International Journal of Nursing Studies 40 (2003) 587–597

Nurses’ and doctors’ perceptions of young people whoengage in suicidal behaviour: a contemporary

grounded theory analysis

Martin Andersona,*, Penny Standenb, Joe Noona

aSchool of Nursing, Faculty of Medicine and Health Sciences, University of Nottingham, University Park Room B50,

Queen’s Medical Centre, Nottingham NG7 2UH, UKbSchool of Community Health Sciences, Faculty of Medicine and Health Sciences, University of Nottingham, University Park Room B50,

Queens Medical Centre, Nottingham NG7 2UH, UK

Received 12 November 2002; received in revised form 20 January 2003; accepted 28 January 2003

Abstract

Over the past 25 years, suicidal behaviour in young people has continued to be a major concern for health services

around the world. Self-harm in individuals aged 13–18 is common and represents a significant reason for admission to

accident and emergency departments, paediatric medical services and child and adolescent mental health services.

Nurses’ and doctors’ working in these areas are the first point of contact for young people following an episode of self-

harm. This paper presents a study exploring nurses and doctors perceptions of young people who engage in suicidal

behaviour. The data presented form part of larger project conducted using both quantitative and qualitative methods,

and a contemporary grounded theory approach to analysis. The findings revealed two main categories and associated

subcategories: Experiences of frustration in practice (subcategories: non-therapeutic situations, insubstantiality of

interventions and value of life) and strategies for relating to young people (sub-categories: specialist skills in care and

reflections on own experience). The meanings of these categories highlight barriers in the relationship nurses and doctors

have with young people who engage in suicidal behaviour. If suicide prevention policies around the world are to succeed

the phenomena impacting on the communication between these professionals and young people needs to be addressed

in research, education and in the development of practice.

r 2003 Elsevier Science Ltd. All rights reserved.

Keywords: Nurses; Doctors; Young people; Suicidal behaviour; Qualitative

1. Introduction

Suicidal behaviour in young people has continued to

be a major concern for health services throughout the

world (Diekstra and Hawton, 1987; Barton, 1995;

McLaughlin et al., 1996; Department of Health, 1999;

Hawton et al., 2000; WHO, 2000; Houston et al., 2001).

The prevention and reduction of suicide has been a

focus of health policy initiatives throughout the 1990s.

In the United Kingdom, the governments most recent

National Suicide Prevention Strategy for England

includes specific objectives to tackle suicidal behaviour

in children and young people under the age of 18

(DoH, 2002). Despite this recognition, there has been

considerable debate over the past thirty years surround-

ing the relationship between self-harm and suicide.

Hill (1995) refers to a ‘suicide spectrum’, and argues

that the motives behind young people who overdose

or injure themselves are wide-ranging. The suicide

ARTICLE IN PRESS

*Corresponding author. Tel.: +44-115-970-9265; fax: +44-

115-970-9955.

E-mail address: martin.anderson@nottingham.ac.uk

(M. Anderson).

0020-7489/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved.

doi:10.1016/S0020-7489(03)00054-3

spectrum is composed of the range of actions that

carry connotations of suicide. At one end of this

spectrum is self-harm, at the other end is suicidal

behaviour: a clear desire to end one’s life. In between,

active within this spectrum, are the behaviours fed by

increasing ambivalence, confusion and volatile incen-

tives of many young people who take overdoses or

self-harm in other ways. The young person’s intent to

die increases across this spectrum. The notion of the

‘suicide spectrum’ is a valid concept to use when

considering the complex terminology used in sui-

cidology.

This paper endorses the work of Hill (1995) and uses

the terms ‘self-harm’ and ‘suicidal behaviour’. Such

behaviour includes taking an overdose (tablets), inges-

tion of other substances (bleach, fuel, etc.), self-

suffocation, self-strangulation, drowning, etc. (Rioch,

1995). In carrying out these behaviours, the individual

may have complex, ambivalent and confused views of

their intent, quite clearly falling within the contexts of

the ‘suicide spectrum’.

The immense scale of suicidal behaviour in young

people, and the public and political response to the issue,

means that new ways of working and approaches are a

central concern for healthcare providers, researchers,

families and young people themselves. Nurses and

doctors practising in accident and emergency (A&E)

departments, paediatric medicine, and child and adoles-

cent psychiatry are likely to hold a range of attitudes,

beliefs and understandings towards a young person who

has been admitted following an episode of self-harm.

These factors will have an impact upon the relationship

with the young person. Establishing effective commu-

nication with people who self-harm is recognised as an

essential part of preventing further self-harm and suicide

(Talseth et al., 1999). Indeed, for the young person who

has felt isolated and unable to communicate for some

time, the opportunity to talk is a great relief (Aguilera,

1994; Hill, 1995; Bonnivier, 1996; Burgess et al., 1998).

