Experience and attitude of psychiatric nurses in caring for patients with repeated non-suicidal self-injury in China: A qualitative study

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Psychiatric nurses play a vital role in the care and treatment of NSSI patients, as they have the most frequent contact with patients. The attitude of nurses has a direct affect on the quality of care they provide to patients. Negative care experiences and attitudes of patient aversion on behalf of nurses may delay the observation and treatment of changes in the patient's condition, leading to irreversible risks. Although cross-sectional studies have investigated the attitudes of medical staff toward NSSI patients, quantitative research results cannot comprehensively reflect the emotional experiences and complex psychological changes of the study subjects. A few studies have focused on the psychiatric nurses' care experiences and attitude toward patients with repeated NSSI. Objective: This study aimedto explore psychiatric nurses' care experiences and attitudestoward patients during repeated NSSI. Methods: A qualitative descriptive design using individual, semi-structured interviews. Using purposive sampling，18 psychiatric nurses were recruited from a mental health center in Chengdu, China. Semi-structured interviews were conducted and audio-recorded. Audio-recordings were transcribed verbatim and analyzed using thematic analysis. Results: Four themes emerged from the analysis: psychiatric nurses’ care experience, perceptions, care attitude and coping style toward repeated NSSI patients. Psychiatric nurses have experienced negative care experiences and severe career burnout during the patient's repeated NSSI. Nurses' attitudes toward NSSI patients changed during repeated NSSI, from understanding to indifference to anger and resentment. At the same time, it was found that nurses' coping style with NSSI patients could be divided into three stages, namely, active coping, neglect and perfunctory, and criticism and punishment. Conclusions: The findings have implications for health care systems regarding interventions to improve nurses' care experience and attitude toward repeated NSSI patients. These findings suggest that enhancing nurses' understanding of NSSI, establishing standardized emergency response and intervention programs, guiding positive professional values and responsibility, and improving nurses' caring attitudes can promote the early detection and timely intervention of NSSI. Non-suicidal self-injury repeated NSSI psychiatric nurses care experience care attitude qualitative study Introduction NSSI (non-suicidal self-injury) refers to the behavior of directly damaging one’s body tissue, such as self-harming, skin scratching, and self-burning [ 1 ]. NSSI usually starts in early adolescence with an estimated global prevalence of 17.2% in nonclinical samples [ 2 ], while it is as high as 40ཞ61% in adolescent inpatients [ 3 ]. A study found that since 2020, the proportion of adolescents who engaged in NSSI has increased dramatically [ 4 ]. NSSI often occurs repeatedly. Multiple episodes of NSSI can lead to serious health problems such as infection and even autoamputation of body tissues [ 5 ]. Additionally, the suicide risk of patients who engage in NSSI is hundreds of times higher than that of the general population [ 6 ]. This is concerning, as self-injury is the single most reliable predictor of suicidal ideation and attempts, with one-fourth of suicides preceded by acts of NSSI within the prior year [ 7 ]. NSSI has become an important issue affecting the health of adolescents. At present, NSSI has been included as an independent mental health issue in the 5th edition of the Diagnostic and Statistical Manual for Mental Disorders and is a major global public health issue [ 8 ]. A Canadian study with large sample (n = 2038) of hospitalized children and adolescents showed that about 29% attempted to self-injure even when under care in a mental health setting [ 9 ]. Research shows that more than half of people who have experienced NSSI often experience repeated NSSI [ 10 ]. However, from clinical practice, these data may be higher. Due to its high detection rate, high risk, and high repeatability, this behavior has become one of the most important public health problems in the world [ 8 ]. It also brings tremendous pressure to clinical work. Psychiatric nurses play a vital role in the care and treatment of NSSI patients, as they have the most frequent contact with patients. They play a crucial role in distinguishing whether patients have attempted self-injury, preventing self-injury, guiding patients in psychotherapy, or providing other assistance within their capabilities. The incidence of repeated NSSI is high, and only about 50% of NSSI adolescents have self-disclosure behavior [ 11 ], which is difficult to identify and prevent, and poses great risks to patient safety. This has become an increasingly difficult point in nursing safety management, causing great distress and pressure to psychiatric nurses [ 12 ]. Although psychiatric nurses expect to maintain professionalism and provide more support to patients, regardless of the emotional weight of this situation, nurses caring for NSSI patients face the risk of empathy fatigue and even a change in attitude toward patients, which can have a negative impact on their empathy and thus affect the patients' experience with care [ 13 ]. An attitude can be defined as a response to a stimulus that involves cognitive, affective and behavioral components, extending to all aspects of intelligence and behavior [ 14 ]. This response is an interior disposition that affects the selection of an action or behavior to be adopted toward persons, events or objectives [ 14 ]. The Knowledge-Attitude-Behavior (KAB) model also explained that knowledge is the foundation of behavior change, and belief and attitude are the driving force of behavior change [ 15 ]. The attitude of nurses seems to have a positive or negative impact on the care provided to NSSI patients [ 16 ]. Studies have shown that negative attitudes toward self-harm behavior are associated with a lack of preparation among professionals and may reinforce self-harm-related stigma and discrimination and decrease the level of care provided to patients who attempt self-harm [ 17 ]. Research reports that NSSI patients describe their experiences with healthcare professionals during hospitalization as judgmental, non-listening, and lacking sufficient knowledge [ 18 ]. Nurses' negative attitudes toward NSSI patients, such as indifference and antipathy, are key factors that hinder patients from continuing treatment and seeking further help. Negative attitudes, which are reported to significantly influence outcomes and are even connected to adverse events such as patient falls and medication errors, are especially problematic [ 19 ]. Therefore, the negative care experience and aversion attitude of nurses may delay the observation and treatment of changes in the patient's condition, which may lead to irreversible risks. Although cross-sectional studies have investigated the attitudes of medical staff toward suicide or self-injury patients [ 20 ], quantitative research results cannot comprehensively reflect the emotional experiences of the study subjects, and psychological measurement scales have difficulty measuring complex psychological changes. Previous qualitative studies have mostly focused on interviews with NSSI patients [ 21 ], parents [ 22 ], and teachers [ 23 ]. It is currently unclear how Chinese psychiatric nurses' care experiences and attitudes toward repeated NSSI patients, as well as how they affect coping style toward repeated NSSI patients. Understanding the care experience and attitude of psychiatric nurses toward NSSI patients plays an important role in preventing and reducing repeated self-injury. This study explores the care experience and attitudes of psychiatric nurses toward patients with repeated NSSI. The study is conducted in the context of Chinese culture using qualitative research methods, and analyzes the difficulties and challenges in nursing practice for NSSI patients. The goal is to provide a research basis for further improving and enhancing nurses' care attitudes, coping style, and support systems toward NSSI patients and to provide a more theoretical basis for the management of NSSI patients. Methods Study design This qualitative study took a phenomenological approach, which attempts to understand human experience and uncover meanings. This approach was selected because it allows researchers to rely on participants’ perspectives on the phenomenon while recognizing the influence of the researcher’s own background and experience. Research setting The study was conducted from March 2023 to June 2023 at the mental health center of a tertiary hospital in Chengdu, Sichuan Province, China. The tertiary hospital we chose is the largest regional medical center in the city, and approximately 600 NSSI patients were hospitalized each year in the last 3 years. The mental health center has 5 wards with a total of 300 beds and approximately 120 nurses, from which the participants were selected and interviewed. Participants and recruitment Purposive sampling methods were used. Age, educational background, professional title, working years, and number of nursing cases of NSSI patients in the past year were factors considered in selecting study subjects, using the maximum difference sampling strategy. Participants eligible for this study were nurses who (a) possessed a professional nursing qualification certificate; (b) were able to independently execute overall responsibility-based nursing care; (c) had a primary role as a staff nurse (bedside) position; (d) had at least 1 year of clinical experience in psychiatry; and (e) had cared for NSSI patients at least once in the past year. Nurses who were on sick leave, personal leave, maternity leave, rotation, and continuing education during the study period were excluded. The sample size was based on the principle of saturation of interview information, and a total of 18 psychiatric nurses who had previous experience in handling NSSI cases were ultimately interviewed. Ethical considerations This study was approved by the Ethics Review Committee of West China Hospital of Sichuan University. The research subjects all provided informed consent and voluntarily participated in this study. Participants were assured that their interview responses would be confidential and anonymized. Issues of concern included participant confidentiality and emotional wellbeing during the interviews. Addressing sensitive topics requires attention to the potential emotional impact the interview may have on the participant and the researcher [ 24 ]. Additional measures included providing contact information for emotional and mental health resource follow-up. It was made clear that the participants could stop the interview at any time if they experienced anxiety or distress and withdraw from the study at any time. Data collection We conducted 18 one-on-one semi-structured interviews with participants in a psychotherapy room. At the time of the interviews, participants were given another opportunity to read the consent form, acknowledge understanding, and ask questions. Participant consent to audio-record the interview was also verified at this time. Verbal consent was obtained, as this was the approved method to maintain participant anonymity. Participant demographic data, recorded interviews, and interview transcripts were all deidentified with a pseudonym to protect participants' identity. The interview guide was developed based on our interests of study and research gaps identified from the literature review and was adjusted after analysis of the first three interviews. The interviews used open-ended questions and focused on 4 topics: (1) nurses’ responses and behaviors to patient NSSI; (2) nurses’ care experience for repeated NSSI; (3) nurses’ perceptions about repeated NSSI; and (4) changes in nurses’ attitudes and behaviors during repeated NSSI. The interviews were semi-structured, following an interview guide (Table 1 ). Each interview lasted 30 to 45 min. No repeat interviews were conducted. Interviews were conducted in Mandarin or Sichuan dialect according to participants’ preferences. Table 1 Interview questions and prompts. nurse’s responses and behaviors when found about NSSI (1) What was the first time that you can remember the patients hurt himself/ herself? (2) What was your reaction? How did you deal with it? Prompts Tell me more about this ... nurses' Care Experience for repeated NSSI (1) With the increasing frequency of repeated self-injury, how has your care experience been? Have you encountered any problems or helpful ones? (2) Has changed compared before? If so, what changed? (3) What accounts for this change? Prompts What else? Tell me more.... how did you feel? nurses’ perception about repeated NSSI What did you think were the causes of such behaviors? Prompts Why would they hurt themselves༟ changes in nurse’s attitude and coping style during repeated NSSI. (1) When a patient in your care repeatedly self-injures, What was your response? what did you say or do? Why did you respond in that way? (2) Whether your care attitudes have changed since the beginning༟If so, what changed? (3) Has your response changed? If so, what changed? Prompts Tell me more about this... What was the outcome of your response? Are there any other concerns or things you would like to discuss about NSSI Data analysis Data analysis began concurrently with the first interview. Interviews were audio-recorded and transcribed verbatim. To ensure accuracy, the primary investigator listened to each recording while proofreading and correcting transcripts as needed. Transcripts were entered into NVivo11 [ 25 ] for further analysis. Thematic analysis was used, following the six-phase process described by Nowell [ 26 ]. It is a rigorous and flexible method that can be used to identify, analyze, organize, describe and report themes found within a data set across a range of epistemologies and research questions [ 27 ]. The primary investigator completed the first three phases separately, including reading and rereading interview transcripts to familiarize with raw data, generating initial codes by attaching labels to identified interesting aspects in the data, and searching for themes by sorting related codes hierarchically. All researchers reviewed coded data under subthemes to ensure a coherent pattern. Themes and subthemes were compared between cases to determine if they needed to be refined according to their supportive data. The research team, together with advisory experts (one head of psychiatric nursing, one mental health consultant, and one nursing professor with extensive qualitative research experience), read through all data, scrutinized coding, and defined and redefined themes until the scope and content of each theme could be clearly and succinctly described and consensus was reached. Rigor To ensure rigor and trustworthiness that the findings reflected participants' words and perspectives, Lincoln and Guba's criteria of credibility, dependability, confirmability and transferability were used in this study [ 28 ]. Strategies included two investigator discussions of coding decisions, maintaining field notes, and an audit trail (confirmability), participant checking and peer debriefing (credibility), an audit trail of coding decisions and theme development (dependability), and providing rich descriptions of participants, data collection process, and context (transferability) [ 29 ]. Result Characteristics of the 18 participants are shown in Table 2 . 