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

A systematic review and thematic synthesis of inpatient nursing staff experiences of working with high-risk patient behaviours

INTRODUCTION

Nursing staff are frequently exposed to high-risk patient behaviours within inpatient health services, yet staff commonly report a lack of training and support in managing these behaviours.

AIM

The aim of the study was to examine nursing staff experiences of high-risk behaviours in inpatient mental health settings.

METHODS

Four electronic databases (CINAHL, Medline, PsycINFO, EMBASE) were searched. The protocol for this review was prospectively registered in PROSPERO (Ref: CRD42022334739). A meta-synthesis of nursing staff's experiences of high-risk behaviours in inpatient mental health settings was conducted.

RESULTS

We identified 30 eligible studies. Six themes were constructed from the meta-synthesis: the social contract of care; the function of risk behaviours; the expectation of risk; risk as a relational concept; navigating contradictions in care; the aftermath.

DISCUSSION

Nursing staff conceptualize risk as a meaningful behaviour shaped by patient, staff and environmental factors. Managing risk is an ethical dilemma for nursing staff and they require more training and support in ethical risk decision-making.

IMPLICATIONS FOR PRACTICE

Inpatient mental healthcare services should formulate and manage risk as a relational concept comprising staff, patient and environmental factors. Future research and clinical practice should place further consideration on the varied experiences of different types of risk behaviours.

RELEVANCE STATEMENT

Nursing staff are frequently exposed to high-risk patient behaviours within inpatient health services, yet staff commonly report a lack of training and support in managing these behaviours. This systematic review offers insights into how high-risk behaviours are experienced by nursing staff and makes recommendations about how to improve the understanding and management of them. Inpatient mental healthcare services should formulate and manage risk as a relational concept comprising staff, patient and environmental factors. Future research and clinical practice should place further consideration on the varied experiences of different types of risk behaviours.

Development and Validation of the 'Self-Efficacy in Dealing with Self-Harm Questionnaire' (SEDSHQ)

Clinicians find it challenging to engage with patients who engage in self-harm. Improving the self-efficacy of professionals who treat self-harm patients may be an important step toward accomplishing better treatment of self-harm. However, there is no instrument available that assesses the self-efficacy of clinicians dealing with self-harm. The aim of this study is to describe the development and validation of the Self-Efficacy in Dealing with Self-Harm Questionnaire (SEDSHQ). This study tests the questionnaire's feasibility, test-retest reliability, internal consistency, content validity, construct validity (factor analysis and convergent validity) and sensitivity to change. The Self-Efficacy in Dealing with Self-Harm Questionnaire is a 27-item instrument which has a 3-factor structure, as found in confirmatory factor analysis. Testing revealed high content validity, significant correlation with a subscale of the Attitude Towards Deliberate Self-Harm Questionnaire (ADSHQ), satisfactory test-retest correlation and a Cronbach's alpha of 0.95. Additionally, the questionnaire was able to measure significant changes after an intervention took place, indicating sensitivity to change. We conclude that the present study indicates that the Self-Efficacy in Dealing with Self-Harm Questionnaire is a valid and reliable instrument for assessing the level of self-efficacy in response to self-harm.

Coercive containment measures for the management of self-cutting versus general disturbed behaviour: Differences in use and attitudes among mental health nursing staff

Self-harm is common in mental health facilities, and coercive containment measures are sometimes used to manage it. Nurses' attitudes towards these measures have been investigated in relation to disturbed behaviour in general, but rarely to self-harm specifically. We therefore investigated mental health nurses' use of and attitudes towards coercive measures (seclusion, restraint, intermittent and constant observations, forced intramuscular medication, and PRN medication) for self-cutting management compared with for disturbed behaviours in general using a cross-sectional, repeated measures survey design. Participants were N = 164 mental health nursing staff. Data collection was via a questionnaire comprising validated attitudinal measures. The study is reported in line with STROBE guidelines. Physical restraint (36.6%), forced intramuscular medication (32.3%) and seclusion (48.2%) had reportedly been used by individuals for self-cutting management. Respondents disapproved of using each coercive measure for self-cutting more than they did for disturbed behaviour in general with the exception of PRN medication. Attitudes to coercive measures differed across target behaviours. Hence, nurses who had used each measure for managing self-cutting disapproved of it less for that purpose than those who had not. Nurses who had used coercive techniques for self-cutting management had less desirable attitudes to their use. We cannot say whether prior use of these techniques led to increased approval or whether greater approval led to an increased willingness to use them. Reducing the use of coercive techniques for self-harm will require attitudes that support its use to be challenged. Less coercive techniques should be encouraged. Harm reduction techniques offer one such alternative.