Research evidence suggests that in practice areas such as

medical units, young people (or ‘adolescents’) are seen as

being difficult (Burr, 1993; Boyes, 1994; Foote, 1997).

However, the World Health Organisation included

suicide in target 12 of Health for all by the year 2000

and in more recent documented guidance on suicide

prevention for physicians and teachers, offers the

following advice:

During the development of the suicidal process,

mutual communication between suicidal young

people and those around them is crucially important

(WHO, 2000).

Communication difficulties and the interplay of

previously held perceptions can reinforce the stigma

associated with suicidal behaviour and therefore jeo-

pardise the effectiveness of professional interventions

(McGaughey, 1995). Often such perceptions are

grounded in every day inaccuracies and myths about

suicide in young people. Lowering suicidal behaviour to

unhelpful representations encourages inappropriate re-

sponses to the young person, distancing them further

from obtaining adequate help and support. Myths

among adults can range from believing that young

people do not think or contemplate suicide, to the

misconception that talking will actually make things

worse (Hill, 1995). Ultimately, healthcare professionals,

such as nurses and doctors, can become confined to their

own set of meanings using language to describe

‘symptoms’ employed to conceptualise suicidal beha-

viour. Barriers are erected between the professional and

the patient because understandings are so far removed

from each other, and shared meanings are never

developed (Aldridge, 1990).

The World Health Organisation has recommended

that educational programmes need to train practitioners

in the diagnosis and treatment of depression (WHO,

2001). School-based interventions involving crisis man-

agement, problem solving and training in coping skills

are also suggested as ways forward in solving the

problem of suicidal behaviour in young people. Degla-

morizing media representations of self-harm and suicide

may also reduce the chances of wider imitation or

contagion effects. There is no doubt that these

interventions may help reduce levels of suicidal beha-

viour. Yet if such interventions are to work, much more

needs to be done in terms of developing people’s views

and understanding of this group of young people. If

health care providers, policy makers, families and

society in general want to help young people who

engage in suicidal behaviour, then it is essential that

these professionals, and other groups in the world of the

young person, come to understand the nature of their

perceptions.

In these contexts, the subject of health professional

attitudes towards suicide has attracted a number of

researchers producing a variety of studies (Patel, 1975;

O’Brien and Stoll, 1977; Ramon, 1980; Hawton et al.,

1981; Platt and Salter, 1987; Hammond and Deluty,

1992; Domino and Perrone, 1993; McLaughlin, 1999).

These studies have presented material arising from

quantitatively based investigations using attitudinal

scales to measure views towards suicidal behaviour

(Domino et al., 2000). In Norway, Talseth et al. (1999)

present interview data representing (adult) patients’

experiences of being cared for by mental health nurses.

However, there remains a lack of qualitative research

exploring health professionals’ perceptions of suicidal

behaviour. The study presented in this paper forms part

of larger project conducted using both quantitative and

qualitative methods, and a contemporary grounded

theory approach to analysis.

ARTICLE IN PRESSM. Anderson et al. / International Journal of Nursing Studies 40 (2003) 587–597588

This paper focuses on suicidal behaviour in young

people by exploring the perceptions of this phenomenon

among nurses and doctors working in accident and

emergency, paediatric medicine and child and adolescent

mental health services. The young people with whom

nurses and doctors come into contact in these areas are

usually between the ages of 11 and 16. Current guidance

in the United Kingdom stipulates that hospital admis-

sion should be the course of action for all cases of self-

harm (Royal College of Psychiatrists, 1998). Therefore,

nurses and doctors are often the first point of contact for

the young person. The objective of the research was to

examine the views of a group of nurses and doctors

working in the front line of services by employing a

contemporary approach to grounded theory analysis.

2. Method

2.1. Sample

As part of a larger on-going study undertaken over

two years, 45 semi-structured interview transcripts from

nurses and doctors working in accident and emergency,

paediatric medicine and child and adolescent mental

health services were analysed. A range of qualified

nurses and doctors, working in the relevant specialty

areas, were invited for interview. The specialty areas and

respective number of participants are detailed in Table 1.

The emphasis here was on developing understandings

rather than merely replicating data (Chamberlain, 1999).

2.2. Grounded theory approach

The grounded theory approach used in this study

endorses the work of key researchers who provide a full

account of the method in various texts (Strauss and

Corbin, 1990; Henwood and Pidgeon, 1992; Rennie,

1998; Denzin and Lincoln, 1998; Chamberlain, 1999).