4 themes and 14 sub-themes emerged from the analysis (Table 3 ). Table 2 Participant demographics. Number Gender Age Professional Title Education YRS RN YRS psychiatry A1 F 54 CN AD 34 34 A2 F 43 SuN BD 22 20 A3 F 41 SeN AD 19 15 A4 F 39 SeN BD 17 15 A5 F 35 SeN BD 14 12 A7 M 36 SeN BD 14 12 A8 M 28 SeN BD 7 5 A9 F 40 SeN BD 16 10 A10 M 23 PN BD 1 1 A11 F 41 SuN BD 20 16 A12 M 29 SuN MSN 4 4 A13 F 41 SeN BD 20 12 A14 F 38 SeN BD 14 12 A15 F 28 SuN MD 2 2 A16 F 33 SeN AD 11 9 A17 M 32 SeN MSN 10 8 A18 F 25 PN AD 4 2 F = female; M = male; AD = associate degree; BD = baccalaureate degree; MSN = master of science in nursing;MD = doctor of medicine༛PN = primary nurse; SeN = senior nurse; SuN = supervisor nurse; CN = co-chief nurse; YRS = years; RN = register nurse Table 3 Themes and sub-themes Themes Sub-themes Care experience of repeated NSSI Feeling powerless and helpless Excessive psychological pressure Empathetic fatigue Struggling on caring them Deteriorating nurse-patient relationship Career frustration and burnout Perceptions of repeated NSSI Coping strategy for reducing mental distress A way to meet a need Care attitude of repeated NSSI Understanding and sympathy Apathy and escape antipathy and resentment Coping style of repeated NSSI Actively respond Neglecting and perfunctory Criticism and discipline 1. Care experience of repeated NSSI This theme describes some of the negative experiences experienced by psychiatric nurses in the course of caring for patients with repeated NSSI, including: empathetic fatigue, excessive psychological pressure, struggling on caring them, feeling confused and helpless, deteriorating nurse patient relationship and career frustration and burnout. (1) Feeling powerless and helpless The nurses in this study clearly show that caring for patients with NSSI is more challenging than caring for other patients. They all work very hard to help patients but often feel powerless and helpless due to a lack of understanding, team support, and standardized intervention protocols. A10: “Without an exact theoretical model and standard intervention program to guide us on how to properly deal with such patients, we lack confidence in the intervention process, and the intervention effect is far from ideal. ” Respondents expressed the need for support from colleagues and leaders and wanted to talk with colleagues or leaders after patient incidents of self-injury. However; a lack of empathy from fellow staff members during these conversations made nurses feel even more isolated and criticized, causing them not to reach out and to distance themselves from potential sources of support, and thereby perpetuating the lack of emotional support. A13: “When I reported this to colleagues and leaders or asked for help, I was often questioned or criticized by them, and thereafter I refused to report or communicate with them when no serious adverse events occurred.” (2) Excessive psychological pressure Psychiatric nurses described high concealment of NSSI, that is, they were not able to predict when patients would commit NSSI, and the unpredictable consequences of NSSI, and nurses felt stressed during work. In addition, most of the nurses lost confidence in the potential for patients’ conditions to improve, and experienced feelings of pessimism and despair. A4: “Since the behavior of NSSI patients is hidden and not easy to prevent, especially in the night shift, the manpower is relatively weak, and I always worry that NSSI patients will show NSSI behavior again when I am busy dealing with other things (which is always the case), which makes me feel particularly stressed and in a state of mental tension.” A8: “My job is to give patients help and hope, but right now I'm the most desperate person on the ward.” (3) Empathetic fatigue Almost all interviewees reported empathy fatigue after long-term care of patients with repeated NSSI. Psychiatric nurses described themselves have faced the pain and suffering of NSSI patients for a long time, may gradually lose their emotional empathy and care for them, and feel that their emotional resources are exhausted and emotionally exhausted. The nurses recounted spending a lot of time and energy to help NSSI patients solve problems or relieve painful emotions, while the patients' self-injury behavior did not decrease, and even suffered from apathy and aggressive behavior. Over time, they felt that their sensory sensitivity gradually decreased, became numb to the patient's pain or self-injury behavior, and felt that they became apathetic, and indifferent. A1: “My child is 14 years old, which is similar to the age of these patients. At first, when I saw them hurt themselves, I would feel very distressed. I would patiently comfort and help them, just like helping my own children. However, not long after each incident, they will hurt themselves in different ways. I have become indifferent to them for a long time” A2: “Well, what's the point? No matter how hard you try, she will still respond the same way, which is to continue NSSI.” (4) Struggling on caring them Most participants mentioned that although after facing the patient's long-term repeated self-injury, they lost confidence in the patient's treatment and became numb and indifferent to self-injury behavior. But they had a responsibility to help patients get better, so they struggling on caring them. A7: “I know I should actively respond to patients' self-injury and needs, but I am struggling internally.” A14: “I sometimes feel like I'm wasting my time dealing with repeated self-injury, but I still have to deal with it!” (5) Deteriorating nurse patient relationship Some interviewed nurses stated that they were embarrassed to admit that they had difficulty establishing a collaborative relationship with NSSI patients. Others stated directly that their tolerance for repeated NSSI patients is low, and that they hold a moral critical attitude toward patients with repeated NSSI. They may blame the patients and are less willing to sympathize and understand them, which will distance the nurse from the patient. In addition, patients gave nurses feedback that they thought nurses did not understand why they hurt themselves, and even blamed and criticized them, which led to patients' reluctance to maintain communication with nurses, resulting in increasingly distant nurse-patient relationship. A9: “I know for sure that one's patience is limited, even though I am a nurse (maintaining a high degree of professional responsibility). When I tried to help a NSSI patient, he still repeatedly demonstrated self-injury behavior. In anger I said to the patient: I am too disappointed in you! He could also sense that I was losing patience with him and began to distance himself from me.” (6) Career frustration and burnout Respondents reported that when some repeated NSSI patients are admitted to the ward, they required too much time to prevent, control, and deal with their self-injury. However, even if nurses spent a lot of time and effort helping them, the results were often disappointing. Most respondents said that the long-term impact of patients' unreasonable demands, destructive behavior, repeated NSSI, and repeated treatment led to a lack of confidence and frustration for nurses, resulting in more serious burnout. A7: “In the face of NSSI patients, we tried everything we could think of, including the application of some psychological therapy techniques, but later, it was still to no avail, and I felt my energy was exhausted, and I gradually lost my passion for this job.” 2. Perceptions of repeated NSSI Nurses have a vague perception of NSSI, meaning that nurses are not sure what the real reason and purpose behind each patient's self-injury is. However, in clinical practice, they often treat NSSI as a way for patients to reduce mental distress and/or meet needs. (1) Coping strategy for reducing mental distress A common feature of the interviews was that psychiatric nurse related NSSI to mental health and portrayed it as a maladaptive coping strategy for reducing mental distress. A2: “ Although I'm not sure why they hurt themselves, I have heard from patients who say that NSSI makes them feel better, or that the physical pain caused by NSSI drives away or relieves their mental pain. ” A17: “When adolescent patients are emotional or depressed, they may choose to relieve their emotions through self-injury, because they lack other coping methods.” (2) A way to meet a need Some psychiatric nurses also see NSSI as a way or tool for adolescents to meet needs such as getting attention, eliciting sympathy, or manipulating caregivers (parents or medical staff). In the hospital, some adolescents commit self-injury when medical personnel refuse their request, and some NSSI become more serious or dangerous. A6: “They threaten parents with self-harm at home, and they threaten staff in the same way at hospitals to meet their demands.” A17: “It is common to encounter NSSI patients who ask to smoke, call their parents or even leave the hospital, and if their requests are not met, they will go to NSSI.” 3. Care attitude of repeated NSSI The care attitude of psychiatric nurses toward NSSI patients changes with the recurrence of NSSI. The attitudes described by the nurses toward patients with NSSI fluctuated between understanding, sympathy, and anger. This change in attitude may stem from the experience of caring for patients with NSSI as well as perceptions of NSSI. (1) Understanding and sympathy Some respondents said that for NSSI patients, self-injury is not only a way to express bad feelings but also a strategy to cope with negative feelings, which is why they choose hospitalization. Patients who commit NSSI have also told nurses that it made them feel better or that the physical pain caused by NSSI drove away or lessened their mental pain. Psychiatric nurses express empathy for the patients’ self-injury, and actively try to help patients. A1: “When I saw their wounds, I was very shocked by how much pain they must have in their hearts to cause them to treat themselves in such a way, it was painful to watch.” A15: “At the moment of their self-injury, they may be very desperate and uncomfortable.” (2) Apathy and escape Most respondents mentioned that they have the responsibility to help patients cope with adverse emotions or meet their reasonable requirements, but with the increasing frequency of repeated NSSI or the increasing severity of NSSI results, nurses gradually lose confidence and patience in the treatment of patients and become numb and indifferent to their self-injury. A11: “When I tried to stop them from hurting themselves, they spoke harshly to me and even attacked me. At this time, I would feel very sad because good intentions would not be rewarded. So that in the later stage, I would ask my colleagues to deal with it, as I did not want to face such patients.” A16: “I know it was not a suicide attempt. Otherwise, the scratch would not be so shallow. I do not even want to care why she continues to do this.” (3) Antipathy and resentment Some interviewed nurses described that their tolerance for repeated NSSI patients is low, and that they hold a moral critical attitude toward patients with repeated NSSI. They may blame the patients and are less willing to sympathize and understand them, which can play a role in recurrent attacks or lack of improvement in the patient's condition. At the same time, interviewed nurses believe that repeated NSSI behavior is a manifestation of intentional manipulation or excessive dependence, causing a serious loss of empathy for patients and resentment among medical staff. A7: “There are plenty of alternative ways in our ward to help her relieve her mood, but she still repeatedly took the way we forbid, which made me very unacceptable and feel frustrated and even caused me to show antipathy.” A10: “They threaten their parents with NSSI at home, and they threaten their staff in the same way at the hospital. This behavior and motivation make me very resentful.” Psychiatric nurses stated that NSSI seems to demonstrate a phenomenon of human-to-human transmission. This may be related to the tendency of teenagers to accept negative information that promotes NSSI and imitates others' NSSI behavior [ 30 ]. In addition, it is not difficult to find in clinical practice that patients with long-term repeated NSSI often try to persuade more adolescents to participate in self-injury. Nurses resents these types of initiators because they make it difficult to manage the entire ward. A6: “When there is a repeatedly hospitalized NSSI patient in the ward, a group of new NSSI patients will emerge at this time. I will be very angry when I find out through tracking that the NSSI behavior of the newly admitted patients is learned from the veteran NSSI patients.” 