

It was noted that both pilot groups finished the questionnaire within a 10-minute period.Some respondents felt that they would benefit from a ‘practice’ vignette in order to enablethem to understand the questionnaire format. As a result, it was felt prudent to include two‘test vignettes’ to aid familiarity with the instrument.

Discussion

The aim of this study was to develop and pilot an instrument to measure staff attitudestowards child self-harm. It is an acknowledged fact within the literature that more researchis needed into the way in which the phenomenon is viewed by those involved in the treat-ment process (Anderson et al., 2005). As already noted, what work has been undertakenfails to take into consideration the unique feature of the condition. By developing an instru-ment that takes salient variables as the starting point of the data collection process, it ishoped that a more in-depth study of the phenomenon can be undertaken.

The use of vignettes ensured that each of these variables could be examined in tandemwith others, ensuring as realistic a presentation of an act of self-harm as possible. By pilot-ing the instrument and measuring its internal consistency it is possible to speculate on itseffectiveness in measuring attitudes (Tables I–III). The high alpha scores obtained indicatethat there is little chance of random error within the instrument and indicates that theinstrument is measuring attitudes towards child self-harm. It is acknowledged that somedifficulties were expressed with the outcome variable of communication. However, theseexpressed difficulties came from three respondents of a population of 25 who needed clari-fication on one variable, suggestive of the instrument’s validity in encompassing the salientfeatures of child self-harm. That the questionnaire engendered a discussion among eachgroup around the patient variables contained within the vignettes was a further indicationthat the contents offer a realistic picture of child self-harm.

Limitations

It is acknowledged that there are a number of limitations within the current study. First,there are issues within the construction of the instrument itself. While the major issues of

Table I. Reliability coefficient of ingestion questionnaire.

N of cases=8 No of items=22Alpha=0.93

Table II. Reliability coefficient of wounding questionnaire.


Table III. Reliability coefficient of pilot study questionnaire.


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child self-harm have been incorporated into the questionnaire, other elements have beenomitted. Issues such as psychiatric illness and imitation theory (Gould et al., 1994) havenot been used as variables within the instrument, even though they have been identified asfactors that affect self-harming behaviour. Outcome variables can also be seen as showingpotential ambiguities, as evidenced in the confusion among some respondents over theterm ‘communication’. Further adaptation of the instrument may be necessary in order toensure that the most suitable variables are used.

The second limitation lies within the testing process employed. It is accepted that thesample population is small, and that a larger number of clinicians may be needed. Otherconsiderations include the lack of statistical analysis in terms of instrument validity, whichimposes limitations on the data obtained.

Significance of the study

This study claims that there are specific features of child self-harm that must be consideredwhen attitudes towards the phenomenon are examined. While these factors have beenacknowledged in other studies (Anderson et al., 2005, 2003), this study argues for the cre-ation of a tool designed to deal with emotive issues such as self-harm in young children(Hill, 1995). Thus, the inclusion of factors such as age and rate of admission will allowtheir perceived impact to be confirmed. If government legislation is to have any impact onreducing the rate of self-destructive behaviour among young people, then clinicians willrequire high levels of support and training (Department of Health, 2002; Royal College ofPsychiatrists, 1998). In order for this to be achieved, the attitudes and needs of these clini-cians must be explored fully.

Conclusion

An instrument has been developed that it is hoped will provide a deeper understanding ofcare staff attitudes towards child self-harm. Given the acknowledgment that past initiativeshave failed (Department of Health, 2004) and a lack of understanding on the part of clini-cians is central to this (Leo, 2002), the identification of awareness levels among care staff isparamount. By using central features of child self-harm to elicit response a richer picture isobtained.

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Appendix. Questionnaire and clinical case vignettes

Case 1

An 11-year-old girl has been brought into the A&E department by her mother after she cuther arms with a razor. Anna is well known to staff within the department as she has had fiveprevious admissions for self-harm. Anna’s father died two years ago after a long battleagainst heart disease, an event that left both Anna and her mother greatly traumatized. As aconsequence of this, Anna’s mother has not been able to deal with her daughter’s emo-tional needs and Anna has become increasingly withdrawn. As with her other acts of self-harm, this episode ties in with an event linked to her father, such as his birthday.

Acts of self-harm have varying degrees of seriousness (low or high lethality). Given theinformation contained above, please indicate which description best fits this case:Low lethality � � High lethality

Do you feel that the patient in the above vignette carried out the act with low or high sui-cidal intent:Low intent � � High intent

Certain acts of self-harm can be used to communicate a message. Given the informationcontained above, please indicate which description best fits this case:Low level of communication � � High level of communication

Case 2

Ten-year-old Sofia lives at home with her parents and older sisters. The baby of the family,she has a close relationship with them all, particularly her older sister Emily, despite the eight-year age gap. Sofia has expressed her concerns around 18-year-old Emily’s leaving home tostart university, in that she feels that Emily will leave for good. Despite the efforts of the fam-ily, Sofia has become increasingly agitated as the date of Emily’s departure draws closer. Twodays before Emily leaves for university a family row ensues, in which Sofia accuses Emily ofnot loving her. After this argument, Sofia cut her arms with a broken audio cassette box andwas found by her mother, who brought her to the A&E department.