However, the method of analysis is based on the work of

Kathy Charmaz. Charmaz (1995) agrees that the

researcher defines the data by relying, in part, upon

the perspectives that they bring to it. In many ways,

collection and analysis of data are about using our

assumptions, experience and knowledge—these will

become essential in developing ‘theoretical sensitivity’.

2.3. The analytic process

2.3.1. Generating the interview guide

The semi-structured interview guide was based around

8 clinical scales identified in the Suicide Opinion

Questionnaire a structured attitudinal instrument devel-

oped by Domino (1996). While initial interviews began

with a set of simple prompts, based on these clinical

scales, the interview guide went through a series of

changes at specific points during data collection and

analysis. This process originates from an important

characteristic of qualitative research in that the ques-

tions focus on particular issues but there would be a

constant interplay of theoretical formulations, literature,

interviewees’ feedback and what made sense (Mathie-

son, 1999). Glaser and Strauss (1967) and Strauss (1987)

suggest, in these early works, that in an inductive

methodology that pulls together theory and data,

categories exist, and leap out of the data itself. Charmaz

(1995) disagrees with this, stating that:

the categories reflect the interaction between the

observer and the observed. Certainly, any observer’s

worldview, disciplinary assumptions, theoretical pro-

clivities and research interests will influence his or her

observations and emerging categories (p. 32).

As part of the larger study nurses and doctors

working in the specified areas responded to the original

SOQ. Yet, in the development of the interview guide the

SOQ was used as a point of departure (Charmaz, 1995),

to observe the data, to listen to interviewees and to think

analytically about the data. This helped enhance, rather

than limit, ideas and as the interviews progressed at

specific stages, the interview guide was revised to

accommodate the participants’ direction (Patton,

1990). The interviews lasted for approximately 45min-

utes and were conducted in a quiet room in each of the

clinical areas. The interviews were audio taped with the

nurse or doctor’s permission and all the interview tapes

were transcribed by the first author.

2.3.2. Analysis of the semi-structured interviews

The generation of the interview guide over specific

stages highlights the inductive approach used in analys-

ing the interview data. Five main principles were used in

ARTICLE IN PRESS

Table 1

Nurses and doctors by clinical area

Specialty Number of participants

Accident and emergency

A&E nurse 10

Paediatric A&E nurse 5

Doctor in A&E 14

Paediatric medicine

Paediatric medicine nurse 6

Doctor in paediatric medicine 2

Psychiatry

Mental health nurse 7

Doctor in psychiatry 1

Total 45

M. Anderson et al. / International Journal of Nursing Studies 40 (2003) 587–597 589

the analysis: (1) open coding and remaining flexible to

the situation, (2) process of collecting and analysing data

simultaneously (subsequently altering the interview

guide as data collection proceeded), (3) constant

comparison, checking for meaning and units of mean-

ing, (4) categorisation, keeping close to the data and

moving towards saturation of categories, and (5)

creating a central theme, categories and sub-categories

(Glaser and Strauss, 1967). The analysis was covered in

7 stages, these are summarised in Fig. 1.1

3. Findings

Nurses and doctors participating in this study talked

about the nature of their relationships with young

people who had engaged in suicidal behaviour. The

main findings arising from this study relate to the

perceptions nurses and doctors had of their relationships

with young people. The meanings arising out of the data

presented highlight the factors influencing the way in

which nurses and doctors work and communicate with

this patient group. Nurses and doctors working in this

first point of contact, identify barriers impacting on the

relationship between the professional and the patient.

Two main categories and associated subcategories

illustrate these findings. Experiences of frustration in

practice (subcategories: non-therapeutic situations, insub-

stantiality of interventions and value of life) and strategies

for relating to young people (sub-categories: specialist

skills in care and reflection on own experience).

4. Experiences of frustration in practice

Nurses and doctors talked about how they felt in their

own relationships with young people they cared for

when practicing. One of the key concepts surrounded

their experiences of frustration in practice. Running

through this concept was the professional and clinical

problem of not having enough time and resources to

enhance their relationships with young people who had

engaged in suicidal behaviour. The specialty setting itself

influenced this, as did the presence of young people

being treated in the same environment but for different

reasons. Experiences of frustration in practice crossed all

specialty settings. The following quote from a doctor

working in paediatric A&E highlights the meaning of

some of the experiences being described:

When you’ve got a department or ward take full of

severe athsma, meningitis, septicaemiayetc and then

you’ve got a couple of young girls who have taken a

cocktail of thingsythere will always be the couple of

girls at the end of the ward who have taken

something. They cannotywith our current resour-

ces...be looked after in the same wayy, which I am

not saying I am proud ofyfeeling

ARTICLE IN PRESS

Stage OneTranscription of interviews (first phase - 10 interviews). Writing up of notes of meetings anddiscussions carried out in the field.