4. Coping style of repeated NSSI Through interviews, we found that psychiatric nurses' responses to repeated NSSI can be divided into three stages: actively respond, neglect and perfunctory, criticism and discipline. Behind the variations in coping styles at each stage are changes in nurses' cognition and attitudes toward NSSI patients. (1)Actively respond Some interviewed nurses believe that for teenagers, NSSI is not only a way to express negative emotions but also a strategy to deal with negative emotions. Psychiatric nurses express understanding of their behavior, actively explore alternative ways to help alleviate negative emotions, and provide suggestions on how to deal with triggering factors. A11: “I will ask them about their feelings and reasons behind NSSI, express concerns about potential health issues that may arise later, and provide advice on how to respond to negative emotions and alternative approaches, as well as how to deal with triggering factors.” A9: “Although I sometimes feel disappointed and resentful about patients' long-term and repeated NSSI behaviors, my responsibility is still to actively handle patients' problems.” (2)Neglect and perfunctory Most respondents mentioned that with the increasing frequency of repeated NSSI or the increasing severity of NSSI results, they gradually lose confidence and patience in the treatment of patients and become numb and indifferent to their self-injury, and sometimes ignored and perfunctory NSSI behaviors of patients. Besides, when nurses believe that NSSI is a way for teenagers to meet their needs or receive attention, and think that NSSI are not causing serious health problems, they will choose to ignore the patient's self-injurious behavior and believe that reducing attention can help the regression of NSSI. A2: “I expressed my powerlessness and helplessness toward his performance, and I have become emotionally numb. Sometimes when I hear NSSI patients calling for help, I delay the response.” A15: “I believe that any method is not helpful in preventing NSSI. In contrast, excessive attention will only reinforce their self-injury.” (3)Criticism and punishment Almost all respondents mentioned that repeated NSSI of patients results in a serious loss of empathy among psychiatric nurses toward patients, and causes aversion and resentment among psychiatric nurses. When nurses believe that teenagers' NSSI is intentional, they may try other approaches to preventing teenagers from engaging in NSSI. One approach is criticism, and the other is punishment. Criticizing and punishing this behavior is to prevent it from happening again. In traditional Chinese culture, criticism and punishment are also very common and practical educational methods. A17 “ If a patient attempts to manipulate us using NSSI (such as requesting discharge), I will tell them which approach is incorrect and express my anger. In addition, warn them that if similar behavior occurs again, I will restrain them.” Some participants also expressed that when they learned that the patient had experienced NSSI again, they found it difficult to control their emotions and expressed anger toward the patient, as they had invested a lot of energy and emotions in exchange for repeated NSSI and aggressive behavior. A3 “ Do you know? After spending a lot of time and energy guiding her on how to deal with negative emotions, shortly after the conversation ended, she hurt herself again, which made me very angry. I blamed and criticized her behavior.” Some interviewed nurses feel strongly that punishment is a very effective way of discipline. From the perspective of immediately stopping bad behavior, punishment is often effective. For psychiatric nurses, ensuring patient safety is the primary task of their work. Protective restraint is a coping method that can have an immediate effect on preventing patients from engaging in NSSI. Another reason why psychiatric nurses use punitive measures is that they are concerned that not punishing them will only pamper adolescent patients and cause them to worry about losing control of the patients. Moreover, punishment is easy and often a "reactive" response. A9: “When my patients engage in NSSI, I will intervene with protective restraints because they are violating the basic principles of mutual respect and trust. “ A18: “I know that adopting protective renstraints on patients with repeated NSSI is often a disguised punishment. However, when faced with patients' bad behavior, I still fall into the old habit of punishment.” Punishment is often effective at stopping bad behavior in the short term, but the problem is that the nurses are not aware of the long-term effects of punishment. Nevertheless, the primary reason psychiatric nurses insist on using punitive measures is that they do not know what else to do. A12: "I do not think restraints are a very effective intervention measure, but we have tried various ways and methods, but still have not effectively solved the problem of NSSI, and I do not know how to deal with it.” Discussion It is necessary to discuss the experience and attitude of psychiatric nurses who care for patients with repeated NSSI, because the nurse's attitude toward patients seems to have an impact (positive or negative) on the quality of patient care. For the first time, this study explored the care experience and attitude of Chinese psychiatric nurses toward repeated NSSI patients through qualitative research methods. Four themes were identified through interviews: care experience, perceptions, care attitude and coping style toward repeated NSSI. Six kinds of care experience were identified as: feeling powerless and helpless, excessive psychological pressure, empathetic fatigue, struggling on caring them, deteriorating nurse patient relationship and career frustration and burnout. In this study, we found that psychiatric nurse felt excessive psychological pressure in the face of NSSI. Hadfield et al. [ 31 ] similarly show that doctors view treating people with self-injuries as a futile task that causes feelings of despair and frustration. In recent years, the proportion of NSSI patients within psychiatric inpatient populations has been increasing [ 32 ]. However, due to the incidence of repeated NSSI is high, and only about 50% of NSSI adolescents have self-disclosure behavior (11) which is difficult to identify and prevent, and poses great distress and pressure to psychiatric nurses, and strong negative emotions such as anxiety and despair. These outcomes have been widely reported in the literature [ 33 , 34 ]. In addition, although many of the nurses in this study had cared for a large number of NSSI patients, they indicated that they did not have an in-depth understanding of NSSI and sometimes had to improvise patient guidance and interventions based on their own experience, with little effect. Nurses make it clear that they work very hard to help NSSI patients but often feel powerless and helpless by the lack of standardized, timely and effective intervention programs. Without a theoretical model to guide this work, the effect of the intervention is very limited, similarly to reports by Kickan [ 34 ]. From a practical perspective, this finding highlights the role and importance of helping nurses enhance their understanding of NSSI behavior. Establishing standardized emergency responses and intervention protocols that help psychiatric nurses objectively understand NSSI, and providing targeted interventions, could help to improve the psychiatric nurses' experience of caring for patients with NSSI, thereby improving overall quality of care. A noteworthy finding of this study was that psychiatric nurses experienced empathy fatigue and career burnout in the process of caring for repeated NSSI patients. Psychiatric nurses recurrently witness repeated self-injury, unreasonable demands, destructive behaviors and repeated hospitalization of NSSI patients. In response, nurses gradually lose patience with patients, become frustrated, and lack confidence in their ability to treat patients. Psychiatric nurses recounted spending a lot of time and energy to help NSSI patients solve problems or relieve painful emotions, while the patients' self-injury behavior did not decrease, and even suffered from apathy and aggressive behavior. This enormous and lasting psychological gap leads to the empathy fatigue of nurses for patients. A meta-analysis shows that mental health nurses face a sense of low value, heavy pressure and hopelessness for a long time, which can easily lead to career burnout [ 35 ]. Burnout not only deteriorates nurses’ work performance but also adversely influences their health and well-being [ 36 ]. Therefore, it is suggested that clinical managers should introduce effective strategies and courses(such as mindfulness-based stress reduction [ 37 ])to reduce nurse burnout while paying attention to staff mental health and stress management. Research has also shown that although psychiatric nurses expect and strive to maintain professionalism and provide as much support as possible to patients, the specific experiences (empathy fatigue, anxiety, hopelessness, etc.) of nurses working in high-stress environments for NSSI patients negatively affects their empathy and willingness to care. However, driven by responsibility and leadership, so they struggling on caring repeated NSSI patients. However, it is worth noting that most participants mentioned that although after facing the patient's long-term repeated self-injury, they lost confidence in the patient's treatment and became numb and indifferent to self-injury behavior. In other words, psychiatric nurses are at risk of reduced or lack of sense of responsibility when caring for patients with repeated NSSI. Responsibility guides nurses to pay attention to patients' emotional changes, seek information, prioritize care, and develop responses [ 38 ]. Reduced or absent accountability can delay the observation and recognition of changes in a patient's condition, with serious consequences [ 39 ]. This finding highlights the need to support the development of nurses' professional values and sense of responsibility throughout their education and career. Psychiatric nurses have a vague perception of NSSI, meaning that nurses are not sure what the real reason and purpose behind each patient's self-injury is. However, in clinical practice, they often treat NSSI as a way for patients to reduce mental distress and/or meet needs (such as getting attention, eliciting sympathy, or manipulating caregivers). This is in line with multiple studies and theories on NSSI [ 31 , 33 , 34 ]. One of the things we must note is that when psychiatric nurses also see NSSI as a way or tool for adolescents to meet needs, it appears to label patients. Labels can carry harmful, implicit biases that negatively affect clinical outcomes for the people they describe [ 40 , 41 ]. For example, our study found some psychiatric nurses will choose to ignore the patient's self-injurious behavior and believe that reducing attention can help the regression of NSSI when they believe that NSSI is a way to meet needs or get attention. Similarly, a previous study found that medical staff see NSSI as an attention-seeking behaviour in emergency department, which is why they refrained from giving too much attention to NSSI patients [ 31 ]. Owens et al. [ 42 ] study found that when care providers withheld sufficient attention to self-injuries patients, it can lead to a tendency to avoid seeking help in the future. Refusing to seek help may miss the best time to receive psychological intervention, with irreversible consequences. In some cases, hold a moral critical attitude toward NSSI among nurse may delayed NSSI patients for proper treatment. Therefore, improving psychiatric nurses' understanding of NSSI may avoid labeling patients and reduce biased statements. The study found that the nurse-patient relationship gradually deteriorated in the process of patients with repeated NSSI. The nurses in this study stated that their tolerance for repeated NSSI patients is low, and that they hold a moral critical attitude toward patients with repeated NSSI. They may blame the patients and are less willing to sympathize and understand them, which will distance the nurse from the patient. Two extreme experiences have been reported by the youths with NSSI: felt satisfied and understood about being cared vs felt numbness and not been understood [ 34 ] Research reports that NSSI patients describe their experiences with healthcare professionals during hospitalization as judgmental, non-listening, and lacking sufficient knowledge [ 18 ]. From this, we can infer that the reason for the gradual deterioration of the nurse-patient relationship is that the negative feelings and misunderstandings toward each other remain from both sides. Therefore, the authors of this study suggest that future quantitative studies could be used to investigate how common this phenomenon is and to explore how to develop a more collaborative nurse-patient relationship In terms of attribution, this study showed that the caring attitude of psychiatric nurses toward NSSI patients changes with the recurrence of NSSI. As NSSI repeats more frequently or NSSI results become increasingly severe, the attitude of nurses toward NSSI patients changes from understanding to indifference to anger and resentment. However; in previous studies, the dynamic changes and depth of this care attitude may have been masked, as these studies used questionnaire-based measurement methods to investigate nurses' attitudes toward NSSI patients and simplified attitudes to positive or negative [ 20 ]. After the nurses invested a great deal of emotion in exchange for the patient's repeated self-injury, they consumed the nurse's patience and compassion, accompanied by a change in attitude. Although nurses acknowledge that 'understanding can generate empathy' and describe the importance of understanding patients to gain more empathy, they also acknowledge that it is difficult to truly understand NSSI because they do not easily accept this coping style. In clinical practice, nurses’ capacity for empathy is