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

Impact of Emergency Department Safety Planning on 30-Day Mental Health Service Use

OBJECTIVE

The aim of this study was to examine the association between emergency department (ED) safety planning and subsequent use of mental health care among individuals treated in the ED for suicidal behavior and to determine whether subsequent use differed by patients' receipt of recent mental health care.

METHODS

Data from 130 hospitals, derived from a 2017-2018 national hospital survey, were paired with national health insurance data from 2,328 patients with suicidal behavior treated in the EDs of these hospitals. Rates of ED readmission, inpatient admission, and outpatient mental health follow-up care in the 30 days after discharge from the index ED visit were examined.

RESULTS

During the 30 days after discharge from the index visit, readmissions to the ED (18% vs. 22%) and inpatient admissions (12% vs. 15%) for suicidal behavior or other mental health issues were significantly lower among patients treated in the EDs that routinely implemented safety planning, compared with those that did not, respectively. Among patients who had not received mental health care within 30 days before the index visit, those treated in an ED implementing routine safety planning were about half as likely (adjusted risk ratio=0.60) as those treated in an ED without such planning to have an ED readmission.

CONCLUSIONS

Safety planning was associated with fewer subsequent ED and inpatient admissions among patients treated in the ED for suicidal behavior. The authors recommend that safety planning be universally implemented in EDs and included in routine outpatient care.

Factors Influencing Emergency Department Staff Decision-Making for People Attending in Suicidal Crisis: A Systematic Review

BACKGROUND

Emergency department (ED) staff are often the first point of contact for individuals in suicidal crisis. Despite this, there is no published research systematically examining the factors influencing decision-making for this patient group.

METHODS

MedLine, CINAHL, PsycINFO, Web of Science and Cochrane Library databases were searched for three key concepts: (1) suicide, (2) accident and emergency department and (3) decision-making. Three reviewers screened titles, abstracts and full papers independently against the eligibility criteria. Data synthesis was achieved by extracting and analyzing study characteristics and findings. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of included studies.

RESULTS

Seventeen studies met the eligibility criteria and were included in this systematic review. Studies were published from 2004 to 2020 and were of good methodological quality. A number of patient (method of self-harm, age, gender), contextual (availability of services and staff) and staff-related factors (attitudes, training, knowledge) were reported to influence decision-making for patients in suicidal crisis presenting to EDs.

CONCLUSION

Decision-making in the ED is complex and is influenced by patient, contextual and staff-related factors. These decisions can have an impact on the future care and clinical pathways of patients in suicidal crisis. Additional training is needed for ED staff specifically related to suicide prevention.

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.

Left with a Sisyphean task - the experiences of nurse practitioners with treating non-suicidal self-injury in the emergency department: a descriptive qualitative study

BACKGROUND

Non-suicidal self-injury (NSSI) is a prevalent phenomenon in somatic emergency departments, where nurses are the most consistent group of healthcare professionals who treat people with NSSI, which means they may affect the NSSI trajectory and help-seeking in the future. The objective of this study was to describe the experiences of nurse practitioners with treatment of people presenting with NSSI in the emergency department.

METHODS

Individual, semi-structured telephone interviews were conducted with seventeen purposefully recruited nurse practitioners from three emergency departments in the Capital Region of Denmark. Interview transcripts were analysed using inductive content analysis, as described by Graneheim and Lundman.

RESULTS

The analysis resulted in the formulation of three categories and 10 subcategories describing how nurse practitioners feel confident and competent in treating physical injuries due to NSSI but at the same time insecure about how to provide adequate care and engage in conversations about NSSI and mental wellbeing with people with NSSI. An overarching theme, 'Left with a Sisyphean task', reflects the nurses' feeling of being handed the responsibility for performing a laborious, never-ending, and futile task.

CONCLUSION

The findings indicate that nurse practitioners feel confident and competent in treating physical injuries due to NSSI but insecure about how to provide adequate care. Therefore, there is a need for training and guidelines.

"Treat Them Like a Human Being…They are Somebody's Somebody": Providers' Perspectives on Treating Patients in the Emergency Department After Self-Injurious Behavior

To understand ED providers' perspective on how to best care for individuals who present to US emergency departments (EDs) following self-injurious behavior, purposive recruitment identified nursing directors, medical directors, and social workers (n = 34) for telephone interviews from 17 EDs. Responses and probes to "What is the single most important thing ED providers and staff can do for patients who present to the ED after self-harm?" were analyzed using directed content analysis approach. Qualitative analyses identified four themes: treat patients with respect and compassion; listen carefully and be willing to ask sensitive personal questions; provide appropriate care during mental health crises; connect patients with mental health care. Participants emphasized treating patients who present to the ED after self-injurious behavior with respect and empathy. Hospitals could incentivize provider mental health training, initiatives promoting patient-provider collaboration, and reimbursement strategies ensuring adequate staffing of providers with time to listen carefully.

Professionals' attitudes towards people with intellectual disabilities who self-harm: A literature review

BACKGROUND

National Institute for Health and Care Excellence (NICE, 2013) Guidance on Self-Harm states that professionals supporting people who self-harm should demonstrate compassion, respect and dignity. This literature review examines the evidence for professionals' attitudes towards people with intellectual disabilities who self-harm.

METHOD

Four databases (PsychInfo, IBSS, CINAHL and Medline) were systematically searched to find relevant research since 2000.

RESULTS

Four studies met the criteria. Attitudes of professionals supporting people with intellectual disabilities are contrasted with those of professionals in settings focused on supporting people without intellectual disabilities. Professionals supporting people with intellectual disabilities tended to display attitudes and attributions reflective of biobehavioural and psychosocial theories of self-harm, with a greater emphasis on relationships.

