'Relieved to be seen'-patient and carer experiences of psychosocial assessment in the emergency department following self-harm: qualitative analysis of 102 free-text survey responses

Staff perceptions of barriers to self-harm care in the emergency department: A cross-sectional survey study

BACKGROUND

Emergency departments (EDs) are often the first point of contact for people with self-harm; however, they do not always receive optimal care. The study objective was to examine the perspectives of ED staff who respond to self-harm presentations, perceived barriers to providing optimal, guideline-concordant care, and staff's familiarity with existing guidelines.

METHODS

An online cross-sectional survey comprising purpose-designed questions concerning self-harm in the ED was completed by 131 staff (83.2% nurses) from two hospitals in Victoria, Australia. Survey results were analysed using Stata version 16 and frequencies and percentages were calculated.

RESULTS

Respondents reported knowledge of how to appropriately manage a person presenting with self-harm. However, lack of space (62.3%) and time (78.7%) to conduct the appropriate assessments, lack of self-harm training (71.8%), and limited awareness of or access to guidelines and recommendations for self-harm management within the ED (63.6%), were identified as primary barriers to their ability to appropriately manage these presenters.

CONCLUSIONS

Improvements to the ED environment and processes, as well as the provision of regular self-harm specific education and training for all ED staff are needed. Implementation of best-practice standards should prioritise guideline-concordant care, with a particular focus on the education needs of nursing staff.

What are the barriers and enablers to trauma-informed emergency departments? A scoping review protocol

INTRODUCTION

There is a high prevalence of psychological trauma among the population. Such people are more likely to have poorer health outcomes and these factors may contribute to increased use of the emergency department. There has been some attempt to implement a trauma-informed approach across public services, especially in health and social care. However, it is unclear how this concept applies to the challenging and high-demand emergency department context. The review aims to locate, examine and describe the literature on trauma-informed care in the unique and challenging healthcare delivery context that is the emergency department. The review aims to identify the barriers and enablers that may facilitate trauma-informed care in the emergency department context.

METHODS AND ANALYSIS

This scoping review will use the Joanna Briggs Institute methodology for scoping reviews. Systematic searches of relevant databases (CINAHL, MEDLINE, PsycINFO, EMBASE, Knowledge Network and Web of Science) will be conducted. Empirical studies of any methodological approach, published in English between January 2001 and September 2023 will be included. The 'grey' literature will also be accessed. Two reviewers will independently screen all studies. Data will be extracted, collated and charted to summarise all the relevant methods, outcomes and key findings in the articles.

ETHICS AND DISSEMINATION

Formal ethical approval is not required. The findings of this study will be disseminated through peer-reviewed publications, conference presentations and condensed summaries for key stakeholders in the field. The data generated will be used to inform a programme of work related to trauma-informed care.

Global prevalence of psychosocial assessment following hospital-treated self-harm: systematic review and meta-analysis

BACKGROUND

Hospital-treated self-harm is common, costly and associated with repeated self-harm and suicide. Providing a comprehensive psychosocial assessment following self-harm is recommended by professional bodies and may improve outcomes.

AIMS

To review the provision of psychosocial assessments after hospital-presenting self-harm and the extent to which macro-level factors indicative of service provision explain variability in these estimates.

METHOD

We searched five electronic databases to 3 January 2023 for studies reporting data on the proportion of patients and/or events that were provided a psychosocial assessment. Pooled weighted prevalence estimates were calculated with the random-effects model. Random-effects meta-regression was used to investigate between-study variability.

RESULTS

119 publications (69 unique samples) were included. Across ages, two-thirds of patients had a psychosocial assessment (0.67, 95% CI 0.58-0.76). The proportion was higher for young people and older adults (0.75, 95% CI 0.36-0.99 and 0.83, 95% CI 0.48-1.00, respectively) compared with adults (0.64, 95% CI 0.54-0.73). For events, around half of all presentations had these assessments across the age range. No macro-level factor explained between-study heterogeneity.

