Experiences of nursing care for patients who self-harm and suggestions for future practices: The perspectives of emergency care nurses

Pathways and transitions for patients admitted to an emergency department after self-harming events

The frequency of people presented in emergency departments (EDs) after self-harming events is increasing. Previous studies have shown that the complexity of the disorders of patients admitted to the ED after self-harming events can be overwhelming for ED healthcare professionals (HCPs) to handle. The objective of this study was to observe and investigate the pathways for patients admitted to the ED after self-harming events to either transition or discharge. Participant observation and interviews were selected as the methods to generate insight into the pathways of patients admitted to the ED after self-harming events. The data were analysed using interpretative phenomenological analysis. A sample size of 20 patients was analysed, and a total of 213 h of observation took place during the data collection. Three main themes appeared: (1) patients' mental stress versus high expectations, (2) uncertainty about how to address the self-harming event and (3) a system of chaos. Patients admitted to the ED after self-harming events struggle with difficult mental stress. Despite this, they face high expectations that they will fit in and cooperate in the ED. The healthcare system is organised with unclear responsibilities and without systematic ways to care for self-harm patients and so provides chaotic patient pathways. There is a need for improved cross-sectional competencies, mutual agreements and systematic communication for discharge, transitions and follow-up care between those involved in the patient's pathway and care.

Opening the black box of registration practice for self-harm and suicide attempts in emergency departments: a qualitative study

BACKGROUND

The World Health Organization has called for improved surveillance of self-harm and suicide attempts worldwide to benefit suicide prevention programs. International comparisons of registrations are lacking, however, and there is a need for systematically collected, high-quality data across countries. The current study investigated healthcare professionals' perceptions of registration practices and their suggestions for ensuring high-quality registration of self-harm and suicide attempts.

METHODS

Qualitative interviews (N = 20) were conducted among medical secretaries, medical doctors, nurses, and registration advisers from psychiatric and somatic emergency departments in all regions of Denmark between September 2022 and March 2023. Content analysis was performed using NVivo.

RESULTS

Despite great efforts to standardize and assure the quality of registration in Denmark, almost all the healthcare professionals perceived registration practice as inconsistent and unreliable. Codes are often misclassified or unused due to insufficient time, non-standardized training, or insufficient information. The interview informants suggested that coding guidelines should be simplified and made more visible, alongside technical solutions in the electronic health record system.

CONCLUSION

The study findings resulted in eight overall recommendations for clinical practice that aim at improving the registration of patients presenting with self-harm or suicide attempts. This would be expected to help improve surveillance and prevention programs.

Mapping clinical interactions in an Australian tertiary hospital emergency department for patients presenting with risk of suicide or self-harm: Network modeling from observational data

BACKGROUND

Reliable assessment of suicide and self-harm risk in emergency medicine is critical for effective intervention and treatment of patients affected by mental health disorders. Teams of clinicians face the challenge of rapidly integrating medical history, wide-ranging psychosocial factors, and real-time patient observations to inform diagnosis, treatment, and referral decisions. Patient outcomes therefore depend on the reliable flow of information through networks of clinical staff and information systems. This study aimed to develop a quantitative data-driven research framework for the analysis of information flow in emergency healthcare settings to evaluate clinical practice and operational models for emergency psychiatric care.

METHODS AND FINDINGS

We deployed 2 observers in a tertiary hospital emergency department during 2018 for a total of 118.5 h to record clinical interactions along patient trajectories for presentations with risk of self-harm or suicide (n = 272 interactions for n = 43 patient trajectories). The study population was reflective of a naturalistic sample of patients presenting to a tertiary emergency department in a metropolitan Australian city. Using the observational data, we constructed a clinical interaction network to model the flow of clinical information at a systems level. Community detection via modularity maximization revealed communities in the network closely aligned with the underlying clinical team structure. The Psychiatric Liaison Nurse (PLN) was identified as the most important agent in the network as quantified by node degree, closeness centrality, and betweenness centrality. Betweenness centrality of the PLN was significantly higher than expected by chance (>95th percentile compared with randomly shuffled networks) and removing the PLN from the network reduced both the global efficiency of the model and the closeness centrality of all doctors. This indicated a potential vulnerability in the system that could negatively impact patient care if the function of the PLN was compromised. We developed an algorithmic strategy to mitigate this risk by targeted strengthening of links between clinical teams using greedy cumulative addition of network edges in the model. Finally, we identified specific interactions along patient trajectories which were most likely to precipitate a psychiatric referral using a machine learning model trained on features from dynamically constructed clinical interaction networks. The main limitation of this study is the use of nonclinical information only (i.e., modeling is based on timing of interactions and agents involved, but not the content or quantity of information transferred during interactions).