CONCLUSION

Much more research is needed which examines the attitudes of professionals supporting people with intellectual disabilities who self-harm.

Cognitive and implicit biases in nurses' judgment and decision-making: A scoping review

BACKGROUND

Cognitive and implicit biases of healthcare providers can lead to adverse events in healthcare and have been identified as a patient safety concern. Most research on the impact of these systematic errors in judgment has been focused on diagnostic decision-making, primarily by physicians. As the largest component of the workforce, nurses make numerous decisions that affect patient outcomes; however, literature on nurses' clinical judgment often overlooks the potential impact of bias on these decisions. The aim of this study was to map the evidence and key concepts related to bias in nurses' judgment and decision-making, including interventions to correct or overcome these biases.

METHODS

We conducted a scoping review using Joanna Briggs methodology. In November 2020 we searched CINAHL, PsychInfo, and PubMed databases to identify relevant literature. Inclusion criteria were primary research about nurses' bias; evidence of a nursing decision or action; and English language. No date or geographic limitations were set.

RESULTS

We found 77 items that met the inclusion criteria. Over half of these items were published in the last 12 years. Most research focused on implicit biases related to racial/ethnic identity, obesity, and gender; other articles examined confirmation, attribution, anchoring, and hindsight biases. Some articles examined heuristics and were included if they described the process of, and the problems with, nurse decision-making. Only 5 studies tested interventions to overcome or correct biases. 61 of the studies relied on vignettes, surveys, or recall methods, rather than examining real-world nursing practice. This could be a serious oversight because contextual factors such as cognitive load, which have a significant impact on judgment and decision-making, are not necessarily captured with vignette or survey studies. Furthermore, survey and vignette studies make it difficult to quantify the impact of these biases in the healthcare system.

CONCLUSIONS

Given the serious effects that bias has on nurses' clinical judgment, and thereby patient outcomes, a concerted, systematic effort to identify and test debiasing strategies in real-world nursing settings is needed.

TWEETABLE ABSTRACT

Bias affects nurses' clinical judgment - we need to know how to fix it.

Changing HCW attitudes: a case study of normalizing HIV service delivery in emergency departments

Background

Delays in the implementation of evidence-based practices are significant and ubiquitous, compromising health outcomes. Resistance to change is a key factor in hindering adoption and integration of new evidence-based interventions. This study seeks to understand the impact of exposure to HIV testing within a research context on provider attitudes towards HIV counselling and testing (HCT) in emergency departments (ED).

Methods

This is a pre-and-post study design measuring the effect of a new ED-based HCT intervention, conducted by lay counsellors, on provider attitudes in Eastern Cape, South Africa. A validated, anonymized, 7-item survey was self-completed by routine care providers (physicians, nurses, and case managers). Questions were scored on a 5-point Likert scale with 5 consistently reflecting a positive attitude. Mean scores were calculated for each question and compared using a two-sample t-test to assess change in sample means for attitudes among providers surveyed before and after the intervention.

Results

A total of 132 surveys were completed across three EDs. Majority of respondents were female (70.5%), 20–29 years old (37.9%), of African race (81.1%), nurses (39.4%), and practicing medicine for 0–4 years (37.9%). Pre-intervention, providers displayed a positive attitude towards ‘the benefit of offering ED-based HCT to patients’ (4.33), ‘the ED offering HCT’ (3.53), ‘all ED patients receiving HCT’ (3.42), ‘concern about patient reaction to HCT’ (3.26), and ‘comfort with disclosing HCT results’ (3.21); and a mildly negative attitude towards ‘only high-risk ED patients receiving HCT’ (2.68), and ‘the burden of offering HCT in a clinical environment’ (2.80). Post-intervention, provider attitudes improved significantly towards ‘all ED patients receiving HCT’ (3.86, p < 0.05), ‘only high-risk ED patients receiving HCT’ (2.30, p < 0.05), ‘the burden of offering HCT in a clinical environment’ (3.21, p < 0.05), and ‘comfort with disclosing HCT results’ (3.81, p < 0.05).

Conclusions

Controlled exposure to new practices with a structured implementation period can shift attitudes beginning a process of practice normalization. In our study, we observed improvements in provider attitudes regarding the benefits of HCT and the burden of offering HCT to all patients in the ED. Research activities may have a role in mitigating resistance to change and supporting intervention adoption.

Suicide Risk Among Hospitalized Versus Discharged Deliberate Self-Harm Patients: Generalized Random Forest Analysis Using a Large Claims Data Set

INTRODUCTION

Suicide rates are extremely high among emergency department patients seen for deliberate self-harm. Inpatient hospitalization is often recommended for these patients, but evidence on the suicide prevention impacts of hospitalization is scarce. Confounding by indication and challenges to implementing randomized designs are barriers to advances in this field.

METHODS

Investigators used 2009-2012 statewide data on 57,312 self-harm emergency department patients from California, linked to mortality records. Naive 12-month and 30-day suicide risks were estimated among patients who were hospitalized versus those who were discharged. Then, generalized random forest methods were applied to estimate the average treatment impacts of hospitalization on suicide, conditioning on observable covariates. Associations were calculated separately for sex- and age-specific subgroups. Analyses were conducted in February 2019-August 2021.

RESULTS

In naive analyses, suicide risk was significantly higher in hospitalized than in discharged patients in each subgroup. In 12-month models accounting for the observed covariates through generalized random forest methods, hospitalized male patients had 5.4 more suicides per 1,000 patients (95% CI=3.0, 7.8), hospitalized patients aged 10-29 years had 2.4 more suicides per 1,000 (95% CI=1.1, 3.6), and those aged ≥50 years had 5.8 more suicides per 1,000 (95% CI=0.5, 11.2) than corresponding discharged patients. Hospitalization was not significantly associated with suicide among female patients or patients aged 30-49 years in generalized random forest analyses. Patterns were similar in 30-day generalized random forest models.