Stage TwoRe-reading of transcripts. Identification of key words and possible category titles noted.Coding of data.

Stage ThreeAfter coding approximately 10 first phase transcripts, the relevant concepts were collapsedinto 12 twelve general categories.

Stage FourFurther analysis of incoming transcripts. Alterations of semi-structured interview guide inaccordance with the emerging concepts and questions. New emerging issues were integratedinto the interview guide to be focused on in subsequent interviews.

Stage FiveFirst set of categories was generated. Further interviews conducted and transcribed.Alterations were made to the interview guide as necessary.

Stage SixNew incoming interview data were typed up and included in the analysis. Transcripts hadbeen read and re-read, and no new information appeared to be arising out of the interviews.The central theme, categories and sub-categories had been generated.

Stage SevenThe researcher continued to work on each category. Reading through original transcripts andchecking original meanings. Saturation of categories. Reflection on the methodologicalconcepts underlying the research methods and revisit the aim and objectives of the study.

Fig. 1. Stages of analysis.

1Note: Should the reader require any further detailed

information on the process of analysis, please contact the first

author directly.

M. Anderson et al. / International Journal of Nursing Studies 40 (2003) 587–597590

A nurse practicing in mental health also expressed

problems associated with not being able to offer

appropriate care:

In all settings, from family or college settings

whatever setting they are inylack of understandin-

gylack of timeylack of communicationyI know

it’s quite an adolescent choice...but you are losing

that quality timey

For nurses and doctors some of the most prominent

meanings were those associated with the nature and

moral reasoning behind their work. Subsequently, three

main meanings evolved: non-therapeutic situations;

insubstantiality of interventions and value of life.

4.1. Non-therapeutic situations

Lack of time, resources, the nature of the specialist

setting and the fact that nurses and doctors were treating

other young people (with other problems) influenced

interactions. Encounters with individuals, who had

come into the setting following an episode of suicidal

behaviour, became non-therapeutic. This was a percep-

tion described, particularly, by those professionals

practicing in the A&E and paediatric settings. Making

sure that the individual was out of physical danger was

the most important thing. The value of spending time to

talk to the individual was secondary to making sure that

they would not come to any more harm. The following

paediatric nurse working in A&E emphasises the time

constraints in a medical setting, but their words describe

the meaning being articulated, that is the busy nature of

the environment hinders any therapeutic input needed to

get to discussing the young person’s problems:

This department isn’t conducive to being able to talk

to them [young people] in private. Nowhere is very

private to talk—and because you are very busy—

there is very limited nurses—you haven’t got time—

you have got different priorities else where—you

don’t give that child justice and an opportunity to

talk.

For some of the mental health nurses interviewed,

there were also frustrations in practice. The non-

therapeutic situation involved the process in which a

young person who engaged in suicidal behaviour

influenced other individuals on the unit. This was also

part of the nature of the environment (specialist setting)

and involved other patients on the unit. The following

comments from a mental health nurse’s discussion of

one particular young person sums up this position:

Is that very fairysupporting them in taking an

overdose—I mean that has happened before—when

someone has actually been involved and been there

when someone has taken an overdose and it is like

what is that about? How has that been a supportive

friend? Because it gets into the realms of well, ‘‘I am a

friend because I was with them’’—and its like you

question them.

These quotes from nurses’ and doctors’ highlight the

frustration of experiencing such non-therapeutic factors

in practice. At times, the situation was seen as being

non-therapeutic for other young people who are patients

in these settings for other reasons e.g., being treated on a

medical unit for life-threatening illness or admission to

the adolescent unit for depression. Yet, the amount of

time available and the busy nature of the environment

influenced the chances of creating a therapeutic situation

in order to communicate effectively and help the young

person.

4.2. Insubstantiality of interventions

Alongside the frustration of not being able to give

more time to young people or make the situation more

therapeutic, nurses and doctors also expressed the

feeling that if they did have the time, would their

interventions be of any use anyway? The following

extract highlights this perception in which a doctor

working in A&E describes a feeling of making ineffective

interventions:

I think it is more a feeling inside which you see and

just mull over and then not worry about it but at the

time its like well I have done this and that is all I can

do. I can’t do any more. It is also on their part—you

get frustrated. Because they just don’t take your help

when you’re offering it—and you think well, ‘‘listen

to me I am trying to help you I am trying to give you

these opportunities but you don’t want them’’.

