Does Changing Clinicians’ Attitudes Toward Self-Harm Reduce Coercive Interventions in Mental Health Inpatient Settings? A Quasi-Experimental Study of Staff Training

Does Changing Clinicians’ Attitudes Toward Self-Harm Reduce Coercive Interventions in Mental Health Inpatient Settings? A Quasi-Experimental Study of Staff Training | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Does Changing Clinicians’ Attitudes Toward Self-Harm Reduce Coercive Interventions in Mental Health Inpatient Settings? A Quasi-Experimental Study of Staff Training Kristine Høst Poulsen, Carsten Hjorthøj, Bo Bach, Erik Simonsen, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8609540/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background: Staff education may improve clinicians’ attitudes toward self-harm, but whether this translates into reduced coercion is unclear. We evaluated a regional strategy to improve care for self-harming patients and its impact on staff attitudes and coercive interventions across services. Methods: Quasi-experimental dual design: (a) interrupted time-series of registry data on coercive interventions (Jan 2021–Dec 2024) and (b) three-wave pre–post surveys using the revised 17-item Self-Harm Antipathy Scale (SHAS-DR) at baseline, 2 months, and 8 months post-training. Change points: June 2022 (strategy announcement) and June 2023 (training implementation). Results: Attitudes improved and were sustained. Mean SHAS-DR decreased from 40.0 (SD 10.8) at baseline to 34.8 (SD 7.4) at 2 months and 35.4 (SD 8.2) at 8 months; baseline-to-follow-up changes were significant (p ≤ .001). In registry data, coercive interventions declined after the strategy announcement (level IRR 0.39, 95% CI 0.21–0.73) with no subsequent trend change. A temporary increase occurred at the training point (level IRR 2.58, 95% CI 1.57–4.25), consistent with implementation disruption. Reductions were largest for mechanical restraints, particularly among self-harming patients, while rapid tranquillization remained most frequent. Annual coercive episodes fell from 1,280 (2021) to 409 (2024). Conclusions: The strategy coincided with an immediate reduction in coercion and a transient rise during training, while staff attitudes became more positive. Sensitivity analyses suggested changes were not driven by high-frequency patients. Sustained reductions likely require continued organizational and relational supports. Trial registration Not applicable. Self-harm Non-suicidal self-injury Staff training Coercion Restraint Inpatient psychiatry Implementation Attitudes Interrupted time series Figures Figure 1 Figure 2 Background In inpatient mental health care, self-harm (including non-suicidal self-injury) is common and may lead to coercive interventions such as mechanical restraint and rapid tranquillization. Yet, it remains unclear whether staff training and improved attitudes translate into measurable reductions in coercion. Self-harm is a common and clinically challenging presentation in inpatient mental health care (Klonsky et al., 2014; Rayner et al., 2019). Staff are often required to balance empathic engagement with immediate safety management, and episodes of self-harm may evoke fear, frustration, and moral judgement that shape how the behavior is interpreted and managed (Brophy et al., 2016; Egan et al., 2012; Ring & Lawn, 2019). These staff responses matter because they can influence whether care is organized around dialogue and de-escalation or around control-based practices. Over recent decades, educational initiatives have sought to improve staff knowledge, confidence, and attitudes toward self-harm (Patterson et al., 2007; Saunders et al., 2012; Tapola et al., 2016; Zarska et al., 2023). Training programs, often DBT-informed and/or co-produced with service users, tend to yield modest but consistent improvements in attitudes and perceived competence (Linehan, 1993; Manning et al., 2017; Rayner et al., 2019). However, it remains uncertain whether attitudinal change translates into sustained changes in ward-level practice, including reduced self-harm and reduced use of coercive interventions. Reviews indicate that effects of ward-based interventions are frequently short-lived and that institutional culture and organizational conditions may shape coercive practice more strongly than training alone (Nawaz et al., 2021; Efkemann et al., 2024). Coercive measures such as mechanical restraints (belts or straps, holding) or rapid tranquillization may ensure immediate safety but risk reinforcing a cycle of dysregulation on both sides of the therapeutic relationship (Brophy et al., 2016; Holth et al., 2018). Although clinical guidelines emphasize relational safety, person-centered care, and therapeutic risk-taking (Felton et al., 2017; NICE, 2022), staff often report moral tension and uncertainty in practice (Egan et al., 2012; Klonsky et al., 2014; Rayner et al., 2019). From the patient’s perspective, coercion can feel punitive, traumatic or shaming, eroding trust and safety (Brophy et al., 2016; Chandler, 2016). In this context, staff attitudes become clinically relevant. Attitudes reflect orientations that link cognition, emotion, and action, and they can shape how responsibility is attributed, whether immediate physical risk is prioritized over relational and longer-term risks, and which responses are considered feasible in practice (Ajzen, 1991; Vandamme et al., 2021). In 2022, Mental Health Services in Region Zealand, Denmark, introduced a comprehensive Regional Self-Harm Strategy aimed at strengthening consistent, relational care for individuals who self-harm across services. The strategy emphasizes validation, collaborative crisis planning, and structured de-escalation, and was implemented system-wide, and structured staff training was rolled out in 2023. The strategy draws on established approaches to relational safety and emotion regulation (e.g., Safewards and DBT-informed principles; Bowers et al., 2014; Bowers et al., 2015; Linehan, 1993). As a system-wide, multi-component quality-improvement initiative, its impact is expected to depend not only on training content but also on contextual and implementation processes (Skivington et al., 2021). Evaluating both staff attitudes and system-level coercion outcomes may therefore clarify whether improvements in attitudes coincide with measurable changes in coercive practice. Aim We examined whether implementation of the regional self-harm strategy and subsequent staff training were associated with changes in: Staff attitudes : More positive staff attitudes toward people who self-harm. Coercion : The use of coercive interventions in adult inpatient units, overall and among episodes involving patients with versus without self-harm. Methods Reporting statement Reporting of the observational components adheres to the STROBE guidelines (von Elm et al., 2007). Reporting of the interrupted time-series analysis follows established methodological guidance for ITS studies (Penfold & Zhang, 2013). Reporting of the implementation components follows the StaRI statement (Pinnock et al., 2017). Study design We used a quasi-experimental dual design with two complementary components: (a) an interrupted time-series (ITS) analysis of monthly registry data on coercive interventions from January 2021 to December 2024, and (b) a three-wave pre–post assessment of staff attitudes toward self-harm. Two predefined milestones structured the analysis: June 2022 (strategy announcement) and June 2023 (post-training). The intervention was implemented system-wide, which made randomization infeasible. The design followed guidance for quasi-experimental evaluation in implementation research (Miller et al., 2020). Because the regional self-harm strategy was implemented system-wide and comprised interacting components beyond training, it can be conceptualized as a complex intervention in which outcomes depend on the interplay between content, context, and implementation processes (Fixsen et al., 2005; Greenhalgh et al., 2017; Skivington et al., 2021). The overall procedure and timeline are illustrated in Supplementary Fig. 1. Setting and participants The study included all five adult inpatient units within Mental Health Services East, Region Zealand, Denmark. Eligible participants were clinical staff with direct patient contact, including nurses, social- and healthcare assistants, social educators, psychologists, occupational and physical therapists, and psychiatrists. Non-clinical personnel were excluded. A total of 187 staff participated in the training, and 182 completed the baseline attitude questionnaire. Of the 182 baseline respondents, 113 provided valid attitude data at two or more time points. The ITS dataset comprised fully de-identified monthly counts of coercive interventions from the same units. Intervention and training program The intervention translated the Regional Self-Harm Strategy (Region Zealand, 2022) into a structured training and education program for inpatient staff. The Strategy is a cross-sector framework that outlines shared principles for the assessment, management, and follow-up of non-suicidal self-harm. It draws on evidence and best practice, including the Safewards model of relational safety (Bowers et al., 2014; Bowers et al., 2015), the recovery-oriented Tidal Model (Barker, 2001; Barker & Buchanan-Barker, 2005), and DBT-informed principles of emotion regulation (Linehan, 1993). The strategy emphasizes dialogue, validation, collaborative crisis planning, and the Ten Interventions for Self-Harm, which provide practical guidance for relational safety and structured de-escalation (see Supplementary Table 8). A five-hour training program was delivered to all inpatient staff between May and June 2023 (see Supplementary Table 7). The curriculum, co-designed by the first author and a person with lived experience of severe self-harm, introduced key elements of the Regional Strategy and focused on strengthening clinical competence and consistency. Implementation fidelity was supported through standardized training materials, local trainers, and structured supervision, and all five inpatient units completed the training as planned. Content covered in the training: theoretical and clinical understandings of self-harm and non-suicidal self-injury (ISSS, 2022; Klonsky et al., 2014); principles of emotional regulation and relational communication, with Strain Psychology (Belastningspsykologi) used to discuss emotional strain in Danish mental health practice (Høgsted, 2018); therapeutic risk-taking as one component within the broader strategy (Felton et al., 2017); legal and ethical aspects of coercion in Danish inpatient care (Nielsen et al., 2020); and DBT-informed clinical tools for emotion regulation and crisis response (Linehan, 1993). Each unit appointed two local trainers who received additional instruction and supported implementation through supervision, consultation, and case-based reflection. Definitions and terminology In this paper, self-harm refers to deliberate self-inflicted injury or behavior, with or without suicidal intent, consistent with clinical terminology in Danish mental health services. The regional self-harm strategy was primarily developed to address non-suicidal self-injury (NSSI), defined as repetitive self-inflicted harm without suicidal intent (International Society for the Study of Self-Injury, 2022; Klonsky et al., 2014). However, in routine clinical documentation and staff practice, distinctions between suicidal and non-suicidal self-harm are often blurred. The present study therefore uses self-harm as an inclusive term, while recognizing that the intervention primarily targeted NSSI-related behavior. Measures Staff attitudes Staff attitudes toward self-harm were assessed using the Self-Harm Antipathy Scale (SHAS), a 30-item questionnaire developed to measure clinicians’ attitudes toward deliberate self-harm (Patterson et al., 2007). At all three time points, participants completed the 30-item Danish translation of the SHAS (SHAS-D), rated on a 7-point scale. Positively worded items were reverse scored so that lower scores indicate more positive attitudes. A Danish psychometric evaluation of the SHAS-D demonstrated that the original 30-item structure did not show adequate structural validity, whereas a revised 17-item scoring (SHAS-DR) provided good model fit, acceptable reliability, and conceptually coherent subscales for use in Danish mental health care (Høst Poulsen et al., 2025). Accordingly, all attitudinal analyses in the present study used SHAS-DR scoring derived from the SHAS-D responses. SHAS-DR total scores were calculated as the sum of the 17 retained items. When two or fewer of the 17 items were missing, prorated scores were computed; otherwise, the questionnaire was excluded from analysis. Coercive interventions Monthly counts of coercive interventions (mechanical restraint with belts, straps, or holding, and rapid tranquillization) were extracted from the national coercion registry (SEI) by a senior Training and Development Instructor responsible for coercion reduction in Mental Health Services East, who was not part of the research group. Each coercive episode was classified according to the patient’s self-harm status (Self-Harming Patient [SHP] vs Non Self-Harming Patient [NSHP]). Inpatient staff first identified whether the patient was known to engage in self-harm, and the senior instructor compiled these classifications for analysis. The first author verified each classification in the electronic health record system (Sundhedsplatformen) under authorized access by reviewing clinical documentation. The analytic dataset contained no directly identifiable patient information. The primary ITS analyses were based on monthly aggregated counts (overall and stratified by coercion type and SHP/NSHP status). Where patient-level information was required for sensitivity and concentration analyses, data were handled in pseudonymized form and are reported only as aggregated summaries. Procedures Administration of the SHAS-D The SHAS-D was administered at three time points: baseline (immediately before training), two months, and eight months. At baseline, participants provided demographic information and written informed consent. The first author assigned each participant a unique number for pseudonymized follow-up. At two and eight months, questionnaires were distributed by ward managers and local trainers. Completed forms were returned to the first author and entered into the dataset. SHAS-DR scoring was applied to the SHAS-D responses as described above. Classification of coercive episodes The classification of SHP and NSHP followed a structured two-step process: identification by ward staff, followed by verification by the first author in the electronic health record. Data remained pseudonymized. Sensitivity and concentration procedures To assess whether observed reductions in coercion were driven by a small number of high-frequency patients, we conducted concentration sensitivity analyses using pseudonymized patient-level registry data from 2021 to 2024. For each year (and separately for each coercion type), patients were ranked by number of coercive episodes, and we calculated the proportion of episodes accounted for by the top 10% and top 5% most frequently exposed patients. We then constructed three alternative scenarios: heavy10, in which episodes contributed by the top 10% of patients were excluded; heavy05, in which episodes contributed by the top 5% were excluded; and cap-1, in which each patient contributed a maximum of one coercive episode per year (i.e., counting unique patient-years). Statistical analysis Segmented regression was used to estimate level and slope changes at the two milestones. Parameters included time, post₁, trend₁, post₂, and trend₂. Post₁ and post₂ represent immediate level changes after each milestone; trend₁ and trend₂ represent changes in monthly slope. Primary models used Poisson regression with robust standard errors. Negative-binomial models were fitted when overdispersion was detected (χ²/df > 1.5). Calendar-month fixed effects adjusted for seasonality. Results are reported as incidence-rate ratios (IRRs, 95% CI). Analyses were repeated separately for SHP and NSHP episodes. Concentration metrics (share of episodes contributed by the top 10% and top 5% of patients, and the heavy10/heavy05/cap-1 scenarios described above) were calculated to assess robustness. Changes in staff attitudes were analyzed using linear mixed-effects models with random intercepts, using the validated SHAS-DR total score as the outcome measure, with paired t-tests as complementary checks. Residual plots were inspected for autocorrelation. All analyses were conducted in Stata 18 (StataCorp LLC, College Station, TX, USA). Results Response rates and attrition A total of 187 staff attended the training sessions, and 182 completed the baseline attitude questionnaire. 