CONCLUSIONS

Emergency department personnel intend to hospitalize self-harm patients with high suicide risk; this study suggests that this goal is largely realized. Analyses that control for confounding by observable covariates did not find clear evidence that hospitalization reduces suicide risk and could not rule out the possibility of iatrogenic effects.

Strategies to Care for Patients Being Treated in the Emergency Department After Self-harm: Perspectives of Frontline Staff

INTRODUCTION

Every year, approximately 500 000 patients in the United States present to emergency departments for treatment after an episode of self-harm. Evidence-based practices such as designing safer ED environments, safety planning, and discharge planning are effective for improving the care of these patients but are not always implemented with fidelity because of resource constraints. The aim of this study was to provide insight into how ED staff innovate processes of care and services by leveraging what is available on-site or in their communities.

METHODS

A total of 34 semi-structured qualitative phone interviews were conducted with 12 nursing directors, 11 medical directors, and 11 social workers from 17 emergency departments. Respondents comprised a purposive stratified sample recruited from a large national survey in the US. Interview transcripts were coded and analyzed using a directed content analysis approach to identify categories of strategies used by ED staff to care for patients being treated after self-harm.

RESULTS

Although respondents characterized the emergency department as an environment that was not well-suited to meet patient mental health needs, they nevertheless described 4 categories of strategies to improve the care of patients seen in the emergency department after an episode of self-harm. These included: adapting the ED environment, improving efficiencies to provide mental health care, supporting the staff who provide direct care for patients, and leveraging community resources to improve access to mental health resources postdischarge.

DISCUSSION

Despite significant challenges in meeting the mental health needs of patients treated in the emergency department after self-harm, the staff identified opportunities to provide mental health care and services within the emergency department and leverage community resources to support patients after discharge.

Staff awareness of suicide and self-harm risk in healthcare settings: A mixed-methods systematic review

BACKGROUND

Suicide risk screening in healthcare settings plays a significant role in suicide prevention. Healthcare staff who are poorly informed about self-harm and suicide risk are less likely to identify and subsequently screen at-risk individuals. This mixed-method systematic review aimed to appraise and synthesise evidence from studies that explored and promoted healthcare staff's knowledge and awareness of suicide and self-harm risk in healthcare settings.

METHODS

Electronic databases (CINAHL, MEDLINE, APA PsycInfo, APA PsycARTICLES, Psychology and behavioural Science Collection, ERIC, and SocINDEX), the Cochrane Library, and various grey literature databases were searched for relevant studies. The level of evidence and methodological quality of the included studies were assessed.

RESULTS

Eighteen empirical studies were included. Levels of knowledge about suicide and self-harm risk varied significantly across the reviewed studies. Face-to-face group training and educational programmes, digital or online educational programmes, and an educational poster campaign were amongst the strategies used to promote awareness of suicide and self-harm risk, with the majority marginally succeeding in doing so.

LIMITATIONS

The reviewed studies were heterogeneous in terms of design, interventions, and outcome measures which made it difficult to make comparisons. The overall level of scientific evidence was classified as being relatively low. The lack of blinding and lack of a control group were amongst the limitations for experimental studies.

CONCLUSIONS

Long-term, routine face-to-face group training programmes should be established to educate healthcare staff about suicide risk across all professions and in specific patient groups.

Perceptions of mental health nurses toward caring for suicidal hospital inpatients in Saudi Arabia

Saudi nurse perceptions of suicide and its effect on their professional and personal lives have not been sufficiently discussed. This study aims to explore related mental health nurse experiences. A phenomenological qualitative inquiry of 20 practicing mental health nurses in one focus group provided data which were subjected to member and peer checking and NVivo software to extract five themes: nurse experience of patient suicide, expressed feelings, psychological responses, the effect on practice, and support. This study illuminated aspects of emotional labor of nurses and perceptions of caring for suicidal patients in Saudi Arabia.

Factors affecting emergency nurses' perceptions of the triage systems

Background: Emergency services use a triage system to prioritize patients according to their level of diagnosis. Triage is one of the mandated skills to be owned by an emergency unit nurse. This research aims to identify factors affecting emergency nurses’ perceptions of the triage systems.

Design and Methods: 90 nurses were chosen based on quota sampling. Data were analyzed using Chi Square test (α 0.05) and logistic regression analysis.

Results: The results show that nurses perceptions were influenced by knowledge (p = 0.017), working experience (p = 0.023), and training (p = 0.041). The factor that had the strongest influence in the formation of nurses’ perceptions was knowledge (p = 0.020 and OR = 3.19).

Conclusions: It can be concluded that knowledge, working experience and training influenced emergency nurses’ perceptions on triage systems.

If You Could Change 1 Thing to Improve the Quality of Emergency Care for Deliberate Self-harm Patients, What Would It Be? A National Survey of Nursing Leadership

INTRODUCTION

Emergency departments increasingly treat patients for deliberate self-harm. This study sought to understand emergency department nursing leadership perspectives on how to improve the quality of emergency care for these patients.

METHODS

ED nursing managers and directors from a national sample of 476 hospitals responded to an open-ended question asking for the 1 thing they would change to improve the quality of care for self-harm patients who present in their emergency departments. We identified and coded key themes for improving the emergency management of these patients, then examined the distribution of these themes and differences by hospital characteristics, including urbanicity, patient volume, and teaching status.

