Getting it right: caring for people who self-harm

The treatment received in emergency departments by people who self-harm depends to a great extent on the behaviour of staff and how this is perceived by service users. In this article, a long-time service user describes how she was pleasantly surprised by the attitudes of the emergency nurses and doctors who cared for her after she had self-harmed.

Safer self-injury or assisted self-harm?

Psychiatric patients may try (or express a desire) to injure themselves in hospital in order to cope with overwhelming emotional pain. Some health care practitioners and patients propose allowing a controlled amount of self-injury to occur in inpatient facilities, so as to prevent escalation of distress. Is this approach an example of professional assistance with harm? Or, is the approach more likely to minimise harm, by ensuring safer self-injury? In this article, I argue that health care practitioners who use harm-minimisation can be considered to be helping physical injury to occur, although they do not encourage the act. I consider why there are compelling reasons to believe that a patient who self-injures is not maximally autonomous in relation to that choice. However, I then move onto argue that allowing a degree of self-injury may enable engagement with psychotherapy (enhancing autonomy) and behavioural change. In these circumstances, allowing injury (with precautions) may not be harm, all things considered.

A grounded theory exploration of deliberate self-harm in incarcerated women

The purpose of this study was to explicate a definition of deliberate self-harm (DSH) and present a model that illustrates the DSH process as experienced by incarcerated women. Grounded theory was used to guide the collection and analysis of data. A circular process of DSH emerged. For the incarcerated women in this study anxiety caused a visceral build-up of tension that reached a critical level necessitating a need to act in some way to gain relief. DSH supplied the mechanism by which overwhelming tension was released. The temporary relief, however, was soon supplanted by the negative consequences of disciplinary detention imposed as a means of punishment that in turn, lead to more anxiety and anger.

IMPLICATIONS

Nurses practicing in corrections need to work towards "decriminalizing" DSH and to develop a prison protocol that gives nurses permission to "just listen" and incarcerated women permission to "just talk" without fear of reprisal.

Self-injury behavior: how can nurses help?

Although historical, religious, and cultural examples provide some understanding of SIB, the importance of further research, especially in adolescent SIB, cannot be underestimated. Nursing research is needed to explore the correlation between SIB and the spiritual needs of adolescents. Shannon (2005) stated that SIB is a common precursor to suicide. If adolescents at risk for this behavior are identified earlier, perhaps fewer teens will be lost to suicide. Although many use self-injury as short-term relief from their problems, it is repetitive in nature. If nurses are able to assist adolescents in interrupting emerging patterns of SIB, future self-injury may be prevented. Adolescents at risk for self-injury behavior are searching for a way to give voice to their pain. When approached with a caring attitude that reflects the love of Christ, when listened to with intentionality, and when nurtured by an authentic presence, self-injurers are relieved to externalize their difficult emotions through verbal means rather than to record their pain with visible stories on their skin. For even when the wounds heal, the scars remain a visible reminder of the hurt hiding within. In essence, the history of the self-injurer is recorded on their skin.

Self-neglect. 2: Nursing assessment and management

This is a two-part unit on self-neglect. Part 1 examined definitions of the phenomenon, its characteristics and risk factors. This article, part 2, discusses nurses' role in the identification and assessment of self-neglect. Due to its complex nature, a multi-agency and multidisciplinary approach is required to meet and protect the needs of vulnerable adults.

Deliberate self-harm: emergency department nurses? attitudes, triage and care intentions

AIM AND OBJECTIVES

This exploratory study investigates emergency department nurses' attitudes towards patients who engage in deliberate self-harm. It examines their attitudes towards, and triage and care decisions with, patients who self-harm.

BACKGROUND

Emergency department nurses sometimes show unsympathetic attitudes towards patients who present with self-harm and these can contribute to difficulties in assessing and providing appropriate care.

DESIGN

A modified version of the Suicide Opinion Questionnaire was used. A non-probability sample of 43 emergency department nurses from a large Australian hospital participated in the study. Data were analysed using SPSS.

RESULTS

Most nurses had received no educational preparation to care for patients with self-harm; over 20% claimed that the department either had no practice guidelines for deliberate self-harm or they did not know of their existence and one-third who knew of them had not read them. Overall, nurses had sympathetic attitudes towards patients who self-harm, including both professional and lay conceptualizations of deliberate self-harm. They did not discriminate against this group of patients in their triage and care decisions.

CONCLUSIONS

The findings of this exploratory study are important because attitudes can affect care decisions. Recommendations are made for improving the educational preparation of emergency department nurses, for improving awareness and implementation of practice guidelines, and for improving attitudes towards patients with deliberate self-harm. Further research is needed to confirm these results.