165 met the SHAS-DR completeness rule (≤ 2 missing of the 17 scored items) and were included in cross-sectional descriptive baseline summaries. Ninety participants responded at two months and seventy-four at eight months. The longitudinal analytic sample included 113 participants who provided valid SHAS-DR data for at least two time points; fifty-one staff completed all three waves. Attrition was highest at eight months and reflected shift schedules, staff turnover, and routine survey fatigue in high-intensity inpatient settings. Participant characteristics Participant characteristics appear in Table 1 . At baseline, seventy-eight percent identified as female, twenty-one percent as male, and one percent did not report gender. The largest professional groups were social- and healthcare assistants (48 percent) and nurses (25 percent). Smaller groups included social educators, physicians, occupational therapists, social workers, psychologists, and support staff. Table 1 Participant professions and gender distribution at baseline and analytic sample Profession Baseline n (%) Female n (%) Male n (%) Included in analysis n (%) Female n (%) Male n (%) Social- and healthcare assistant 87 (47.8) 69 (79.3) 17 (19.5) 55 (48.7) 45 (81.8) 9 (16.4) Nurse 45 (24.7) 40 (88.9) 5 (11.1) 31 (27.4) 27 (87.1) 4 (12.9) Social educator 15 (8.2) 12 (80.0) 3 (20.0) 10 (8.8) 8 (80.0) 2 (20.0) Doctor 9 (4.9) 5 (55.6) 4 (44.4) 2 (1.8) 1 (50.0) 1 (50.0) Mental health care attendant 6 (3.3) 3 (50.0) 3 (50.0) 2 (1.8) 1 (50.0) 1 (50.0) Occupational therapist 5 (2.7) 3 (60.0) 2 (40.0) 3 (2.7) 2 (66.7) 1 (33.3) Social worker 5 (2.7) 4 (80.0) 1 (20.0) 5 (4.4) 4 (80.0) 1 (20.0) Psychologist 3 (1.6) 2 (66.7) 1 (33.3) 1 (0.9) 0 (0.0) 1 (100.0) Support staff 4 (2.2) 4 (100.0) 0 (0.0) 4 (3.5) 4 (100.0) 0 (0.0) Physical therapist 2 (1.1) 0 (0.0) 2 (100.0) – – – Total 182 (100) 142 (78.0) 38 (20.9) 113 (100) 92 (81.4) 20 (17.7) Notes: Baseline n = 182; analytic sample = 113 staff with ≥ 2 valid SHAS time points. Percentages may not sum exactly due to rounding. Staff attitudes toward self-harm Descriptive results Descriptive results appear in Table 2 , paired comparisons in Table 3 , and mixed-effects estimates in Table 4 . Estimated means with 95 percent confidence intervals are visualized in Fig. 1 . Table 2 Self-Harm Antipathy Scale – Danish Revised (SHAS-DR) scores before and after training Time point n Mean (SD) Change from baseline Baseline 165 40.0 (10.8) – 2 months 88 34.8 (7.4) –5.2 8 months 72 35.4 (8.2) –4.6 Notes: Lower SHAS-DR scores = more positive attitudes toward people who self-harm. Change from baseline = raw mean difference. Table 3 Within-person change in SHAS-DR scores following training Comparison n pairs Mean difference 95% CI p Baseline → 2 months 82 3.20 [1.78, 4.61] < .001 Baseline → 8 months 64 2.94 [1.23, 4.65] .001 Notes: Paired-sample t-tests. Positive values indicate higher antipathy at baseline relative to follow-up (i.e., improvement). CI = confidence interval. Table 4 Linear mixed-effects model of SHAS-DR scores (n = 113) Effect Estimate (b) SE 95% CI p Baseline (intercept) 39.81 0.77 [38.31, 41.31] < .001 2 months vs baseline –3.63 0.67 [–4.95, − 2.32] < .001 8 months vs baseline –3.55 0.74 [–4.99, − 2.11] < .001 Notes: Random-intercept model; negative b = improvement (lower SHAS-DR scores). SE = standard error; CI = confidence interval. Mean SHAS-DR total scores decreased from 40.0 (SD = 10.8) at baseline to 34.8 (SD = 7.4) at two months and 35.4 (SD = 8.2) at eight months, indicating more positive attitudes toward people who self-harm. A similar pattern was observed across the three SHAS-DR subscales, with the largest raw-score improvement seen in Judgmental Perception . Paired comparisons Among participants with matched data, SHAS-DR total scores declined significantly from baseline to two months (mean difference = 3.20, 95% CI [1.78, 4.61], p < .001) and from baseline to eight months (mean difference = 2.94, 95% CI [1.23, 4.65], p = .001). There was no significant difference between two and eight months (mean difference = 0.41, p = .60), indicating that the initial improvement was maintained without further change. These findings correspond to moderate effect sizes at both follow-up points. Mixed-effects models Linear mixed-effects models confirmed these changes. Compared with baseline, SHAS-DR scores were 3.63 points lower at two months ( b = − 3.63, SE = 0.67, p < .001) and 3.55 points lower at eight months ( b = − 3.55, SE = 0.74, p < .001). The model-implied means were 39.81 at baseline, 36.18 at two months, and 36.26 at eight months (Fig. 1 ). Substantial between-person variability was indicated by the random intercept (Var[ID] = 79.23). Together, the results indicate that structured staff training produced moderate, statistically robust, and sustained improvements in staff attitudes toward people who self-harm. Coercive interventions Figure 2 shows trends in monthly coercive episodes, with segmented regression results in Table 5 and annual totals in Table 6 . Total coercive episodes declined from 1,280 in 2021 to 543 in 2022 (a 58 percent reduction). Annual totals then stabilized and were identical in 2023 and 2024 (409 episodes in each year). Table 5 Segmented regression of monthly coercive interventions (ITS model) Parameter IRR 95% CI p Time (months pre) 1.00 0.94–1.07 0.939 Level change at June 2022 0.39 0.21–0.73 0.003 Trend change after June 2022 0.94 0.86–1.03 0.182 Level change at June 2023 2.58 1.57–4.25 < .001 Trend change after June 2023 1.03 0.97–1.09 0.328 Notes: Poisson regression with robust SEs (NB fallback). IRR 1 = increase. Model includes calendar-month fixed effects. Milestones = June 2022 (strategy) and June 2023 (training). Table 6 Annual totals of coercive interventions across all inpatient units Year Total episodes 2021 1 280 2022 543 2023 409 2024 409 Notes: Aggregated across five adult inpatient units, Mental Health Care Services East, Region Zealand. Totals reflect registry counts; 58 % reduction from 2021 to 2022 followed by stabilization. Mean monthly episodes decreased from 93 before the strategy (January 2021 to May 2022) to 28 during the policy phase (June 2022 to May 2023) and then increased to 38 after training (June 2023 to December 2024). Interrupted time-series results Segmented regression identified a large immediate reduction at the time of the strategy announcement (IRR = 0.39, 95% CI [0.21, 0.73], p = .003). The slope did not change after this point (IRR = 0.94, p = .182). At the training point, a temporary increase appeared (IRR = 2.58, 95% CI [1.57, 4.25], p < .001), consistent with short-term implementation-related disturbance rather than an effect of the training itself. The slope again remained unchanged (IRR = 1.03, p = .328). The overall pattern reflected two step changes rather than gradual trends. By coercion type Mechanical restraint showed the largest reductions. Between 2021 and 2024, use of belts decreased by 74 percent, straps by 81 percent, and holding by 82 percent. Rapid tranquillization decreased by 51 percent but remained the most frequent coercive measure. Full values appear in Supplementary Table 1. By NSSI status (SHP vs. NSHP) The composition of coercion shifted over time. In 2021, self-harming patients (SHP) accounted for most episodes (960 vs. 320 non-self-harming patients (NSHP)). By 2023 and 2024, NSHP episodes exceeded SHP episodes. Stratified ITS plots followed the same temporal pattern as the overall series. Supplementary Tables 1–3 provide full results, and Supplementary Table 6 shows coercion type by patient status. Sensitivity analyses Heavy-patient analyses examined whether reductions in coercion were driven by a small group of frequently restrained individuals. Across all years, the ten percent most frequently restrained patients accounted for 52 to 58 percent of episodes, and the top five percent accounted for 35 to 41 percent. These proportions were stable. Removing the heavy10 group changed annual totals by less than five percent, and a cap-1 analysis, which limited each patient to one episode per year, showed a similar trajectory. Concentration was highest for mechanical restraint and lowest for rapid tranquillization. Full results appear in Supplementary Tables 4 and 5. These findings indicate that the decline in coercion reflected a broad change in clinical practice rather than shifts among a small number of high-frequency patients. Discussion Attitudes improved significantly and remained improved at eight months. Coercion fell sharply after the strategy announcement and stabilized at this lower level over the study period. A temporary rise occurred during the training period but did not alter long-term trends. Mechanical restraints showed the largest reductions. Rapid tranquillization remained the most frequent coercive measure. The number of coercion episodes involving self-harming patients declined over time. Together, the results suggest that improved attitudes are important but that sustained reductions in coercion also require ongoing structural and organizational support. Because this was a system-wide quality improvement initiative without a control group (i.e. another mental health service), firm causal inferences are not possible. Even so, the temporal specificity of the changes, the pre-specified milestones, and the robustness of the sensitivity analyses support the interpretation that the strategy and associated training were linked to real behavioral change rather than to secular trends. Interpretation and theoretical implications The immediate decline in coercion after the strategy announcement may represent an organizational “unfreezing” in Lewin’s sense (Lewin, 1947), an early phase of cultural change initiated by leadership attention and a shared focus on self-harm rather than by new skills alone (Felton et al., 2017; Miller et al., 2020; NICE, 2022). Similar patterns have been observed in other improvement efforts, where symbolic commitment and policy emphasis create initial movement, while training and tools later provide structure and language for changes that have already begun (Miller et al., 2020; Penfold & Zhang, 2013). Within complex intervention frameworks, such shifts are understood as the product of interactions between content, context, and implementation processes rather than of content alone (Fixsen et al., 2005; Greenhalgh et al., 2017; Skivington et al., 2021). Importantly, the regional self-harm strategy was not a single training package but a multi-component, cross-sector framework. It emphasized validation, collaborative crisis planning, and structured de-escalation, and it drew on established approaches to relational safety and emotion regulation (Bowers et al., 2014; Bowers et al., 2015; Barker, 2001; Barker & Buchanan-Barker, 2005; Linehan, 1993). In this light, the drop in coercion at the time of the strategy announcement may reflect changes in shared meaning and expectations—how self-harm is framed and what “safe care” is taken to entail—while the later training period may have represented a transitional phase in which new relational routines were rehearsed and consolidated under real-world constraints (Felton et al., 2017; Miller et al., 2020; Penfold & Zhang, 2013; Skivington et al., 2021). From an affective and sociological perspective, the findings can also be read through the lens of emotional labor. Hochschild (1983) described how professionals regulate and display emotion according to institutional norms. In mental health care, this often means transforming fear, frustration, or helplessness into calm and care. Such deep acting relies on continuous emotion regulation (Gross, 1998) and sits at the center of staff–patient contact, yet it rarely counts as technical expertise within systems that privilege observable procedures (Hochschild, 1983; Boukouvalas et al., 2020; Brophy et al., 2016; Egan et al., 2012). Menzies Lyth (1960) conceptualized institutions as social defenses against anxiety, where routines and hierarchies contain collective fear. When a self-harm strategy invites staff to replace coercive procedures with relational dialogue, these defenses are disturbed, and new emotional and moral capacities are required. Later work by Ashforth and Humphrey (1993) and Tracy (2005) emphasize that rules for emotional display are bound to professional identity. To change them is to question what it means to be competent. The temporary rise in coercion during the training period may represent a defensive rebound, a short return to familiar control practices under strain rather than a failure of the strategy itself (Menzies Lyth, 1960; Penfold & Zhang, 2013). Short-term increases around implementation points are well described in the implementation science literature as transition effects or implementation dips, where existing routines are unsettled before new practices stabilize (Fullan, 2001; Penfold & Zhang, 2013; Miller et al., 2020; Skivington et al., 2021). At a cognitive level, the Theory of Planned Behavior suggests that behavior is shaped by attitudes, perceived norms, and perceived control (Ajzen, 1991). The present study indicates that attitudes and perceived competence improved after training, yet coercion did not continue to fall beyond the initial step change. This pattern supports the view that attitude change is necessary but not sufficient for durable behavioral change when structural constraints and institutional norms remain intact (Ajzen, 1991; Felton et al., 2017; Miller et al., 2020). Vandamme et al. (2021) similarly showed that even when staff explicitly endorse the reduction of coercion, implicit associations with control and safety persist, quietly shaping practice. Moral psychology further illuminates these dynamics. Judgements about responsibility and deservingness influence whether self-harm is understood as a symptom or as a choice (Chaney, 2017; Ring & Lawn, 2019; Varga et al., 2025). When self-harm is seen as voluntary or manipulative, irritation and blame can surface, leading to distance or control (Chandler, 2016; Holth et al., 2018; Vandamme et al., 2021). By (re-)framing self-harm as a form of emotional regulation rather than as an expression of intent, the regional strategy may have supported cognitive reappraisal, shifted moral judgement, and opened space for empathy (Klonsky et al., 2014; Linehan, 1993; Gross, 1998). Qualitative work by Thomas et al. (2023) shows how clinicians describe their work with self-harm as an ongoing balancing act between empathy, responsibility, and self-protection, which resonates with the patterns observed here. Structural and organizational mechanisms The lack of further decline in coercion after training suggests that organizational and emotional structures continued to shape everyday practice. As Menzies Lyth (1960) argued, institutions often maintain practices that protect staff from anxiety, even when these practices conflict with stated values. High workloads, staff turnover, and resource constraints can keep coercive routines in place, functioning as a psychological safety net when staff feel overwhelmed (Egan et al., 2012; Rayner et al., 2019). This is consistent with institutional perspectives on health care, which show that accountability systems and valuation regimes privilege what can be counted, while relational and affective work remains comparatively invisible unless tied to measurable outcomes (Timmermans & Berg, 2003; Boltanski & Thévenot, 2006). Recent qualitative studies report similar tensions, pointing to systemic pressures, professional hierarchies, and institutional inertia as barriers to reducing coercion (Möll et al., 2025). Möll et al. (2025) found that coercive practices may persist not because individual staff wish to use them, but because they provide psychological containment at the organizational level. In a Danish context, this can be read alongside the notion of a “lean relational space”, where efficiency demands and documentation requirements limit time and legitimacy for relational care (Hviid et al., 2021). Implementation research underlines that sustainable change depends on leadership, supervision, and consistent feedback loops (Miller et al., 2020; NICE, 2022; Nielsen et al., 2020). Without these supports, emotional labor becomes a solitary task, which increases the risk of burnout and a reversion to control-based norms (Hochschild, 1983; Egan et al., 2012; Christensen et al., 2019; Vandamme et al., 2021). Organizational learning frameworks suggest that sustainability arises when data are linked to reflection and when evidence legitimizes new forms of work (Miller et al., 2020; NICE, 2022). In this light, the sharp fall in coercion after the 2022 announcement may reflect increased monitoring and accountability as well as cultural change. Maintaining that reduction likely depends on continued spaces for reflection and on recognizing relational work as legitimate professional activity. From the perspective of institutional work, embedding relational safety into policies, supervision, and evaluation metrics is one way that local experimentation becomes durable organizational norm (Cloutier et al., 2016). Strengths, limitations, and future directions This study contributes to a growing body of work that views change in mental health care as both behavioral and organizational. Strengths include the multi-year, system-level dataset, the use of pre-specified intervention points, and the integration of attitudinal and behavioral outcomes. Compared with simple pre–post designs, the interrupted time series approach strengthens causal interpretation by modelling pre-existing trends and temporal alignment with the intervention (Penfold & Zhang, 2013). The concentration analyses further support the robustness of the observed reductions by showing that results were not driven by a small group of high-frequency patients. Several limitations must be noted. First, the absence of randomization and of a contemporaneous control series (e.g., other Danish regions or national comparator trends) leaves the analyses vulnerable to unmeasured influences and concurrent initiatives within and beyond the system and limits causal inference (Penfold & Zhang, 2013; Miller et al., 2020). Relatedly, we did not benchmark observed changes against regional or national time trends in coercion; therefore, we cannot determine the extent to which the observed step changes reflect strategy-specific effects versus broader secular developments in coercion reduction. Second, incomplete denominators, such as patient-days, limited rate calculations and compelled a focus on counts. Changes in bed occupancy, admission patterns, or case-mix over time could therefore have contributed to changes in counts independent of changes in clinical practice. Third, although the intervention milestones were pre-specified and the ITS design reduces bias relative to simple pre–post comparisons, regression to the mean remains a potential concern if baseline levels of coercion in the early period were unusually high. However, the long pre-intervention observation window and explicit modelling of pre-intervention trends mitigate (but do not eliminate) this threat to inference (Penfold & Zhang, 2013). Fourth, attrition in SHAS-DR responses may have biased attitudinal findings towards those more engaged with the training, although the direction of this bias is uncertain. Fifth and lastly, a limitation concerns the classification of self-harming versus non-self-harming patients. Because Danish health registries do not yet include standardized codes for self-harm or NSSI, identification depended on staff reports and manual verification in the electronic health record. This procedure increases validity compared with registry-only approaches but may still introduce minor misclassification. The lack of systematic coding highlights the need for improved documentation to support surveillance and research. Staff turnover may also have influenced implementation and sustainability, as not all staff working in the units over time were exposed to the training. In addition, we did not include direct observational measures of implementation fidelity. Although training completion and support