RESULTS

Five themes regarding how to improve care for deliberate self-harm patients were identified: greater access to hospital mental health staff or treatment (26.4%); better access to community-based services and resources (26.4%); more inpatient psychiatric beds readily accessible (20.9%); separate safe spaces in the emergency department (18.6%); and dedicated staff coverage (7.8%). Endorsement of findings did not differ based on hospital characteristics.

DISCUSSION

ED nursing leadership strongly endorsed the need for greater access to both hospital- and community-based mental health treatment resources for deliberate self-harm patients. Additional ED staff and training, along with greater continuity among systems of care in the community, would further improve the quality of emergency care for these patients. Broad policies that address the scarcity of mental health services should also be considered to provide comprehensive care for this high-risk patient population.

KEY WORDS

Emergency department management of self-harm; Mental health care; Emergency nursing care.

Emergency department nurse's attitudes towards patients who self-harm: A meta-analysis

Self-harm is a major challenge to public health. Emergency department (ED) nurses treat significant proportions of patients with self-harm injuries, and positive therapeutic patient-nurse interactions are imperative to the physical and psychological outcome of this vulnerable patient group. Research, both nationally and internationally, suggests that treating those with self-harm injuries is emotionally challenging, and ambivalence, powerlessness, and ineffectiveness are commonly manifested in negative attitudes towards these patients. Following the PRISMA guidelines, this systematic review with meta-analyses examined the attitudes of ED nurses towards patients who self-harm, based on currently available evidence. The following databases were searched: CINAHL complete; Medline complete; PsycARTICLES; PsycINFO; The Allied and Complementary Medicine Database; Health Source: Nursing/Academic Edition; PsycEXTRA; and Psychology and Behavioural Sciences Collection. Clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant reports to identify additional studies, were also searched. Five studies were included in the meta-analysis. The Self-Harm Antipathy Scale (SHAS) was used as an outcome in two studies appropriate for meta-analysis. The Attitudes Towards Deliberate Self-Harm Questionnaire (ADSHQ) scale was used as an outcome in three studies appropriate for meta-analysis. Results demonstrated limited empathy and negativity towards patients who self-harm, indicating a requirement for education and supervision of ED staff, where the SHAS or the ADSHQ can be used to monitor attitude change. Self-harm educational content for ED staff should include areas of knowledge building including explanations and causes of self-harm; range, forms, and functions of self-harm; staff responses to self-harm; assessment, management, and interventions; professional practice issues.

Nursing students' attitudes to suicide and suicidal persons: A cross-national and cultural comparison between Turkey and the United Kingdom

WHAT IS KNOWN ON THE SUBJECT?: Mental healthcare requires acceptance of suicide and flexible attitudes especially in relation to caring for people who have suicidal thoughts or who have attempted suicide. Nurse education programmes for student nurses can shape positively the attitudes of individual participants, yet limited research exists on what nursing students' attitudes currently are towards people who are suicidal. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This paper adds to the developing international comparative work that is providing a greater understanding of cultural perceptions of suicide amongst students. This paper along with existing literature highlights a potential relationship between certain religious belief systems and their potential to be protective against suicide. At the same time, such religious belief is more likely to be associated with more judgmental attitude towards suicidal behaviour. This paper using a validated research tool, devised by a research psychologist, scored for the first time, individual student attitudes towards caring for people that are suicidal, whilst establishing the overall differences between the two countries from which the data are collected. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This paper offers potential explanations for differences in nursing students' attitudes between the UK and Turkey. Disparities under discussion include gender, type of education, culture and religion. This is an important discussion in the consideration of nurse education worldwide. It is recognized that students may come from a variety of different backgrounds, with varying personal and social attitudes to begin with; yet, there exists the potential to positively influence overall attitudes towards service users whilst learners are still within a training programme, consisting of education and practice experiences. The merits of a specialist mental health nurse training programme and its potential to impact more favourably on students attitudes deserve more attention and research.

ABSTRACT

Introduction Suicide is a major public health issue internationally, and the impact of positive or negative attitudes amongst the mental health professional workforce warrants scrutiny. The study aimed to examine English and Turkish nursing students' attitudes towards people with suicidal behaviour. Method This cross-cultural study reports on attitudes of 240 nursing students towards suicide in Turkey and 82 nursing students in the UK. A reliable and valid 24 item "Attitudes towards Suicide Scale" and "Social Reactions to Suicidal Persons Scale" were used to measure attitudes. Results The UK nursing students were found to display more accepting attitudes to suicide, and scored higher on acceptability of suicide, seeing suicide as a solution and open reporting and discussion of suicide subscales than their Turkish counterparts. Turkish nursing students scored higher on punishment after death and hiding suicidal behaviour subscales than the UK students. Turkish nursing students scored significantly higher on deterring subscale of reactions to a suicidal peer scale than the UK nursing students. Implications for practice It is vital for nurse students to develop positive acceptance of suicide through education, reflection and clinical supervision to be more therapeutic towards suicidal patients.

Public Perceptions of Self-Harm: Perceived Motivations of (and Willingness to Help in Response to) Adolescent Self-Harm

We investigated public perceptions of, and responses to, adolescent self-harm-an under-researched topic, given that the majority of self-harm in this group is not disclosed to formal support services. Participants (N = 355, aged 18-67 years) were presented with 1 of 10 vignettes and completed self-report measures assessing perceived motivations for self-harm and helping/rejecting responses. Vignettes were manipulated across conditions for stated motivation, controllability of stated cause, and presentation format. Results indicate that stated motivation for self-harm, controllability of stated cause, and presentation format affect perceived motivations. Further, participants demonstrate an understanding of the complex nature of self-harm, indicating an appreciation that an individual may hold multiple motivations simultaneously. Perceived motivations for self-harm are associated with the endorsement of helping/rejecting behaviors. These relationships are important to explore, given the critical importance of initial responses to self-harm on subsequent disclosures and help-seeking.