Part of the feeling here is that whatever you [nurses

and doctors] do, nothing seems to work. However, the

core meaning is about suicidal behaviour being treated

in a specialist setting which is used to ‘changing things’

with physical interventions. The meaning of frustration

in this sense was linked to not being able to treat suicidal

behaviour as if it were a physical illness, which is the

objective of a medical unit. Subsequently, as this nurse

explains such young people would have to come second

to other young patients:

I think it is frustrating because that whatever support

they are getting doesn’t seem to be adequate

maybe...that may not necessarily be true...you can

give them the most input and they still go and do

these things. It is frustrating in the fact that we can’t

seem to help them or can’t seem to do something that

will stop them from doing this, and maybe lead a

more normal life. It’s maybe normal for them but

you know it’s...I find it frustrating that I can’t help

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the people that ...I know of kids that have been

here—my colleagues have said that have been regular

attenders—self-harm—it’s frustrating it’s not some-

thing that you can stick a plaster on. It is a

completely different type of nursing in that respect.

Because you can’t stick a plaster on it and can’t put a

bandage on it—and that makes it more difficult to

accept. For me, more than anything else...you can’t

physically do anything...you have got to encourage

them to...I mean that is the frustrating part of it,

there is no easy explanation or easy treatment for it.

The feeling of not being able to help young people

who engage in suicidal behaviour is also highlighted in

the interview material from staff practicing in mental

health care. The meaning here is less to do with not

being able to attend to symptoms or putting a plaster on

the problem, and more to do with giving help but then

things breaking down. This is reflected in the extract

below from two nurses (1 and 2) working in mental

health:

It is quite frustrating when you are making good

progressydoing individual work and you feel that

things are moving on then they do something like cut

themselvesyor take an overdoseyquite frustra-

tingy(1)

We’d already spent time with her, she’d got a lot of staffs

time, which didn’t seem fair on the other residents, a lot

of the trips were cancelled becauseyit was not just her

faultyand it frustrates meyhow much time do they

want? (2)

4.3. Value of life

Looking back at working with the young person who

has engaged in suicidal behaviour, nurses and doctors

maintained a certain moral standard with a view to the

value of a young person’s life. Suicidal behaviour was

seen as a potential waste of life, therefore such

behaviour was risky and very often, young people, had

no respect for the danger of taking an overdose. This

appeared to be a reflection of the fact that many nurses

and doctors saw their role as preservers of life—suicidal

behaviour was seen as being opposite to that objective.

This was one of the most frustrating parts of working

with such young people, who were seen as having a

whole life ahead of them and that there must be

something in their life that is positive. The nurses and

doctors struggled with the thought that these young

people were doing something that was so dangerous and

a risk to life because of something that seemed, at face

value, relatively trivial. A nurse in A&E reflects:

Sometimes young girls if they have a row with their

boyfriends—I don’t think they realise how poten-

tially life threatening it is. I think they take the tablets

and almost don’t think of the consequencesyand

you cannot get them to see the seriousness of what

they have takenyand sometimes it is very frustrat-

ing. The serial offendersyfor want of a better

wordythey too can be very frustrating.

Seeing these young people as individuals, who were

doing something that was potentially life threatening

and dangerous, raised further issues in terms of the place

they were being admitted to for treatment. When asked

about what it was to care for young people on the unit,

nurses in paediatric medicine in particular, felt that there

was a problem in mixing young people who have

engaged in suicidal behaviour with other patients. These

are people who have ‘done it to themselves’, and putting

them with young people who may be dying from a

terminal illness was problematic. This was related to a

number of different effects on others (other children,

parents of other children, staff, and how the young

person who self-harms might be seen) as the following

nurse working in paediatric medicine describes:

We have not had an incident where someone has

blown up and said ‘‘I don’t believe that they are on

this ward’’ or ‘‘my child is dying and they [young

people who engage in suicidal behaviour] obviously

don’t believe in life’’. No-body has done that. But

there is the potential there. There is the opinion that

they don’t value their life and that life is so precious

and so important, and yet they are willing to waste it,

because of sometimes what you perceive to be a very

minor problem.

Such a quote illustrates that preserving life, was a very

central factor in their work. Those who threatened the

gift of life, particularly at such a young age (adoles-

cence), may often be considered to be individuals who

have selected an action irrespective of that gift. Choice

became a central factor in the face of certain circum-

stances, from relationship problems to terminal illness.

Talking about such a subject with young people in mind,

the focus was very often related to the person’s stage in

life and individual right. Across all specialities, nurses

and doctors regarded this area as complex but reported

the importance of trying to maintain individual choice.