'Then I just showed her my arms . . .' Bodily sensations in moments of alienation related to self-injurious behaviour. A hermeneutic phenomenological study

People committing self-injurious behaviour are often perceived as difficult patients; confronted with unhelpful reactions from nurses, the patients find themselves left alone in their distress. A connection between self-injurious behaviour and feelings of alienation is suggested in the literature. Alienation is described as a state in which the self is perceived as strange, machinelike and not in contact with its emotional and physical needs. On one hand, complex neuro-biological processes are seen as responsible for this; on the other hand, alienation is seen as a means of self-protection when one is exposed to a threatening or traumatic situation. Nursing interventions focus on the nurse-patient relationship and on the handling of self-injuries, but they tend to ignore the client's previous experience. Proceeding from the assumption that patients committing self-injurious behaviour are the experts on their own harm, the purpose of the present study is to get insight into their 'lived experience' and to contribute to the understanding of this vulnerable group. Adopting a hermeneutic phenomenological research perspective, methods of participant observation and qualitative interviewing were chosen to generate data. The database consists of 99 observational sequences, five interviews and a set of email texts written by a self-injuring woman. A thematic analysis as described by Van Manen was done. The main findings are that alienation is experienced in several stages, that nurses can detect early signs of an impending loss of control, and that self-injurious behaviour is an effective strategy to end a painful experience of alienation. Self-injurious behaviour is appropriately understood as a form of 'self-care'.

Measuring nurse attitudes towards deliberate self-harm: the Self-Harm Antipathy Scale (SHAS)

Most mental health nurses engage at some point with clients who harm themselves and these nurses often experience strong negative emotional reactions. Prolonged engagement with relapsing clients can lead to antipathy, and 'malignant alienation'. The study reported here has the aim of developing a brief, robust instrument for assessing nurse attitudes in this area. The Self-Harm Antipathy Scale, developed here on a sample of 153 healthcare professionals, has 30 attitudinal items with six factors. It has acceptable face validity, good internal consistency and some evidence of good test-retest reliability. It discriminates effectively between criterion groups. Overall this is evidence for the complexity of nurses' responses to this client group but such complex attitudes can still be assessed using a relatively brief structured instrument.

Care staff attributions toward self-injurious behaviour exhibited by adults with intellectual disabilities

Challenging behaviours may elicit negative emotional reactions and increase stress within care staff. The Leeds Attributional Coding System (LACS) was used to elicit spontaneous causal attributions of staff toward hypothetical clients with challenging behaviours. It was hypothesized that there would be relationships (1) between staff exposure to challenging behaviours and burnout, and (2) between staff cognitions and burnout. Using a cross-sectional correlational design, 41 care staff took part in a 10 minute interview about two vignettes depicting self-injurious behaviour. Staff also completed measures of demographic information and burnout. Participants made attributions toward self-injurious behaviour that were typically internal to the client, uncontrollable, unstable and specific. There was a significant association between number of clients cared for and emotional exhaustion and personal accomplishment. Staff who made fewer stable attributions had higher levels of burnout. There were no other relationships found between staff cognition and burnout. The LACS can be successfully employed in this context, and may have some benefits over other methods. Future research is required to explore the relationship between cognition and burnout.

Testing the effectiveness of an educational intervention aimed at changing attitudes to self-harm

Nurses' attitudes toward service users who repeatedly self-harm can be negative and may interfere with the user's willingness to engage with services. The effectiveness of an educational intervention aimed at improving nurses' attitudes in this area was tested in this study. The intervention consisted of attendance on an accredited course on self-harm over a period of 15 weeks and the outcome of interest was attitudes as measured by the Self Harm Antipathy Scale. When deployed in a before-and-after design with two non-randomly allocated groups, there was evidence of a 20% reduction in antipathy toward self-harm among course attenders maintained over a period of at least 18 months (compared with a 9% reduction in a comparison group). Three of the six Self Harm Antipathy Scale attitude dimensions showed significant short-term change with some further long-term effects. This is preliminary evidence for the effectiveness of the chosen intervention in reducing overall antipathy toward self-harm clients and enhancing a sense of competence, a valuing of the care process and an awareness of the factors contributing to self-harm.