also easily affected by patients' negative emotions and aggressive behaviors, resulting in antipathy and aversion toward patients [ 43 ]. Although nurses are well aware that NSSI is a disorder that requires psychological assistance, many staff members may inadvertently revert to indifference, anger, or resentment when they encounter repeated NSSI if they do not fully understand the patterns and mechanisms of repeated NSSI. Therefore, this finding emphasizes the importance and urgency of studying the mechanism of NSSI and the pattern of repeated NSSI. Our study also highlights that how nurses respond to NSSI patients is not simply determined by perceptions of NSSI, and that nurses' attitudes towards patients are another strong predictor. An attitude is not specifically a behavior but instead an inclination toward actions, modes or ways to address, react or face a situation or problem in a variety of circumstances [ 14 ]. The KAB model elaborates that a person's knowledge directly affects their attitude and indirectly affects their behavior through their attitude [ 15 ]. With this model, it can be assumed that the knowledge of psychiatric nurses about NSSI affects their attitudes toward it, and that their attitudes affect the actions (behaviors) they take. In this study, nurses who understood and sympathized with patients' self-injurious behavior in the past were more likely to mediate, avoid conflict, and cooperate with patients. Nurses who had expressed indifference and resentment to patients' self-injurious behavior in the past were more likely to deny, be perfunctory, or criticize and punish them. Social psychology believes that attitude is the most important breakthrough point in influencing strategies [ 44 ]. The ultimate goal of social influence may be behavioral change, but reaching this ultimate goal requires a complex channel of attitude. Only by mobilizing a person's real and implicit attitude and exerting his subjective initiative can he affect his behavior [ 45 ]. Therefore, relying solely on training and guidelines might prove inadequate in enhancing the care provided to individuals with NSSI. Ideally, comprehensive competence development should encompass not only the acquisition of skills but also the cultivation of awareness regarding attitudes and the promotion of reflection on the nurses’ influence on the patients’ trajectory. Strengths and limitations This is the first qualitative study to explore the experience and attitudes of psychiatric nurses in caring for patients with repeated NSSI in China. Despite the promising findings of this study, there were several limitations. As with all qualitative research, the findings are limited by self-reporting and are subjected to social desirability bias. This was a relatively small local study; therefore, the findings are not necessarily representative of a broader cross section of psychiatric nurses. The findings may not be transferable to nurses working in other types of hospitals, cultures or countries. In addition, this study explored nurses' caregiving experience and attitude towards repeated NSSI patients from the perspective of nurses, and did not explore other factors that might affect nurses' caregiving experience and attitude towards patients, such as their own personality traits and coping styles. It is hoped that future studies can make up for the above limitations. Despite this, the recurring nature of key phrases and words lends weight to the strength and credibility of the findings. Several factors add to the trustworthiness of the study's findings. The investigators used an established method of data analysis and several strategies (included two investigator discussions of coding decisions, maintaining field notes, and an audit trail, participant checking and peer debriefing, an audit trail of coding decisions and theme development, and providing rich descriptions of participants, data collection process, and context) to enhance the trustworthiness of the findings. Data collection continued until saturation was reached and confirmed by two investigators. Analysis of the findings was validated by three investigators and by several participants of the study. Conclusions Through interviews with psychiatric nurses, this study found that psychiatric nurses have experienced negative care experiences and severe career burnout during the patient's repeated NSSI. It is of concern that psychiatric nurses are not sure what the real reason and purpose behind each patient's self-injury is. Nurses' attitudes toward NSSI patients changed during repeated NSSI, from understanding to indifference to anger and resentment. At the same time, it was found that psychiatric nurses' coping style with NSSI patients could be divided into three stages. Behind the changes in coping style at each stage were the changes in nurses' perceptions and attitude toward repeated NSSI patients. These findings suggest that enhancing nurses' understanding of NSSI behavior, establishing standardized emergency response and intervention programs, guiding positive professional values and responsibility, and improving nurses' caring attitudes can promote the early detection and timely intervention of NSSI. Declarations Acknowledgements Not applicable. Authors’ contributions Leiyu Yue and Jianying Yu were responsible for study design, interviewing participants face-to-face. Leiyu Yue and Rui Zhao were responsible for data analysis. Yu Zhuo and Xiaomin Kou were responsible for recruiting and screening participants and transcribing interviews verbatim. Yue wrote the main manuscript and all authors reviewed the manuscript. The author(s) read and approved the final manuscript. Funding No funding Data availability The primary author is willing to share all of the transcribed interview data upon request. Declaration of Competing Interest All authors report no personal or financial relationships or other conflicts of interest with people or organizations that could have influenced this work. Ethics approval and consent to participate Ethical approval was granted by the Medical Ethics Committee of West China Hospital, Sichuan University before data collection. All methods were carried out in accordance with relevant guidelines and regulations. (eg.Helsinki declaration). All participants were informed of procedures and contents of the study, especially that interviews would be audio-recorded. 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Cognitive-Affective Inconsistency and Ambivalence: Impact on the Overall Attitude-Behavior Relationship. Pers Soc Psychol Bull. 2021;47:673-687. doi: 10.1177/0146167220945900 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 27 Sep, 2024 Read the published version in BMC Psychiatry → Version 1 posted Editorial decision: Revision requested 24 May, 2024 Submission checks completed at journal 21 May, 2024 Editor assigned by journal 21 May, 2024 First submitted to journal 10 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4398962","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":306333042,"identity":"661b880c-e01e-4de4-8692-b21d6ee20bba","order_by":0,"name":"Leiyu Yue","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Leiyu","middleName":"","lastName":"Yue","suffix":""},{"id":306333043,"identity":"f66595f2-b0f7-4571-aa33-0a36b6f1e6ca","order_by":1,"name":"Rui Zhao","email":"","orcid":"","institution":"The Fourth People's Hospital of Chengdu","correspondingAuthor":false,"prefix":"","firstName":"Rui","middleName":"","lastName":"Zhao","suffix":""},{"id":306333044,"identity":"f0e31892-e01e-4a66-937d-7ed8a11f17a8","order_by":2,"name":"Yu Zhuo","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Zhuo","suffix":""},{"id":306333045,"identity":"e983b035-ee04-48ac-86ca-0fd4d45735ec","order_by":3,"name":"Xiaomin Kou","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Xiaomin","middleName":"","lastName":"Kou","suffix":""},{"id":306333046,"identity":"c006060f-fbb0-4f0f-89ce-75c3aa7070ad","order_by":4,"name":"Jianying Yu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYHCChANAgoeBgbHxwYcKCTl5ErQwNxvOOGNhbNhAvG3sbdK8bRWJDAcIqDO4kfDwwM8dh2XM+Rc2SPPOk0hgbGB++OgGfi0JB3vPHOaxnPGwwXDuNok8dgY2Y+McAloO8LYd5jG4cbAh4e02iWLGBh42aUJaDv6FajnAO0ciseEAEVoOg20539jYyNtAhBbJMw8SDsu2pQNtYWxmnHFMwtiwmYBf+I7nJH9822Ztb3D++PMfH2rq5OTZmx8+xqdF4QBPApBqZmCQSIAKMeNRDgLyDewHgFQdAwP/AQJKR8EoGAWjYMQCACXWWXkApLDkAAAAAElFTkSuQmCC","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":true,"prefix":"","firstName":"Jianying","middleName":"","lastName":"Yu","suffix":""}],"badges":[],"createdAt":"2024-05-10 07:36:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4398962/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4398962/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12888-024-06064-9","type":"published","date":"2024-09-27T15:57:44+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":65628385,"identity":"fca0f8ec-8dd4-458f-97cc-29041e539cb6","added_by":"auto","created_at":"2024-09-30 16:18:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":789271,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4398962/v1/fc4f231a-8d49-421a-9bbe-b98d55266e18.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Experience and attitude of psychiatric nurses in caring for patients with repeated non-suicidal self-injury in China: A qualitative study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNSSI (non-suicidal self-injury) refers to the behavior of directly damaging one\u0026rsquo;s body tissue, such as self-harming, skin scratching, and self-burning [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. NSSI usually starts in early adolescence with an estimated global prevalence of 17.2% in nonclinical samples [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], while it is as high as 40ཞ61% in adolescent inpatients [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. A study found that since 2020, the proportion of adolescents who engaged in NSSI has increased dramatically [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. NSSI often occurs repeatedly. Multiple episodes of NSSI can lead to serious health problems such as infection and even autoamputation of body tissues [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Additionally, the suicide risk of patients who engage in NSSI is hundreds of times higher than that of the general population [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This is concerning, as self-injury is the single most reliable predictor of suicidal ideation and attempts, with one-fourth of suicides preceded by acts of NSSI within the prior year [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. NSSI has become an important issue affecting the health of adolescents. At present, NSSI has been included as an independent mental health issue in the 5th edition of the Diagnostic and Statistical Manual for Mental Disorders and is a major global public health issue [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA Canadian study with large sample (n\u0026thinsp;=\u0026thinsp;2038) of hospitalized children and adolescents showed that about 29% attempted to self-injure even when under care in a mental health setting [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Research shows that more than half of people who have experienced NSSI often experience repeated NSSI [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, from clinical practice, these data may be higher. Due to its high detection rate, high risk, and high repeatability, this behavior has become one of the most important public health problems in the world [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. It also brings tremendous pressure to clinical work. Psychiatric nurses play a vital role in the care and treatment of NSSI patients, as they have the most frequent contact with patients. They play a crucial role in distinguishing whether patients have attempted self-injury, preventing self-injury, guiding patients in psychotherapy, or providing other assistance within their capabilities. The incidence of repeated NSSI is high, and only about 50% of NSSI adolescents have self-disclosure behavior [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], which is difficult to identify and prevent, and poses great risks to patient safety. This has become an increasingly difficult point in nursing safety management, causing great distress and pressure to psychiatric nurses [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Although psychiatric nurses expect to maintain professionalism and provide more support to patients, regardless of the emotional weight of this situation, nurses caring for NSSI patients face the risk of empathy fatigue and even a change in attitude toward patients, which can have a negative impact on their empathy and thus affect the patients' experience with care [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAn attitude can be defined as a response to a stimulus that involves cognitive, affective and behavioral components, extending to all aspects of intelligence and behavior [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This response is an interior disposition that affects the selection of an action or behavior to be adopted toward persons, events or objectives [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The Knowledge-Attitude-Behavior (KAB) model also explained that knowledge is the foundation of behavior change, and belief and attitude are the driving force of behavior change [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The attitude of nurses seems to have a positive or negative impact on the care provided to NSSI patients [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Studies have shown that negative attitudes toward self-harm behavior are associated with a lack of preparation among professionals and may reinforce self-harm-related stigma and discrimination and decrease the level of care provided to patients who attempt self-harm [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Research reports that NSSI patients describe their experiences with healthcare professionals during hospitalization as judgmental, non-listening, and lacking sufficient knowledge [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Nurses' negative attitudes toward NSSI patients, such as indifference and antipathy, are key factors that hinder patients from continuing treatment and seeking further help. Negative attitudes, which are reported to significantly influence outcomes and are even connected to adverse events such as patient falls and medication errors, are especially problematic [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Therefore, the negative care experience and aversion attitude of nurses may delay the observation and treatment of changes in the patient's condition, which may lead to irreversible risks.