CONCLUSIONS

There is room for improvement in the universal provision of psychosocial assessments for self-harm. This represents a missed opportunity to review and tailor aftercare supports for those at risk. Given the marked unexplained heterogeneity between studies, the person- and system-level factors that influence provision of psychosocial assessments after self-harm should be studied further.

A Qualitative Study on the Psychological Experience of Emergency Department Medical Staff Caring for Patients with Suicide Attempts in Northeastern Sichuan

The purpose of this study was to explore the psychological experiences of emergency department staff in northeastern Sichuan when treating patients with suicide attempts and to provide a theoretical basis for developing appropriate clinical interventions and improving mental health services for suicidal patients. Sixteen emergency department staff members who met recruitment requirements at two hospitals in Nanchong, China, were interviewed using Colizzi descriptive phenomenological analysis. The interviews were in-depth and semi-structured. The qualitative analysis of this study revealed three main themes: (1) aspects of the emotional experience that may be detrimental to helping people in crisis (e.g., sympathy and regret, confusion and bewilderment, worry and stress); (2) aspects of the cognitive experience (e.g., inability to deal with patients' psychological issues and having new perspective on the medical profession); and (3) raising awareness of mental health services. Future reform efforts should consider training medical staff in suicide prevention knowledge and communication skills, using a compassion-centered approach to alleviate the suffering of patients who attempt suicide, using the Safety Screening Scale (PSS-3), providing counselors for patients, developing family-focused interventions, and involving family members in suicide risk prevention and treatment.

Digital therapeutics in the hospital for suicide crisis - content and design recommendations from young people and hospital staff

Objective

Hospital emergency departments lack the resources to adequately support young people who present for suicidal crisis. Digital therapeutics could fill this service gap by providing psychological support without creating additional burden on hospital staff. However, existing research on what is needed for successful integration of digital therapeutics in hospital settings is scant. Thus, this study sought to identify key considerations for implementing digital therapeutics to manage acute suicidal distress in hospitals.

Method

Participants were 17 young people who recently presented at the hospital for suicide-related crisis, and 12 hospital staff who regularly interacted with young people experiencing mental ill-health in their day-to-day work. Interviews were conducted via videoconference. Framework analysis and reflexive thematic analysis were used to interpret the data obtained.

Results

Qualitative insights were centred around three major themes: hospital-specific content, therapeutic content, and usability. Digital therapeutics were seen as a useful means for facilitating hospital-based assessment and treatment planning, and for conducting post-discharge check-ins. Therapeutic content should be focused on helping young people self-manage suicide-related distress while they wait for in-person services. Features to promote usability, such as the availability of customisable features and the use of inclusive design or language, should be considered in the design of digital therapeutics.

Conclusions

Digital therapeutics in hospital settings need to benefit both patients and staff. Given the unique context of the hospital setting and acute nature of suicidal distress, creating specialty digital therapeutics may be more viable than integrating existing ones.

Attitudes toward and experiences of clinical and non-clinical services among individuals who self-harm or attempt suicide: a systematic review

The prevalence of self-harm has increased substantially in recent decades. Despite the development of guidelines for better management and prevention of self-harm, service users report that quality of care remains variable. A previous systematic review of research published to June 2006 documented largely negative experiences of clinical services among patients who self-harm. This systematic review summarized the literature published since then to July 2022 to examine contemporary attitudes toward and experience of clinical and non-clinical services among individuals who self-harm and their relatives. We systematically searched for literature using seven databases. Quality of studies was assessed using the Mixed-Methods Appraisal Tool and findings were summarized using a narrative synthesis. We identified 29 studies that met our inclusion criteria, all of which were from high- or middle-income countries and were generally of high methodological quality. Our narrative synthesis identified negative attitudes toward clinical management and organizational barriers across services. Generally, more positive attitudes were found toward non-clinical services providing therapeutic contact, such as voluntary sector organizations and social services, than clinical services, such as emergency departments and inpatient units. Views suggested that negative experiences of service provision may perpetuate a cycle of self-harm. Our review suggests that in recent years there has been little improvement in attitudes toward and experiences of services for patients who self-harm. These findings should be used to reform clinical guidelines and staff training across clinical services to promote patient-centered and compassionate care and deliver more effective, acceptable and accessible services.