structures were in place, variation in local enactment of the strategy could not be systematically assessed. Despite these limitations, the dual design offers complementary perspectives on psychological and organizational mechanisms of change and aligns with current recommendations for studying complex interventions in routine systems (Ajzen, 1991; Hochschild, 1983; Gross, 1998; Miller et al., 2020; NICE, 2022; Skivington et al., 2021). Future research should examine whether training that explicitly targets emotional labor and moral appraisal can influence long-term behavioral outcomes and whether structural interventions can modify institutional defenses over time (Hochschild, 1983; Menzies Lyth, 1960; Miller et al., 2020; NICE, 2022). Comparative designs with staggered implementation or matched control sites would strengthen causal inference (Penfold & Zhang, 2013). Mixed-level analyses that link staff attitudes to inpatient-level coercion data could clarify how psychological change connects to organizational dynamics (Ajzen, 1991; Gross, 1998; Miller et al., 2020; NICE, 2022). Qualitative inquiry remains important for understanding how clinicians negotiate moral and emotional boundaries in practice and how cultural change becomes embodied in everyday work (Chandler, 2016; Holth et al., 2018; Vandamme et al., 2021). Implications for practice and policy The findings have several implications for practice and policy. First, training on self-harm should address emotional regulation and moral appraisal explicitly, not only knowledge and procedures (Hochschild, 1983; Boukouvalas et al., 2020; Brophy et al., 2016; Gross, 1998; Chandler, 2016; Holth et al., 2018; Vandamme et al., 2021). Recognizing emotional labor as part of professional skill may reduce moralization and help protect staff from burnout (Hochschild, 1983; Menzies Lyth, 1960; Egan et al., 2012; Christensen et al., 2019). Second, structural support is essential. Supervision, peer reflection, and stable staffing are needed to turn individual learning into collective practice and to prevent responsibility for emotional regulation from resting solely with the individual clinician (Menzies Lyth, 1960; Egan et al., 2012; Miller et al., 2020; NICE, 2022). Third, substitution effects must be monitored. The marked fall in mechanical restraint, combined with more modest change in rapid tranquillization, underscores the need to monitor all forms of coercion to ensure that one form of containment is not simply replaced by another (Brophy et al., 2016; Holth et al., 2018; Penfold & Zhang, 2013; Rayner et al., 2019). The sharper reduction in mechanical restraint may reflect modality-specific drivers, such as differences in visibility, normative acceptability, and local implementation focus, rather than differential change in underlying clinical risk. From a policy and ethics perspective, this pattern highlights the importance of making “least restrictive” principles explicit across coercion types and of interpreting changes in coercion profiles in light of patient experience, not only counts (Brophy et al., 2016; Chandler, 2016). Future evaluations should benchmark local trajectories against national coercion statistics to clarify whether differential reductions represent broader secular trends or strategy-specific change. Fourth, outcome frameworks should incorporate indicators of ward climate and relational engagement, so that relational care is visible in the same way as procedural activity. Aligning evaluation metrics with the relational and emotional dimensions of care may help secure the legitimacy of these practices in systems that otherwise prioritize what is easily measurable (Hochschild, 1983; Boukouvalas et al., 2020; Felton et al., 2017; Miller et al., 2020; Timmermans & Berg, 2003; Boltanski & Thévenot, 2006). One established approach is the Ward Atmosphere Scale, which captures multiple dimensions of inpatient milieu relevant to the structural and group-level emotional climate (e.g., anger/aggression and staff control) and has been revised for contemporary psychiatric settings (Røssberg & Friis, 2003). Finally, the later increase in non-self-harm-related coercion suggests that approaches developed for self-harm may have wider relevance and that broader restraint-reduction strategies could benefit from integrating similar relational and emotional components (Nielsen et al., 2020). Conclusions The regional self-harm strategy was associated with an immediate reduction in coercive interventions at the time of the strategy announcement, while staff attitudes toward self-harm improved following training and remained more positive eight months later. These effects stabilized rather than continuing to grow. The findings suggest that lasting change requires more than new knowledge: it depends on emotional regulation, moral reframing, and organizational containment. Emotional labor and social-defense theory offer one way to understand why change in mental health care is rarely linear. To become ordinary, new practices must be adopted, repeated, and supported, not only at the level of the individual clinician but within the structures that define everyday care. Abbreviations BPD Borderline personality disorder DBT Dialectical Behavior Therapy ITS Interrupted time–series NSSI Non–suicidal self–injury NSHP Non–self–harming patients SHP Self–harming patients SHAS Self–Harm Antipathy Scale Declarations Ethics approval and consent to participate The study was approved as a quality and development project ( kvalitets- og udviklingsprojekt ) within Region Zealand. In accordance with Danish regulations, the Regional Committee on Health Research Ethics (Videnskabsetisk Komité) confirmed that separate ethical approval was not required. Access to the electronic health record system ( Sundhedsplatformen ) for verification of self-harm classifications was granted through authorization from the Director of Mental Health Services, Region Zealand, under the approved project framework. All participating staff provided written informed consent for the use of their questionnaire data, and pseudonymization was achieved by assigning individual trial numbers after completion of the baseline SHAS forms, ensuring that only the first author could link names to codes. The study complies with data-protection regulations outlined by the Danish Data Protection Agency. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to confidentiality agreements with participants but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study received no external funding. Authors’ contributions K.H.P. conceived and designed the study, coordinated data collection, conducted the analyses, and drafted the manuscript. C.H. provided statistical supervision, contributed to data analysis and interpretation, and co-developed the analytic strategy. M.T.K. served as primary supervisor and contributed to the theoretical framework, methodological design, interpretation, and critical revision of the manuscript. B.B. and E.S. served as co-supervisors, contributing to methodological guidance and manuscript review. All authors approved the final manuscript and agree to be accountable for all aspects of the work. AI disclosure Portions of manuscript organization and language editing were supported by an AI language model (GPT-5, OpenAI) under author supervision. The model is not credited as an author and bears no responsibility for content. Acknowledgements The authors thank the participating staff of Mental Health Services East, Region Zealand, and the local NSSI trainers for their engagement throughout the study. The authors thank Susanne Winkel, Nurse and Senior Training and Development Instructor, Mental Health Services East, Region Zealand, for her assistance in extracting and classifying registry data and for her support throughout the project. References Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50 (2), 179–211. https://doi.org/10.1016/0749-5978(91)90020-T Andover, M. S., & Gibb, B. E. (2010). Non-suicidal self-injury, attempted suicide, and suicidal intent among psychiatric inpatients. Psychiatry Research, 178 (1), 101–105. https://doi.org/10.1016/j.psychres.2009.03.019 Andrews, H. E., Hulbert, C., Cotton, S. M., Betts, J., & Chanen, A. M. (2019). Relationships between the frequency and severity of non-suicidal self-injury and suicide attempts in youth with borderline personality disorder. Early Intervention in Psychiatry, 13 (1), 194–201. https://doi.org/10.1111/eip.12461 Ashforth, B. E., & Humphrey, R. H. (1993). Emotional labor in service roles: The influence of identity. Academy of Management Review, 18 (1), 88–115. https://doi.org/10.5465/amr.1993.3997508 Barker, P. (2001). The Tidal Model: Developing an empowering, person-centred approach to recovery within psychiatric and mental health nursing. Journal of Psychiatric and Mental Health Nursing, 8(3), 233–240. https://doi.org/10.1046/j.1365-2850.2001.00391.x Barker, P., & Buchanan-Barker, P. (2005). The Tidal Model: A guide for mental health professionals. Brunner-Routledge. Boltanski, L., & Thévenot, L. (2006). On justification: Economies of worth (C. Porter, Trans.). Princeton University Press. (Original work published 1991) Boukouvalas, E., El-Den, S., Murphy, A. L., Salvador-Carulla, L., & O’Reilly, C. L. (2020). Exploring health care professionals’ knowledge of, attitudes towards, and confidence in caring for people at risk of suicide: A systematic review. Archives of Suicide Research, 24 (Suppl. 2), S1–S31. https://doi.org/10.1080/13811118.2019.1678530 Bowers, L. (2014). Safewards: A new model of conflict and containment on psychiatric wards. Journal of Psychiatric and Mental Health Nursing, 21(6), 499–508. https://doi.org/10.1111/jpm.12129 Bowers, L., James, K., Quirk, A., Simpson, A., Stewart, D., & Hodsoll, J. (2015). Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomized controlled trial. International Journal of Nursing Studies, 52(9), 1412–1422. https://doi.org/10.1016/j.ijnurstu.2015.05.001 Brophy, L. M., Roper, C. E., Hamilton, B. E., Tellez, J. J., & McSherry, B. M. (2016). Consumers’ and their supporters’ perspectives on barriers and strategies to reducing seclusion and restraint in mental health settings. Australian Health Review, 40 (6), 599–604. https://doi.org/10.1071/AH15128 Carroll, R., Thomas, K. H., Bramley, K., et al. (2016). Self-cutting and risk of subsequent suicide. Journal of Affective Disorders, 192 , 8–10. https://doi.org/10.1016/j.jad.2015.12.007 Castellví, P., Lucas-Romero, E., Miranda-Mendizabal, A., et al. (2017). Longitudinal association between self-injurious thoughts and behaviors and suicidal behavior in adolescents and young adults: A systematic review with meta-analysis. Journal of Affective Disorders, 215 , 37–48. https://doi.org/10.1016/j.jad.2017.03.035 Chaney, S. (2017). Psyche on the skin: A history of self-harm. Reaktion Books. Chandler, A. (2016). Self-injury, medicine and society: Authentic bodies. Palgrave Macmillan. https://doi.org/10.1057/978-1-137-40528-9 Christensen, T. N., Jensen, M., & Stenager, E. (2019). Effects of individual placement and support on employment in people with mental illness in Denmark. The Lancet Psychiatry, 6 (3), 203–214. https://doi.org/10.1016/S2215-0366(18)30489-4 Cloutier, C., Denis, J.-L., Langley, A., & Lamothe, L. (2016). Agency at the managerial interface: Public sector reform as institutional work. Journal of Public Administration Research and Theory, 26 (2), 259–276. https://doi.org/10.1093/jopart/muv009 Egan, R., Sarma, K. M., & O’Neill, M. (2012). Factors influencing perceived effectiveness in dealing with self-harming patients in a sample of emergency department staff. Journal of Emergency Medicine, 43 (6), 1084–1090. https://doi.org/10.1016/j.jemermed.2012.01.049 Efkemann, S. A., Schildmann, J., Hoffmann, K., et al. (2024). Staff attitudes toward the use of coercion in mental health care: A scoping review. Frontiers in Psychiatry, 15 , 11354183. https://doi.org/10.3389/fpsyt.2024.11354183 Felton, A., Wright, N., & Stacey, G. (2017). Therapeutic risk-taking: A justifiable choice. BJPsych Advances, 23 (2), 81–88. https://doi.org/10.1192/apt.bp.115.015701 Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature (FMHI Publication #231). University of South Florida, National Implementation Research Network. https://nirn.fpg.unc.edu/resources/implementation-research-synthesis-literature Fullan, M. (2001). The new meaning of educational change (3rd ed.). Teachers College Press. Goodman, M., Tomas, I. A., Temes, C. M., et al. (2017). Suicide attempts and self-injurious behaviours in adolescent and adult patients with borderline personality disorder. Personality and Mental Health, 11 (3), 157–163. https://doi.org/10.1002/pmh.1375 Greenhalgh, T., Wherton, J., Papoutsi, C., Lynch, J., Hughes, G., A’Court, C., Hinder, S., Fahy, N., Procter, R., & Shaw, S. (2017). Beyond adoption: A new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies. Journal of Medical Internet Research, 19 (11), e367. https://doi.org/10.2196/jmir.8775 Gross, J. J. (1998). The emerging field of emotion regulation: An integrative review. Review of General Psychology, 2 (3), 271–299. https://doi.org/10.1037/1089-2680.2.3.271 Hochschild, A. R. (1983). The managed heart: Commercialization of human feeling. University of California Press. Holth, F., Walby, F., Røstbakken, T., Lunde, I., Ringen, P. A., Ramleth, R. K., & Kvarstein, E. H. (2018). Extreme challenges: Psychiatric inpatients with severe self-harming behavior in Norway: A national screening investigation. Nordic Journal of Psychiatry, 72 (8), 605–612. https://doi.org/10.1080/08039488.2018.1511751 Høgsted, R. (2018). Belastningspsykologi i arbejdet med mennesker. Hans Reitzels Forlag. Huband, N., & Tantam, D. (2000a). Attitudes to self-injury within a group of mental health staff. British Journal of Medical Psychology, 73 (4), 495–504. https://doi.org/10.1348/000711200160688 Huband, N., & Tantam, D. (2000b). Attitudes to self-injury: Survey of mental health professionals. British Journal of Psychiatry, 176 (5), 458–462. https://doi.org/10.1192/bjp.176.5.458 Hviid, E. A., Søndergaard, J., & Grønning, A. (Eds.). (2021). Relationer i sundhedsvæsenet – hvorfor og hvordan? Samfundslitteratur. International Society for the Study of Self-Injury. (2022). Definition of NSSI. https://www.itriples.org/aboutnssi Høst Poulsen, K., Bach, B., Hjorthøj, C., Simonsen, E., Austin, S. F., & Kongerslev, M. T. (2025). Measuring attitudes toward self-harm among mental health care staff: psychometric evaluation of the Self-Harm Antipathy Scale (SHAS) in Denmark. Nordic journal of psychiatry , 1–7. Advance online publication. https://doi.org/10.1080/08039488.2025.2589478 Klonsky, E. D., Victor, S. E., & Saffer, B. Y. (2014). Non-suicidal self-injury: What we know, and what we need to know. Canadian Journal of Psychiatry, 59 (11), 565–568. https://doi.org/10.1177/070674371405901101 Leather, J. Z., O’Connor, R. C., Quinlivan, L., et al. (2020). Healthcare professionals’ implementation of national guidelines with patients who self-harm. Journal of Psychiatric Research, 130 , 405–411. https://doi.org/10.1016/j.jpsychires.2020.08.031 Lewin, K. (1947). Frontiers in group dynamics II: Channels of group life; social planning and action research . Human Relations, 1, 143–153. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press. Manning, J. C., Carter, T., Latif, A., et al. (2017). “Our care through our eyes”: Impact of a co-produced digital educational programme on nurses’ knowledge, confidence and attitudes in providing care for children and young people who have self-harmed. BMJ Open, 7 (4), e014750. https://doi.org/10.1136/bmjopen-2016-014750 Menzies Lyth, I. (1960). A case study in the functioning of social systems as a defence against anxiety. Human Relations, 13 (2), 95–121. https://doi.org/10.1177/001872676001300201 Miller, C. J., Smith, S. N., & Pugatch, M. (2020). Experimental and quasi-experimental designs in implementation research. Psychiatry Research, 283 , 112452. https://doi.org/10.1016/j.psychres.2019.06.027 Møhl, B. (2019). Assessment and treatment of non-suicidal self-injury: A clinical perspective. Routledge. https://doi.org/10.4324/9780429296352 Möll, A., Kettunen, A., Hansson, L., et al. (2025). Perceived determinants of the use of coercion in inpatient mental health care: A qualitative study. BMC Psychiatry, 25 (1), 66. https://doi.org/10.1186/s12888-025-06690-x National Institute for Health and Care Excellence. (2022). Self-harm: Assessment, management and preventing recurrence (NG225). https://www.nice.org.uk/guidance/ng225 Nawaz, R. F., Taylor, P. J., Tyrer, P., et al. (2021). Interventions to reduce self-harm on inpatient wards: A systematic review. BJPsych Open, 7 (3), e91. https://doi.org/10.1192/bjo.2021.54 Nielsen, A. B., Harder, S., & Lauridsen, S. (2020). The effect of Flexible Assertive Community Treatment (FACT) on psychiatric admissions and coercion. Nordic Journal of Psychiatry, 74 (5), 367–374. https://doi.org/10.1080/08039488.2020.1743693 Ring, D., & Lawn, S. (2019). Stigma perpetuation at the interface of mental health care: A review to compare patient and clinician perspectives of stigma and borderline personality disorder. Journal of Mental Health, 28 (5), 505–514. https://doi.org/10.1080/09638237.2019.1581337 Patterson, P., Whittington, R., & Bogg, J. (2007). Testing the effectiveness of an educational intervention aimed at changing attitudes to self-harming patients. Journal of Psychiatric and Mental Health Nursing, 14(1), 100–105. https://doi.org/10.1111/j.1365-2850.2007.01052.x Penfold, R. B., & Zhang, F. (2013). Use of interrupted time series analysis in evaluating health care quality improvements. Annals of Internal Medicine, 158 (5 Pt. 2), 413–418. https://doi.org/10.7326/0003-4819-158-5-201303051-00006 Pinnock, H., Barwick, M., Carpenter, C. R., Eldridge, S., Grandes, G., Griffiths, C. J., Heaton, J., Howick, J. B., Lucas, P. J., Meissner, P., Murray, E., Patel, A., Sheikh, A., & Taylor, S. J. C. (2017). Standards for Reporting Implementation Studies (StaRI) statement. BMJ, 356 , i6795. https://doi.org/10.1136/bmj.i6795 Rayner, G., Allen, S. L., & Johnson, M. (2019). Causal attributions for self-harm: A systematic review and synthesis of qualitative literature. Journal of Affective Disorders, 252 , 314–323. https://doi.org/10.1016/j.jad.2019.04.021 Rayner, G., Blackburn, J., Edward, K., et al. (2019). Emergency department nurses’ attitudes towards patients who self-harm: A meta-analysis. International Journal of Mental Health Nursing, 28 (1), 40–53. https://doi.org/10.1111/inm.12503 Røssberg, J. I., & Friis, S. (2003). A suggested revision of the Ward Atmosphere Scale. Acta Psychiatrica Scandinavica, 108 (5), 374–380. https://doi.org/10.1034/j.1600-0447.2003.00191.x Skivington, K., Matthews, L., Simpson, S. A., Craig, P., Baird, J., Blazeby, J. M., Boyd, K. A., Craig, N., French, D. P., McIntosh, E., Petticrew, M., Rycroft-Malone, J., White, M., & Moore, L. (2021). A new framework for developing and evaluating complex interventions: Update of Medical Research Council guidance. BMJ, 374 , n2061. https://doi.org/10.1136/bmj.n2061 Tapola, V., Wahlström, J., & Lappalainen, R. (2016). Effects of training on attitudes of psychiatric personnel towards patients who self-injure. Nursing Open, 3(3), 140–151. https://doi.org/10.1002/nop2.45 Thomas, J. B., Shaw, J., Hemming, R., et al. (2023). How people who self-harm negotiate the inpatient environment: The mental-healthcare workers’ perspective. Journal of Psychiatric and Mental Health Nursing, 30 (6), 1455–1466. https://doi.org/10.1111/jpm.12977 Timmermans, S., & Berg, M. (2003). The gold standard: The challenge of evidence-based medicine and standardization in health care. Temple University Press. Tracy, S. J. (2005). Locking up emotion: Moving beyond dissonance for understanding emotion labor discomfort. Communication Monographs, 72 (3), 261–283. https://doi.org/10.1080/03637750500206474 Varga, S., Latham, A. J., & Machery, E. (in press). “They had it coming!” The effect of moral character on somatic and mental health judgments. Royal Institute of Philosophy Supplements . Vandamme, A., Dierckx, B., Claes, C., et al. (2021). The role of implicit and explicit staff attitudes in the use of coercion: A cross-sectional study. Frontiers in Psychiatry, 12 , 699446. https://doi.org/10.3389/fpsyt.2021.699446 von Elm, E., Altman, D. G., Egger, M., Pocock, S. J., Gøtzsche, P. C., Vandenbroucke, J. P., & STROBE Initiative. (2007). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. Annals of Internal Medicine, 147 (8), 573–577. https://doi.org/10.7326/0003-4819-147-8-200710160-00010 Walle, M. F., Langvik, M. H., Jessen, R. S., & Stänicke, L. I. (2025). Sharing, carrying, and tolerating the pain: A meta-synthesis of clinicians’ experiences from working with adolescents who self-harm. Psychotherapy Research , 1–14. https://doi.org/10.1080/10503307.2025.2481604 Zarska, A., Barnicot, K., Lavelle, M., Dorey, T., & McCabe, R. (2023). A systematic review of training interventions for emergency department providers and psychosocial interventions delivered by emergency department providers for patients who self-harm. Archives of Suicide Research, 27(3), 829–850. https://doi.org/10.1080/13811118.2022.2071660 Additional Declarations No competing interests reported. Supplementary Files ChangingAttitudesCoercionSupplementaryTables.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 17 Mar, 2026 Reviews received at journal 16 Mar, 2026 Reviewers agreed at journal 23 Feb, 2026 Reviews received at journal 27 Jan, 2026 Reviewers agreed at journal 20 Jan, 2026 Reviewers invited by journal 20 Jan, 2026 Editor assigned by journal 16 Jan, 2026 Submission checks completed at journal 15 Jan, 2026 First submitted to journal 15 Jan, 2026 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. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-8609540","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":577637703,"identity":"ddf965c5-74a1-4d6d-a6e2-e5161b080469","order_by":0,"name":"Kristine Høst Poulsen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEUlEQVRIie2RsUrEQBBAJwxsmvFsE1ayv5AlEIsTW39jg2A+QJADhQSETROwVQx+gzaphUBs7hskNlddoY3E7pKAkGZzrWBeMTM7zFt2GYCZmT+IA1YKsOoq7I8EsLCHjP60sh4pDPcqHZYedfYq7mOlm6+nd0+cYf3RHp16DHHTbGEZmBS+iDL5UF4GsmJxQHQeMGTHsoA4NCkeWZoflCp6uaWQA2GkEUJOUJ1MK4VKesVtKUk02t+TCh+UVCmBFDpElWJd0SvGh7m5lcn7WslnZBec6E1qpCu38GPj9521vWk+b5QQd1Xt/uTX4tDOSme7WsrU5HSLGKL/2gUr/20atzJSxHBpOzk5MzMz80/ZARdeQ4uNlT7YAAAAAElFTkSuQmCC","orcid":"","institution":"Central and West Zealand Hospital, Region Zealand","correspondingAuthor":true,"prefix":"","firstName":"Kristine","middleName":"Høst","lastName":"Poulsen","suffix":""},{"id":577637704,"identity":"e7e91058-be6b-4ea0-8194-1f2a7f3440fa","order_by":1,"name":"Carsten Hjorthøj","email":"","orcid":"","institution":"Copenhagen Research Center for Mental Health - CORE, Bispebjerg and Frederiksberg Hospital","correspondingAuthor":false,"prefix":"","firstName":"Carsten","middleName":"","lastName":"Hjorthøj","suffix":""},{"id":577637705,"identity":"3ba2eb4e-3ada-478c-8d4f-feb4b1f289d9","order_by":2,"name":"Bo Bach","email":"","orcid":"","institution":"Central and West Zealand Hospital, Region Zealand","correspondingAuthor":false,"prefix":"","firstName":"Bo","middleName":"","lastName":"Bach","suffix":""},{"id":577637707,"identity":"5fc47e4a-f419-4e83-b71c-e291eaecd5d1","order_by":3,"name":"Erik Simonsen","email":"","orcid":"","institution":"Central and West Zealand Hospital, Region Zealand","correspondingAuthor":false,"prefix":"","firstName":"Erik","middleName":"","lastName":"Simonsen","suffix":""},{"id":577637709,"identity":"2f3bbf2e-cc03-49d5-b49a-c6213d95d4a2","order_by":4,"name":"Mickey T. Kongerslev","email":"","orcid":"","institution":"Central and West Zealand Hospital, Region Zealand","correspondingAuthor":false,"prefix":"","firstName":"Mickey","middleName":"T.","lastName":"Kongerslev","suffix":""}],"badges":[],"createdAt":"2026-01-15 10:38:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8609540/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8609540/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100929449,"identity":"b939197d-fc3b-438e-9947-37de70eae5b8","added_by":"auto","created_at":"2026-01-23 00:36:23","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":167334,"visible":true,"origin":"","legend":"","description":"","filename":"ChangingAttitudesCoercionManusccriptSubmission.docx","url":"https://assets-eu.researchsquare.com/files/rs-8609540/v1/ad78cc441769fe63fe0204e3.docx"},{"id":100951333,"identity":"aebaa6da-f6ee-4390-897c-d04211732203","added_by":"auto","created_at":"2026-01-23 07:10:30","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":7713,"visible":true,"origin":"","legend":"","description":"","filename":"0495fcff4c81499e8820d0048f0a4093.json","url":"https://assets-eu.researchsquare.com/files/rs-8609540/v1/7b10e7ce5ce700a8cbfd8859.json"},{"id":100929454,"identity":"5643a5e2-e595-49d3-b4fd-81a89b78c670","added_by":"auto","created_at":"2026-01-23 00:36:23","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":2313343,"visible":true,"origin":"","legend":"","description":"","filename":"ChangingAttitudesCoercionSupplementaryTables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8609540/v1/92b2aa4c8dc99c3be89f5723.docx"},{"id":100929456,"identity":"33767709-6255-411a-9ee1-8e4bc3c3058f","added_by":"auto","created_at":"2026-01-23 00:36:23","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":124056,"visible":true,"origin":"","legend":"","description":"","filename":"0495fcff4c81499e8820d0048f0a40931enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8609540/v1/4ec0cadb3c72c145f10e2679.xml"},{"id":100951592,"identity":"153a4f9a-f1a7-46fe-93d9-074bfe603d2c","added_by":"auto","created_at":"2026-01-23 07:10:55","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":11195,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8609540/v1/dca4f8e48275cf0919e7d0f6.png"},{"id":100929451,"identity":"8276e4cb-493a-47d6-a1ea-7a7a3a833f8b","added_by":"auto","created_at":"2026-01-23 00:36:23","extension":"png","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":22675,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8609540/v1/239bca911affc3d2513f41e9.png"},{"id":100950872,"identity":"acf4c999-c2e9-4d2b-9093-22cfc047793a","added_by":"auto","created_at":"2026-01-23 07:09:25","extension":"xml","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":120198,"visible":true,"origin":"","legend":"","description":"","filename":"0495fcff4c81499e8820d0048f0a40931structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8609540/v1/3a02137b45e5478fe97590ac.xml"},{"id":100951731,"identity":"d7c5cb5e-716e-4d44-b8be-cb2aeb8f16e3","added_by":"auto","created_at":"2026-01-23 07:11:09","extension":"html","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":136687,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8609540/v1/8e1e434ec66e414ba80874bf.html"},{"id":100929448,"identity":"5257ba21-d71d-45d1-95e2-b48f798c1ff1","added_by":"auto","created_at":"2026-01-23 00:36:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":46093,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eEstimated mean SHAS-DR scores with 95% confidence intervals.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNotes:\u003c/em\u003e Lower scores indicate more positive staff attitudes toward self-harm. Mixed-effects estimates (n = 113) showed a decrease from 39.81 at baseline to 36.18 at two months, with scores remaining stable at 36.26 at eight months.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8609540/v1/f75a2be74868ec2450c4de36.png"},{"id":100929459,"identity":"547acda1-e6a3-4ee6-8fa8-745d1841d6b4","added_by":"auto","created_at":"2026-01-23 00:36:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":89369,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMonthly coercive interventions, January 2021–December 2024.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNotes: \u003c/em\u003eThe gray line represents observed monthly counts; the navy line shows the 3-month moving average. Vertical dashed lines mark June 2022 (strategy announcement) and June 2023 (post-training). The step-down after June 2022 illustrates the immediate policy impact, while the smaller rise in June 2023 reflects a transitional effect.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8609540/v1/6ad5a59628cccdc1345317a9.png"},{"id":100953041,"identity":"bb6ec204-1cbb-454c-a5de-6071d967b76b","added_by":"auto","created_at":"2026-01-23 07:19:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1335945,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8609540/v1/6244f122-719c-45e9-b048-da21d9e5c084.pdf"},{"id":100951141,"identity":"1c80a7af-a499-4698-8e1f-9165c3c7a649","added_by":"auto","created_at":"2026-01-23 07:10:02","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":2313343,"visible":true,"origin":"","legend":"","description":"","filename":"ChangingAttitudesCoercionSupplementaryTables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8609540/v1/470cf09bee7f53683517a56c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Does Changing Clinicians’ Attitudes Toward Self-Harm Reduce Coercive Interventions in Mental Health Inpatient Settings? A Quasi-Experimental Study of Staff Training","fulltext":[{"header":"Background","content":"\u003cp\u003eIn inpatient mental health care, self-harm (including non-suicidal self-injury) is common and may lead to coercive interventions such as mechanical restraint and rapid tranquillization. Yet, it remains unclear whether staff training and improved attitudes translate into measurable reductions in coercion.\u003c/p\u003e \u003cp\u003eSelf-harm is a common and clinically challenging presentation in inpatient mental health care (Klonsky et al., 2014; Rayner et al., 2019). Staff are often required to balance empathic engagement with immediate safety management, and episodes of self-harm may evoke fear, frustration, and moral judgement that shape how the behavior is interpreted and managed (Brophy et al., 2016; Egan et al., 2012; Ring \u0026amp; Lawn, 2019). These staff responses matter because they can influence whether care is organized around dialogue and de-escalation or around control-based practices.\u003c/p\u003e \u003cp\u003eOver recent decades, educational initiatives have sought to improve staff knowledge, confidence, and attitudes toward self-harm (Patterson et al., 2007; Saunders et al., 2012; Tapola et al., 2016; Zarska et al., 2023). Training programs, often DBT-informed and/or co-produced with service users, tend to yield modest but consistent improvements in attitudes and perceived competence (Linehan, 1993; Manning et al., 2017; Rayner et al., 2019). However, it remains uncertain whether attitudinal change translates into sustained changes in ward-level practice, including reduced self-harm and reduced use of coercive interventions. Reviews indicate that effects of ward-based interventions are frequently short-lived and that institutional culture and organizational conditions may shape coercive practice more strongly than training alone (Nawaz et al., 2021; Efkemann et al., 2024).\u003c/p\u003e \u003cp\u003eCoercive measures such as mechanical restraints (belts or straps, holding) or rapid tranquillization may ensure immediate safety but risk reinforcing a cycle of dysregulation on both sides of the therapeutic relationship (Brophy et al., 2016; Holth et al., 2018). Although clinical guidelines emphasize relational safety, person-centered care, and therapeutic risk-taking (Felton et al., 2017; NICE, 2022), staff often report moral tension and uncertainty in practice (Egan et al., 2012; Klonsky et al., 2014; Rayner et al., 2019). From the patient\u0026rsquo;s perspective, coercion can feel punitive, traumatic or shaming, eroding trust and safety (Brophy et al., 2016; Chandler, 2016).\u003c/p\u003e \u003cp\u003eIn this context, staff attitudes become clinically relevant. Attitudes reflect orientations that link cognition, emotion, and action, and they can shape how responsibility is attributed, whether immediate physical risk is prioritized over relational and longer-term risks, and which responses are considered feasible in practice (Ajzen, 1991; Vandamme et al., 2021).\u003c/p\u003e \u003cp\u003eIn 2022, Mental Health Services in Region Zealand, Denmark, introduced a comprehensive Regional Self-Harm Strategy aimed at strengthening consistent, relational care for individuals who self-harm across services. The strategy emphasizes validation, collaborative crisis planning, and structured de-escalation, and was implemented system-wide, and structured staff training was rolled out in 2023. The strategy draws on established approaches to relational safety and emotion regulation (e.g., Safewards and DBT-informed principles; Bowers et al., 2014; Bowers et al., 2015; Linehan, 1993). As a system-wide, multi-component quality-improvement initiative, its impact is expected to depend not only on training content but also on contextual and implementation processes (Skivington et al., 2021). Evaluating both staff attitudes and system-level coercion outcomes may therefore clarify whether improvements in attitudes coincide with measurable changes in coercive practice.\u003c/p\u003e\n\u003ch3\u003eAim\u003c/h3\u003e\n\u003cp\u003eWe examined whether implementation of the regional self-harm strategy and subsequent staff training were associated with changes in:\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eStaff attitudes\u003c/b\u003e: More positive staff attitudes toward people who self-harm.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eCoercion\u003c/b\u003e: The use of coercive interventions in adult inpatient units, overall and among episodes involving patients with versus without self-harm.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003cp\u003e\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003ch2\u003eReporting statement\u003c/h2\u003e\n\u003cp\u003eReporting of the observational components adheres to the STROBE guidelines (von Elm et al., 2007). Reporting of the interrupted time-series analysis follows established methodological guidance for ITS studies (Penfold \u0026amp; Zhang, 2013). Reporting of the implementation components follows the StaRI statement (Pinnock et al., 2017).\u003c/p\u003e\n\u003ch3\u003eStudy design\u003c/h3\u003e\n\u003cp\u003eWe used a quasi-experimental dual design with two complementary components:\u003c/p\u003e\n\u003cp\u003e(a) an interrupted time-series (ITS) analysis of monthly registry data on coercive interventions from January 2021 to December 2024, and\u003c/p\u003e\n\u003cp\u003e(b) a three-wave pre\u0026ndash;post assessment of staff attitudes toward self-harm.\u003c/p\u003e\n\u003cp\u003eTwo predefined milestones structured the analysis: June 2022 (strategy announcement) and June 2023 (post-training). The intervention was implemented system-wide, which made randomization infeasible. The design followed guidance for quasi-experimental evaluation in implementation research (Miller et al., 2020). Because the regional self-harm strategy was implemented system-wide and comprised interacting components beyond training, it can be conceptualized as a complex intervention in which outcomes depend on the interplay between content, context, and implementation processes (Fixsen et al., 2005; Greenhalgh et al., 2017; Skivington et al., 2021). The overall procedure and timeline are illustrated in Supplementary Fig.\u0026nbsp;1.\u003c/p\u003e\n\u003ch3\u003eSetting and participants\u003c/h3\u003e\n\u003cp\u003eThe study included all five adult inpatient units within Mental Health Services East, Region Zealand, Denmark. Eligible participants were clinical staff with direct patient contact, including nurses, social- and healthcare assistants, social educators, psychologists, occupational and physical therapists, and psychiatrists. Non-clinical personnel were excluded.\u003c/p\u003e\n\u003cp\u003eA total of 187 staff participated in the training, and 182 completed the baseline attitude questionnaire. Of the 182 baseline respondents, 113 provided valid attitude data at two or more time points. The ITS dataset comprised fully de-identified monthly counts of coercive interventions from the same units.\u003c/p\u003e\n\u003ch3\u003eIntervention and training program\u003c/h3\u003e\n\u003cp\u003eThe intervention translated the Regional Self-Harm Strategy (Region Zealand, 2022) into a structured training and education program for inpatient staff. The Strategy is a cross-sector framework that outlines shared principles for the assessment, management, and follow-up of non-suicidal self-harm. It draws on evidence and best practice, including the Safewards model of relational safety (Bowers et al., 2014; Bowers et al., 2015), the recovery-oriented Tidal Model (Barker, 2001; Barker \u0026amp; Buchanan-Barker, 2005), and DBT-informed principles of emotion regulation (Linehan, 1993). The strategy emphasizes dialogue, validation, collaborative crisis planning, and the Ten Interventions for Self-Harm, which provide practical guidance for relational safety and structured de-escalation (see Supplementary Table\u0026nbsp;8).