\u003c/p\u003e \u003cp\u003eAlthough cross-sectional studies have investigated the attitudes of medical staff toward suicide or self-injury patients [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], quantitative research results cannot comprehensively reflect the emotional experiences of the study subjects, and psychological measurement scales have difficulty measuring complex psychological changes. Previous qualitative studies have mostly focused on interviews with NSSI patients [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], parents [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and teachers [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. It is currently unclear how Chinese psychiatric nurses' care experiences and attitudes toward repeated NSSI patients, as well as how they affect coping style toward repeated NSSI patients. Understanding the care experience and attitude of psychiatric nurses toward NSSI patients plays an important role in preventing and reducing repeated self-injury. This study explores the care experience and attitudes of psychiatric nurses toward patients with repeated NSSI. The study is conducted in the context of Chinese culture using qualitative research methods, and analyzes the difficulties and challenges in nursing practice for NSSI patients. The goal is to provide a research basis for further improving and enhancing nurses' care attitudes, coping style, and support systems toward NSSI patients and to provide a more theoretical basis for the management of NSSI patients.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis qualitative study took a phenomenological approach, which attempts to understand human experience and uncover meanings. This approach was selected because it allows researchers to rely on participants\u0026rsquo; perspectives on the phenomenon while recognizing the influence of the researcher\u0026rsquo;s own background and experience.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eResearch setting\u003c/h2\u003e \u003cp\u003eThe study was conducted from March 2023 to June 2023 at the mental health center of a tertiary hospital in Chengdu, Sichuan Province, China. The tertiary hospital we chose is the largest regional medical center in the city, and approximately 600 NSSI patients were hospitalized each year in the last 3 years. The mental health center has 5 wards with a total of 300 beds and approximately 120 nurses, from which the participants were selected and interviewed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eParticipants and recruitment\u003c/h2\u003e \u003cp\u003ePurposive sampling methods were used. Age, educational background, professional title, working years, and number of nursing cases of NSSI patients in the past year were factors considered in selecting study subjects, using the maximum difference sampling strategy. Participants eligible for this study were nurses who (a) possessed a professional nursing qualification certificate; (b) were able to independently execute overall responsibility-based nursing care; (c) had a primary role as a staff nurse (bedside) position; (d) had at least 1 year of clinical experience in psychiatry; and (e) had cared for NSSI patients at least once in the past year. Nurses who were on sick leave, personal leave, maternity leave, rotation, and continuing education during the study period were excluded. The sample size was based on the principle of saturation of interview information, and a total of 18 psychiatric nurses who had previous experience in handling NSSI cases were ultimately interviewed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e This study was approved by the Ethics Review Committee of West China Hospital of Sichuan University. The research subjects all provided informed consent and voluntarily participated in this study. Participants were assured that their interview responses would be confidential and anonymized. Issues of concern included participant confidentiality and emotional wellbeing during the interviews. Addressing sensitive topics requires attention to the potential emotional impact the interview may have on the participant and the researcher [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Additional measures included providing contact information for emotional and mental health resource follow-up. It was made clear that the participants could stop the interview at any time if they experienced anxiety or distress and withdraw from the study at any time.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003e We conducted 18 one-on-one semi-structured interviews with participants in a psychotherapy room. At the time of the interviews, participants were given another opportunity to read the consent form, acknowledge understanding, and ask questions. Participant consent to audio-record the interview was also verified at this time. Verbal consent was obtained, as this was the approved method to maintain participant anonymity. Participant demographic data, recorded interviews, and interview transcripts were all deidentified with a pseudonym to protect participants' identity. The interview guide was developed based on our interests of study and research gaps identified from the literature review and was adjusted after analysis of the first three interviews. The interviews used open-ended questions and focused on 4 topics: (1) nurses\u0026rsquo; responses and behaviors to patient NSSI; (2) nurses\u0026rsquo; care experience for repeated NSSI; (3) nurses\u0026rsquo; perceptions about repeated NSSI; and (4) changes in nurses\u0026rsquo; attitudes and behaviors during repeated NSSI. The interviews were semi-structured, following an interview guide (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Each interview lasted 30 to 45 min. No repeat interviews were conducted. Interviews were conducted in Mandarin or Sichuan dialect according to participants\u0026rsquo; preferences.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInterview questions and prompts.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003enurse\u0026rsquo;s responses and behaviors when found about NSSI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(1) What was the first time that you can remember the patients hurt himself/ herself?\u003c/p\u003e \u003cp\u003e(2) What was your reaction? How did you deal with it?\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrompts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTell me more about this ...\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enurses' Care Experience for repeated NSSI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(1) With the increasing frequency of repeated self-injury, how has your care experience been? Have you encountered any problems or helpful ones?\u003c/p\u003e \u003cp\u003e(2) Has changed compared before? If so, what changed?\u003c/p\u003e \u003cp\u003e(3) What accounts for this change?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrompts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat else? Tell me more.... how did you feel?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enurses\u0026rsquo; perception about repeated NSSI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhat did you think were the causes of such behaviors?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrompts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhy would they hurt themselves༟\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003echanges in nurse\u0026rsquo;s attitude and coping style during repeated NSSI.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(1) When a patient in your care repeatedly self-injures, What was your response? what did you say or do? Why did you respond in that way?\u003c/p\u003e \u003cp\u003e(2) Whether your care attitudes have changed since the beginning༟If so, what changed?\u003c/p\u003e \u003cp\u003e(3) Has your response changed? If so, what changed?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrompts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTell me more about this... What was the outcome of your response?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAre there any other concerns or things you would like to discuss about NSSI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData analysis began concurrently with the first interview. Interviews were audio-recorded and transcribed verbatim. To ensure accuracy, the primary investigator listened to each recording while proofreading and correcting transcripts as needed. Transcripts were entered into NVivo11 [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] for further analysis. Thematic analysis was used, following the six-phase process described by Nowell [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. It is a rigorous and flexible method that can be used to identify, analyze, organize, describe and report themes found within a data set across a range of epistemologies and research questions [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The primary investigator completed the first three phases separately, including reading and rereading interview transcripts to familiarize with raw data, generating initial codes by attaching labels to identified interesting aspects in the data, and searching for themes by sorting related codes hierarchically. All researchers reviewed coded data under subthemes to ensure a coherent pattern. Themes and subthemes were compared between cases to determine if they needed to be refined according to their supportive data. The research team, together with advisory experts (one head of psychiatric nursing, one mental health consultant, and one nursing professor with extensive qualitative research experience), read through all data, scrutinized coding, and defined and redefined themes until the scope and content of each theme could be clearly and succinctly described and consensus was reached.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eRigor\u003c/h2\u003e \u003cp\u003eTo ensure rigor and trustworthiness that the findings reflected participants' words and perspectives, Lincoln and Guba's criteria of credibility, dependability, confirmability and transferability were used in this study [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Strategies included two investigator discussions of coding decisions, maintaining field notes, and an audit trail (confirmability), participant checking and peer debriefing (credibility), an audit trail of coding decisions and theme development (dependability), and providing rich descriptions of participants, data collection process, and context (transferability) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Result","content":"\u003cp\u003eCharacteristics of the 18 participants are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. 4 themes and 14 sub-themes emerged from the analysis (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant demographics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProfessional Title\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYRS RN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eYRS psychiatry\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSuN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSeN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSeN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSeN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSeN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSeN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSeN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSuN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSuN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMSN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSeN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSeN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSuN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSeN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSeN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMSN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eF\u0026thinsp;=\u0026thinsp;female; M\u0026thinsp;=\u0026thinsp;male; AD\u0026thinsp;=\u0026thinsp;associate degree; BD\u0026thinsp;=\u0026thinsp;baccalaureate degree; MSN\u0026thinsp;=\u0026thinsp;master of science in nursing;MD\u0026thinsp;=\u0026thinsp;doctor of medicine༛PN\u0026thinsp;=\u0026thinsp;primary nurse; SeN\u0026thinsp;=\u0026thinsp;senior nurse; SuN\u0026thinsp;=\u0026thinsp;supervisor nurse; CN\u0026thinsp;=\u0026thinsp;co-chief nurse; YRS\u0026thinsp;=\u0026thinsp;years; RN\u0026thinsp;=\u0026thinsp;register nurse\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes and sub-themes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-themes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCare experience of repeated NSSI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFeeling powerless and helpless\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExcessive psychological pressure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmpathetic fatigue\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStruggling on caring them\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeteriorating nurse-patient relationship\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCareer frustration and burnout\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceptions of repeated NSSI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCoping strategy for reducing mental distress\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA way to meet a need\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCare attitude of repeated NSSI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderstanding and sympathy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eApathy and escape\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eantipathy\u0026nbsp;and resentment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoping style of repeated NSSI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eActively respond\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeglecting and perfunctory\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCriticism and discipline\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e1. Care experience of repeated NSSI\u003c/h2\u003e \u003cp\u003eThis theme describes some of the negative experiences experienced by psychiatric nurses in the course of caring for patients with repeated NSSI, including: empathetic fatigue, excessive psychological pressure, struggling on caring them, feeling confused and helpless, deteriorating nurse patient relationship and career frustration and burnout.