Lived experience codesign of self-harm interventions: a scoping review

OBJECTIVES

This study aims to map existing literature describing how people with lived experience of self-harm have engaged in codesigning self-harm interventions, understand barriers and facilitators to this engagement, and how the meaningfulness of codesign has been evaluated.

DESIGN

Scoping review by Joanna Briggs Institute methodology. A protocol was published online (http://dx.doi.org/10.17605/OSF.IO/P52UD).

DATA SOURCES

PubMed, Embase, PsycINFO, Web of Science, Cochrane Library, PROSPERO, ClinicalTrials.gov and relevant websites were searched on 24 December 2022 (repeated 4 November 2023).

ELIGIBILITY CRITERIA

We included studies where individuals with lived experience of self-harm (first-hand or caregiver) have codesigned self-harm interventions.

DATA EXTRACTION AND SYNTHESIS

Results were screened at title and abstract level, then full-text level by two researchers independently. Prespecified data were extracted, charted and sorted into themes.

RESULTS

We included 22 codesigned interventions across mobile health, educational settings, prisons and emergency departments. Involvement varied from designing content to multistage involvement in planning, delivery and dissemination. Included papers described the contribution of 159 female, 39 male and 21 transgender or gender diverse codesigners. Few studies included contributors from a minoritised ethnic or LGBTQIA+ group. Six studies evaluated how meaningfully people with lived experience were engaged in codesign: by documenting the impact of contributions on intervention design or through postdesign reflections. Barriers included difficulties recruiting inclusively, making time for meaningful engagement in stretched services and safeguarding concerns for codesigners. Explicit processes for ensuring safety and well-being, flexible schedules, and adequate funding facilitated codesign.

CONCLUSIONS

To realise the potential of codesign to improve self-harm interventions, people with lived experience must be representative of those who use services. This requires processes that reassure potential contributors and referrers that codesigners will be safeguarded, remunerated, and their contributions used and valued.

Evaluation of a national clinical programme for the management of self-harm in hospital emergency departments: impact on patient outcomes and the provision of care

BACKGROUND

Emergency departments are important points of intervention, to reduce the risk of further self-harm and suicide. A national programme to standardise the management of people presenting to the emergency department with self-harm and suicidal ideation (NCPSHI) was introduced in Ireland in 2014. The aim of this study was to evaluate the impact of the NCPSHI on patient outcomes and provision of care.

METHODS

Data on self-harm presentations were obtained from the National Self-Harm Registry Ireland from 2012 to 2017. The impacts of the NCPSHI on study outcomes (3-month self-harm repetition, biopsychosocial assessment provision, admission, post-discharge referral, and self-discharge) were examined at an individual and aggregate (hospital) level, using a before and after study design and interrupted time series analyses, respectively. The 15 hospitals that implemented the programme by January 2015 (of a total of 24 between 2015 and 2017) were included in the analyses.

RESULTS

There were 31,970 self-harm presentations during the study period. In hospitals with no service for self-harm (n = 4), risk of patients not being assessed reduced from 31.8 to 24.7% following the introduction of the NCPSHI. Mental health referral in this hospital group increased from 42.2 to 59.0% and medical admission decreased from 27.5 to 24.3%. Signs of a reduction in self-harm repetition were observed for this hospital group, from 35.1 to 30.4% among individuals with a history of self-harm, but statistical evidence was weak. In hospitals with a pre-existing liaison psychiatry service (n = 7), risk of self-discharge was lower post-NCPSHI (17.8% vs. 14.8%). In hospitals with liaison nurse(s) pre-NCPSHI (n = 4), medical admission reduced (27.5% vs. 24.3%) and there was an increase in self-harm repetition (from 5.2 to 7.8%. for those without a self-harm history).

CONCLUSION

The NCPSHI was associated with improvements in the provision of care across hospital groups, particularly those with no prior service for self-harm, highlighting the need to consider pre-existing context in implementation planning. Our evaluation emphasises the need for proper resourcing to support the implementation of clinical guidelines on the provision of care for people presenting to hospital with self-harm.

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.