". . . If You're Not Part of the Institution You Fall by the Wayside": Service Providers' Perspectives on Moving Young Men From Disconnection and Isolation to Connection and Belonging

There have been increasing calls for more gender-specific service provision to support young men's (20-29 years) mental health and well-being. In Ireland, young men are the demographic group that are most likely to die by suicide but among the least likely to seek help. This study sought to investigate service providers' perspectives on the factors that support or inhibit young men from engaging in services targeted at supporting their mental/emotional well-being. Qualitative methodologies (focus groups, n = 9; interviews, n = 7) were used for this study. Disconnection from family and community was identified as a key indicator of "at-risk" groups of young men who, more typically, had experienced significant disruption in their lives. The discord between demands and expectations facing young men on one hand, and insufficient life-management and coping skills on the other, left many young men vulnerable and bereft. The desire to save face and preserve one's masculine identity was linked to young men's reluctance to seek help when feeling down. There was a strong consensus that there could be no shortcuts to [re]connecting with young men. While sport, technology, and social media were cited as appropriate media in which to engage young men, the essence of sustained connection revolved around creating safety, trust, rapport, and meaningful relationships. The findings from this study have informed the development of a Train the Trainer program ("Connecting with Young Men"), which is currently being delivered to service providers in Ireland and which may have implications for service provision elsewhere.

Identification of At-Risk Youth by Suicide Screening in a Pediatric Emergency Department

The pediatric emergency department (ED) is a critical location for the identification of children and adolescents at risk for suicide. Screening instruments that can be easily incorporated into clinical practice in EDs to identify and intervene with patients at increased suicide risk is a promising suicide prevention strategy and patient safety objective. This study is a retrospective review of the implementation of a brief suicide screen for pediatric psychiatric ED patients as standard of care. The Ask Suicide Screening Questions (ASQ) was implemented in an urban pediatric ED for patients with psychiatric presenting complaints. Nursing compliance rates, identification of at-risk patients, and sensitivity for repeated ED visits were evaluated using medical records from 970 patients. The ASQ was implemented with a compliance rate of 79 %. Fifty-three percent of the patients who screened positive (237/448) did not present to the ED with suicide-related complaints. These identified patients were more likely to be male, African American, and have externalizing behavior diagnoses. The ASQ demonstrated a sensitivity of 93 % and specificity of 43 % to predict return ED visits with suicide-related presenting complaints within 6 months of the index visit. Brief suicide screening instruments can be incorporated into standard of care in pediatric ED settings. Such screens can identify patients who do not directly report suicide-related presenting complaints at triage and who may be at particular risk for future suicidal behavior. Results have the potential to inform suicide prevention strategies in pediatric EDs.

Testing the validity and reliability of an instrument to measure nurses' antipathy towards patients who self-harm: Korean version of the Self-Harm Antipathy Scale

AIM

To investigate the validity and reliability of the Korean version of the Self-Harm Antipathy Scale (SHAS-K) to be used to measure nurses' antipathy towards patients who self-harm.

METHODS

The internal consistency reliability and construct validity, using exploratory and confirmatory factor analysis, was evaluated.The survey data were collected from 249 nurses who worked in emergency care facilities in South Korea.

RESULTS

The Cronbach's α values regarding internal consistency were 0.54-0.88 for the subscales of the SHAS-K. The factor loadings of the 26 items on the four subscales ranged from 0.44 to 0.86. The four-subscale model was validated by a confirmatory factor analysis.

CONCLUSION

This study shows that the SHAS-K should be used with caution when measuring nurses' antipathy towards patients in Korea who self-harm.

"This is a question we have to ask everyone": asking young people about self-harm and suicide

WHAT IS KNOWN ON THE SUBJECT?: An essential part of the mental health assessment is to evaluate the risk of harm to self. Fundamentally this involves asking directly about self-harming behaviour and suicidal thoughts or urges, but practitioners often find it difficult to open up these conversations. This evaluation of risk is particularly important as self-harm and suicidal thoughts are frequently found in young people who attend mental health services. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Young people are not always routinely asked directly about self-harm or suicidal thoughts when they are assessed. There are two ways that mental health practitioners introduce this topic: first, by building up to it by initially asking about general feelings, and second by stating that it is a requirement to ask everyone. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: These questions should not be avoided by mental health practitioners just because they are difficult. We offer suggestions as to how to ask questions about self-harm and suicide based on real-world practice.

ABSTRACT

Introduction Questions about self-harm and suicide are essential in risk assessments with children and young people, yet little is known about how mental health practitioners do this. Aim The core aim was to examine how questions about self-harm and suicidal ideation are asked in real-world practice. Method A qualitative design was employed to analyse 28 video-recorded naturally occurring mental health assessments in a child and adolescent mental health service. Data were analysed using conversation analysis (CA). Results In 13 cases young people were asked about self-harm and suicide, but 15 were not. Analysis revealed how practitioners asked these questions. Two main styles were revealed. First was an incremental approach, beginning with inquiries about emotions and behaviours, building to asking about self-harm and suicidal intent. Second was to externalize the question as being required by outside agencies. Discussion The study concluded that the design of risk questions to young people had implications for how open they were to engaging with the practitioner. Implications for practice The study has implications for training and practice for psychiatric nurses and other mental health practitioners in feeling more confident in communicating with young people about self-harm and suicidal ideation.

Designing for Risk Assessment Systems for Patient Triage in Primary Health Care: A Literature Review

Background

This literature review covers original journal papers published between 2011 and 2015. These papers review the current status of research on the application of human factors and ergonomics in risk assessment systems’ design to cope with the complexity, singularity, and danger in patient triage in primary health care.