'There is no progression in prevention' - The experiences of mental health nurses working with repeated self-harm

Caring for people who self-harm is an everyday experience for mental health nurses and an important part of their role. How mental health nurses respond to and support those who self-harm can have a significant impact on the outcomes for service users and their intentions to seek help in the future. Repeated self-harm can be a particularly challenging phenomenon as it is often misunderstood and can have a negative impact on the therapeutic relationship. This qualitative descriptive study aims to explore how mental health nurses understand and work with repeated self-harm. Nine nurses working in a range of mental health settings within one service participated in semi-structured interviews which were analysed thematically. Findings are presented in two themes exploring participants' perceptions and understanding of repeated self-harm, and the process of learning to work with repeated self-harm, and are reported in accordance with the consolidated criteria for reporting qualitative research guidelines (COREQ). Participants reported that nursing practice relating to repeated self-harm remains largely focused on maintenance of safety and prevention of self-harm despite the identification that this often does not work. It was accepted that there is sometimes a lack of understanding about the function of self-harm; however, participants reported understanding increased following specific education about self-harm. Participants also identified the potential for more empowering and recovery-orientated responses, including the utilization of harm reduction approaches, to the care of those who repeatedly self-harm.

Harm-reduction approaches for self-cutting in inpatient mental health settings: Development and preliminary validation of the Attitudes to Self-cutting Management (ASc-Me) Scale

WHAT IS KNOWN ON THE SUBJECT?: Nurses in mental health inpatient settings use a range of methods to try and help service users who self-harm Harm-reduction approaches are intended to help service users reduce the impact of their self-harm rather than simply to prevent them self-harming Harm-reduction techniques might be helpful for people who cut themselves because there are some clear ways harm can be minimized such as providing advice about cutting No one has previously tried to measure whether harm-reduction techniques are more or less acceptable to mental health practitioners and service users than traditional methods. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper describes the development of the Attitudes to Self-cutting Management scale. It met the criteria required of a good measurement tool. Each method of managing self-cutting has a unique acceptability profile Harm-reduction methods like advising on wound care and providing a first aid kit are endorsed by nurses and former service users Nurses providing sterile razors or remaining present during self-cutting attract more divergent opinions but are preferred to seclusion and restraint. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses should talk through the approaches to management with service users and agree which techniques are preferred. ABSTRACT: Introduction Harm-reduction approaches for self-harm in mental health settings have been under-researched. Aim To develop a measure of the acceptability of management approaches for self-cutting in mental health inpatient settings. Methods Stage one: scale items were generated from relevant literature and staff/service user consultation. Stage two: A cross-sectional survey and statistical methods from classical test theory informed scale development. Results/Findings At stage one, N = 27 staff and service users participated. At stage two, N = 215 people (n = 175 current mental health practitioners and n = 40 people with experience of self-cutting as a UK mental health inpatient) completed surveys. Principal components analysis revealed a simple factor structure such that each method had a unique acceptability profile. Reliability, construct validity and internal consistency were acceptable. The harm-reduction approaches "advising on wound care" and "providing a first aid kit" were broadly endorsed; "providing sterile razors" and "maintaining a supportive nursing presence during cutting" were less acceptable but more so than seclusion and restraint. Discussion The Attitudes to Self-cutting Management scale is a reliable and valid measure that could inform service design and development. Implications for practice Nurses should discuss different options for management of self-cutting with service users. Harm-reduction approaches may be more acceptable than coercive measures.