Pragmatism rules: the intervention and prevention strategies used by psychiatric nurses working with non-suicidal self-harming individuals

Self harm in the absence of expressed suicidal intent is an under explored area in psychiatric nursing research. This paper reports on findings of a study undertaken in two acute psychiatric inpatient units in Ireland. The purpose of the study was to gain an understanding of the practices of psychiatric nurses in relation to people who self harm, but who are not considered suicidal. Semi structured interviews were held with eight psychiatric nurses. Content analysis revealed several themes. For the purpose of this paper the prevention and intervention strategies psychiatric nurses engage in when working with non-suicidal self harming individuals are presented. Recommendations for further research are offered.

Junior staffing changes and the temporal ecology of adverse incidents in acute psychiatric wards

AIM

This paper reports an examination of the relationship between adverse incident rates, the arrival of new junior staff on wards, and days of the week on acute psychiatric wards.

BACKGROUND

Incidents of violence, absconding and self-harm in acute inpatient services pose risks to patients and staff. Previous research suggests that the arrival of inexperienced new staff may trigger more adverse incidents. Findings on the relationship between incidents and the weekly routine are inconsistent.

METHOD

A retrospective analysis was conducted of formally reported incident rates, records of nursing student allocations and junior doctor rotation patterns, using Poisson Regression. Variance between days of the week was explored using contingency table analysis. The data covered 30 months on 17 psychiatric wards, and were collected in 2002-2004.

FINDINGS

The arrival of new and inexperienced staff on the wards was not associated with increases in adverse incident rates. Most types of incidents were less frequent at weekends and midweek. Incident rates were unchanged on ward-round days, but increased rates were found on the days before and after ward rounds.

CONCLUSION

Increased patient tension is associated with raised incident rates. It may be possible to reduce incident rates by moderating stimulation in the environment and by mobilizing support for patients during critical periods.

Adverse incidents, patient flow and nursing workforce variables on acute psychiatric wards: the Tompkins Acute Ward Study

BACKGROUND

Adverse incidents (violence, self-harm and absconding) can cause significant harm to patients and staff, are difficult to predict, and are driving an increase in security measures and defensive practice.

AIMS

To explore the relationship between adverse incidents on acute psychiatric wards, admissions and nursing workforce variables.

METHODS

A retrospective analysis of officially collected data covering a period of 30 months on 14 acute wards at three hospitals. This data included 69 serious untoward incidents.

RESULTS

Adverse incidents were more likely during and after weeks of high numbers of male admissions, during weeks when other incidents also occurred, and during weeks of high regular staff absence through leave and vacancy.

CONCLUSIONS

It may be possible to predict adverse incidents. Careful staff management and deployment may reduce the risks.

Assessment of risk and special observations in mental health practice: a comparison of forensic and non-forensic settings

The use of special observations in psychiatric practice may be employed as an alternative to more restrictive methods such as the use of seclusion and restraint. From the literature, special observations are used for a complex array of signs and symptoms (and risk behaviours) which include suicidal intent, self-injurious behaviour, hallucinatory experiences, and absconding. This paper reports on research into the use of special observations in both forensic and non-forensic psychiatric settings. A comparative approach was adopted to establish if the perceived risk factors leading to the adoption of special observations were similar in both settings. Three groups of nursing staff were requested to assess 30 patients who were placed on special observations. Before this, nurses were requested to rate the risk factors in terms of their severity on a 7-point Likert scale. The rank-ordering analysis revealed a similarity of identified risk factors and anova (one-way, unrelated) and the Jonckheere Trend Test revealed that there were significant differences between the scores in the forensic and the non-forensic settings. The statistical differences existed for risk factors relating to harm to self and others but not for psychiatric symptomatology.

Understanding psychiatric nursing care with nonsuicidal self-harming patients in acute psychiatric admission units: the views of psychiatric nurses

Self-harm in the absence of suicidal intent is an underexplored area in psychiatric nursing research. This article reports on findings of a study undertaken in two acute psychiatric admission units in Ireland. The purpose of this study was to gain an understanding of the practices of psychiatric nurses in relation to people who self-harm but who are not considered suicidal. Semistructured interviews were held with eight psychiatric nurses. Content analysis revealed several themes, some of which will be presented and discussed in this article, namely, the participants' understanding of self-harm, their approach to care, and factors in the acute psychiatric admission setting, which impacted on their care. Recommendations for further research are offered.

Suicide and Documentation: Don’t Let the Pen Kill Your Career

1. Nurses' notes must reflect the assessment performed regarding their patients' risk factors, red flags, and protective supports, especially for suicidal patients. 2. Nursing interventions range from the least-restrictive methods to full restraints, if necessary to prevent patients from harming themselves. 3. Medications, such as antidepressant, antipsychotic, and antimanic agents, as well as benzodiazepines, have been shown to help psychiatric patients cope with depression, psychosis, and mood stability.