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e(1) Feeling powerless and helpless\u003c/h2\u003e \u003cp\u003eThe nurses in this study clearly show that caring for patients with NSSI is more challenging than caring for other patients. They all work very hard to help patients but often feel powerless and helpless due to a lack of understanding, team support, and standardized intervention protocols.\u003c/p\u003e \u003cp\u003e \u003cem\u003eA10: \u0026ldquo;Without an exact theoretical model and standard intervention program to guide us on how to properly deal with such patients, we lack confidence in the intervention process, and the intervention effect is far from ideal.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e \u003cp\u003eRespondents expressed the need for support from colleagues and leaders and wanted to talk with colleagues or leaders after patient incidents of self-injury. However; a lack of empathy from fellow staff members during these conversations made nurses feel even more isolated and criticized, causing them not to reach out and to distance themselves from potential sources of support, and thereby perpetuating the lack of emotional support.\u003c/p\u003e \u003cp\u003e \u003cem\u003eA13: \u0026ldquo;When I reported this to colleagues and leaders or asked for help, I was often questioned or criticized by them, and thereafter I refused to report or communicate with them when no serious adverse events occurred.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e(2) Excessive psychological pressure\u003c/h2\u003e \u003cp\u003ePsychiatric nurses described high concealment of NSSI, that is, they were not able to predict when patients would commit NSSI, and the unpredictable consequences of NSSI, and nurses felt stressed during work. In addition, most of the nurses lost confidence in the potential for patients\u0026rsquo; conditions to improve, and experienced feelings of pessimism and despair.\u003c/p\u003e \u003cp\u003e \u003cem\u003eA4: \u0026ldquo;Since the behavior of NSSI patients is hidden and not easy to prevent, especially in the night shift, the manpower is relatively weak, and I always worry that NSSI patients will show NSSI behavior again when I am busy dealing with other things (which is always the case), which makes me feel particularly stressed and in a state of mental tension.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eA8: \u0026ldquo;My job is to give patients help and hope, but right now I'm the most desperate person on the ward.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e(3) Empathetic fatigue\u003c/h2\u003e \u003cp\u003eAlmost all interviewees reported empathy fatigue after long-term care of patients with repeated NSSI. Psychiatric nurses described themselves have faced the pain and suffering of NSSI patients for a long time, may gradually lose their emotional empathy and care for them, and feel that their emotional resources are exhausted and emotionally exhausted. The nurses recounted spending a lot of time and energy to help NSSI patients solve problems or relieve painful emotions, while the patients' self-injury behavior did not decrease, and even suffered from apathy and aggressive behavior. Over time, they felt that their sensory sensitivity gradually decreased, became numb to the patient's pain or self-injury behavior, and felt that they became apathetic, and indifferent.\u003c/p\u003e \u003cp\u003e \u003cem\u003eA1: \u0026ldquo;My child is 14 years old, which is similar to the age of these patients. At first, when I saw them hurt themselves, I would feel very distressed. I would patiently comfort and help them, just like helping my own children. However, not long after each incident, they will hurt themselves in different ways. I have become indifferent to them for a long time\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eA2: \u0026ldquo;Well, what's the point? No matter how hard you try, she will still respond the same way, which is to continue NSSI.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e(4) Struggling on caring them\u003c/h2\u003e \u003cp\u003eMost participants mentioned that although after facing the patient's long-term repeated self-injury, they lost confidence in the patient's treatment and became numb and indifferent to self-injury behavior. But they had a responsibility to help patients get better, so they struggling on caring them.\u003c/p\u003e \u003cp\u003e \u003cem\u003eA7: \u0026ldquo;I know I should actively respond to patients' self-injury and needs, but I am struggling internally.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eA14: \u0026ldquo;I sometimes feel like I'm wasting my time dealing with repeated self-injury, but I still have to deal with it!\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e(5) Deteriorating nurse patient relationship\u003c/h2\u003e \u003cp\u003eSome interviewed nurses stated that they were embarrassed to admit that they had difficulty establishing a collaborative relationship with NSSI patients. Others stated directly that their tolerance for repeated NSSI patients is low, and that they hold a moral critical attitude toward patients with repeated NSSI. They may blame the patients and are less willing to sympathize and understand them, which will distance the nurse from the patient. In addition, patients gave nurses feedback that they thought nurses did not understand why they hurt themselves, and even blamed and criticized them, which led to patients' reluctance to maintain communication with nurses, resulting in increasingly distant nurse-patient relationship.\u003c/p\u003e \u003cp\u003e \u003cem\u003eA9: \u0026ldquo;I know for sure that one's patience is limited, even though I am a nurse (maintaining a high degree of professional responsibility). When I tried to help a NSSI patient, he still repeatedly demonstrated self-injury behavior. In anger I said to the patient: I am too disappointed in you! He could also sense that I was losing patience with him and began to distance himself from me.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e(6) Career frustration and burnout\u003c/h2\u003e \u003cp\u003eRespondents reported that when some repeated NSSI patients are admitted to the ward, they required too much time to prevent, control, and deal with their self-injury. However, even if nurses spent a lot of time and effort helping them, the results were often disappointing. Most respondents said that the long-term impact of patients' unreasonable demands, destructive behavior, repeated NSSI, and repeated treatment led to a lack of confidence and frustration for nurses, resulting in more serious burnout.\u003c/p\u003e \u003cp\u003e \u003cem\u003eA7: \u0026ldquo;In the face of NSSI patients, we tried everything we could think of, including the application of some psychological therapy techniques, but later, it was still to no avail, and I felt my energy was exhausted, and I gradually lost my passion for this job.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e2. Perceptions of repeated NSSI\u003c/h2\u003e \u003cp\u003eNurses have a vague perception of NSSI, meaning that nurses are not sure what the real reason and purpose behind each patient's self-injury is. However, in clinical practice, they often treat NSSI as a way for patients to reduce mental distress and/or meet needs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e(1) Coping strategy for reducing mental distress\u003c/h2\u003e \u003cp\u003eA common feature of the interviews was that psychiatric nurse related NSSI to mental health and portrayed it as a maladaptive coping strategy for reducing mental distress.\u003c/p\u003e \u003cp\u003e \u003cem\u003eA2: \u0026ldquo;\u003c/em\u003eAlthough I'm not sure why they hurt themselves, \u003cem\u003eI have heard from patients who say that NSSI makes them feel better, or that the physical pain caused by NSSI drives away or relieves their mental pain.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e \u003cp\u003e \u003cem\u003eA17: \u0026ldquo;When adolescent patients are emotional or depressed, they may choose to relieve their emotions through self-injury, because they lack other coping methods.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e(2) A way to meet a need\u003c/h2\u003e \u003cp\u003eSome psychiatric nurses also see NSSI as a way or tool for adolescents to meet needs such as getting attention, eliciting sympathy, or manipulating caregivers (parents or medical staff). In the hospital, some adolescents commit self-injury when medical personnel refuse their request, and some NSSI become more serious or dangerous.\u003c/p\u003e \u003cp\u003e \u003cem\u003eA6: \u0026ldquo;They threaten parents with self-harm at home, and they threaten staff in the same way at hospitals to meet their demands.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e\u003cem\u003e A17: \u0026ldquo;It is common to encounter NSSI patients who ask to smoke, call their parents or even leave the hospital, and if their requests are not met, they will go to NSSI.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e3. Care attitude of repeated NSSI\u003c/h2\u003e \u003cp\u003eThe care attitude of psychiatric nurses toward NSSI patients changes with the recurrence of NSSI. The attitudes described by the nurses toward patients with NSSI fluctuated between understanding, sympathy, and anger. This change in attitude may stem from the experience of caring for patients with NSSI as well as perceptions of NSSI.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e(1) Understanding and sympathy\u003c/h2\u003e \u003cp\u003eSome respondents said that for NSSI patients, self-injury is not only a way to express bad feelings but also a strategy to cope with negative feelings, which is why they choose hospitalization. Patients who commit NSSI have also told nurses that it made them feel better or that the physical pain caused by NSSI drove away or lessened their mental pain. Psychiatric nurses express empathy for the patients\u0026rsquo; self-injury, and actively try to help patients.\u003c/p\u003e \u003cp\u003e \u003cem\u003eA1: \u0026ldquo;When I saw their wounds, I was very shocked by how much pain they must have in their hearts to cause them to treat themselves in such a way, it was painful to watch.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eA15: \u0026ldquo;At the moment of their self-injury, they may be very desperate and uncomfortable.\u0026rdquo;\u003c/h2\u003e \u003cdiv id=\"Sec24\" class=\"Section4\"\u003e \u003ch2\u003e(2) Apathy and escape\u003c/h2\u003e \u003cp\u003eMost respondents mentioned that they have the responsibility to help patients cope with adverse emotions or meet their reasonable requirements, but with the increasing frequency of repeated NSSI or the increasing severity of NSSI results, nurses gradually lose confidence and patience in the treatment of patients and become numb and indifferent to their self-injury.\u003c/p\u003e \u003cp\u003e \u003cem\u003eA11: \u0026ldquo;When I tried to stop them from hurting themselves, they spoke harshly to me and even attacked me. At this time, I would feel very sad because good intentions would not be rewarded. So that in the later stage, I would ask my colleagues to deal with it, as I did not want to face such patients.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eA16: \u0026ldquo;I know it was not a suicide attempt. Otherwise, the scratch would not be so shallow. I do not even want to care why she continues to do this.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003e(3) Antipathy and resentment\u003c/h2\u003e \u003cp\u003eSome interviewed nurses described that their tolerance for repeated NSSI patients is low, and that they hold a moral critical attitude toward patients with repeated NSSI. They may blame the patients and are less willing to sympathize and understand them, which can play a role in recurrent attacks or lack of improvement in the patient's condition. At the same time, interviewed nurses believe that repeated NSSI behavior is a manifestation of intentional manipulation or excessive dependence, causing a serious loss of empathy for patients and resentment among medical staff.\u003c/p\u003e \u003cp\u003e \u003cem\u003eA7: \u0026ldquo;There are plenty of alternative ways in our ward to help her relieve her mood, but she still repeatedly took the way we forbid, which made me very unacceptable and feel frustrated and even caused me to show antipathy.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eA10: \u0026ldquo;They threaten their parents with NSSI at home, and they threaten their staff in the same way at the hospital. This behavior and motivation make me very resentful.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003ePsychiatric nurses stated that NSSI seems to demonstrate a phenomenon of human-to-human transmission. This may be related to the tendency of teenagers to accept negative information that promotes NSSI and imitates others' NSSI behavior [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In addition, it is not difficult to find in clinical practice that patients with long-term repeated NSSI often try to persuade more adolescents to participate in self-injury. Nurses resents these types of initiators because they make it difficult to manage the entire ward.