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Case 3

Paula has been brought to the A&E department by her father after he had found that shehad cut her arms with broken glass. Paula’s relationship with her family is a difficult one,with a good deal of resentment between Paula and her stepmother. This difficulty hasmanifested itself in problem behaviour in school, for which she has been suspended inthe past, an event that precipitated her cutting her arms with her father’s razor blade.This act of self-harm has also followed an incident at her junior school, in which Paulafought with another child; an event which her stepmother felt was due to Paula’s fatherspoiling her.


Do you feel that the patient in the above vignette carried out the act with low or highsuicidal intent:Low intent � � High intent


Case 4

Rachel is a student at a local girls’ grammar school, who is about to sit her GCSE examina-tions. A bright but shy pupil, she lives at home with both parents; her brother is away atuniversity. As the time of her examinations has drawn closer, Rachel has become increas-ingly agitated and has expressed her anxieties that she will fail. Three days ago, Rachel satthe first of her examinations and despite answering all questions, she has convinced herselfthat she has failed. This morning, Rachel was due to sit the second of her examinations,and when her mother went to wake her she found that a tearful Rachel had awoken earlyand had cut her arms with a broken glass.




Case 5

A pair of anxious parents have brought their 14-year-old daughter into the A&E depart-ment after she had cut her arms with a disposable razor. Louise has difficulties in schoolwith a group of older children who bully her. Louise has had an episode of self-harm in the

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past, again after an incident of bullying. This episode followed an incident in which two girlsfollowed Louise home, called her names and spat in her hair. Both girls told Louise that worsetreatment awaited her on her return to school after the weekend. A shy, withdrawn child, Lou-ise is unable to mention the bullying to staff, despite her mother’s requests that she does so.




Case 6

A 15-year-old girl who has had six previous admissions for self-harm behaviour has beenbrought into the A&E department by her mother. Elaine has cut her arms with broken glassafter an argument with her mother about her boyfriend. This incident follows a patternsimilar to all her previous attempts; Elaine’s mother has difficulty with her daughter’s rela-tionship with a much older boy, which often leads to conflict. Elaine normally becomestearful and accuses her mother of not listening, after which she leaves the house beforeinforming her mother of her actions on her return.




Case 7

Jake is a pupil at a local junior school and lives at home with his parents and older sisterNatalie. The family is a close-knit one and Jake has a good relationship with all members.Natalie has been diagnosed recently with motor neurone disease and as a result has beenadmitted to hospital. Jake’s parents have been extremely distressed and have been unableto spend time with Jake, who has also been anxious about his sister’s failing health. After avery difficult hospital visit, Jake locked himself in the bathroom and cut his arms with hisfather’s razor blade before informing his mother.


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Case 8

Ben is the 11-year-old son of a couple who live quite close to the hospital. He has beenbrought into the A&E department after he cut his arms with a craft knife. This is thesecond time that he has been admitted to the department for the treatment of self-harmbehaviour. Both occasions have followed the death of a grandparent; Ben’s relationshipwith both was close. Ben has displayed high levels of distress since his grandmotherdied, actions that his father has found hard to accept, leading to a number of familyarguments.




Case 9

At 15, Carl is well known to the staff in the A&E department after several admissionsfor self-harm. Carl lives with both parents and four younger sisters. Carl has a poorrelationship with his father who places high demands on Carl, who often has to care forhis younger siblings. As with his previous acts of self-harm, Carl has used a brokenglass to cut his arms; this follows a violent argument with his father who has accusedCarl of failing to carry out the tasks assigned to him and locked Carl in his bedroom fora day.




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Case 10

An 8-year-old boy has been brought into the A&E department by his father after he hadbeen found to have used a knife to cut his arms. Ryan has been admitted to the departmenton several occasions within the last year. Ryan’s mother has suffered from depressionintermittently for the last six years and has made a number of suicide attempts herself.Ryan’s acts of self-harm follow those of his mother and often he is withdrawn for a numberof days prior to the act, something that his father attempts to hide from her.




Case 11

Shaun has been brought to the A&E department by his father after he was found to havecut his arms with a cassette box. Shaun is a popular student in his fifth year at a local com-prehensive, where he is expected to do well academically. Shaun has had a relationshipwith Lisa, a girl in his class, for over a year. Recently, Lisa has ended the relationship, muchto Shaun’s distress. The day he carried out his act of self-harm Shaun had attempted a rec-onciliation with Lisa, who refused a tearful Shaun, who then locked himself in his bedroomto cut his arms before he told his parents of his actions.




Case 12

Alan is a 14-year-old boy who lives at home with both parents. Alan has had two previousadmissions for self-harm behaviour, both within the last year. This behaviour began withthe death of a close friend. Alan has expressed anger at the death of his friend and guilt atnot dying himself. Alan cut his arms with a disposable razor after a family row about whatAlan’s father describes as ‘unacceptable despondency’ on the part of his son. After he hadcarried out the act, Alan informed his mother of his actions, who brought him to the A&Edepartment.

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Documents

The development and piloting of an instrument to measure care staff attitudes towards child self-harm