\u003c/p\u003e\n\u003cp\u003eA five-hour training program was delivered to all inpatient staff between May and June 2023 (see Supplementary Table\u0026nbsp;7). The curriculum, co-designed by the first author and a person with lived experience of severe self-harm, introduced key elements of the Regional Strategy and focused on strengthening clinical competence and consistency. Implementation fidelity was supported through standardized training materials, local trainers, and structured supervision, and all five inpatient units completed the training as planned.\u003c/p\u003e\n\u003cp\u003eContent covered in the training:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003etheoretical and clinical understandings of self-harm and non-suicidal self-injury (ISSS, 2022; Klonsky et al., 2014);\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eprinciples of emotional regulation and relational communication, with Strain Psychology (Belastningspsykologi) used to discuss emotional strain in Danish mental health practice (H\u0026oslash;gsted, 2018);\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003etherapeutic risk-taking as one component within the broader strategy (Felton et al., 2017);\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003elegal and ethical aspects of coercion in Danish inpatient care (Nielsen et al., 2020); and\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eDBT-informed clinical tools for emotion regulation and crisis response (Linehan, 1993).\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eEach unit appointed two local trainers who received additional instruction and supported implementation through supervision, consultation, and case-based reflection.\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003eDefinitions and terminology\u003c/h2\u003e\n\u003cp\u003eIn this paper, self-harm refers to deliberate self-inflicted injury or behavior, with or without suicidal intent, consistent with clinical terminology in Danish mental health services. The regional self-harm strategy was primarily developed to address non-suicidal self-injury (NSSI), defined as repetitive self-inflicted harm without suicidal intent (International Society for the Study of Self-Injury, 2022; Klonsky et al., 2014). However, in routine clinical documentation and staff practice, distinctions between suicidal and non-suicidal self-harm are often blurred. The present study therefore uses self-harm as an inclusive term, while recognizing that the intervention primarily targeted NSSI-related behavior.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n\u003ch2\u003eStaff attitudes\u003c/h2\u003e\n\u003cp\u003eStaff attitudes toward self-harm were assessed using the Self-Harm Antipathy Scale (SHAS), a 30-item questionnaire developed to measure clinicians\u0026rsquo; attitudes toward deliberate self-harm (Patterson et al., 2007). At all three time points, participants completed the 30-item Danish translation of the SHAS (SHAS-D), rated on a 7-point scale. Positively worded items were reverse scored so that lower scores indicate more positive attitudes.\u003c/p\u003e\n\u003cp\u003eA Danish psychometric evaluation of the SHAS-D demonstrated that the original 30-item structure did not show adequate structural validity, whereas a revised 17-item scoring (SHAS-DR) provided good model fit, acceptable reliability, and conceptually coherent subscales for use in Danish mental health care (H\u0026oslash;st Poulsen et al., 2025). Accordingly, all attitudinal analyses in the present study used SHAS-DR scoring derived from the SHAS-D responses. SHAS-DR total scores were calculated as the sum of the 17 retained items. When two or fewer of the 17 items were missing, prorated scores were computed; otherwise, the questionnaire was excluded from analysis.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n\u003ch2\u003eCoercive interventions\u003c/h2\u003e\n\u003cp\u003eMonthly counts of coercive interventions (mechanical restraint with belts, straps, or holding, and rapid tranquillization) were extracted from the national coercion registry (SEI) by a senior Training and Development Instructor responsible for coercion reduction in Mental Health Services East, who was not part of the research group.\u003c/p\u003e\n\u003cp\u003eEach coercive episode was classified according to the patient\u0026rsquo;s self-harm status (Self-Harming Patient [SHP] vs Non Self-Harming Patient [NSHP]). Inpatient staff first identified whether the patient was known to engage in self-harm, and the senior instructor compiled these classifications for analysis. The first author verified each classification in the electronic health record system (Sundhedsplatformen) under authorized access by reviewing clinical documentation.\u003c/p\u003e\n\u003cp\u003eThe analytic dataset contained no directly identifiable patient information. The primary ITS analyses were based on monthly aggregated counts (overall and stratified by coercion type and SHP/NSHP status). Where patient-level information was required for sensitivity and concentration analyses, data were handled in pseudonymized form and are reported only as aggregated summaries.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n\u003ch2\u003eProcedures\u003c/h2\u003e\n\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\n\u003ch2\u003eAdministration of the SHAS-D\u003c/h2\u003e\n\u003cp\u003eThe SHAS-D was administered at three time points: baseline (immediately before training), two months, and eight months. At baseline, participants provided demographic information and written informed consent. The first author assigned each participant a unique number for pseudonymized follow-up. At two and eight months, questionnaires were distributed by ward managers and local trainers. Completed forms were returned to the first author and entered into the dataset. SHAS-DR scoring was applied to the SHAS-D responses as described above.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n\u003ch2\u003eClassification of coercive episodes\u003c/h2\u003e\n\u003cp\u003eThe classification of SHP and NSHP followed a structured two-step process: identification by ward staff, followed by verification by the first author in the electronic health record. Data remained pseudonymized.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n\u003ch2\u003eSensitivity and concentration procedures\u003c/h2\u003e\n\u003cp\u003eTo assess whether observed reductions in coercion were driven by a small number of high-frequency patients, we conducted concentration sensitivity analyses using pseudonymized patient-level registry data from 2021 to 2024. For each year (and separately for each coercion type), patients were ranked by number of coercive episodes, and we calculated the proportion of episodes accounted for by the top 10% and top 5% most frequently exposed patients.\u003c/p\u003e\n\u003cp\u003eWe then constructed three alternative scenarios: heavy10, in which episodes contributed by the top 10% of patients were excluded; heavy05, in which episodes contributed by the top 5% were excluded; and cap-1, in which each patient contributed a maximum of one coercive episode per year (i.e., counting unique patient-years).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n\u003ch2\u003eStatistical analysis\u003c/h2\u003e\n\u003cp\u003eSegmented regression was used to estimate level and slope changes at the two milestones. Parameters included time, post₁, trend₁, post₂, and trend₂. Post₁ and post₂ represent immediate level changes after each milestone; trend₁ and trend₂ represent changes in monthly slope. Primary models used Poisson regression with robust standard errors. Negative-binomial models were fitted when overdispersion was detected (\u0026chi;\u0026sup2;/df\u0026thinsp;\u0026gt;\u0026thinsp;1.5). Calendar-month fixed effects adjusted for seasonality. Results are reported as incidence-rate ratios (IRRs, 95% CI). Analyses were repeated separately for SHP and NSHP episodes. Concentration metrics (share of episodes contributed by the top 10% and top 5% of patients, and the heavy10/heavy05/cap-1 scenarios described above) were calculated to assess robustness.\u003c/p\u003e\n\u003cp\u003eChanges in staff attitudes were analyzed using linear mixed-effects models with random intercepts, using the validated SHAS-DR total score as the outcome measure, with paired t-tests as complementary checks. Residual plots were inspected for autocorrelation. All analyses were conducted in Stata 18 (StataCorp LLC, College Station, TX, USA).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n\u003ch2\u003eResponse rates and attrition\u003c/h2\u003e\n\u003cp\u003eA total of 187 staff attended the training sessions, and 182 completed the baseline attitude questionnaire. 165 met the SHAS-DR completeness rule (\u0026le;\u0026thinsp;2 missing of the 17 scored items) and were included in cross-sectional descriptive baseline summaries. Ninety participants responded at two months and seventy-four at eight months. The longitudinal analytic sample included 113 participants who provided valid SHAS-DR data for at least two time points; fifty-one staff completed all three waves. Attrition was highest at eight months and reflected shift schedules, staff turnover, and routine survey fatigue in high-intensity inpatient settings.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n\u003ch2\u003eParticipant characteristics\u003c/h2\u003e\n\u003cp\u003eParticipant characteristics appear in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. At baseline, seventy-eight percent identified as female, twenty-one percent as male, and one percent did not report gender. The largest professional groups were social- and healthcare assistants (48 percent) and nurses (25 percent). Smaller groups included social educators, physicians, occupational therapists, social workers, psychologists, and support staff.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eParticipant professions and gender distribution at baseline and analytic sample\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eProfession\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eBaseline n (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eFemale n (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMale n (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eIncluded in analysis n (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eFemale n (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMale n (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSocial- and healthcare assistant\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e87 (47.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e69 (79.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e17 (19.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e55 (48.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e45 (81.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (16.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNurse\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e45 (24.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e40 (88.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5 (11.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31 (27.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27 (87.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (12.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSocial educator\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15 (8.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e12 (80.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3 (20.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10 (8.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 (80.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (20.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDoctor\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (4.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5 (55.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4 (44.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (1.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (50.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (50.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMental health care attendant\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (3.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3 (50.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3 (50.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (1.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (50.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (50.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOccupational therapist\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (2.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3 (60.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2 (40.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (2.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (66.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (33.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSocial worker\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (2.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4 (80.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1 (20.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (4.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (80.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (20.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePsychologist\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (1.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2 (66.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1 (33.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (0.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (100.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSupport staff\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (2.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4 (100.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (3.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (100.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysical therapist\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (1.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2 (100.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ndash;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ndash;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ndash;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e182 (100)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e142 (78.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e38 (20.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e113 (100)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e92 (81.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20 (17.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNotes:\u003c/em\u003e Baseline n = 182; analytic sample = 113 staff with \u0026ge; 2 valid SHAS time points. Percentages may not sum exactly due to rounding.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n\u003ch2\u003eStaff attitudes toward self-harm\u003c/h2\u003e\n\u003cdiv id=\"Sec21\" class=\"Section3\"\u003e\n\u003ch2\u003eDescriptive results\u003c/h2\u003e\n\u003cp\u003eDescriptive results appear in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, paired comparisons in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e, and mixed-effects estimates in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e. Estimated means with 95 percent confidence intervals are visualized in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eSelf-Harm Antipathy Scale \u0026ndash; Danish Revised (SHAS-DR) scores before and after training\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTime point\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMean (SD)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eChange from baseline\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBaseline\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e165\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e40.0 (10.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ndash;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e88\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e34.8 (7.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ndash;5.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e72\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e35.4 (8.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ndash;4.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003cem\u003eNotes:\u003c/em\u003e Lower SHAS-DR scores = more positive attitudes toward people who self-harm. Change from baseline = raw mean difference.\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eWithin-person change in SHAS-DR scores following training\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eComparison\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en pairs\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMean difference\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e95% CI\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ep\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBaseline \u0026rarr; 2 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e82\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3.20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e[1.78, 4.61]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBaseline \u0026rarr; 8 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2.94\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e[1.23, 4.65]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003cbr /\u003e\n\u003cp\u003e\u003cem\u003eNotes:\u003c/em\u003e Paired-sample t-tests. Positive values indicate higher antipathy at baseline relative to follow-up (i.e., improvement). CI = confidence interval.