Review: Systematic review and metasynthesis of qualitative literature on young people's experiences of going to A&E/emergency departments for mental health support

BACKGROUND

There has been an increase in children and young people attending emergency departments for mental health reasons, including self-harm. Patients often report having poor experiences when attending emergency departments for mental health support. However, there has yet to be a review exploring the experiences of young people. Our aim in this study was to synthesise qualitative literature on young people's experiences of going to emergency departments for mental health support.

METHODS

A systematic review and metasynthesis were conducted. Five databases and grey literature were searched for relevant studies. Five articles met study criteria and were analysed using an iterative process of thematic synthesis.

RESULTS

The synthesis yielded four overarching themes: (a) emergency departments' inability to meet the mental health needs of young people, (b) emergency departments exacerbating patient distress, (c) patients feeling like a burden or undeserving of treatment and (d) consequences of poor emergency department experiences.

CONCLUSIONS

These findings (based on a still very limited literature) highlight the role that emergency departments have in relation to being a key point of contact with young people who self-harm. To properly engage with patients, emergency departments need to have the resources to provide compassionate care and follow clinical guidelines regarding assessments.

An Ideal-Type Analysis of People's Perspectives on Care Plans Received from the Emergency Department following a Self-Harm or Suicidal Crisis

People presenting to Emergency Departments (EDs) in a self-harm/suicidal crisis in England receive a psychosocial assessment and care plan. We aimed to construct a typology of peoples' perspectives on crisis care plans to explore the range of experiences of care plans. Thirty-two semi-structured interviews with people who presented to EDs following a self-harm/suicidal crisis in England were analysed using an ideal-type analysis. Cases were systematically compared to form clusters of cases with similar experiences of care plans. People's perspectives on care plans fitted into three types: (1) personalised care plans (n = 13), consisting of advice or referrals perceived as helpful; (2) generic care plans (n = 13), consisting of generic advice that the person already knew about or had already tried; and (3) did not receive a care plan (n = 6) for those who reported not receiving a care plan, or who were only provided with emergency contacts. Care planning in the ED following a suicidal/self-harm crisis was perceived as supportive if it provided realistic and personalised advice, based on what had/had not worked previously. However, many people reported not receiving a helpful care plan, as it was ill-fitted to their needs or was not considered sufficient to keep them safe, which may mean that these patients are at increased risk of repeat self-harm.

Developing a consensus of recovery from suicidal ideations and behaviours: A Delphi study with experts by experience

BACKGROUND

Understanding recovery in mental health has received significant attention and consequently, recovery has been incorporated into health policy across many countries in the Global North. In comparison, the concept of 'recovery' from suicidal thoughts and behaviours has received little attention. However, the few studies in this area appear to suggest that recovery is a complex and an idiosyncratic process with many contributing factors. This can present a challenge for clinicians and services seeking to become more recovery focused. Thus, it seems of importance to develop a consensus on how recovery from suicidal thoughts and behaviours is conceptualised.

AIM

The study aimed to use the Delphi design to establish a consensus of how recovery is defined by those with lived experience of suicidal thoughts and behaviours. The Delphi method draws on the expertise of a panel, often involving clinicians, researchers and lived experience experts to develop consensus over a topic by inviting them to rate the importance of, often a series of statements to a given topic area.

METHOD

Lived experience experts were asked to complete two rounds of questionnaires distributed online to capture their views on recovery.

RESULTS

A total of 196 individuals gave their views on the first round of the study and 97 gave their views on the second round. A final list of 110 statements was developed that 80% or more of participants defined as essential or important. Statements covered items that were important in defining, facilitation and hindering the process of recovery.

CONCLUSION

Findings are consistent with the wider literature that suggests that recovery is an idiosyncratic process, but with many commonly shared features. Here we also show that a comprehensive definition of recovery must include factors that hinder the process of recovery. Implications and recommendations for practice, policy development and future research are discussed.