However, a common feeling expressed was that it was

very difficult to judge a young person’s competency, and

that young people have not developed enough in order

to make such decisions concerning their life. Under these

circumstances young people should not have a choice to

refuse treatment and some doctors in particular

expressed the view that they would not give someone

the choice as to whether they want an intervention or

not. This appeared to be more so when a young person

was involved, as this nurse based in paediatric medicine

describes:

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They are young and they have got so much to live

for...and taking their life so early if they do take their

life—whereas people who have had a lot of problems

all through their life and who are lots older, then

maybe there is nothing left for them...young people.

We want to preserve life as children’s nurses—that is

what we aim to do—when they come in they are so

young to try to take their life at such a young agey

Stability, soundness of mind and happiness in life

would protect a young person from carrying out an act

of suicidal behaviour. However, the comparison of a

young person experiencing terminal illness and a young

person who is unhappy and may or may not want to die

had a specific difference. In the former very little can be

done, in the young person who is unhappy and engages

in suicidal behaviour—something can be done. As in the

last quote, this surrounds a duty of care, because a

young person is a young person, but also because nurses

and doctors felt they have a duty that is not always

shared by the public. The following nurse working in

paediatric medicine illustrates this with an analogy

between young people who engage in suicidal behaviour

and those with disabilities:

That is why I talk about society’s responsibility—it’s

like with disabled people, lets not label a child

something because they are disabled—I think that

perhaps it’s because society doesn’t want to look

after them and I think we all have a responsibilityy

On the one hand, it was felt that young people who

engage in suicidal behaviour should not be doing what

they do, but some nurses and doctors questioned their

right to dictate what they do. The feeling among nurses

and doctors was ‘who am I to say’ whether they should

or should not engage in suicidal behaviour. In the

specialist area of mental health, choice in behaviour and

risk taking might sometimes be used as a therapeutic

technique. For example, building a trusting relationship

with the young person, the action might be—letting an

individual who has engaged in suicidal behaviour, go

out to the shops. Nurses working in mental health

regarded their role as preserving life or improving life.

Nurses and doctors showed understanding that this is

the way young people feel and suicidal behaviour has

been their choice in way of dealing with their problems.

What ever they have experienced, or are experiencing, it

has led them to carry out an act of suicidal behaviour.

5. Strategies for relating to young people

Nurses’ and doctors’ explored the nature of the skills

required to work with young people who self-harm and

many used personal reflection to talk through these

issues. These form the category strategies for relating to

young people. The key meaning nurses and doctors

expressed were: specialist skills in care and reflections on

own experience.

5.1. Specialist skills in care

Young people who engage in suicidal behaviour were

regarded as people requiring specialist help and profes-

sionals should possess specialist skills. It emerged that

specialist interventions, required to help young people,

would be needed to ascertain and understand the

reasons behind the incident of suicidal behaviour. The

specialist skills required for moving deeper in assessing

the young person’s problem(s) would normally be held

by those in a ‘specialist’ role, working within a mental

health team. However, this was recognition that two (or

more) agencies would be working together, the following

view from a doctor in paediatric medicine illustrates this:

I would think that from looking after those young

people, I see the wider team includes the psychiatric

nurses and psychiatrists. So I see them as that—one

team—so I would hope, and I am sure that they do,

that those two groups of individuals bring more of

listening and working through problems into the

setting. I think the acute nurses, acute doctors, if you

will excuse the crude split—do have the skills too,

and the feeling that for individuals, there is some-

thing else going on here.

Being skilled in looking at the circumstances leading

up to the incident of suicidal behaviour, to discover

details of the problems, required professionals that were

able to listen, talk and be motivated in establishing

interaction with these young people. During the inter-

views with nurses working in paediatric medicine and

A&E, there came a realisation that they were less able to

offer specific skills (i.e., competency in communicating

with this patient group). In this, there is an emphasis on

what nurses working in this area felt they were, and were

not, able to do with these young people. It emerged that

this was seen as a result of a lack of qualification, a

missing aspect of their pre- and post-registration

training and subsequent feelings of inadequacy. In the

following extract, a nurse practicing in paediatric A&E

reflects on previous experiences of caring for young

people who had engaged in suicidal behaviour on a

medical ward in an attempt to explain this position:

I think its lack of training. We really didn’t know

what we were doing at all. We are children’s nurses.

We look after sick children—we are not trained to

sort of help children that are in this kind of situation.

I wasn’t happy about it, but then again, I wasn’t

happy about them being on the children’s ward

because it wasn’t an appropriate place for them.

From that point of view, we weren’t qualified to look

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after them. I mean in casualty—all we do is stabilise

their condition and make sure that they are

physically OKy

yWe just haven’t. Just being able to talk to them I

mean—I know from my point of view I am ever so

self-conscious of what I am saying to these children.

Is that going to make them feel worse—what have I

just said—is that going to make them blow up or

something?