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eLinear mixed-effects model of SHAS-DR scores (n\u0026thinsp;=\u0026thinsp;113)\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eEffect\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eEstimate (b)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSE\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e95% CI\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ep\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBaseline (intercept)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e39.81\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.77\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e[38.31, 41.31]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 months vs baseline\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026ndash;3.63\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e[\u0026ndash;4.95, \u0026minus;\u0026thinsp;2.32]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 months vs baseline\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026ndash;3.55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.74\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e[\u0026ndash;4.99, \u0026minus;\u0026thinsp;2.11]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eNotes:\u003c/em\u003e Random-intercept model; negative b = improvement (lower SHAS-DR scores). SE = standard error; CI = confidence interval.\u003c/p\u003e\n\u003cp\u003eMean SHAS-DR total scores decreased from 40.0 (SD\u0026thinsp;=\u0026thinsp;10.8) at baseline to 34.8 (SD\u0026thinsp;=\u0026thinsp;7.4) at two months and 35.4 (SD\u0026thinsp;=\u0026thinsp;8.2) at eight months, indicating more positive attitudes toward people who self-harm.\u003c/p\u003e\n\u003cp\u003eA similar pattern was observed across the three SHAS-DR subscales, with the largest raw-score improvement seen in \u003cem\u003eJudgmental Perception\u003c/em\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\n\u003ch2\u003ePaired comparisons\u003c/h2\u003e\n\u003cp\u003eAmong participants with matched data, SHAS-DR total scores declined significantly from baseline to two months (mean difference\u0026thinsp;=\u0026thinsp;3.20, 95% CI [1.78, 4.61], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and from baseline to eight months (mean difference\u0026thinsp;=\u0026thinsp;2.94, 95% CI [1.23, 4.65], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.001). There was no significant difference between two and eight months (mean difference\u0026thinsp;=\u0026thinsp;0.41, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.60), indicating that the initial improvement was maintained without further change. These findings correspond to moderate effect sizes at both follow-up points.\u003c/p\u003e\n\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\n\u003ch2\u003eMixed-effects models\u003c/h2\u003e\n\u003cp\u003eLinear mixed-effects models confirmed these changes. Compared with baseline, SHAS-DR scores were 3.63 points lower at two months (\u003cem\u003eb\u003c/em\u003e = \u0026minus;\u0026thinsp;3.63, SE\u0026thinsp;=\u0026thinsp;0.67, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and 3.55 points lower at eight months (\u003cem\u003eb\u003c/em\u003e = \u0026minus;\u0026thinsp;3.55, SE\u0026thinsp;=\u0026thinsp;0.74, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). The model-implied means were 39.81 at baseline, 36.18 at two months, and 36.26 at eight months (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Substantial between-person variability was indicated by the random intercept (Var[ID]\u0026thinsp;=\u0026thinsp;79.23).\u003c/p\u003e\n\u003cp\u003eTogether, the results indicate that structured staff training produced moderate, statistically robust, and sustained improvements in staff attitudes toward people who self-harm.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\n\u003ch2\u003eCoercive interventions\u003c/h2\u003e\n\u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e shows trends in monthly coercive episodes, with segmented regression results in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e and annual totals in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e. Total coercive episodes declined from 1,280 in 2021 to 543 in 2022 (a 58 percent reduction). Annual totals then stabilized and were identical in 2023 and 2024 (409 episodes in each year).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab5\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eSegmented regression of monthly coercive interventions (ITS model)\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eParameter\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eIRR\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e95% CI\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ep\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTime (months pre)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.94\u0026ndash;1.07\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.939\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLevel change at June 2022\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.39\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.21\u0026ndash;0.73\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.003\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTrend change after June 2022\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.94\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.86\u0026ndash;1.03\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.182\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLevel change at June 2023\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2.58\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.57\u0026ndash;4.25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTrend change after June 2023\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.03\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.97\u0026ndash;1.09\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.328\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u003cem\u003eNotes:\u003c/em\u003e Poisson regression with robust SEs (NB fallback). IRR \u0026lt; 1 = decrease; \u0026gt; 1 = increase. Model includes calendar-month fixed effects. Milestones = June 2022 (strategy) and June 2023 (training).\u003c/div\u003e\n\u003ctable id=\"Tab6\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eAnnual totals of coercive interventions across all inpatient units\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eYear\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTotal episodes\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2021\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 280\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2022\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e543\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2023\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e409\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2024\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e409\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNotes:\u003c/em\u003e Aggregated across five adult inpatient units, Mental Health Care Services East, Region Zealand. Totals reflect registry counts; 58 % reduction from 2021 to 2022 followed by stabilization.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eMean monthly episodes decreased from 93 before the strategy (January 2021 to May 2022) to 28 during the policy phase (June 2022 to May 2023) and then increased to 38 after training (June 2023 to December 2024).\u003c/p\u003e\n\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\n\u003ch2\u003eInterrupted time-series results\u003c/h2\u003e\n\u003cp\u003eSegmented regression identified a large immediate reduction at the time of the strategy announcement (IRR\u0026thinsp;=\u0026thinsp;0.39, 95% CI [0.21, 0.73], p\u0026thinsp;=\u0026thinsp;.003). The slope did not change after this point (IRR\u0026thinsp;=\u0026thinsp;0.94, p\u0026thinsp;=\u0026thinsp;.182). At the training point, a temporary increase appeared (IRR\u0026thinsp;=\u0026thinsp;2.58, 95% CI [1.57, 4.25], p\u0026thinsp;\u0026lt;\u0026thinsp;.001), consistent with short-term implementation-related disturbance rather than an effect of the training itself. The slope again remained unchanged (IRR\u0026thinsp;=\u0026thinsp;1.03, p\u0026thinsp;=\u0026thinsp;.328). The overall pattern reflected two step changes rather than gradual trends.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\n\u003ch2\u003eBy coercion type\u003c/h2\u003e\n\u003cp\u003eMechanical restraint showed the largest reductions. Between 2021 and 2024, use of belts decreased by 74 percent, straps by 81 percent, and holding by 82 percent. Rapid tranquillization decreased by 51 percent but remained the most frequent coercive measure. Full values appear in Supplementary Table\u0026nbsp;1.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\n\u003ch2\u003eBy NSSI status (SHP vs. NSHP)\u003c/h2\u003e\n\u003cp\u003eThe composition of coercion shifted over time. In 2021, self-harming patients (SHP) accounted for most episodes (960 vs. 320 non-self-harming patients (NSHP)). By 2023 and 2024, NSHP episodes exceeded SHP episodes. Stratified ITS plots followed the same temporal pattern as the overall series. Supplementary Tables\u0026nbsp;1\u0026ndash;3 provide full results, and Supplementary Table\u0026nbsp;6 shows coercion type by patient status.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\n\u003ch2\u003eSensitivity analyses\u003c/h2\u003e\n\u003cp\u003eHeavy-patient analyses examined whether reductions in coercion were driven by a small group of frequently restrained individuals. Across all years, the ten percent most frequently restrained patients accounted for 52 to 58 percent of episodes, and the top five percent accounted for 35 to 41 percent. These proportions were stable. Removing the heavy10 group changed annual totals by less than five percent, and a cap-1 analysis, which limited each patient to one episode per year, showed a similar trajectory. Concentration was highest for mechanical restraint and lowest for rapid tranquillization. Full results appear in Supplementary Tables\u0026nbsp;4 and 5.\u003c/p\u003e\n\u003cp\u003eThese findings indicate that the decline in coercion reflected a broad change in clinical practice rather than shifts among a small number of high-frequency patients.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAttitudes improved significantly and remained improved at eight months. Coercion fell sharply after the strategy announcement and stabilized at this lower level over the study period. A temporary rise occurred during the training period but did not alter long-term trends. Mechanical restraints showed the largest reductions. Rapid tranquillization remained the most frequent coercive measure. The number of coercion episodes involving self-harming patients declined over time. Together, the results suggest that improved attitudes are important but that sustained reductions in coercion also require ongoing structural and organizational support.\u003c/p\u003e \u003cp\u003eBecause this was a system-wide quality improvement initiative without a control group (i.e. another mental health service), firm causal inferences are not possible. Even so, the temporal specificity of the changes, the pre-specified milestones, and the robustness of the sensitivity analyses support the interpretation that the strategy and associated training were linked to real behavioral change rather than to secular trends.\u003c/p\u003e\n\u003ch3\u003eInterpretation and theoretical implications\u003c/h3\u003e\n\u003cp\u003eThe immediate decline in coercion after the strategy announcement may represent an organizational \u0026ldquo;unfreezing\u0026rdquo; in Lewin\u0026rsquo;s sense (Lewin, 1947), an early phase of cultural change initiated by leadership attention and a shared focus on self-harm rather than by new skills alone (Felton et al., 2017; Miller et al., 2020; NICE, 2022). Similar patterns have been observed in other improvement efforts, where symbolic commitment and policy emphasis create initial movement, while training and tools later provide structure and language for changes that have already begun (Miller et al., 2020; Penfold \u0026amp; Zhang, 2013). Within complex intervention frameworks, such shifts are understood as the product of interactions between content, context, and implementation processes rather than of content alone (Fixsen et al., 2005; Greenhalgh et al., 2017; Skivington et al., 2021).\u003c/p\u003e \u003cp\u003eImportantly, the regional self-harm strategy was not a single training package but a multi-component, cross-sector framework. It emphasized validation, collaborative crisis planning, and structured de-escalation, and it drew on established approaches to relational safety and emotion regulation (Bowers et al., 2014; Bowers et al., 2015; Barker, 2001; Barker \u0026amp; Buchanan-Barker, 2005; Linehan, 1993). In this light, the drop in coercion at the time of the strategy announcement may reflect changes in shared meaning and expectations\u0026mdash;how self-harm is framed and what \u0026ldquo;safe care\u0026rdquo; is taken to entail\u0026mdash;while the later training period may have represented a transitional phase in which new relational routines were rehearsed and consolidated under real-world constraints (Felton et al., 2017; Miller et al., 2020; Penfold \u0026amp; Zhang, 2013; Skivington et al., 2021).\u003c/p\u003e \u003cp\u003eFrom an affective and sociological perspective, the findings can also be read through the lens of emotional labor. Hochschild (1983) described how professionals regulate and display emotion according to institutional norms. In mental health care, this often means transforming fear, frustration, or helplessness into calm and care. Such deep acting relies on continuous emotion regulation (Gross, 1998) and sits at the center of staff\u0026ndash;patient contact, yet it rarely counts as technical expertise within systems that privilege observable procedures (Hochschild, 1983; Boukouvalas et al., 2020; Brophy et al., 2016; Egan et al., 2012).\u003c/p\u003e \u003cp\u003eMenzies Lyth (1960) conceptualized institutions as social defenses against anxiety, where routines and hierarchies contain collective fear. When a self-harm strategy invites staff to replace coercive procedures with relational dialogue, these defenses are disturbed, and new emotional and moral capacities are required. Later work by Ashforth and Humphrey (1993) and Tracy (2005) emphasize that rules for emotional display are bound to professional identity. To change them is to question what it means to be competent. The temporary rise in coercion during the training period may represent a defensive rebound, a short return to familiar control practices under strain rather than a failure of the strategy itself (Menzies Lyth, 1960; Penfold \u0026amp; Zhang, 2013). Short-term increases around implementation points are well described in the implementation science literature as transition effects or implementation dips, where existing routines are unsettled before new practices stabilize (Fullan, 2001; Penfold \u0026amp; Zhang, 2013; Miller et al., 2020; Skivington et al., 2021).\u003c/p\u003e \u003cp\u003eAt a cognitive level, the Theory of Planned Behavior suggests that behavior is shaped by attitudes, perceived norms, and perceived control (Ajzen, 1991). The present study indicates that attitudes and perceived competence improved after training, yet coercion did not continue to fall beyond the initial step change. This pattern supports the view that attitude change is necessary but not sufficient for durable behavioral change when structural constraints and institutional norms remain intact (Ajzen, 1991; Felton et al., 2017; Miller et al., 2020). Vandamme et al. (2021) similarly showed that even when staff explicitly endorse the reduction of coercion, implicit associations with control and safety persist, quietly shaping practice.\u003c/p\u003e \u003cp\u003eMoral psychology further illuminates these dynamics. Judgements about responsibility and deservingness influence whether self-harm is understood as a symptom or as a choice (Chaney, 2017; Ring \u0026amp; Lawn, 2019; Varga et al., 2025). When self-harm is seen as voluntary or manipulative, irritation and blame can surface, leading to distance or control (Chandler, 2016; Holth et al., 2018; Vandamme et al., 2021). By (re-)framing self-harm as a form of emotional regulation rather than as an expression of intent, the regional strategy may have supported cognitive reappraisal, shifted moral judgement, and opened space for empathy (Klonsky et al., 2014; Linehan, 1993; Gross, 1998). Qualitative work by Thomas et al. (2023) shows how clinicians describe their work with self-harm as an ongoing balancing act between empathy, responsibility, and self-protection, which resonates with the patterns observed here.\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eStructural and organizational mechanisms\u003c/h2\u003e \u003cp\u003eThe lack of further decline in coercion after training suggests that organizational and emotional structures continued to shape everyday practice. As Menzies Lyth (1960) argued, institutions often maintain practices that protect staff from anxiety, even when these practices conflict with stated values. High workloads, staff turnover, and resource constraints can keep coercive routines in place, functioning as a psychological safety net when staff feel overwhelmed (Egan et al., 2012; Rayner et al., 2019). This is consistent with institutional perspectives on health care, which show that accountability systems and valuation regimes privilege what can be counted, while relational and affective work remains comparatively invisible unless tied to measurable outcomes (Timmermans \u0026amp; Berg, 2003; Boltanski \u0026amp; Th\u0026eacute;venot, 2006).\u003c/p\u003e \u003cp\u003eRecent qualitative studies report similar tensions, pointing to systemic pressures, professional hierarchies, and institutional inertia as barriers to reducing coercion (M\u0026ouml;ll et al., 2025). M\u0026ouml;ll et al. (2025) found that coercive practices may persist not because individual staff wish to use them, but because they provide psychological containment at the organizational level. In a Danish context, this can be read alongside the notion of a \u0026ldquo;lean relational space\u0026rdquo;, where efficiency demands and documentation requirements limit time and legitimacy for relational care (Hviid et al., 2021).\u003c/p\u003e \u003cp\u003eImplementation research underlines that sustainable change depends on leadership, supervision, and consistent feedback loops (Miller et al., 2020; NICE, 2022; Nielsen et al., 2020). Without these supports, emotional labor becomes a solitary task, which increases the risk of burnout and a reversion to control-based norms (Hochschild, 1983; Egan et al., 2012; Christensen et al., 2019; Vandamme et al., 2021). Organizational learning frameworks suggest that sustainability arises when data are linked to reflection and when evidence legitimizes new forms of work (Miller et al., 2020; NICE, 2022). In this light, the sharp fall in coercion after the 2022 announcement may reflect increased monitoring and accountability as well as cultural change. Maintaining that reduction likely depends on continued spaces for reflection and on recognizing relational work as legitimate professional activity. From the perspective of institutional work, embedding relational safety into policies, supervision, and evaluation metrics is one way that local experimentation becomes durable organizational norm (Cloutier et al., 2016).