How people who self-harm negotiate the inpatient environment: the mental healthcare workers perspective

WHAT IS KNOWN ABOUT THE SUBJECT?: Self-harm plays a function, commonly in the form of distress management. There has been little focussed exploration of how individuals who use self-harm to manage distress cope when prevented from self-harm in an inpatient environment and how staff respond to this issue.

WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE

This paper uses the experiences of mental health staff to add to the existing knowledge that self-harm has a functional role and supports the notion that interventions for self-harm should focus on the origins of distress. It describes the potential consequences that focussing on prevention of self-harm as opposed to actually managing distress may have on service-users, how staff attempt to manage these consequences and factors that may impact on staff interventions to prevent further distress/harm. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The findings suggest that mental healthcare staff should aim to understand the function of self-harm, use this understanding to develop an individualized care plan with the aim of managing distress and identify barriers to the effectiveness of the interventions so they can be worked around.

ABSTRACT

Introduction Literature describes self-harm as functional and meaningful. This creates difficulties for service-users detained in an inpatient environment where self-harm is prevented. Aim Mental healthcare staff were interviewed to build on existing evidence of issues with the prevention approach and explore, from a staff perspective, how self-harm prevention impacts on service-users, how they manage distress and how this impacts on staff and their approach to care. Methods Qualitative methods were used to allow unexpected themes to arise. Ten semi-structured interviews were carried out with mental healthcare staff and thematically analysed. Findings and discussion The findings provide new evidence on the benefits and limitations of the inpatient environment for individuals who self-harm. Findings indicate that being unable to self-harm can lead to a continuation of distress and subsequent potentially harmful attempts to manage distress. Staff described experiencing a struggle for control in preventing self-harm, leading to increasingly harmful methods of self-harm. Alternatively some staff were able to support service-users with distress management. We discuss factors influencing which of these 'paths' service-users followed. Implications Considerations for care planning including understanding self-harm, using individualized care planning and attending to barriers are outlined with the ultimate aim of reducing distress and the impact of prevention of self-harm.

Hospital staff experiences of their relationships with adults who self-harm: A meta-synthesis

PURPOSE

This review aimed to synthesize qualitative literature exploring inpatient hospital staff experiences of their relationships with people who self-harm.

METHODS

Nine studies were identified from a systematic search of five research databases. Papers included the experiences of physical health and mental health staff working in inpatient settings. The studies employed various qualitative research methods and were appraised using an adapted quality assessment tool (Tong, Sainsbury, & Craig, 2007). A meta-synthesis was conducted using traditional qualitative analysis methods including coding and categorizing data into themes.

RESULTS

Three main themes derived from the data. 'The impact of the system' influenced the extent to which staff were 'Fearing the harm from self-harm', or were 'Working alongside the whole person'. A fear-based relationship occurred across mental health and physical health settings despite differences in training; however, 'Working alongside the whole person' primarily emerged from mental health staff experiences. Systemic factors provided either an inhibitory or facilitative influence on the relational process.

CONCLUSIONS

Staff experiences of their relationship with people who self-harm were highlighted to have an important impact on the delivery and outcome of care. Increasing support for staff with a focus on distress tolerance, managing relational issues, and developing self-awareness within the relationship may lead to a more mutually beneficial experience of care. Equally, structure, clarity, and support within inpatient systems may empower staff to feel more confident in utilizing their existing skills.

PRACTITIONER POINTS

Working with people who self-harm can be emotionally challenging and how staff cope with this can significantly impact on the engagement of staff and patients. Increasing the skills of staff in managing relational issues and tolerating distress, as well as providing support and reflective practice groups may be useful in managing emotional responses to working with people who self-harm. Refining the supportive, procedural, and environmental structures surrounding the caregiving relationship may help enable better integration of physical and mental health care.

Mental Health Nurses' Experiences of Caring for Suicidal Patients in Psychiatric Wards: An Emotional Endeavor

The purpose of the study is to investigate mental health nurses' experiences of recognizing and responding to suicidal behavior/self-harm and dealing with the emotional challenges in the care of potentially suicidal inpatients. Interview data of eight mental health nurses were analyzed by systematic text condensation. The participants reported alertness to patients' suicidal cues, relieving psychological pain and inspiring hope. Various emotions are evoked by suicidal behavior. Mental health nurses seem to regulate their emotions and emotional expressions, and balance involvement and distance to provide good care of patients and themselves. Mental health nurses have an important role and should receive sufficient formal support.

