A Qualitative Account of Young People's Experiences Seeking Care from Emergency Departments for Self-Harm

Experiences of individuals presenting to the emergency department for mental health reasons: A systematic mixed studies review

OBJECTIVE

Emergency departments the world over have seen substantial increases in the number of individuals presenting for mental health reasons. However, we have a limited understanding of their experiences of care. The aim of this review was to systematically examine and synthesise literature relating to the experiences of individuals presenting to emergency department for mental health reasons.

METHODS

We followed Pluye and Hong's seven-step approach to conducting a systematic mixed studies review. Studies were included if they investigated adult mental health experiences in emergency department from the users' perspective. Studies describing proxy, carer/family or care provider experiences were excluded.

RESULTS

Sixteen studies were included. Thematic synthesis identified three themes and associated subthemes. Theme 1 - ED staff can make-or-break and ED experience - comprised: Feeling understood and heard; Engaging in judgement-free interactions; Receiving therapeutic support; Being actively and passively invalidated for presenting to the ED; and Once a psych patient, always a psych patient. Theme 2 - Being in the ED environment is counter-therapeutic - comprised: Waiting for an 'extremely' long time; and Lacking privacy. Theme 3 was Having nowhere else to go.

CONCLUSIONS

The experiences described by individuals presenting to emergency department for mental health reasons were mostly poor. The results illustrate a need for increased mental health education and training for all emergency department staff. Employment of specialist and lived experience workers should also be prioritised to support more therapeutic relationships and emergency department environments. In addition, greater investment in mental health systems is required to manage the current crisis and ensure future sustainability.

Care giving and receiving for people with complex emotional needs within a crisis resolution/home treatment setting: A qualitative evidence synthesis

WHAT IS KNOWN ON THE SUBJECT?: The term 'complex emotional needs' (CEN) is used here to describe people with difficulties and needs that are often associated with the diagnostic label of 'personality disorder'. People with CEN might use out of hours services such as emergency departments and Crisis Resolution/Home Treatment (CRHT) teams more often when experiencing a mental health crisis. Very little is understood about the experiences of both those receiving, and those delivering care, for people with CEN within CRHT settings. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: There are differences between priorities for those delivering and those receiving care within CRHT settings. CRHT staff members are likely to focus more upon those aspects of their role relating to risk issues. managing resources, anxieties and the expectations of others. Service users, meanwhile, focus upon the caring relationship, wanting staff to listen to them, and to feel supported and reassured. In the papers reviewed, service users experiencing CEN did not always feel 'listened to' or 'taken seriously' especially in relation to risk issues and decision-making. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Relating the findings to mental health nursing and CEN within the context of CRHT, to better understand the person experiencing a mental health crisis, mental health nurses need to focus more upon the person and when making decisions around their care and must be aware of the potential for power imbalances. Collaborative 'sense-making' in relation to a person's risk behaviours may help. ABSTRACT: Background A growing body of qualitative evidence focusing upon the experiences of care within Crisis Resolution/Home Treatment (CRHT) is emerging; however, a firm evidence base regarding both the giving and receiving of care for those with complex emotional needs (CEN) in this context is yet to be established. Objective A qualitative evidence synthesis was used to develop a comprehensive understanding of how crisis care for people with CEN is experienced by both those giving and receiving care, within the context of CRHT. Method Findings from 19 research papers considering both clinician and service users' experiential accounts of CRHT were synthesised using meta-ethnography. Findings Both the giving and receiving of care within a CRHT context was experienced across four related meta-themes: 'contextual', 'functional', 'relational' and 'decisional'. Discussion Service user accounts focused upon relational aspects, highlighting a significance to their experience of care. Meanwhile, clinicians focused more upon contextual issues linked to the management of organisational anxieties and resources. For those with CEN, a clinician's focus upon risk alone highlighted power differentials in the caring relationship. Conclusions There is a need for nurses to connect with the experience of the person in crisis, ensuring a better balance between contextual issues and relational working.

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.

Practitioner Review: Treatments for young people who self-harm - challenges and recommendations for research and clinical practice

BACKGROUND

Self-harm is very common in young people and is associated with suicide. Rates of both self-harm and suicide have increased in young people, particularly in females. There is a clear need to identify new approaches to prevent repeat self-harm.