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eStrengths, limitations, and future directions\u003c/h2\u003e \u003cp\u003eThis study contributes to a growing body of work that views change in mental health care as both behavioral and organizational. Strengths include the multi-year, system-level dataset, the use of pre-specified intervention points, and the integration of attitudinal and behavioral outcomes. Compared with simple pre\u0026ndash;post designs, the interrupted time series approach strengthens causal interpretation by modelling pre-existing trends and temporal alignment with the intervention (Penfold \u0026amp; Zhang, 2013). The concentration analyses further support the robustness of the observed reductions by showing that results were not driven by a small group of high-frequency patients.\u003c/p\u003e \u003cp\u003eSeveral limitations must be noted. First, the absence of randomization and of a contemporaneous control series (e.g., other Danish regions or national comparator trends) leaves the analyses vulnerable to unmeasured influences and concurrent initiatives within and beyond the system and limits causal inference (Penfold \u0026amp; Zhang, 2013; Miller et al., 2020). Relatedly, we did not benchmark observed changes against regional or national time trends in coercion; therefore, we cannot determine the extent to which the observed step changes reflect strategy-specific effects versus broader secular developments in coercion reduction.\u003c/p\u003e \u003cp\u003eSecond, incomplete denominators, such as patient-days, limited rate calculations and compelled a focus on counts. Changes in bed occupancy, admission patterns, or case-mix over time could therefore have contributed to changes in counts independent of changes in clinical practice.\u003c/p\u003e \u003cp\u003eThird, although the intervention milestones were pre-specified and the ITS design reduces bias relative to simple pre\u0026ndash;post comparisons, regression to the mean remains a potential concern if baseline levels of coercion in the early period were unusually high. However, the long pre-intervention observation window and explicit modelling of pre-intervention trends mitigate (but do not eliminate) this threat to inference (Penfold \u0026amp; Zhang, 2013).\u003c/p\u003e \u003cp\u003eFourth, attrition in SHAS-DR responses may have biased attitudinal findings towards those more engaged with the training, although the direction of this bias is uncertain.\u003c/p\u003e \u003cp\u003eFifth and lastly, a limitation concerns the classification of self-harming versus non-self-harming patients. Because Danish health registries do not yet include standardized codes for self-harm or NSSI, identification depended on staff reports and manual verification in the electronic health record. This procedure increases validity compared with registry-only approaches but may still introduce minor misclassification. The lack of systematic coding highlights the need for improved documentation to support surveillance and research. Staff turnover may also have influenced implementation and sustainability, as not all staff working in the units over time were exposed to the training. In addition, we did not include direct observational measures of implementation fidelity. Although training completion and support structures were in place, variation in local enactment of the strategy could not be systematically assessed.\u003c/p\u003e \u003cp\u003eDespite these limitations, the dual design offers complementary perspectives on psychological and organizational mechanisms of change and aligns with current recommendations for studying complex interventions in routine systems (Ajzen, 1991; Hochschild, 1983; Gross, 1998; Miller et al., 2020; NICE, 2022; Skivington et al., 2021).\u003c/p\u003e \u003cp\u003eFuture research should examine whether training that explicitly targets emotional labor and moral appraisal can influence long-term behavioral outcomes and whether structural interventions can modify institutional defenses over time (Hochschild, 1983; Menzies Lyth, 1960; Miller et al., 2020; NICE, 2022). Comparative designs with staggered implementation or matched control sites would strengthen causal inference (Penfold \u0026amp; Zhang, 2013). Mixed-level analyses that link staff attitudes to inpatient-level coercion data could clarify how psychological change connects to organizational dynamics (Ajzen, 1991; Gross, 1998; Miller et al., 2020; NICE, 2022). Qualitative inquiry remains important for understanding how clinicians negotiate moral and emotional boundaries in practice and how cultural change becomes embodied in everyday work (Chandler, 2016; Holth et al., 2018; Vandamme et al., 2021).\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003eImplications for practice and policy\u003c/h2\u003e \u003cp\u003eThe findings have several implications for practice and policy. First, training on self-harm should address emotional regulation and moral appraisal explicitly, not only knowledge and procedures (Hochschild, 1983; Boukouvalas et al., 2020; Brophy et al., 2016; Gross, 1998; Chandler, 2016; Holth et al., 2018; Vandamme et al., 2021). Recognizing emotional labor as part of professional skill may reduce moralization and help protect staff from burnout (Hochschild, 1983; Menzies Lyth, 1960; Egan et al., 2012; Christensen et al., 2019).\u003c/p\u003e \u003cp\u003eSecond, structural support is essential. Supervision, peer reflection, and stable staffing are needed to turn individual learning into collective practice and to prevent responsibility for emotional regulation from resting solely with the individual clinician (Menzies Lyth, 1960; Egan et al., 2012; Miller et al., 2020; NICE, 2022).\u003c/p\u003e \u003cp\u003eThird, substitution effects must be monitored. The marked fall in mechanical restraint, combined with more modest change in rapid tranquillization, underscores the need to monitor all forms of coercion to ensure that one form of containment is not simply replaced by another (Brophy et al., 2016; Holth et al., 2018; Penfold \u0026amp; Zhang, 2013; Rayner et al., 2019). The sharper reduction in mechanical restraint may reflect modality-specific drivers, such as differences in visibility, normative acceptability, and local implementation focus, rather than differential change in underlying clinical risk. From a policy and ethics perspective, this pattern highlights the importance of making \u0026ldquo;least restrictive\u0026rdquo; principles explicit across coercion types and of interpreting changes in coercion profiles in light of patient experience, not only counts (Brophy et al., 2016; Chandler, 2016). Future evaluations should benchmark local trajectories against national coercion statistics to clarify whether differential reductions represent broader secular trends or strategy-specific change.\u003c/p\u003e \u003cp\u003eFourth, outcome frameworks should incorporate indicators of ward climate and relational engagement, so that relational care is visible in the same way as procedural activity. Aligning evaluation metrics with the relational and emotional dimensions of care may help secure the legitimacy of these practices in systems that otherwise prioritize what is easily measurable (Hochschild, 1983; Boukouvalas et al., 2020; Felton et al., 2017; Miller et al., 2020; Timmermans \u0026amp; Berg, 2003; Boltanski \u0026amp; Th\u0026eacute;venot, 2006). One established approach is the Ward Atmosphere Scale, which captures multiple dimensions of inpatient milieu relevant to the structural and group-level emotional climate (e.g., anger/aggression and staff control) and has been revised for contemporary psychiatric settings (R\u0026oslash;ssberg \u0026amp; Friis, 2003). Finally, the later increase in non-self-harm-related coercion suggests that approaches developed for self-harm may have wider relevance and that broader restraint-reduction strategies could benefit from integrating similar relational and emotional components (Nielsen et al., 2020).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe regional self-harm strategy was associated with an immediate reduction in coercive interventions at the time of the strategy announcement, while staff attitudes toward self-harm improved following training and remained more positive eight months later. These effects stabilized rather than continuing to grow. The findings suggest that lasting change requires more than new knowledge: it depends on emotional regulation, moral reframing, and organizational containment. Emotional labor and social-defense theory offer one way to understand why change in mental health care is rarely linear. To become ordinary, new practices must be adopted, repeated, and supported, not only at the level of the individual clinician but within the structures that define everyday care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eBPD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBorderline personality disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eDBT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDialectical Behavior Therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eITS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInterrupted time\u0026ndash;series\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eNSSI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon\u0026ndash;suicidal self\u0026ndash;injury\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eNSHP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon\u0026ndash;self\u0026ndash;harming patients\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSHP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSelf\u0026ndash;harming patients\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSHAS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSelf\u0026ndash;Harm Antipathy Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cbr\u003eThe study was approved as a quality and development project (\u003cem\u003ekvalitets- og udviklingsprojekt\u003c/em\u003e) within Region Zealand. In accordance with Danish regulations, the Regional Committee on Health Research Ethics (Videnskabsetisk Komité) confirmed that separate ethical approval was not required. Access to the electronic health record system (\u003cem\u003eSundhedsplatformen\u003c/em\u003e) for verification of self-harm classifications was granted through authorization from the Director of Mental Health Services, Region Zealand, under the approved project framework. All participating staff provided written informed consent for the use of their questionnaire data, and pseudonymization was achieved by assigning individual trial numbers after completion of the baseline SHAS forms, ensuring that only the first author could link names to codes. The study complies with data-protection regulations outlined by the Danish Data Protection Agency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to confidentiality agreements with participants but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eK.H.P. conceived and designed the study, coordinated data collection, conducted the analyses, and drafted the manuscript.\u003cbr\u003e\u0026nbsp;C.H. provided statistical supervision, contributed to data analysis and interpretation, and co-developed the analytic strategy.\u003cbr\u003e\u0026nbsp;M.T.K. served as primary supervisor and contributed to the theoretical framework, methodological design, interpretation, and critical revision of the manuscript.\u003cbr\u003e\u0026nbsp;B.B. and E.S. served as co-supervisors, contributing to methodological guidance and manuscript review.\u003cbr\u003e\u0026nbsp;All authors approved the final manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAI disclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePortions of manuscript organization and language editing were supported by an AI language model (GPT-5, OpenAI) under author supervision. The model is not credited as an author and bears no responsibility for content.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the participating staff of Mental Health Services East, Region Zealand, and the local NSSI trainers for their engagement throughout the study.\u003c/p\u003e\n\u003cp\u003eThe authors thank Susanne Winkel, Nurse and Senior Training and Development Instructor, Mental Health Services East, Region Zealand, for her assistance in extracting and classifying registry data and for her support throughout the project.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAjzen, I. (1991). The theory of planned behavior. \u003cem\u003eOrganizational Behavior and Human Decision Processes, 50\u003c/em\u003e(2), 179\u0026ndash;211. https://doi.org/10.1016/0749-5978(91)90020-T\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndover, M. S., \u0026amp; Gibb, B. E. (2010). Non-suicidal self-injury, attempted suicide, and suicidal intent among psychiatric inpatients. \u003cem\u003ePsychiatry Research, 178\u003c/em\u003e(1), 101\u0026ndash;105. https://doi.org/10.1016/j.psychres.2009.03.019\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndrews, H. E., Hulbert, C., Cotton, S. M., Betts, J., \u0026amp; Chanen, A. M. (2019). Relationships between the frequency and severity of non-suicidal self-injury and suicide attempts in youth with borderline personality disorder. \u003cem\u003eEarly Intervention in Psychiatry, 13\u003c/em\u003e(1), 194\u0026ndash;201. https://doi.org/10.1111/eip.12461\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAshforth, B. E., \u0026amp; Humphrey, R. H. (1993). Emotional labor in service roles: The influence of identity. \u003cem\u003eAcademy of Management Review, 18\u003c/em\u003e(1), 88\u0026ndash;115. https://doi.org/10.5465/amr.1993.3997508\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarker, P. (2001). The Tidal Model: Developing an empowering, person-centred approach to recovery within psychiatric and mental health nursing. Journal of Psychiatric and Mental Health Nursing, 8(3), 233\u0026ndash;240. https://doi.org/10.1046/j.1365-2850.2001.00391.x\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarker, P., \u0026amp; Buchanan-Barker, P. (2005). The Tidal Model: A guide for mental health professionals. Brunner-Routledge.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoltanski, L., \u0026amp; Th\u0026eacute;venot, L. (2006). \u003cem\u003eOn justification: Economies of worth\u003c/em\u003e (C. Porter, Trans.). Princeton University Press. (Original work published 1991)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoukouvalas, E., El-Den, S., Murphy, A. L., Salvador-Carulla, L., \u0026amp; O\u0026rsquo;Reilly, C. L. (2020). Exploring health care professionals\u0026rsquo; knowledge of, attitudes towards, and confidence in caring for people at risk of suicide: A systematic review. \u003cem\u003eArchives of Suicide Research, 24\u003c/em\u003e(Suppl. 2), S1\u0026ndash;S31. https://doi.org/10.1080/13811118.2019.1678530\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowers, L. (2014). Safewards: A new model of conflict and containment on psychiatric wards. Journal of Psychiatric and Mental Health Nursing, 21(6), 499\u0026ndash;508. https://doi.org/10.1111/jpm.12129\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowers, L., James, K., Quirk, A., Simpson, A., Stewart, D., \u0026amp; Hodsoll, J. (2015). Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomized controlled trial. International Journal of Nursing Studies, 52(9), 1412\u0026ndash;1422. https://doi.org/10.1016/j.ijnurstu.2015.05.001\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrophy, L. M., Roper, C. E., Hamilton, B. E., Tellez, J. J., \u0026amp; McSherry, B. M. (2016). Consumers\u0026rsquo; and their supporters\u0026rsquo; perspectives on barriers and strategies to reducing seclusion and restraint in mental health settings. \u003cem\u003eAustralian Health Review, 40\u003c/em\u003e(6), 599\u0026ndash;604. https://doi.org/10.1071/AH15128\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarroll, R., Thomas, K. H., Bramley, K., et al. (2016). Self-cutting and risk of subsequent suicide. \u003cem\u003eJournal of Affective Disorders, 192\u003c/em\u003e, 8\u0026ndash;10. https://doi.org/10.1016/j.jad.2015.12.007\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCastellv\u0026iacute;, P., Lucas-Romero, E., Miranda-Mendizabal, A., et al. (2017). Longitudinal association between self-injurious thoughts and behaviors and suicidal behavior in adolescents and young adults: A systematic review with meta-analysis. \u003cem\u003eJournal of Affective Disorders, 215\u003c/em\u003e, 37\u0026ndash;48. https://doi.org/10.1016/j.jad.2017.03.035\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChaney, S. (2017). \u003cem\u003ePsyche on the skin: A history of self-harm.\u003c/em\u003e Reaktion Books.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChandler, A. (2016). \u003cem\u003eSelf-injury, medicine and society: Authentic bodies.\u003c/em\u003e Palgrave Macmillan. https://doi.org/10.1057/978-1-137-40528-9\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChristensen, T. N., Jensen, M., \u0026amp; Stenager, E. (2019). Effects of individual placement and support on employment in people with mental illness in Denmark. \u003cem\u003eThe Lancet Psychiatry, 6\u003c/em\u003e(3), 203\u0026ndash;214. https://doi.org/10.1016/S2215-0366(18)30489-4\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCloutier, C., Denis, J.