Nurses' attitudes towards self-harm: a literature review

People who self-harm experience many problems and needs related to management of emotional and practical stress. A positive attitude among nurses is especially important given the close contact they have with people who self-harm. This article is based on a review of the literature. It includes articles that concern both general and mental health nurses who work in various healthcare settings (e.g. acute inpatients wards, community mental health, emergency departments and medical admission units). The literature shows that negative attitudes towards self-harm are common among nurses. It remains unclear how nurses' age, work experience and gender influence their attitudes. The setting in which nurses work appears to influence their attitude, as does their level of qualification. For example, mental health nurses appear to have more positive attitudes than general nurses. Nurses' attitudes can be improved with the help of education comprising reflective and interactive elements. Supervision and support from colleagues appear to be especially important for mental health nurses. Self-harm is a growing health problem. Nurses in a variety of healthcare settings play a central role in the care of people who self-harm. Their professional attitudes towards these people are essential for high-quality care. This review aims to develop insight into nurses' attitudes towards self-harm as they exist in contemporary nursing practice. A literature search was conducted in four databases, and a total of 15 relevant articles were found. This review indicates that negative attitudes towards self-harm are common among nurses. The influence of nurses' age, gender and work experience remains unclear. Healthcare setting and qualification level appear to be influencing factors. Education can have a positive influence on nurses' attitudes towards self-harm, especially when it includes reflective and interactive components. It is demonstrated in this review that a major change is needed regarding nurses' attitudes. To realize this change, nurses need to be trained and educated adequately concerning self-harm. They need time and resources to build a therapeutic relationship with people who harm themselves so they can offer high-quality care for this vulnerable group.

Features of everyday life in psychiatric inpatient care for self-harming: an observational study of six women

This study aimed to describe the features of everyday life in psychiatric inpatient care as experienced by women who self-harm. Participant observations and informal interviews were conducted with six women and were subjected to qualitative content analysis. The major feature of everyday life in psychiatric inpatient care was 'being surrounded by disorder', which consisted of 'living in a confusing environment, being subject to routines and rules that offer safety but lack consistency' and 'waiting both in loneliness and in togetherness'. The nursing staff spent minimal time with the patients and the women turned to each other for support, care and companionship.

Mental health nurses' experiences of caring for patients suffering from self-harm

The aim of this study was to explore mental health nurses' experiences of caring for inpatients who self-harm during an acute phase. The setting was four psychiatric clinics in Norway. Fifteen mental health nurses (MHNs) were recruited. Semistructured interviews comprised the method for data collection, with content analysis used for data analysis. Two main categories emerged: challenging and collaborative nurse-patient relationship and promoting well-being through nursing interventions. The underlying meaning of the main categories was interpreted and formulated as a latent theme: promoting person-centered care to patients suffering from self-harm. How MHNs promote care for self-harm patients can be described as a person-centered nursing process. MHNs, through the creation of a collaborative nurse-patient relationship, reflect upon nursing interventions and seek to understand each unique patient. The implication for clinical practice is that MHNs are in a position where they can promote patients' recovery processes, by offering patients alternative activities and by working in partnership with patients to promote their individual strengths and life knowledge. MHNs strive to help patients find new ways of living with their problems. The actual study highlighted that MHNs use different methods and strategies when promoting the well-being of self-harm patients.

Attitudes and knowledge of clinical staff regarding people who self-harm: a systematic review

BACKGROUND

The attitudes held by clinical staff towards people who harm themselves, together with their knowledge about self-harm, are likely to influence their clinical practice and hence the experiences and outcomes of patients. Our aim was to systematically review the nature of staff attitudes towards people who engage in self-harm, including the factors that influence them, and the impact of training on attitudes, knowledge and behaviour of staff.

