Student thesis: Phd


Background: The prevalence of self-harm has increased dramatically, resulting in a growing proportion of healthcare professionals that encounter patients who self-harm. National guidance is available for healthcare professionals that assess and manage self-harm, but uptake of these guidelines is low. Poor adherence to the guidance generates substantial risks for vulnerable patients, but few theory-based strategies exist to enable best practice. The principal objective of this research was to use a ground-up approach to develop a quality improvement intervention to increase implementation of national guidance for self-harm. Methods: A combined quantitative and qualitative methodological approach was used to identify a target population and understand the behavioural drivers of following the NICE guidelines for self-harm. A cross-sectional online survey was undertaken to collect data from a large, nationally representative sample of UK healthcare professionals (n = 1020). The survey explored awareness of the self-harm guidance, and measured potential determinants of guideline implementation. Follow-up interviews (n = 33) were analysed using the Theoretical Domains Framework to gain a deeper understanding of the barriers and enablers that influenced primary care professionals' capacity to follow the guidelines. The results were synthesised using the Behaviour Change Wheel approach to intervention design to select candidate intervention functions and behaviour change techniques. Results: The survey identified a lack of awareness of the guidelines, particularly among healthcare professionals that do not work in mental health settings. Half of respondents failed to implement the guidelines when they encountered a patient at risk of self-harm due to low automatic motivation (i.e.: habits) and few physical opportunities (i.e.: environmental restrictions). However, healthcare professionals had high capabilities (i.e.: knowledge and skills) to follow the guidance, corresponding with the observed association between guideline implementation and prior training and knowledge about self-harm. Primary care was identified as an appropriate target for intervention, due to the high recorded incidence of self-harm in this setting. Analysis of interviews with GPs (n = 21) and primary care nurses (n = 12) revealed a need for further knowledge about self-harm risk factors, and interpersonal skills training to help navigate high-pressure consultations in a sensitive manner. In addition to information and skills provision, the results implied that primary care professionals require interventions that address clinical uncertainty about assessing and managing self-harm to bolster their professional confidence (i.e.: beliefs about capabilities; professional role and identity). Modifications to the format of the NICE guidelines, and supporting resources such as reminder prompts are warranted to overcome perceptions that the guidelines are inaccessible and distracting during patient interactions (i.e.: memory, attention and decision processes; environmental context and resources). Conclusions: This research challenges traditional approaches to healthcare professional behaviour change by positing that education and training interventions are insufficient; implementation strategies must also support healthcare professionals' capabilities, opportunities, and motivations using appropriate intervention functions and behaviour change techniques for sustained adherence to national self-harm guidance. Future research should aim to test the acceptability and effectiveness of the candidate interventions outlined within this thesis to facilitate evidence-based practice for self-harm.
Date of Award1 Aug 2022
Original languageEnglish
Awarding Institution
  • The University of Manchester
SupervisorStephen Campbell (Supervisor), Navneet Kapur (Supervisor) & Christopher Arden Armitage (Supervisor)


  • general practice
  • implementation
  • primary care
  • evidence based guidelines
  • self-harm
  • intervention development
  • national guidelines
  • behaviour change wheel

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