Believing that it is possible to say the wrong thing, in

this case, arose from being confronted with a young

female patient where there were suspicions of sexual

abuse from the father. The feeling was a sense of ‘what

do you say’ and that such encounters were frightening.

The fear, in a number of interviews, seemed to return to

the preconception that talking about the problem would

make things worse. Some nurses felt that attempting to

get information out of young people, under these

circumstances, might not be the right thing to do if

you do not know what you are doing. Not having the

experience or knowledge to be able to deal with the

mental health of young people came from getting only a

brief amount of exposure to such issues during training.

Training, in the eyes of some of the doctors working in

A&E, was not necessarily the answer. Here, more

emphasis is placed on experience where skills need to

be developed over time and professionals are seen as

learning more skills or how to enhance skills. The

following doctor’s comments provides a summary of this

position:

You can train people all you like. I mean you can

train people to be better listeners and whatever. My

own personal feeling is that you can either do it or

you can’t. You can train people to be better listeners

but there are lots of areas to cover in an A&E unit in

terms of skills. I think it is an experience thing as

well—experienced nurses would find it easier than

younger nurses and doctors, for that matter.

These issues are influenced by some of the same

factors found in nurses’ and doctors’ experiences of

frustration in practice. The amount of time they have to

offer young people and the environment in which they

work are important factors. Practising on a busy unit,

which is not a therapeutic environment, and not

conducive to sitting, listening and giving young people

quality attention, hinders the development of such skills.

5.2. Reflections on own experience

The act of suicidal behaviour separated the nurse or

doctor and young person, in that it was something that

they would have never resorted to themselves at that

time in life. Not being able to imagine taking some

tablets or hurting themselves distanced the nurses and

doctors further from the young people who had engaged

in such behaviour. Yet nurses and doctors saw the

suicidal behaviour as a young person’s way of coping,

and they reflected on the way that they had coped with

problems during their teenage years. At this point, such

reflections on their own experience underpinned nurses’

and doctors’ perception that this patient group are

unconventional and difficult to associate with when

thinking about their own experiences of life. As the

following doctor working in A&E observes:

When I was a child it’s not something that I would

have even considered. And you see some children 9

or 10 taking paracetamol. When I was that age, I was

just running around, playing football in the park, its

not something I would have even contemplated or

thought about...even when I was a teenager.

In a similar way, nurses and doctors reflected on what

they have now, in their own lives. This again involved

separating out their life experiences (experiences with

their own children) and the experience for the young

person. This feeling, for some nurses, came with

sympathy—that is—feeling sorry for the individual

because their family life is so different from their own

(past and present). In this sense these young people

because they had been failed by the system and failed by

their families. For this paediatric nurse, these individuals

do not receive the emotional support within a network

of family and friends. The following quote sums this

feeling up:

I think its a shame that they don’t have (and they

should have)... —because I have got—a stable family

life. I have always had a stable life—I can’t imagine

children leading this kind of rollercoaster kind if

life...and coming out of it OK. I think it just makes

me sad that they haven’t got it, they haven’t had what

I have had or haven’t got what my children have.

This strategy enabled nurses and doctors to present to

themselves the differences in experience between them

and the young person engaging in suicidal behaviour.

Never feeling or being in a situation that they would

want to harm themselves, having an adequate support

network, again separated these professionals from their

patients. Seeing young people using suicidal behaviour

as way of coping, as a way of saying something about

themselves, was so far removed from how nurses and

doctors presented themselves and dealt with life issues

when they were teenagers. However, this process of

relating or comparing the young person’s experience to

their own, appeared also to be one of the nurses’ and

doctors’ ways of understanding young people who

engage in suicidal behaviour.

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6. Discussion

This study presents a picture of nurses’ and doctors’

perceptions of the young people they encounter every

day following an episode of self-harm. At the core of

nurses’ and doctors’ perceptions of young people who

engage in this suicidal behaviour is the nature of the

relationship they have with the young person. Experi-

ence of frustration in practice and strategies for relating

to young people start to provide an explanation of the

ways in which nurses and doctors perceive young people

who engage in suicidal behaviour. For nurses and

doctors in the present research there is little time to

give to someone who may require that opportunity to

talk. When help is offered, there is more frustration

because such interventions appear to have little impact.

Such situations are exacerbated by the fact that the

nurses and doctors are working in busy environments

making encounters with young people difficult. These

meanings were illustrated under the subcategories non-

therapeutic situations and insubstantiality of interven-

tions. These meanings highlight barriers that are

constructed, which may be crucial in the effectiveness

of the communication between nurses, doctors and

young people.