METHODS AND FINDINGS

A comprehensive search for relevant studies was performed on six electronic databases. Two independent reviewers screened titles, abstracts and full reports of studies, extracted data and gave each paper a quality rating. Qualitative and quantitative studies published in English were included. A total of 74 studies were included. Attitudes of general hospital staff, especially doctors, were largely negative, particularly towards individuals who repeatedly self-harm. Self-harm patients were viewed more negatively than other patients, except those abusing alcohol or drugs. Psychiatric staff in community and hospital settings displayed more positive attitudes than general hospital staff. Negative attitudes were more common among doctors than nursing staff although this was only true of general hospital staff. Active training led to consistent improvements in attitude and knowledge in all groups.

CONCLUSIONS

Attitudes of general hospital staff towards self-harm patients are often negative, mirroring the experience of service users. Interventions can have a positive impact and improve the quality of patient care.

LIMITATIONS

Included only English language publications.

Self-harm and attempted suicide within inpatient psychiatric services: a review of the literature

Self harm is a major public health concern, yet there are considerable challenges in providing support for those who self harm within psychiatric inpatient services. This paper presents the first review of research into self harm within inpatient settings. Searches of the main electronic databases were conducted using key words for self harm and inpatient care. There was substantial variation in the rates of self-harm and attempted suicide between studies, but rates were highest on forensic wards. There was no evidence of differences in prevalence of self-harm between men and women; women, however, were at increased risk of attempting suicide. People were more likely to self-harm in private areas of the ward and in the evening hours, and often self-harmed in response to psychological distress, or elements of nursing care that restricted their freedom. Wards used a variety of strategies to prevent self-harm; however, there is little research into their effectiveness.

Helping self-mutilating adolescents: descriptions of Finnish nurses

This study focused on the views of Finnish nurses in regards to providing help for adolescents who self-mutilate. Nine nurses participated, and when the interviews and written descriptions were qualitatively analysed, four main categories of information emerged. The first category comprises the nurses' views on self-mutilation. The second category describes the people who are able to be helpers. The third category describes the content of help, which is made up of a variety of acts provided by non-health professionals that promote the healthy development of adolescents. The fourth category describes care provided by nurses to adolescents who self-mutilate. Guidelines for caring for self-mutilating adolescents are needed, including information on the phenomenon of self-mutilation.

A systematic literature review: self-mutilation among adolescents as a phenomenon and help for it-what kind of knowledge is lacking?

The aim of this review article is to present current knowledge of self-mutilation among adolescents as a phenomenon and to define what kind of knowledge is lacking based on existing literature. The literature searches were executed in the CINAHL and Medline databases in 2010. The analysed data consisted of 126 articles and inductive content analysis was carried out. Existing knowledge of self-mutilation was categorized into the following two classes: (1) self-mutilation as a phenomenon and (2) caring for persons who self-mutilate or self-harm.

Service users' experiences of a therapeutic group programme in an acute psychiatric inpatient unit

Psychiatric nurses have been facilitating therapeutic groups in acute psychiatric inpatient units for many years; however, there is a lack of nursing research related to this important aspect of care. This paper reports the findings of a study which aimed to gain an understanding of service users' experiences in relation to therapeutic group activities in an acute inpatient unit. A qualitative descriptive study was undertaken with eight service users in one acute psychiatric inpatient unit in Ireland. Data were collected using in-depth semi-structured interviews and analysed using Burnard's method of thematic content analysis. Several themes emerged from the findings which are presented in this paper.

Perspectives of mental health professionals and patients on self-injury in psychiatry: a literature review

Professionals in psychiatry often encounter patients who injure themselves. To explore the perspectives of mental health professionals and patients on self-injurious behavior and treatment, the authors carried out a literature review. The reviewers found little documented data that elucidated or discussed any shared understanding about self-injurious behavior between patients and professionals or between professionals themselves. Many of the problems experienced in relation to self-injury may be due to this lack of a common view. There were few evidence-based strategies for managing self-injury that received any attention in the literature. Future studies should focus on the development and testing of preventative interventions, putting particular emphasis on effective communication between professionals and patients.