The experiences of emergency hospital care among adolescents and young adults with self-harm: A systematic review and thematic synthesis of qualitative evidence

QUESTION

The incidence of self-injurious behavior in adolescents and young adults is on the rise. Seeking care in the emergency department after self-injurious behavior is one way they signal for help. The purpose of this systematic evaluation was to synthesize the best available qualitative research evidence on young people's experiences of emergency department visits following self-harm behaviors and their need for emergency medical services.

STUDY SELECTION AND ANALYSIS

Eleven databases were retrieved with predefined search terms from database construction to February 4, 2022. Literature was screened according to inclusion and exclusion criteria and quality assessment.

FINDINGS

Eleven studies yielded fifty-five findings that were summarized into eight categories and aggregated into three composite statements: (1) positive emergency department experience; (2) negative emergency department experience; and (3) desire for help.

CONCLUSIONS

Young people with a history of self-injurious behavior have a mixed sense of experience in the emergency department. The sense of negative experience makes patients feel dissatisfied and disappointed with healthcare services, and positive experiences can help them seek further help. The emergency departments should improve the diagnosis and treatment model of self-injured adolescent patients to ensure that they receive effective and high-quality medical resources.

Liaison psychiatry practitioners' views on accessing aftercare and psychological therapies for patients who present to hospital following self-harm: multi-site interview study

BACKGROUND

Timely provision of aftercare following self-harm may reduce risks of repetition and premature death, but existing services are frequently reported as being inadequate.

AIMS

To explore barriers and facilitators to accessing aftercare and psychological therapies for patients presenting to hospital following self-harm, from the perspective of liaison psychiatry practitioners.

METHOD

Between March 2019 and December 2020, we interviewed 51 staff members across 32 liaison psychiatry services in England. We used thematic analyses to interpret the interview data.

RESULTS

Barriers to accessing services may heighten risk of further self-harm for patients and burnout for staff. Barriers included: perceived risk, exclusionary thresholds, long waiting times, siloed working and bureaucracy. Strategies to increase access to aftercare included: (a) improving assessments and care plans via input from skilled staff working in multidisciplinary teams (e.g. including social workers and clinical psychologists); (b) supporting staff to focus on assessments as therapeutic intervention; (c) probing boundaries and involving senior staff to negotiate risk and advocate for patients; and (d) building relationships and integration across services.

CONCLUSIONS

Our findings highlight practitioners' views on barriers to accessing aftercare and strategies to circumvent some of these impediments. Provision of aftercare and psychological therapies as part of the liaison psychiatry service were deemed as an essential mechanism for optimising patient safety and experience and staff well-being. To close treatment gaps and reduce inequalities, it is important to work closely with staff and patients, learn from experiences of good practice and implement change more widely across services.

"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.

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.

Suicide and self-harm

Suicide and self-harm are major health and societal issues worldwide, but the greatest burden of both behaviours occurs in low-income and middle-income countries. Although rates of suicide are higher in male than in female individuals, self-harm is more common in female individuals. Rather than having a single cause, suicide and self-harm are the result of a complex interplay of several factors that occur throughout the life course, and vary by gender, age, ethnicity, and geography. Several clinical and public health interventions show promise, although our understanding of their effectiveness has largely originated from high-income countries. Attempting to predict suicide is unlikely to be helpful. Intervention and prevention must include both a clinical and community focus, and every health professional has a crucial part to play.

Patient and Public Involvement in Dermatology Research: A Review

Patient and public involvement (PPI) in research is defined as research being carried out ‘with’ or ‘by’ members of the public, patients, and carers, on both an individual and a group level, rather than simply ‘about’, or ‘for’ them. Within dermatology, PPI is increasingly recognised as a vital component of research as it helps to ensure that research remains relevant to the populations we intend to serve. Dermatology scholarship, with its rich psychosocial implications due to the stigma, physical disability, and mental health burdens these conditions may incur, is in a unique position to benefit from PPI to unlock previously inaccessible patient lived experiences or therapeutic consequences. Throughout the rapid growth of PPI, it has been infused throughout the research lifecycle, from design to dissemination and beyond. After first explaining the principles of PPI, we examine the existing evidence base at each research stage to explore whether our specialty has effectively harnessed this approach and to identify any subsequent impact of PPI. Finally, we scrutinise the challenges faced by those implementing PPI in dermatology research.