CONCLUSIONS

This study demonstrates a data-driven research framework, new to the best of our knowledge, to assess and reinforce important information pathways that guide clinical decision processes and provide complementary insights for improving clinical practice and operational models in emergency medicine for patients at risk of suicide or self-harm. Our findings suggest that PLNs can play a crucial role in clinical communication, but overreliance on PLNs may pose risks to reliable information flow. Operational models that utilize PLNs may be made more robust to these risks by improving interdisciplinary communication between doctors. Our research framework could also be applied more broadly to investigate service delivery in different healthcare settings or for other medical specialties, patient groups, or demographics.

Staff perspectives of emergency department pathways for people attending in suicidal crisis: A qualitative study

WHAT IS KNOWN ON THE SUBJECT?: Emergency departments (ED) are key settings to support and manage suicidal crisis; thus, ED staff are often the first point of contact for people in suicidal crisis. Despite this, some ED staff receive little training and/or education on how to best support such patients.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

Previous research focuses on one staffing role (e.g. triage nurses) whereas this paper includes staff working across the ED pathway. Administrative staff have often been excluded from research, despite representing a key part of the clinical pathway and being a person's initial contact with the ED. Overall findings demonstrate that staff experience a lack of confidence, training and burnout due to regularly supporting people in suicidal crisis. Staff also perceive there to be a negative ED culture, which often leads to poor attitudes towards suicidal crisis. The main challenges reported are an increase in working pressures, unavailability of resources and staff retention. Findings build upon previous research to highlight key challenges different staff face along the clinical pathway and the implications this can have on a patient's journey and follow-up care provided. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Findings are of particular importance and relevance to ED managers, and more broadly NHS England. Negative ED culture, poor staff attitudes and confidence can have a detrimental impact on both staff health and wellbeing, as well as a patient's journey throughout the ED, resulting in repeat presentations and absconding as appropriate support is not received. Policymakers need to consider staff burnout and lack of resources in mental health care strategies, and training programmes should be developed to improve culture and confidence among ED staff and managers to improve care for people attending EDs in suicidal crisis.

ABSTRACT

INTRODUCTION: Emergency departments (EDs) are often the first point of contact for people in suicidal crisis. Yet, previous work has tended to focus on only one type of staffing role, failing to account for different staff perspectives along the clinical pathway.

AIMS

To explore and synthesise the perspectives of ED administrative (i.e. receptionists), medical (triage nurses) and mental health staff (liaison psychiatrists) working with people presenting in suicidal crisis.

METHOD

Qualitative study guided by thematic analysis of semi-structured interviews with 23 ED staff across six EDs in Cheshire and Merseyside, England.

RESULTS

Findings demonstrate that staff experience a lack of confidence, training and burnout due to regularly supporting people in suicidal crisis. The main challenges reported are an increase in working pressures, unavailability of resources and staff retention.

DISCUSSION

Staff felt unequipped to deal with suicide-related presentations. Organisational support is perceived to be lacking, with increased staffing pressures and poor service availability. This lack of support was linked to job dissatisfaction.

IMPLICATIONS FOR PRACTICE

Findings are of particular relevance to individual EDs and NHS England. Addressing the challenges staff are reporting can have positive implications for staff wellbeing, as well as a patient's experience and journey throughout the ED.

Help! Caring for People With Mental Health Problems in the Emergency Department: A Qualitative Study

INTRODUCTION

After coronavirus disease 2019, there has been an increase in patients in the emergency department with mental health conditions. They are usually received by professionals who are not specialized in mental health. This study aimed to describe nursing staff's experiences in the emergency department, in the care they provide to people with mental health problems who often feel stigmatized by society and also in health care settings.

METHODS

This is a descriptive qualitative study with a phenomenological approach. The participants were nurses from the Spanish Health Service from the emergency department of the Community of Madrid hospitals. Recruitment was performed by convenience sampling snowball sampling until data satruation was met. Data were collected through semistructured interviews conducted during January and February 2022.

RESULTS

The exhaustive and detailed analysis of the nurses' interviews made it possible to extract 3 main categories-health care, psychiatric patient, and work environment-with 10 subcategories.