Objective

This paper presents a systematic literature review that aims to identify, analyze, and interpret the application of available evidence from human factors and ergonomics to the design of tools, devices, and work processes to support risk assessment in the context of health care.

Methods

Electronic search was performed on 7 bibliographic databases of health sciences, engineering, and computer sciences disciplines. The quality and suitability of primary studies were evaluated, and selected papers were classified according to 4 classes of outcomes.

Results

A total of 1845 papers were retrieved by the initial search, culminating in 16 selected for data extraction after the application of inclusion and exclusion criteria and quality and suitability evaluation.

Conclusions

Results point out that the study of the implications of the lack of understanding about real work performance in designing for risk assessment in health care is very specific, little explored, and mostly focused on the development of tools.

Effects of training on attitudes of psychiatric personnel towards patients who self-injure

Background

Improving attitudes of personnel towards self‐injurious patients leads to better working alliance and contributes to better patient outcomes. Previous research into the improvement of these attitudes has recorded the need for specific training in evidence‐based assessment and treatment of self‐injurious patients.

Aim

The current study describes the attitudes towards self‐injurious patients among psychiatric personnel. The study also evaluates the effect of a structured clinical training program on psychiatric personnel's attitudes towards patients who self‐injure. It further examines whether age, education, frequency of self‐injurious patients contact, and work experience of the personnel are associated with the existing attitudes.

Methods

Psychiatric personnel (N = 50) attended a four‐day training program, presenting evidence‐based knowledge regarding self‐injury assessment and treatment, using group exercises and reflective learning principles. The personnel completed the Understanding Suicidal Patients Questionnaire (USP) anonymously PreTraining, on 17 January 2014, and PostTraining, on 20 June 2014. The mean differences as well as single USP items before and after the training were tested by unpaired t‐test. Two‐way ANOVA was used to test impact of background variables on the USP scores.

Results

The training program had statistically significant impact (P < 0·01) on the following individual items of the USP scale: Patients who have tried to commit suicide are usually treated well in my work unit (d = 1·02); A person who has made several suicide attempt is at greater risk of committing suicide (d = 0·64); Because the patients who have tried to commit suicide have emotional problems, they need the best possible treatment (d = 0·57). The results also suggested that the frequency of patient contact had impact on attitudes towards self‐injurious patients.

Medical students' attitude toward suicide attempters

BACKGROUND

Majority of health professionals have unfavorable attitudes toward the patients presenting with self-harm, which further compromises their therapeutic endeavors and outcomes.

OBJECTIVES

This study was aimed to assess the medical students' attitudes toward suicide attempters.

MATERIALS AND METHODS

A cross-sectional study was conducted in a tertiary care medical institute of Haryana, a Northern state of India. Two hundred and five final year medical students were recruited through total enumeration method. "Suicide Opinion Questionnaire" was administered to assess their attitudes toward suicide attempters.

RESULTS

Only minority had previous exposure of managing any suicidal patient and attended suicide prevention programs. Majority agreed for suicide attempters being lonely and depressed. Nearly half of the students reported small family, disturbed interpersonal relationship, weak personality, self-punishment approach, cultural inhibitions in emotional expression, national instability, and disbelief in afterlife, as a major push to attempt suicide. Compared to boys, girls reported the greater contribution of weak personality and self-destructive behaviors and lesser contribution of family disturbances and religious convictions as suicide triggers. They held favorable attitude for only one-third of the attitudinal statement, and they were uncertain for two-third of the attitudinal statements.

CONCLUSIONS

Such a high proportion of uncertain responses imply toward lack of awareness and clinical expertise for managing suicide attempters. It also signifies the urgent need for enhancing their educational and clinical exposure, to improve their attitudes toward patients presenting with self-harm.

Does Sexual Assault Nurse Examiner (SANE) Training Affect Attitudes of Emergency Department Nurses Toward Sexual Assault Survivors?

There are over 243,800 female sexual assaults in the United States annually. Of those who seek healthcare services after being sexually assaulted, 90% present to hospitals. Unfortunately, care and services for women who have been sexually assaulted are inconsistent. Increased burnout, frustration, and feelings of inadequacy can lead healthcare providers to exhibit personal biases or negative attitudes toward their patients. The Joint Commission, responsible for accreditation of healthcare organizations, has stated that nurses must provide competent care to all patients. Therefore, Sexual Assault Nurse Examiner (SANE) training needs to be available for emergency department (ED) nurses who care for patients who have been sexually assaulted. A survey using the Attitude Toward Rape Victims Scale was sent to 1503 ED nurses throughout the United States, from the Emergency Nursing Association's mailing list. The results of the survey showed that there was a significant difference in attitudes toward the patients between SANE-trained emergency nurses and those without training. This study also showed that 35.5% of hospitals represented by the respondents did not have SANE services available for adult patients who had been sexually assaulted, and furthermore, 85.5% of the respondents who cared for adult patients who had been sexually assaulted were not SANE trained. The negative attitudes held toward such patients as found in this study, coupled with a lack of training provides evidence that ED nurses may benefit from education related to appropriate treatment for patients who have been sexually assaulted. As evidence-based practice becomes the gold standard of care, ensuring that nurses are properly trained to care for all patients must be the goal.

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.