-L., Langley, A., \u0026amp; Lamothe, L. (2016). Agency at the managerial interface: Public sector reform as institutional work. \u003cem\u003eJournal of Public Administration Research and Theory, 26\u003c/em\u003e(2), 259\u0026ndash;276. https://doi.org/10.1093/jopart/muv009\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEgan, R., Sarma, K. M., \u0026amp; O\u0026rsquo;Neill, M. (2012). Factors influencing perceived effectiveness in dealing with self-harming patients in a sample of emergency department staff. \u003cem\u003eJournal of Emergency Medicine, 43\u003c/em\u003e(6), 1084\u0026ndash;1090. https://doi.org/10.1016/j.jemermed.2012.01.049\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEfkemann, S. A., Schildmann, J., Hoffmann, K., et al. (2024). Staff attitudes toward the use of coercion in mental health care: A scoping review. \u003cem\u003eFrontiers in Psychiatry, 15\u003c/em\u003e, 11354183. https://doi.org/10.3389/fpsyt.2024.11354183\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFelton, A., Wright, N., \u0026amp; Stacey, G. (2017). Therapeutic risk-taking: A justifiable choice. \u003cem\u003eBJPsych Advances, 23\u003c/em\u003e(2), 81\u0026ndash;88. https://doi.org/10.1192/apt.bp.115.015701\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., \u0026amp; Wallace, F. (2005). \u003cem\u003eImplementation research: A synthesis of the literature\u003c/em\u003e (FMHI Publication #231). University of South Florida, National Implementation Research Network. https://nirn.fpg.unc.edu/resources/implementation-research-synthesis-literature\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFullan, M. (2001). \u003cem\u003eThe new meaning of educational change\u003c/em\u003e (3rd ed.). Teachers College Press.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoodman, M., Tomas, I. A., Temes, C. M., et al. (2017). Suicide attempts and self-injurious behaviours in adolescent and adult patients with borderline personality disorder. \u003cem\u003ePersonality and Mental Health, 11\u003c/em\u003e(3), 157\u0026ndash;163. https://doi.org/10.1002/pmh.1375\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreenhalgh, T., Wherton, J., Papoutsi, C., Lynch, J., Hughes, G., A\u0026rsquo;Court, C., Hinder, S., Fahy, N., Procter, R., \u0026amp; Shaw, S. (2017). Beyond adoption: A new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies. \u003cem\u003eJournal of Medical Internet Research, 19\u003c/em\u003e(11), e367. https://doi.org/10.2196/jmir.8775\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGross, J. J. (1998). The emerging field of emotion regulation: An integrative review. \u003cem\u003eReview of General Psychology, 2\u003c/em\u003e(3), 271\u0026ndash;299. https://doi.org/10.1037/1089-2680.2.3.271\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHochschild, A. R. (1983). \u003cem\u003eThe managed heart: Commercialization of human feeling.\u003c/em\u003e University of California Press.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolth, F., Walby, F., R\u0026oslash;stbakken, T., Lunde, I., Ringen, P. A., Ramleth, R. K., \u0026amp; Kvarstein, E. H. (2018). Extreme challenges: Psychiatric inpatients with severe self-harming behavior in Norway: A national screening investigation. \u003cem\u003eNordic Journal of Psychiatry, 72\u003c/em\u003e(8), 605\u0026ndash;612. https://doi.org/10.1080/08039488.2018.1511751\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eH\u0026oslash;gsted, R. (2018). \u003cem\u003eBelastningspsykologi i arbejdet med mennesker.\u003c/em\u003e Hans Reitzels Forlag.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuband, N., \u0026amp; Tantam, D. (2000a). Attitudes to self-injury within a group of mental health staff. \u003cem\u003eBritish Journal of Medical Psychology, 73\u003c/em\u003e(4), 495\u0026ndash;504. https://doi.org/10.1348/000711200160688\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuband, N., \u0026amp; Tantam, D. (2000b). Attitudes to self-injury: Survey of mental health professionals. \u003cem\u003eBritish Journal of Psychiatry, 176\u003c/em\u003e(5), 458\u0026ndash;462. https://doi.org/10.1192/bjp.176.5.458\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHviid, E. A., S\u0026oslash;ndergaard, J., \u0026amp; Gr\u0026oslash;nning, A. (Eds.). (2021). \u003cem\u003eRelationer i sundhedsv\u0026aelig;senet \u0026ndash; hvorfor og hvordan?\u003c/em\u003e Samfundslitteratur.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInternational Society for the Study of Self-Injury. (2022). \u003cem\u003eDefinition of NSSI.\u003c/em\u003e https://www.itriples.org/aboutnssi\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eH\u0026oslash;st Poulsen, K., Bach, B., Hjorth\u0026oslash;j, C., Simonsen, E., Austin, S. F., \u0026amp; Kongerslev, M. T. (2025). Measuring attitudes toward self-harm among mental health care staff: psychometric evaluation of the Self-Harm Antipathy Scale (SHAS) in Denmark. \u003cem\u003eNordic journal of psychiatry\u003c/em\u003e, 1\u0026ndash;7. Advance online publication. https://doi.org/10.1080/08039488.2025.2589478\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKlonsky, E. D., Victor, S. E., \u0026amp; Saffer, B. Y. (2014). Non-suicidal self-injury: What we know, and what we need to know. \u003cem\u003eCanadian Journal of Psychiatry, 59\u003c/em\u003e(11), 565\u0026ndash;568. https://doi.org/10.1177/070674371405901101\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeather, J. Z., O\u0026rsquo;Connor, R. C., Quinlivan, L., et al. (2020). Healthcare professionals\u0026rsquo; implementation of national guidelines with patients who self-harm. \u003cem\u003eJournal of Psychiatric Research, 130\u003c/em\u003e, 405\u0026ndash;411. https://doi.org/10.1016/j.jpsychires.2020.08.031\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eLewin, K. (1947).\u003c/span\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eFrontiers in group dynamics II: Channels of group life; social planning and action research\u003c/span\u003e. \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eHuman Relations, 1, 143\u0026ndash;153.\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLinehan, M. M. (1993). \u003cem\u003eCognitive-behavioral treatment of borderline personality disorder.\u003c/em\u003e Guilford Press.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManning, J. C., Carter, T., Latif, A., et al. (2017). \u0026ldquo;Our care through our eyes\u0026rdquo;: Impact of a co-produced digital educational programme on nurses\u0026rsquo; knowledge, confidence and attitudes in providing care for children and young people who have self-harmed. \u003cem\u003eBMJ Open, 7\u003c/em\u003e(4), e014750. https://doi.org/10.1136/bmjopen-2016-014750\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMenzies Lyth, I. (1960). A case study in the functioning of social systems as a defence against anxiety. \u003cem\u003eHuman Relations, 13\u003c/em\u003e(2), 95\u0026ndash;121. https://doi.org/10.1177/001872676001300201\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiller, C. J., Smith, S. N., \u0026amp; Pugatch, M. (2020). Experimental and quasi-experimental designs in implementation research. \u003cem\u003ePsychiatry Research, 283\u003c/em\u003e, 112452. https://doi.org/10.1016/j.psychres.2019.06.027\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM\u0026oslash;hl, B. (2019). \u003cem\u003eAssessment and treatment of non-suicidal self-injury: A clinical perspective.\u003c/em\u003e Routledge. https://doi.org/10.4324/9780429296352\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM\u0026ouml;ll, A., Kettunen, A., Hansson, L., et al. (2025). Perceived determinants of the use of coercion in inpatient mental health care: A qualitative study. \u003cem\u003eBMC Psychiatry, 25\u003c/em\u003e(1), 66. https://doi.org/10.1186/s12888-025-06690-x\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Institute for Health and Care Excellence. (2022). \u003cem\u003eSelf-harm: Assessment, management and preventing recurrence\u003c/em\u003e (NG225). https://www.nice.org.uk/guidance/ng225\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNawaz, R. F., Taylor, P. J., Tyrer, P., et al. (2021). Interventions to reduce self-harm on inpatient wards: A systematic review. \u003cem\u003eBJPsych Open, 7\u003c/em\u003e(3), e91. https://doi.org/10.1192/bjo.2021.54\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNielsen, A. B., Harder, S., \u0026amp; Lauridsen, S. (2020). The effect of Flexible Assertive Community Treatment (FACT) on psychiatric admissions and coercion. \u003cem\u003eNordic Journal of Psychiatry, 74\u003c/em\u003e(5), 367\u0026ndash;374. https://doi.org/10.1080/08039488.2020.1743693\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRing, D., \u0026amp; Lawn, S. (2019). Stigma perpetuation at the interface of mental health care: A review to compare patient and clinician perspectives of stigma and borderline personality disorder. \u003cem\u003eJournal of Mental Health, 28\u003c/em\u003e(5), 505\u0026ndash;514. https://doi.org/10.1080/09638237.2019.1581337\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatterson, P., Whittington, R., \u0026amp; Bogg, J. (2007). Testing the effectiveness of an educational intervention aimed at changing attitudes to self-harming patients. Journal of Psychiatric and Mental Health Nursing, 14(1), 100\u0026ndash;105. https://doi.org/10.1111/j.1365-2850.2007.01052.x\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePenfold, R. B., \u0026amp; Zhang, F. (2013). Use of interrupted time series analysis in evaluating health care quality improvements. \u003cem\u003eAnnals of Internal Medicine, 158\u003c/em\u003e(5 Pt. 2), 413\u0026ndash;418. https://doi.org/10.7326/0003-4819-158-5-201303051-00006\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePinnock, H., Barwick, M., Carpenter, C. R., Eldridge, S., Grandes, G., Griffiths, C. J., Heaton, J., Howick, J. B., Lucas, P. J., Meissner, P., Murray, E., Patel, A., Sheikh, A., \u0026amp; Taylor, S. J. C. (2017). Standards for Reporting Implementation Studies (StaRI) statement. \u003cem\u003eBMJ, 356\u003c/em\u003e, i6795. https://doi.org/10.1136/bmj.i6795\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRayner, G., Allen, S. L., \u0026amp; Johnson, M. (2019). Causal attributions for self-harm: A systematic review and synthesis of qualitative literature. \u003cem\u003eJournal of Affective Disorders, 252\u003c/em\u003e, 314\u0026ndash;323. https://doi.org/10.1016/j.jad.2019.04.021\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRayner, G., Blackburn, J., Edward, K., et al. (2019). Emergency department nurses\u0026rsquo; attitudes towards patients who self-harm: A meta-analysis. \u003cem\u003eInternational Journal of Mental Health Nursing, 28\u003c/em\u003e(1), 40\u0026ndash;53. https://doi.org/10.1111/inm.12503\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eR\u0026oslash;ssberg, J. I., \u0026amp; Friis, S. (2003). A suggested revision of the Ward Atmosphere Scale. \u003cem\u003eActa Psychiatrica Scandinavica, 108\u003c/em\u003e(5), 374\u0026ndash;380. https://doi.org/10.1034/j.1600-0447.2003.00191.x\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkivington, K., Matthews, L., Simpson, S. A., Craig, P., Baird, J., Blazeby, J. M., Boyd, K. A., Craig, N., French, D. P., McIntosh, E., Petticrew, M., Rycroft-Malone, J., White, M., \u0026amp; Moore, L. (2021). A new framework for developing and evaluating complex interventions: Update of Medical Research Council guidance. \u003cem\u003eBMJ, 374\u003c/em\u003e, n2061. https://doi.org/10.1136/bmj.n2061\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTapola, V., Wahlstr\u0026ouml;m, J., \u0026amp; Lappalainen, R. (2016). \u003cem\u003eEffects of training on attitudes of psychiatric personnel towards patients who self-injure.\u003c/em\u003e Nursing Open, 3(3), 140\u0026ndash;151. https://doi.org/10.1002/nop2.45\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomas, J. B., Shaw, J., Hemming, R., et al. (2023). How people who self-harm negotiate the inpatient environment: The mental-healthcare workers\u0026rsquo; perspective. \u003cem\u003eJournal of Psychiatric and Mental Health Nursing, 30\u003c/em\u003e(6), 1455\u0026ndash;1466. https://doi.org/10.1111/jpm.12977\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTimmermans, S., \u0026amp; Berg, M. (2003). \u003cem\u003eThe gold standard: The challenge of evidence-based medicine and standardization in health care.\u003c/em\u003e Temple University Press.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTracy, S. J. (2005). Locking up emotion: Moving beyond dissonance for understanding emotion labor discomfort. \u003cem\u003eCommunication Monographs, 72\u003c/em\u003e(3), 261\u0026ndash;283. https://doi.org/10.1080/03637750500206474\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVarga, S., Latham, A. J., \u0026amp; Machery, E. (in press). \u0026ldquo;They had it coming!\u0026rdquo; The effect of moral character on somatic and mental health judgments. \u003cem\u003eRoyal Institute of Philosophy Supplements\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVandamme, A., Dierckx, B., Claes, C., et al. (2021). The role of implicit and explicit staff attitudes in the use of coercion: A cross-sectional study. \u003cem\u003eFrontiers in Psychiatry, 12\u003c/em\u003e, 699446. https://doi.org/10.3389/fpsyt.2021.699446\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evon Elm, E., Altman, D. G., Egger, M., Pocock, S. J., G\u0026oslash;tzsche, P. C., Vandenbroucke, J. P., \u0026amp; STROBE Initiative. (2007). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. \u003cem\u003eAnnals of Internal Medicine, 147\u003c/em\u003e(8), 573\u0026ndash;577. https://doi.org/10.7326/0003-4819-147-8-200710160-00010\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalle, M. F., Langvik, M. H., Jessen, R. S., \u0026amp; St\u0026auml;nicke, L. I. (2025). Sharing, carrying, and tolerating the pain: A meta-synthesis of clinicians\u0026rsquo; experiences from working with adolescents who self-harm. \u003cem\u003ePsychotherapy Research\u003c/em\u003e, 1\u0026ndash;14. https://doi.org/10.1080/10503307.2025.2481604\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZarska, A., Barnicot, K., Lavelle, M., Dorey, T., \u0026amp; McCabe, R. (2023). \u003cem\u003eA systematic review of training interventions for emergency department providers and psychosocial interventions delivered by emergency department providers for patients who self-harm.\u003c/em\u003e Archives of Suicide Research, 27(3), 829\u0026ndash;850. https://doi.org/10.1080/13811118.2022.2071660\u003c/span\u003e\u003c/li\u003e\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":"borderline-personality-disorder-and-emotion-dysregulation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bded","sideBox":"Learn more about [Borderline Personality Disorder and Emotion Dysregulation](http://bpded.biomedcentral.com)","snPcode":"40479","submissionUrl":"https://submission.nature.com/new-submission/40479/3","title":"Borderline Personality Disorder and Emotion Dysregulation","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Self-harm, Non-suicidal self-injury, Staff training, Coercion, Restraint, Inpatient psychiatry, Implementation, Attitudes, Interrupted time series","lastPublishedDoi":"10.21203/rs.3.rs-8609540/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8609540/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStaff education may improve clinicians’ attitudes toward self-harm, but whether this translates into reduced coercion is unclear. We evaluated a regional strategy to improve care for self-harming patients and its impact on staff attitudes and coercive interventions across services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuasi-experimental dual design: (a) interrupted time-series of registry data on coercive interventions (Jan 2021–Dec 2024) and (b) three-wave pre–post surveys using the revised 17-item Self-Harm Antipathy Scale (SHAS-DR) at baseline, 2 months, and 8 months post-training. Change points: June 2022 (strategy announcement) and June 2023 (training implementation).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAttitudes improved and were sustained. Mean SHAS-DR decreased from 40.0 (SD 10.8) at baseline to 34.8 (SD 7.4) at 2 months and 35.4 (SD 8.2) at 8 months; baseline-to-follow-up changes were significant (p ≤ .001). In registry data, coercive interventions declined after the strategy announcement (level IRR 0.39, 95% CI 0.21–0.73) with no subsequent trend change. A temporary increase occurred at the training point (level IRR 2.58, 95% CI 1.57–4.25), consistent with implementation disruption. Reductions were largest for mechanical restraints, particularly among self-harming patients, while rapid tranquillization remained most frequent. Annual coercive episodes fell from 1,280 (2021) to 409 (2024).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe strategy coincided with an immediate reduction in coercion and a transient rise during training, while staff attitudes became more positive. Sensitivity analyses suggested changes were not driven by high-frequency patients. Sustained reductions likely require continued organizational and relational supports.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Does Changing Clinicians’ Attitudes Toward Self-Harm Reduce Coercive Interventions in Mental Health Inpatient Settings? A Quasi-Experimental Study of Staff Training","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-23 00:36:18","doi":"10.21203/rs.3.rs-8609540/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-17T11:47:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-16T13:27:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"86907094627714128078132835915179271215","date":"2026-02-23T15:29:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-27T11:51:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"100721291908601855283271437936224503465","date":"2026-01-20T17:15:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-20T16:10:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-16T10:56:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-16T01:11:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"Borderline Personality Disorder and Emotion Dysregulation","date":"2026-01-15T10:17:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"borderline-personality-disorder-and-emotion-dysregulation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bded","sideBox":"Learn more about [Borderline Personality Disorder and Emotion Dysregulation](http://bpded.biomedcentral.com)","snPcode":"40479","submissionUrl":"https://submission.nature.com/new-submission/40479/3","title":"Borderline Personality Disorder and Emotion Dysregulation","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0da52956-2562-41a3-8680-219262c5ed6e","owner":[],"postedDate":"January 23rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-17T06:39:29+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-23 00:36:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8609540","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8609540","identity":"rs-8609540","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}