DISCUSSION

The main study findings were the need to train emergency nurses to be prepared to care for people who experience mental health concerns including bias education and the need for implementation of standardized protocols. Emergency nurses never doubted their ability to care for people experiencing mental health disorders. Still, they recognized that they needed specialized professionals' support at certain critical moments.

Missed nursing care in emergency departments: A scoping review

BACKGROUND

Patient safety is a global health priority. Errors of omission, such as missed nursing care in hospitals, are frequent and may lead to adverse events. Emergency departments (ED) are especially vulnerable to patient safety errors, and the significance missed nursing care has in this context is not as well known as in other contexts.

AIM

The aim of this scoping review was to summarize and disseminate research about missed nursing care in the context of EDs.

METHOD

A scoping review following the framework suggested by Arksey and O'Malley was used to (1) identify the research question; (2) identify relevant studies; (3) select studies; (4) chart the data; (5) collate, summarize, and report the results; and (6) consultation.

RESULTS

In total, 20 themes were derived from the 55 included studies. Missed or delayed assessments or other fundamental care were examples of missed nursing care characteristics. EDs not staffed or dimensioned in relation to the patient load were identified as a cause of missed nursing care in most included studies. Clinical deteriorations and medication errors were described in the included studies in relation to patient safety and quality of care deficiencies. Registered nurses also expressed that missed nursing care was undignified and unsafe.

CONCLUSION

The findings from this scoping review indicate that patients' fundamental needs are not met in the ED, mainly because of the patient load and how the ED is designed. According to registered nurses, missed nursing care is perceived as undignified and unsafe.

An Integrative Model of In-Hospital and Out-of-Hospital Nursing Care for Non-Suicidal Self-Injury: A Narrative Review

Background: Non-suicidal self-injury (NSSI) refers to the intentional and repeated physical trauma of an individual without explicit suicidal intent, which has negative effects on the physical and mental well-being of an individual, especially for adolescents. Timely and accessible nursing care may play an important role in the survival and rehabilitation process of NSSI. Methods: In this review, we systematically discuss the nursing care of NSSI behavior and provide recommendations based on an integrated nursing model for NSSI management. Results: As reported in previous studies, a variety of factors can contribute to NSSI behavior, such as personality traits, current psychological status, history of mental illnesses, as well as family and social factors. In-hospital care is the most necessary and effective care during acute episodes of NSSI behavior. To effectively manage inpatients with NSSI behaviors, nurses should first understand the motivation of NSSI, and provide comprehensive and multi-level care through nurse-patient communication, individualized psychological care, and multidisciplinary cooperation with other professionals. While the purpose of out-of-hospital nursing is to reduce the frequency of NSSI behaviors by screening high-risk individuals, providing psychological support, promoting health education, and improving self-awareness. Conclusions: An integrative model of in-hospital and out-of-hospital nursing care can help improve the clinical management and long-term prognosis of patients with NSSI and minimize the risk of suicidal ideation or suicidal behavior.

Nursing Staff's Experiences of Caring for People with Mental Ill-Health in General Emergency Departments: A Qualitative Descriptive Study

While people with mental ill-health report unsatisfying experiences and poor treatment in general emergency departments, nursing staff report a lack of adequate knowledge and training. This study describes nursing staff's experiences caring for people with mental ill-health in general emergency departments. A qualitative descriptive design was used and 14 interviews were subjected to qualitative content analysis. Results show that nursing staff are dealing with uncertainty and competing priorities when caring for people with mental ill-health. Nursing staff must both take and be given the opportunity to maintain and develop confidence and independence and need support in promoting mental health recovery.

Understanding Emergency Department Healthcare Professionals' Perspectives of Caring for Individuals in Suicidal Crisis: A Qualitative Study

Help seekers regularly present to Emergency Departments (EDs) when in suicidal crisis for intervention to ensure their immediate safety, which may assist in reducing future attempts. The emergency health workforce have unique insights that can inform suicide prevention efforts during this critical junction in an individual's experience with suicide. This paper explores the treatment and care delivery experiences of 54 health professionals working in EDs within one of the LifeSpan suicide prevention trial sites in Australia. Data was collected via six focus groups and six interviews. Thematic analysis resulted in three themes: (1) physicality of the emergency department, (2) juggling it all-the bureaucracy, practicalities, and human approach to care, and (3) impact of care delivery on ED staff. Findings highlight the need for workplace training that incorporates responding to the uncertainty of suicidal crisis, to compliment the solution-focused medical model of care. Broader policy changes to the ED system are also considered to ensure better outcomes for health professionals and help-seekers alike.