Emergency department staff attitudes towards mental health consumers: a literature review and thematic content analysis

Visits to the emergency department (ED) for mental health reasons account for 10-15% of all visits. Consumers of mental health ED services, however, report that they often feel sent to the back of the queue and that their mental health concerns are not taken seriously, suggesting that societal stigma has impacted their care in the ED. In this study, we systematically explore the research concerning the attitudes of ED professional staff towards those who present with issues related to mental health. Four themes emerge from the literature: consumer perspectives, whose tenor is generally one of negativity; staff-reported attitudes and influencing factors, such as age, experience, and confidence in working with mental health presentations; the environmental climate of the ED, which might not be conducive to good mental health care; and interventions that have been used to evaluate changes in attitudes.

Nursing students' attitude towards suicide attempters: A study from rural part of Northern India

Context:

Majority of health professionals have unfavorable attitudes towards patients presenting with self-harm, which further compromises their willingness and outcome of care.

Aims:

To assess the nursing students’ attitudes toward suicide attempters.

Settings and Design:

Cross-sectional study was conducted in two nursing colleges of north India.

Material and Methods:

Three hundred and eight nursing students were recruited through total enumeration method from May to June 2012. ‘Suicide opinion questionnaire’ was administered to assess their attitudes towards suicide attempters.

Statistical Analysis Used:

Descriptive statistics was employed with Statistical Package for Social Sciences version 14.0 for Windows.

Results:

Majority were single females, from urban locality, with the mean age of 20 years. Only minority had previous exposure to suicide prevention programs and management of such cases. Majority of students agreed for mental illness, disturbed family life, and depression as major push to attempt suicide. They held favorable attitude for half of the attitudinal statement, but they were uncertain for rest half of the statements.

Conclusions:

They generally had favorable attitude towards suicide attempters. Their uncertain response highlights the need for enhancing educational exposure of nursing students and new staff at the earliest opportunity, to carve their favorable attitude towards patients presenting with self-harm.

Nursing students' attitude toward suicide prevention

BACKGROUND

Preventing suicide depends upon different health professionals' knowledge regarding suicide, attitude toward suicide attempters, skills to assess and manage suicidal risk.

OBJECTIVES

This study was aimed to assess the attitude of nursing students toward suicide prevention.

MATERIALS AND METHODS

308 nursing students were recruited from the two institutions through total enumeration method. Attitude toward suicide prevention scale was administered. Study design was cross-sectional.

RESULTS

Majority were single females, from urban locality, who were pursuing BSc Nursing with the mean age of 20 years. Only minority had previous exposure to suicide prevention programs or workshops. Nearly half of the subjects had positive attitude toward working with suicidal patients. Again half of the subjects considered unemployment and poverty as main causes of suicide and were quite hopeless about it and they also perceived that most of the suicidal people would not reveal their suicidal plans to others.

CONCLUSIONS

Merely half of the students had positive attitude toward working with suicidal patients. Hence, there is strong need to organize more educational and training programs on suicide prevention so that these budding health professionals could be more equipped and trained to manage these suicidal patients.

Attitudes of emergency care staff towards young people who self-harm: a scoping review

AIM

To determine whether reported attitudes towards patients who attend A&E following self-harm extend to young people.

BACKGROUND

Historically A&E staff have displayed negative attitudes towards patients who self-harm, although more recent research suggests that attitudes have shifted. There is retrospective evidence of low satisfaction with A&E services by individuals who self-harmed as adolescents, with comparatively little research which has specifically examined attitudes towards adolescent self-harm available.

METHOD

A scoping review of papers published from 2000 to 2012 was undertaken, papers accessed through the following databases, British Nursing Index, CINAHL, Medline, Psychology and Behavioural Science Collection, and PsychINFO. Hawker et al.'s (2002) methodology for critical appraisal was adopted.

RESULTS

Eleven papers derived from nine studies were located; three studies adopted qualitative methods, two mixed methods; the remainder were quantitative adopting a survey approach to measure attitudes. The studies revealed inconsistent findings, although the setting, patients' characteristics and education and training all appear to have a bearing on attitudes towards young people who self-harm.

CONCLUSION

Further research is required which considers attitudes of emergency care practitioners within the context of emergency care work, and which investigates whether being a young person per se has an influence on attitudes.

Association of training on attitudes towards self-injuring clients across health professionals

The objective of this study was to evaluate associations between self-injury training and attitudes across different health care professions. In the study, 342 psychologists, social workers, psychiatric, and medical nurses were recruited from 12 hospitals in Belgium. Participants completed a confidential questionnaire assessing attitudes, perceived knowledge/competence in self-injury, and prior self-injury training. Professionals with training reported more positive empathy, less negative attitudes, and greater perceived knowledge/competence, which was related to positive attitudes. Mental health providers had more positive attitudes than medical professionals.

CONCLUSIONS

Attitudes towards self-injuring patients are multifaceted and vary across health professions. Training on self-injury should be incorporated into the educational curriculum of all health care professions.

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.

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.

Attitudes of psychologists and nurses toward suicide and suicide prevention in Ghana: a qualitative study

BACKGROUND

One way of preventing suicide has been increasing awareness among health care professionals of their own attitudes and taboos toward suicide and its prevention.

OBJECTIVE

The purpose of this study was to understand the attitudes of health professionals toward suicidal behavior and its prevention in Ghana.

METHODS

A total of 17 informants (9 clinical psychologists and 8 emergency ward nurses) in an urban center were interviewed using a semi-structured interview guide. Interpretative Phenomenological Analysis (IPA) was used to analyze the data.

RESULTS

We found that the attitudes of these health workers toward suicide and suicide prevention seemed to be transiting between morality and mental health. The psychologists generally saw suicide as a mental health issue, emphasized a caring and empathic view of suicidal persons and approached suicide prevention from a health-service point of view. Mental health education and improvements in primary health care were reported as practical approaches toward suicide prevention. The nurses on the other hand, held a moralistic attitude toward suicide as a crime, viewed suicide persons as blameworthy and approached suicide prevention from a proscriptive perspective. Informal approaches such as talking to people, strengthening the legal code against suicide and threatening suicidal persons with the religious consequences of the act were also indicated as practical approaches to suicide prevention. Educational level, clinical experience with suicidal persons, and religious values, are discussed as influencing the differences in attitudes toward suicide and suicide prevention between psychologists and nurses.