\u003c/p\u003e \u003cp\u003e \u003cem\u003eA6: \u0026ldquo;When there is a repeatedly hospitalized NSSI patient in the ward, a group of new NSSI patients will emerge at this time. I will be very angry when I find out through tracking that the NSSI behavior of the newly admitted patients is learned from the veteran NSSI patients.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003e\u003cb\u003e4. Coping style of repeated NSSI\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eThrough interviews, we found that psychiatric nurses' responses to repeated NSSI can be divided into three stages: actively respond, neglect and perfunctory, criticism and discipline. Behind the variations in coping styles at each stage are changes in nurses' cognition and attitudes toward NSSI patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003e(1)Actively respond\u003c/h2\u003e \u003cp\u003eSome interviewed nurses believe that for teenagers, NSSI is not only a way to express negative emotions but also a strategy to deal with negative emotions. Psychiatric nurses express understanding of their behavior, actively explore alternative ways to help alleviate negative emotions, and provide suggestions on how to deal with triggering factors.\u003c/p\u003e \u003cp\u003e \u003cem\u003eA11: \u0026ldquo;I will ask them about their feelings and reasons behind NSSI, express concerns about potential health issues that may arise later, and provide advice on how to respond to negative emotions and alternative approaches, as well as how to deal with triggering factors.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eA9: \u0026ldquo;Although I sometimes feel disappointed and resentful about patients' long-term and repeated NSSI behaviors, my responsibility is still to actively handle patients' problems.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003e(2)Neglect and perfunctory\u003c/h2\u003e \u003cp\u003eMost respondents mentioned that with the increasing frequency of repeated NSSI or the increasing severity of NSSI results, they gradually lose confidence and patience in the treatment of patients and become numb and indifferent to their self-injury, and sometimes ignored and perfunctory NSSI behaviors of patients. Besides, when nurses believe that NSSI is a way for teenagers to meet their needs or receive attention, and think that NSSI are not causing serious health problems, they will choose to ignore the patient's self-injurious behavior and believe that reducing attention can help the regression of NSSI.\u003c/p\u003e \u003cp\u003e \u003cem\u003eA2: \u0026ldquo;I expressed my powerlessness and helplessness toward his performance, and I have become emotionally numb. Sometimes when I hear NSSI patients calling for help, I delay the response.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eA15: \u0026ldquo;I believe that any method is not helpful in preventing NSSI. In contrast, excessive attention will only reinforce their self-injury.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003e(3)Criticism and punishment\u003c/h2\u003e \u003cp\u003eAlmost all respondents mentioned that repeated NSSI of patients results in a serious loss of empathy among psychiatric nurses toward patients, and causes aversion and resentment among psychiatric nurses. When nurses believe that teenagers' NSSI is intentional, they may try other approaches to preventing teenagers from engaging in NSSI. One approach is criticism, and the other is punishment. Criticizing and punishing this behavior is to prevent it from happening again. In traditional Chinese culture, criticism and punishment are also very common and practical educational methods.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eA17\u003c/strong\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eIf a patient attempts to manipulate us using NSSI (such as requesting discharge), I will tell them which approach is incorrect and express my anger. In addition, warn them that if similar behavior occurs again, I will restrain them.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003e Some participants also expressed that when they learned that the patient had experienced NSSI again, they found it difficult to control their emotions and expressed anger toward the patient, as they had invested a lot of energy and emotions in exchange for repeated NSSI and aggressive behavior.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eA3\u003c/strong\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eDo you know? After spending a lot of time and energy guiding her on how to deal with negative emotions, shortly after the conversation ended, she hurt herself again, which made me very angry. I blamed and criticized her behavior.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003eSome interviewed nurses feel strongly that punishment is a very effective way of discipline. From the perspective of immediately stopping bad behavior, punishment is often effective. For psychiatric nurses, ensuring patient safety is the primary task of their work. Protective restraint is a coping method that can have an immediate effect on preventing patients from engaging in NSSI. Another reason why psychiatric nurses use punitive measures is that they are concerned that not punishing them will only pamper adolescent patients and cause them to worry about losing control of the patients. Moreover, punishment is easy and often a \"reactive\" response.\u003c/p\u003e \u003cp\u003e \u003cem\u003eA9: \u0026ldquo;When my patients engage in NSSI, I will intervene with protective restraints because they are violating the basic principles of mutual respect and trust. \u0026ldquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eA18: \u0026ldquo;I know that adopting protective renstraints on patients with repeated NSSI is often a disguised punishment. However, when faced with patients' bad behavior, I still fall into the old habit of punishment.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003ePunishment is often effective at stopping bad behavior in the short term, but the problem is that the nurses are not aware of the long-term effects of punishment. Nevertheless, the primary reason psychiatric nurses insist on using punitive measures is that they do not know what else to do.\u003c/p\u003e \u003cp\u003e \u003cem\u003eA12: \"I do not think restraints are a very effective intervention measure, but we have tried various ways and methods, but still have not effectively solved the problem of NSSI, and I do not know how to deal with it.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e It is necessary to discuss the experience and attitude of psychiatric nurses who care for patients with repeated NSSI, because the nurse's attitude toward patients seems to have an impact (positive or negative) on the quality of patient care. For the first time, this study explored the care experience and attitude of Chinese psychiatric nurses toward repeated NSSI patients through qualitative research methods. Four themes were identified through interviews: care experience, perceptions, care attitude and coping style toward repeated NSSI. Six kinds of care experience were identified as: feeling powerless and helpless, excessive psychological pressure, empathetic fatigue, struggling on caring them, deteriorating nurse patient relationship and career frustration and burnout.\u003c/p\u003e \u003cp\u003eIn this study, we found that psychiatric nurse felt excessive psychological pressure in the face of NSSI. Hadfield et al. [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] similarly show that doctors view treating people with self-injuries as a futile task that causes feelings of despair and frustration. In recent years, the proportion of NSSI patients within psychiatric inpatient populations has been increasing [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. However, due to the incidence of repeated NSSI is high, and only about 50% of NSSI adolescents have self-disclosure behavior (11) which is difficult to identify and prevent, and poses great distress and pressure to psychiatric nurses, and strong negative emotions such as anxiety and despair. These outcomes have been widely reported in the literature [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In addition, although many of the nurses in this study had cared for a large number of NSSI patients, they indicated that they did not have an in-depth understanding of NSSI and sometimes had to improvise patient guidance and interventions based on their own experience, with little effect. Nurses make it clear that they work very hard to help NSSI patients but often feel powerless and helpless by the lack of standardized, timely and effective intervention programs. Without a theoretical model to guide this work, the effect of the intervention is very limited, similarly to reports by Kickan [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. From a practical perspective, this finding highlights the role and importance of helping nurses enhance their understanding of NSSI behavior. Establishing standardized emergency responses and intervention protocols that help psychiatric nurses objectively understand NSSI, and providing targeted interventions, could help to improve the psychiatric nurses' experience of caring for patients with NSSI, thereby improving overall quality of care.\u003c/p\u003e \u003cp\u003eA noteworthy finding of this study was that psychiatric nurses experienced empathy fatigue and career burnout in the process of caring for repeated NSSI patients. Psychiatric nurses recurrently witness repeated self-injury, unreasonable demands, destructive behaviors and repeated hospitalization of NSSI patients. In response, nurses gradually lose patience with patients, become frustrated, and lack confidence in their ability to treat patients. Psychiatric nurses recounted spending a lot of time and energy to help NSSI patients solve problems or relieve painful emotions, while the patients' self-injury behavior did not decrease, and even suffered from apathy and aggressive behavior. This enormous and lasting psychological gap leads to the empathy fatigue of nurses for patients. A meta-analysis shows that mental health nurses face a sense of low value, heavy pressure and hopelessness for a long time, which can easily lead to career burnout [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Burnout not only deteriorates nurses\u0026rsquo; work performance but also adversely influences their health and well-being [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Therefore, it is suggested that clinical managers should introduce effective strategies and courses(such as mindfulness-based stress reduction [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e])to reduce nurse burnout while paying attention to staff mental health and stress management.\u003c/p\u003e \u003cp\u003eResearch has also shown that although psychiatric nurses expect and strive to maintain professionalism and provide as much support as possible to patients, the specific experiences (empathy fatigue, anxiety, hopelessness, etc.) of nurses working in high-stress environments for NSSI patients negatively affects their empathy and willingness to care. However, driven by responsibility and leadership, so they struggling on caring repeated NSSI patients. However, it is worth noting that most participants mentioned that although after facing the patient's long-term repeated self-injury, they lost confidence in the patient's treatment and became numb and indifferent to self-injury behavior. In other words, psychiatric nurses are at risk of reduced or lack of sense of responsibility when caring for patients with repeated NSSI. Responsibility guides nurses to pay attention to patients' emotional changes, seek information, prioritize care, and develop responses [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Reduced or absent accountability can delay the observation and recognition of changes in a patient's condition, with serious consequences [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. This finding highlights the need to support the development of nurses' professional values and sense of responsibility throughout their education and career.\u003c/p\u003e \u003cp\u003ePsychiatric nurses have a vague perception of NSSI, meaning that nurses are not sure what the real reason and purpose behind each patient's self-injury is. However, in clinical practice, they often treat NSSI as a way for patients to reduce mental distress and/or meet needs (such as getting attention, eliciting sympathy, or manipulating caregivers). This is in line with multiple studies and theories on NSSI [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. One of the things we must note is that when psychiatric nurses also see NSSI as a way or tool for adolescents to meet needs, it appears to label patients. Labels can carry harmful, implicit biases that negatively affect clinical outcomes for the people they describe [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. For example, our study found some psychiatric nurses will choose to ignore the patient's self-injurious behavior and believe that reducing attention can help the regression of NSSI when they believe that NSSI is a way to meet needs or get attention. Similarly, a previous study found that medical staff see NSSI as an attention-seeking behaviour in emergency department, which is why they refrained from giving too much attention to NSSI patients [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Owens et al. [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] study found that when care providers withheld sufficient attention to self-injuries patients, it can lead to a tendency to avoid seeking help in the future. Refusing to seek help may miss the best time to receive psychological intervention, with irreversible consequences. In some cases, hold a moral critical attitude toward NSSI among nurse may delayed NSSI patients for proper treatment. Therefore, improving psychiatric nurses' understanding of NSSI may avoid labeling patients and reduce biased statements.