One of the most profound meanings associated with

young people who come into hospital following an

episode of suicidal behaviour comes within the sub-

category value of life. In particular, nurses and doctors

describe the problem of placing these young people with

other patients who are physically very ill. This experi-

ence challenges the very purpose and reason as to why

nurses and doctors came into healthcare—to preserve

and maintain life. These findings contribute to previous

evidence describing the perceived difficulties of placing

adolescents on wards with people from other age groups

(Burr, 1993; Foote, 1997). Yet they also corroborate

Boyes (1994) finding that self-harm evokes frustration in

staff and the subsequent difficulty in helping the young

person. Moreover, this meaning in nurses’ and doctors’

perceptions can be located in the much earlier work of

Patel (1975) who found that many of the nurses and

doctors in his study felt that self-poisoning patients were

unsatisfactory to treat and that they did not benefit from

their stay in hospital. He also showed that a preference

was made between the person who was experiencing a

physical illness, such as myocardial infarction and those

patients who were admitted for self-poisoning. Ramon

(1980) also demonstrated ambiguous, stereotyped per-

ceptions of self-poisoning patients amongst nurses and

doctors. He portrays this as a reflection of existing

contradictory societal approaches to people who self-

poison themselves. O’Brien and Stoll (1977) showed that

the views towards individuals, who had taken an

overdose, among nursing staff in particular, were

connected to feeling unable to cope with the patients’

demands, irritation towards the patient and little

satisfaction gained from the treatment provided.

The second main category arising from the data was

labelled strategies for young people. One of the first views

emerging was that young people who engage in suicidal

behaviour need to be listened to in particular way. This is

evident in the perceptions nurses and doctors express

under the sub-category specialist skills in care. Under this

category, professionals saw that there was a skill in

talking to these young people. Yet, the barrier here,

between professionals and patients, comes in the fact that

nurses and doctors also believed that they were unable to

talk to these young people because they did not have the

intervention skills to do so. The most profound division is

created by the perception that only certain nurses are able

or interested in the mental health of a young person and

therefore would be able to sit and talk to them. Talseth

et al. (1999) revealed that adult patients engaging in

suicidal behaviour gained value from nurses giving them

time, being listened to, accepting their feelings and

communicating hope. Other recent studies confirm

aspects of communication as being crucial to both nurses

and patients (McLaughlin, 1999).

Burgess et al. (1998) found that out of 25 adolescents

who had taken overdoses 64% mentioned that having

someone to talk to about their problems was important.

Hill (1995) includes in her myths surrounding young

people and suicide that ‘talking about suicide’ en-

courages the behaviour. She maintains that this is a

crucial issue in relation to suicide prevention. The

commonality of hints, warning signs and threats

indicates that most individuals would want to divulge

information about their suicidal feelings. Giving a young

person the opportunity to talk through their real fears

may be offering that person a lifeline. Considering the

fact that nurses and doctors expressed this ambiguity

around how to talk to young people who engage in

suicidal behaviour is significant in the contexts of this

literature. However, what perhaps compounds this

barrier between the professional and patient is the

nurses’ and doctors’ comparison of their own teenage

life with the lives of the young people they see following

an episode of deliberate self-harm. These data are found

under the sub-category reflections on own experiences.

This illustrates the difficulty in generating empathy for

that young persons’ experience of their own social life

and environment. Instead, nurses and doctors create a

barrier, meaning—‘these young people are different

from how I was when I was that age’. This divides the

professional and patient and subsequently, meanings are

not shared. Aldridge (1992) clearly points out that such

a process hinders the effectiveness of encounters between

the professional and the patient.

Recent research continues to emphasise the impor-

tance of relationships for young people who engage in

suicidal behaviour (Houston et al., 2001). Whilst it is

ARTICLE IN PRESSM. Anderson et al. / International Journal of Nursing Studies 40 (2003) 587–597 595

recognised that disruption of relationships with partners

and family members can be a contributory antecedent,

there is still little recognition of the impact of subsequent

encounters and relationships with healthcare profes-

sionals. Nurses and doctors working in health services

such as, accident and emergency, paediatric medicine

and child and adolescent mental health services, offering

care to young people who engage in suicidal behaviour,

are key players in suicide prevention work. The

continued involvement of primary care, schools, col-

leges, families and the wider community, including the

public and the media, will be essential. The quality of a

health professional’s relationship with a young person

who engages in self-harm is a global concern. If

proposed national and international policies on suicide

prevention are to work the phenomena impacting on

these relationships need to be addressed (DoH, 1999;

WHO, 2001). Future research programmes should focus

on these factors and in turn such evidence should be

used in the education and practice development of

nurses, doctors and other allied health professionals.

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