METHOD

We significantly update and build on previous reviews with the aim of identifying issues in research relevant to clinical practice. We identify challenges in developing, implementing and evaluating treatments for self-harm in children and adolescents, suggest a way forward for research, and provide clear and practical guidance for clinicians on how to apply current research evidence in the real world.

RESULTS

Currently, there is limited evidence for effective interventions, other than some support for dialectical behaviour therapy for adolescents (DBT-A). To improve research and, by extension, clinical practice, future studies need to address psychosocial factors associated with youth self-harm and suicide, investigate the critical mechanism(s) of action, ensure trials are sufficiently powered and representative, and involve young people more actively in the design, implementation and evaluation of these approaches. Consideration should also be given to alternative research designs, such as pragmatic or adaptive clinical trials, as well as registry-based randomised controlled trials which leverage administrative data collected in routine clinical practice, to help meet these goals.

CONCLUSIONS

Recommendations for practice include undertaking comprehensive assessment and formulation, and offering DBT-A where indicated. There should be further development and evaluation (with input from young people) of Cognitive Behavioural-based Therapy adapted for young people. Greater attention to the role of the therapeutic relationship and family involvement (where possible) is also an important considerations, irrespective of the specific therapeutic modality. Finally, more consideration should be given to improving staff training to ensure all clinical staff feel equipped to treat young people who self-harm in a person-centred and compassionate manner.

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.

Trauma-Informed Approach to Qualitative Interviewing in Non-Suicidal Self-Injury Research

Non-suicidal self-injury (NSSI) is recognized as a public health concern owing to its chronic nature, association with suicide risk, and its growing prevalence rates across the globe. Including individuals living with NSSI in research is crucial as it offers opportunities to give primacy to participant voices and insights, further guiding therapeutic interventions. Research has established an association between history of traumatic events and adverse childhood experiences with subsequent risk of NSSI. When planning a qualitative research study with individuals with potential trauma history, researchers need to be aware of and sensitive to potential re-traumatization and distressing emotions that participants may experience during interviews, as well as complex trauma reactions that may affect individuals after study participation. The article emphasizes that researchers be cognizant of the multifaceted nature of trauma and how it can impact individuals and communities and be sensitive in their approach to interviewing vulnerable groups such as individuals with experiences of NSSI. The authors propose adopting a trauma-informed approach to ethically plan and conduct qualitative interviews exploring NSSI experiences. Trauma-informed recommendations for preparing and carrying out specific steps during different stages of NSSI interviews are detailed.

Examining the Feasibility of Implementing Digital Mental Health Innovations Into Hospitals to Support Youth in Suicide Crisis: Interview Study With Young People and Health Professionals

BACKGROUND

Hospitals are insufficiently resourced to appropriately support young people who present with suicidal crises. Digital mental health innovations have the potential to provide cost-effective models of care to address this service gap and improve care experiences for young people. However, little is currently known about whether digital innovations are feasible to integrate into complex hospital settings or how they should be introduced for sustainability.

OBJECTIVE

This qualitative study explored the potential benefits, barriers, and collective action required for integrating digital therapeutics for the management of suicidal distress in youth into routine hospital practice. Addressing these knowledge gaps is a critical first step in designing digital innovations and implementation strategies that enable uptake and integration.

METHODS

We conducted a series of semistructured interviews with young people who had presented to an Australian hospital for a suicide crisis in the previous 12 months and hospital staff who interacted with these young people. Participants were recruited from the community nationally via social media advertisements on the web. Interviews were conducted individually, and participants were reimbursed for their time. Using the Normalization Process Theory framework, we developed an interview guide to clarify the processes and conditions that influence whether and how an innovation becomes part of routine practice in complex health systems.

RESULTS

Analysis of 29 interviews (n=17, 59% young people and n=12, 41% hospital staff) yielded 4 themes that were mapped onto 3 Normalization Process Theory constructs related to coherence building, cognitive participation, and collective action. Overall, digital innovations were seen as a beneficial complement to but not a substitute for in-person clinical services. The timing of delivery was important, with the agreement that digital therapeutics could be provided to patients while they were waiting to be assessed or shortly before discharge. Staff training to increase digital literacy was considered key to implementation, but there were mixed views on the level of staff assistance needed to support young people in engaging with digital innovations. Improving access to technological devices and internet connectivity, increasing staff motivation to facilitate the use of the digital therapeutic, and allowing patients autonomy over the use of the digital therapeutic were identified as other factors critical to integration.