CONCLUSION

Health workers in Ghana need training in suicidology to improve both knowledge and skills relevant for suicide prevention.

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.

Self-harm: what's the problem? A literature review of the factors affecting attitudes towards self-harm

People who have experienced self-harm report dissatisfaction with the care provided by statutory services. This review provides a critical exploration of the evidence examining the attitudes of healthcare professionals across both mental health and medical settings towards people who self-harm. It also explored in detail service users perceptions of care. A literature search conducted via electronic databases and cross-matching reference lists produced 19 papers that met the inclusion criteria. A thematic analysis of the literature indicated six key areas which contributed to the development of attitudes defined as positive or negative towards people who self-harm. Negative attitudes and experiences of care were associated with lack of education and training, the impact of differences in perceptions of health professionals' role and the influence of clinical culture as well as how self-harm was perceived as a health need. More positive attitudes were associated with a greater understanding of experiences of self-harm and improved training. However, the nature of care reported by service users indicates that there are still significant improvements needed to the attitudes in health settings to ensure they receive a high-quality service.

Activated charcoal: to give or not to give?

There has been much debate about the use of activated charcoal in patients who have taken overdoses and then present to Emergency Departments. There are clinical trials, research and position statements that have examined the effectiveness of activated charcoal in a number of overdoses of different medications, but there is still a debate surrounding the evidence based practice of administering activated charcoal in patients who have taken a drug overdose due to lack of evidence. This article will examine on the two main guidelines on activated charcoal, one produced by the National Institute for Clinical Excellence and the second produced by American Academy of Clinical Toxicology. It will discuss the methods of administration on activated charcoal, contraindications and the difficulties or challenges in adhering to these guidelines in the clinical setting.

Emergency provider attitudes and barriers to universal HIV testing in the emergency department

BACKGROUND

The Centers for Disease Control and Prevention (CDC) recently published recommendations for routine, voluntary human immunodeficiency virus (HIV) testing of adults in all health care settings, including the emergency department (ED).

STUDY OBJECTIVE

The objective of this study was to examine the willingness of ED providers to offer HIV testing, as well as their perceived barriers to implementation of these guidelines.

METHODS

Before the establishment of a routine HIV testing program in the ED, a 21-item survey was used to assess ED providers' knowledge, attitudes, and perceived challenges to HIV testing. Six months after program initiation, the identical survey was re-administered to determine whether HIV testing program experience altered providers' perceptions.

RESULTS

There were 108 of 146 (74%) providers who completed both the pre- and post-implementation surveys. Although the majority of emergency providers at 6 months were supportive of an ED-based HIV testing program (59/108 [55%]), only 38% (41/108) were willing to offer the HIV test most or all of the time. At 6 months, the most frequently cited barriers to offering a test were: inadequate time (67/108 [62%]), inadequate resources (65/108 [60%]), and concerns regarding provision of follow-up care (64/108 [59%]).

CONCLUSIONS

After the implementation of a large-scale HIV testing program in an ED, the majority of emergency providers were supportive of routine HIV testing. Nevertheless, 6 months after program initiation, providers were still reluctant to offer the test due to persistent barriers. Further studies are needed to identify feasible implementation strategies that minimize barriers to routine HIV testing in the ED.

Revealing triage behaviour patterns in ER using a new technology for handwritten data acquisition

INTRODUCTION

Data acquisition is still one of the important challenges to be met in clinical settings. This is even more critic in settings with high cognitive workloads, such as emergency room (ER). Observations in these settings are difficult to realize without biases and there is little means to trace fine acquisition activities done in natural environments, using pen and papers. This study is based on the usage of a digital pen and paper (DPP) technology for the acquisition of triage information by nurses in ER. The DPP technology has been used to ease acquisition using a natural mechanism; it also minimizes the external influence of observation during acquisition activities. The aim of this study is to determine whether data recorded by the DPP technology allows explaining how ER triage nurses use the triage forms in real working conditions.

METHODOLOGY

The chief physicians of the ER service wanted to have answers about three main concerns pertaining to the triage process: (1) the average time spent during the triage process; (2) the sequence in which the fields of the forms were filled and; (3) the contribution of objective measurements, such as vital signs, to the triage emergency level and decisions. In order to answer these questions, detailed log data recorded by the DPP during form filling as been analyzed and allowed to built several representations of the triage process. In addition, we completed this analysis with ethnographical-like observations.

RESULTS

For seven consecutive days, 1183 triage forms have been recorded in the ER for all patients admitted. Among them, 954 forms have been digitalized and 906 forms have been considered as valid and complete. Based on this set of data, the median duration of the triage process is 143 s. There are no converging habits in filling the forms and the sequence of filling fields present a high variability. The emphasis of the objective measurements in the decisional process is rather low, as vital signs are recorded in less than 17% of the cases.

CONCLUSION

The DPP technology is an original approach to study data acquisition processes in unbiased conditions. The technical raw data recorded by the DPP allows building the time series of all activities on the paper, therefore letting to constructing several representations of the process. However, the technology is not able to provide information about the context of use, for example interruptions of the form filling processes due to calls or other activities. Therefore, it is necessary to complete these analyses with qualitative approaches such as observational studies and interviews. Noticeably, as a result of this study, the head physicians of ER have redesigned the triage form to enforce the use of objective measurements and ease the data acquisition process.