\u003c/p\u003e \u003cp\u003eThe study found that the nurse-patient relationship gradually deteriorated in the process of patients with repeated NSSI. The nurses in this study stated that their tolerance for repeated NSSI patients is low, and that they hold a moral critical attitude toward patients with repeated NSSI. They may blame the patients and are less willing to sympathize and understand them, which will distance the nurse from the patient. Two extreme experiences have been reported by the youths with NSSI: felt satisfied and understood about being cared vs felt numbness and not been understood [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] Research reports that NSSI patients describe their experiences with healthcare professionals during hospitalization as judgmental, non-listening, and lacking sufficient knowledge [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. From this, we can infer that the reason for the gradual deterioration of the nurse-patient relationship is that the negative feelings and misunderstandings toward each other remain from both sides. Therefore, the authors of this study suggest that future quantitative studies could be used to investigate how common this phenomenon is and to explore how to develop a more collaborative nurse-patient relationship\u003c/p\u003e \u003cp\u003eIn terms of attribution, this study showed that the caring attitude of psychiatric nurses toward NSSI patients changes with the recurrence of NSSI. As NSSI repeats more frequently or NSSI results become increasingly severe, the attitude of nurses toward NSSI patients changes from understanding to indifference to anger and resentment. However; in previous studies, the dynamic changes and depth of this care attitude may have been masked, as these studies used questionnaire-based measurement methods to investigate nurses' attitudes toward NSSI patients and simplified attitudes to positive or negative [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. After the nurses invested a great deal of emotion in exchange for the patient's repeated self-injury, they consumed the nurse's patience and compassion, accompanied by a change in attitude. Although nurses acknowledge that 'understanding can generate empathy' and describe the importance of understanding patients to gain more empathy, they also acknowledge that it is difficult to truly understand NSSI because they do not easily accept this coping style. In clinical practice, nurses\u0026rsquo; capacity for empathy is also easily affected by patients' negative emotions and aggressive behaviors, resulting in antipathy and aversion toward patients [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Although nurses are well aware that NSSI is a disorder that requires psychological assistance, many staff members may inadvertently revert to indifference, anger, or resentment when they encounter repeated NSSI if they do not fully understand the patterns and mechanisms of repeated NSSI. Therefore, this finding emphasizes the importance and urgency of studying the mechanism of NSSI and the pattern of repeated NSSI.\u003c/p\u003e \u003cp\u003eOur study also highlights that how nurses respond to NSSI patients is not simply determined by perceptions of NSSI, and that nurses' attitudes towards patients are another strong predictor. An attitude is not specifically a behavior but instead an inclination toward actions, modes or ways to address, react or face a situation or problem in a variety of circumstances [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The KAB model elaborates that a person's knowledge directly affects their attitude and indirectly affects their behavior through their attitude [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. With this model, it can be assumed that the knowledge of psychiatric nurses about NSSI affects their attitudes toward it, and that their attitudes affect the actions (behaviors) they take. In this study, nurses who understood and sympathized with patients' self-injurious behavior in the past were more likely to mediate, avoid conflict, and cooperate with patients. Nurses who had expressed indifference and resentment to patients' self-injurious behavior in the past were more likely to deny, be perfunctory, or criticize and punish them. Social psychology believes that attitude is the most important breakthrough point in influencing strategies [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. The ultimate goal of social influence may be behavioral change, but reaching this ultimate goal requires a complex channel of attitude. Only by mobilizing a person's real and implicit attitude and exerting his subjective initiative can he affect his behavior [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Therefore, relying solely on training and guidelines might prove inadequate in enhancing the care provided to individuals with NSSI. Ideally, comprehensive competence development should encompass not only the acquisition of skills but also the cultivation of awareness regarding attitudes and the promotion of reflection on the nurses\u0026rsquo; influence on the patients\u0026rsquo; trajectory.\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis is the first qualitative study to explore the experience and attitudes of psychiatric nurses in caring for patients with repeated NSSI in China. Despite the promising findings of this study, there were several limitations. As with all qualitative research, the findings are limited by self-reporting and are subjected to social desirability bias. This was a relatively small local study; therefore, the findings are not necessarily representative of a broader cross section of psychiatric nurses. The findings may not be transferable to nurses working in other types of hospitals, cultures or countries. In addition, this study explored nurses' caregiving experience and attitude towards repeated NSSI patients from the perspective of nurses, and did not explore other factors that might affect nurses' caregiving experience and attitude towards patients, such as their own personality traits and coping styles. It is hoped that future studies can make up for the above limitations. Despite this, the recurring nature of key phrases and words lends weight to the strength and credibility of the findings. Several factors add to the trustworthiness of the study's findings. The investigators used an established method of data analysis and several strategies (included two investigator discussions of coding decisions, maintaining field notes, and an audit trail, participant checking and peer debriefing, an audit trail of coding decisions and theme development, and providing rich descriptions of participants, data collection process, and context) to enhance the trustworthiness of the findings. Data collection continued until saturation was reached and confirmed by two investigators. Analysis of the findings was validated by three investigators and by several participants of the study.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThrough interviews with psychiatric nurses, this study found that psychiatric nurses have experienced negative care experiences and severe career burnout during the patient's repeated NSSI. It is of concern that psychiatric nurses are not sure what the real reason and purpose behind each patient's self-injury is. Nurses' attitudes toward NSSI patients changed during repeated NSSI, from understanding to indifference to anger and resentment. At the same time, it was found that psychiatric nurses' coping style with NSSI patients could be divided into three stages. Behind the changes in coping style at each stage were the changes in nurses' perceptions and attitude toward repeated NSSI patients. These findings suggest that enhancing nurses' understanding of NSSI behavior, establishing standardized emergency response and intervention programs, guiding positive professional values and responsibility, and improving nurses' caring attitudes can promote the early detection and timely intervention of NSSI.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLeiyu\u0026nbsp;Yue and Jianying Yu were responsible for study design, interviewing participants face-to-face. Leiyu Yue and Rui Zhao were responsible for data analysis. Yu Zhuo and Xiaomin Kou were responsible for recruiting and screening participants and transcribing interviews verbatim. Yue wrote the main manuscript and all authors reviewed the manuscript. The author(s) read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary author is willing to share all of the transcribed interview data upon request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Competing Interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors report no personal or financial relationships or other conflicts of interest with people or organizations that could have influenced this work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the Medical Ethics Committee of West China Hospital, Sichuan University before data collection. All methods were carried out in accordance with relevant guidelines and regulations. (eg.Helsinki declaration). All participants were informed of procedures and contents of the study, especially that interviews would be audio-recorded. Written informed consent was obtained from participants before interviews.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAmerican Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed; 2013. https://doi.org/10.1176/appi.books.97808 90425596. \u003c/li\u003e\n\u003cli\u003eSwannell SV, Martin GE, Page A, Hasking P, St John NJ. Prevalence of non- suicidal self-injury in nonclinical samples: systematic review, meta-analysis and meta-regression. Suicide Life Threat Behav. 2014;44(3):273\u0026ndash;303. https://doi.org/10.1111/sltb.12070. \u003c/li\u003e\n\u003cli\u003eHurry J. 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Cognitive-Affective Inconsistency and Ambivalence: Impact on the Overall Attitude-Behavior Relationship. \u003cem\u003ePers Soc Psychol Bull.\u003c/em\u003e 2021;47:673-687. doi: 10.1177/0146167220945900\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Non-suicidal self-injury, repeated NSSI, psychiatric nurses, care experience, care attitude, qualitative study","lastPublishedDoi":"10.21203/rs.3.rs-4398962/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4398962/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Theincidence of non-suicidal self-injury (NSSI) is high and often occurs repeatedly. Psychiatric nurses play a vital role in the care and treatment of NSSI patients, as they have the most frequent contact with patients. The attitude of nurses has a direct affect on the quality of care they provide to patients. Negative care experiences and attitudes of patient aversion on behalf of nurses may delay the observation and treatment of changes in the patient's condition, leading to irreversible risks. Although cross-sectional studies have investigated the attitudes of medical staff toward NSSI patients, quantitative research results cannot comprehensively reflect the emotional experiences and complex psychological changes of the study subjects. A few studies have focused on the psychiatric nurses' care experiences and attitude toward patients with repeated NSSI.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eThis study aimedto explore psychiatric nurses' care experiences and attitudestoward patients during repeated NSSI.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA qualitative descriptive design using individual, semi-structured interviews. Using purposive sampling，18 psychiatric nurses were recruited from a mental health center in Chengdu, China. Semi-structured interviews were conducted and audio-recorded. Audio-recordings were transcribed verbatim and analyzed using thematic analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eFour themes emerged from the analysis: psychiatric nurses’ care experience, perceptions, care attitude and coping style toward repeated NSSI patients. Psychiatric nurses have experienced negative care experiences and severe career burnout during the patient's repeated NSSI. Nurses' attitudes toward NSSI patients changed during repeated NSSI, from understanding to indifference to anger and resentment. At the same time, it was found that nurses' coping style with NSSI patients could be divided into three stages, namely, active coping, neglect and perfunctory, and criticism and punishment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThe findings have implications for health care systems regarding interventions to improve nurses' care experience and attitude toward repeated NSSI patients. These findings suggest that enhancing nurses' understanding of NSSI, establishing standardized emergency response and intervention programs, guiding positive professional values and responsibility, and improving nurses' caring attitudes can promote the early detection and timely intervention of NSSI.\u003c/p\u003e","manuscriptTitle":"Experience and attitude of psychiatric nurses in caring for patients with repeated non-suicidal self-injury in China: A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-05 08:41:59","doi":"10.21203/rs.3.rs-4398962/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-24T10:58:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-21T16:22:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-21T16:22:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2024-05-10T07:33:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a1344891-fa91-48e5-9008-27709764114a","owner":[],"postedDate":"June 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-30T16:13:53+00:00","versionOfRecord":{"articleIdentity":"rs-4398962","link":"https://doi.org/10.1186/s12888-024-06064-9","journal":{"identity":"bmc-psychiatry","isVorOnly":false,"title":"BMC Psychiatry"},"publishedOn":"2024-09-27 15:57:44","publishedOnDateReadable":"September 27th, 2024"},"versionCreatedAt":"2024-06-05 08:41:59","video":"","vorDoi":"10.1186/s12888-024-06064-9","vorDoiUrl":"https://doi.org/10.1186/s12888-024-06064-9","workflowStages":[]},"version":"v1","identity":"rs-4398962","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4398962","identity":"rs-4398962","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}