CONCLUSIONS

Integrating digital innovations into current models of patient care for young people presenting to hospital in acute suicide crises is challenging because of several existing resource, logistical, and technical barriers. Scoping the appropriateness of new innovations with relevant key stakeholders as early as possible in the development process should be prioritized as the best opportunity to preemptively identify and address barriers to implementation.

The impact of mental health stigma in a young Malaysian lady with recurrent suicidal ideations and moribund presentations to the Emergency Department: a case report

Introduction

Mental health stigma (MHS) has been a pervasive social issue and a significant barrier to treatment seeking behavior. The treatment pathways and outcomes for people with mental illness, specifically those with recurrent suicidal ideations and attempts have been influenced by how MHS was experienced in clinical practice.

Methods

We reported a case of a young lady diagnosed with bipolar II disorder, obsessive-compulsive disorder and borderline personality disorder who had recurrent visits to various emergency departments (ED) of tertiary hospitals in Malaysia for suicidality; each time presenting with increased mortality risk and escalating near-lethal outcomes. Among the multiple ED visits after her alleged overdoses of psychotropic medications, thrice she was near-unconscious and had to be intubated for airway protection, subsequently requiring ventilatory support and ICU care. These near-lethal presentations in ED were due to her delays in seeking treatment for fear of re-experiencing the stigmatizing environment among healthcare staff and professionals in the ED.

Discussion

The impact of MHS is detrimental. Effective interventions at various levels in the clinical setting is of utmost importance to prevent the negative consequences of suicidality against MHS.

Implying implausibility and undermining versus accepting peoples' experiences of suicidal ideation and self-harm in Emergency Department psychosocial assessments

Background

Patients seeking emergency care for self-harm and suicidality report varying experiences from being believed and taken seriously to not being believed and taken seriously. Epistemic injustice provides a conceptual framework to explore how peoples' experiences of self-harm and suicidality are believed or not. We use an empirical method -conversation analysis - to analyze epistemics in clinical communication, focusing on how knowledge is claimed, contested and negotiated. In courtroom, police and political interaction, conversation analysis has identified communication practices implying implausibility in a person's story to contest and recharacterize their accounts.

Aims

To investigate communication practices in Emergency Department (ED) biopsychosocial assessments that may (1) undermine, imply implausibility and recharacterize or (2) accept peoples' experiences of suicidal ideation and self-harm.

Methods

Using conversation analysis, we micro-analyzed verbal and non-verbal communication in five video-recorded biopsychosocial assessments with people presenting to the ED with self-harm or suicidal ideation, and conducted supplementary analysis of participants' medical records and post-visit interviews. We present three cases where experiences were not accepted and undermined/recharacterized and two cases where experiences were accepted and validated.

Results

When peoples' experiences of suicidality and self-harm were not accepted or were undermined, questioners: did not acknowledge or accept the person's account; asked questions that implied inconsistency or implausibility ("Didn't you tell your GP that you were coping okay?"); juxtaposed contrasting information to undermine the person's account ("You said you were coping okay before, and now you're saying you feel suicidal"); asked questions asserting that, e.g., asking for help implied they were not intending to end their life ("So when you called 111 what were you expecting them to do"); and resistinged or directly questioned the person's account. Multiple practices across the assessment built on each other to assert that the person was not suicidal, did not look or act like they were suicidal; that the person's decision to attend the ED was not justified; that an overdose was impulsive and not intended to end life; asking why the person didn't take a more harmful medication to overdose; that self-harming behaviors were not that serious and should be in the person's control. Alternative characterizations were used to justify decisions not to provide further support or referrals to specialist services. At times, these practices were also delivered when speaking over the patient. When peoples' experiences were accepted, practitioners acknowledged, accepted, validated suicidality/self-harm and introduced a shared understanding of experiences that patients found helpful. Non-verbal feedback such as nodding and eye contact was central in acceptance of patients' accounts.

Conclusion

These findings advance our understanding of how peoples' experiences of suicidality or self-harm are undermined or accepted in mental health encounters in the ED. They have important clinical implications: patients report that when their experiences are not accepted or undermined, this makes them more distressed, less hopeful about the future and discourages future help-seeking when in crisis. Conversely, acknowledging, accepting and validating suicidality/self-harm and introducing a new ways of understanding peoples' experiences may make people less suicidal and more hopeful, generates shared understanding and encourages future help-seeking.

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.