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.

Understanding suicide clusters through exploring self-harm: Semi-structured interviews with individuals presenting with near-fatal self-harm during a suicide cluster

There was a highly publicised cluster of at least ten suicides in South Wales, United Kingdom, in 2007-2008. We carried out a qualitative descriptive study using cross-case thematic analysis to investigate the experiences and narratives of eight individuals who lived in the area where the cluster occurred and who survived an episode of near-fatal self-harm at the time of the cluster. Interviews were conducted from 01.01.2015 to 31.12.2015. All interviewees denied that the other deaths in the area had affected their own suicidal behaviour. However, in other sections of the interviews they spoke about the cluster contributing to difficulties they were experiencing at the time, including damage to social relationships, feelings of loss and being out of control. When asked about support, the interviewees emphasized the importance of counselling, which they would have found helpful but in most cases did not receive, even in the case of close contacts of individuals who had died. The findings suggest that effective prevention messaging must be subtle, since those affected may not be explicitly aware of or acknowledge the imitative aspects of their behaviour. This could be related to stigma attached to suicidal behaviour in a cluster context. Lessons for prevention include changing the message from asking if people 'have been affected by' the suicide deaths to emphasising the preventability of suicide, and directly reaching out to individuals rather than relying on people to come forward.

"A Sustained, Productive, Constructive Relationship with Someone Who Can Help"-A Qualitative Exploration of the Experiences of Help Seekers and Support Persons Using the Emergency Department during a Suicide Crisis

For Australians experiencing a suicide crisis, the emergency department (ED) is the recommended point of contact for intervention and to ensure personal safety. However, negative ED experiences can deter individuals from returning, thus impacting future suicide risk. In order to improve the ED environment for individuals in suicidal crisis, an in-depth understanding of this experience is needed. In-depth semi-structured interviews with 17 help seekers and 16 support persons were conducted. A grounded theory approach uncovered a core organising concept—all participants wanted a “a sustained, productive, constructive relationship with someone who can help” during the ED visit—which guided analysis. Thematic analysis resulted in two themes and four subthemes exploring the systemic and interpersonal aspects of the ED visit and the roadblocks and pathways to development of the relationship. Interpersonal factors included aspects of staff interaction and presence of a support person. Systemic factors related to aspects controlled by the physical space and internal policies and procedures and included aspects such as the chaotic environment, long waiting times, and access to staff. Overwhelmingly, there were more roadblocks than pathways reported by participants. Improving the ED environment, increasing staff training and encouraging the presence of support persons may help mitigate some of these roadblocks.

Experiences of care for self-harm in the emergency department: comparison of the perspectives of patients, carers and practitioners

Background

Each year, 220 000 episodes of self-harm are managed by emergency departments in England, providing support to people at risk of suicide.

Aims

To explore treatment of self-harm in emergency departments, comparing perspectives of patients, carers and practitioners.

Method

Focus groups and semi-structured interviews with 79 people explored experiences of receiving/delivering care. Participants were patients (7 young people, 12 adults), 8 carers, 15 generalist emergency department practitioners and 37 liaison psychiatry practitioners. Data were analysed using framework analysis.

Results

We identified four themes. One was common across stakeholder groups: (a) the wider system is failing people who self-harm: they often only access crisis support as they are frequently excluded from services, leading to unhelpful cycles of attending the emergency department. Carers felt over-relied upon and ill-equipped to keep the person safe. Three themes reflected different perspectives across stakeholders: (b) practitioners feel powerless and become hardened towards patients, with patients feeling judged for seeking help which exacerbates their distress; (c) patients need a human connection to offer hope when life feels hopeless, yet practitioners underestimate the therapeutic potential of interactions; and (d) practitioners are fearful of blame if someone takes their life: formulaic question-and-answer risk assessments help make staff feel safer but patients feel this is not a valid way of assessing risk or addressing their needs.

Conclusions

Emergency department practitioners should seek to build a human connection and validate patients’ distress, which offers hope when life feels hopeless. Patients consider this a therapeutic intervention in its own right. Investment in self-harm treatment is indicated.