Systems Approach to Suicide Prevention: Strengthening Culture, Practice, and Education

Contemporary approaches to suicide prevention extend beyond an individual's interactions with care providers to seek opportunities for improvement in the wider care system. A systems-based analysis can yield opportunities to improve prevention and recovery across the care continuum. This article uses an example of an individual seeking care in an emergency department to show how a traditional clinical case formulation can be framed in terms of the outer and inner contexts of the EPIS (Exploration, Preparation, Implementation, Sustainment) framework to illuminate the impact of systemic factors on outcomes and to identify opportunities for improvement. Three mutually reinforcing domains (a culture of safety and prevention; best practices, policies, and pathways; and workforce education and development) of a systems approach to suicide prevention are outlined, along with their defining characteristics. A culture of safety and prevention requires engaged, informed leaders who prioritize prevention; lived experience integrated into leadership teams; and adverse events review in a Restorative Just Culture focused on healing and improvement. Best practices, policies, and pathways that promote safety, recovery, and health require codesign of processes and services and evolve through continuous measurement and improvement. To support a culture of safety and prevention, and caring, competent application of policy, organizations benefit from a longitudinal approach to workforce education. This includes a common framework and language; models clinical and lived experience collaboration; and supports continuous learning, as well as onboarding of new staff, rather than following a "one-and-done" approach, so that suicide prevention training remains top of mind across the workforce.

Effects of the physical environment on children and families in hospital-based emergency departments: A systematic literature review

Every year, millions of children seek care in emergency departments (EDs) for various conditions. Though the physical environment of the ED provides the context and setting for care delivery, influences workflows, and shapes interactions between users, the noisy, sterile, stimulating nature of the ED can be counter-therapeutic to pediatric patients and families. This systematic literature review investigates this complex dynamic and asks how the physical environment of emergency departments affects children and their families or guardians. Using PRISMA methods, this review searched four databases to identify and analyze twenty-one peer-reviewed articles that explored the impacts of the physical environment of hospital-based EDs on children or family members. Several themes emerged from the literature - concerning control, positive distractions, family and social supports, and designing for a safe and comfortable experience - that illustrate opportunities for future ED design and highlight knowledge gaps and avenues for future research.

"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.

Communication in youth mental health clinical encounters: Introducing the agential stance

When young people seek support from mental health care practitioners, the encounters may affect the young people's sense of self, and in particular undermine their sense of agency. For this study, an interdisciplinary team of academics and young people collaboratively analysed video-recorded encounters between young people and mental healthcare practitioners in emergency services. They identified five communication techniques that practitioners can use to avoid undermining the young person's sense of agency in the clinical encounter. They conceptualise the use of those techniques as the adoption of an agential stance towards the young person. The agential stance consists of: (a) validating the young person's experiences, (b) legitimising the young person's choice to seek help, (c) refraining from objectifying the young person, (d) affirming the young person's capacity to contribute to positive change, and (e) involving the young person in the decision-making process.

Cardiac disease in pregnancy and the first year postpartum: a story of mental health, identity and connection

Background

Women with cardiac disease in pregnancy and the first year postpartum often face uncertainty about their condition and the trajectory of their recovery. Cardiac disease is a leading cause of serious maternal morbidity and mortality, and the prevalence is increasing. Affected women are at risk of worsening cardiac disease, chronic illness, mental illness and trauma. This compounded risk may lead to significant and long-term negative outcomes. The aim of this study is to correct the lack of visibility and information on the experiences of women with cardiac disease in pregnancy and the first year postpartum.

Methods

A qualitative study using in-depth semi-structured interviews with twenty-five women who had acquired, congenital or genetic cardiac disease during pregnancy or the first year postpartum. Data were analysed and interpreted using a thematic analysis framework.

Results

Analysis of the interviews produced three major themes: 1) Ground zero: index events and their emotional and psychological impact, 2) Self-perception, identity and worthiness, and 3) On the road alone; isolation and connection. There was a narrative consistency across the interviews despite the women being diverse in age, cardiac diagnosis and cardiac health status, parity and timing of diagnosis. The thread prevailing over the temporal and clinical differences was one of distress, biographical disruption, identity, isolation, a necessitated re-imagining of their lives, and the process of multi-layered healing.

Conclusion

Acknowledging and understanding the breadth, complexity and depth of women’s experiences is fundamental to improving outcomes. Our findings provide unique insights into women’s experiences and challenges across a spectrum of diseases. Most women did not report an isolated trauma or distressing event, rather there was a layering and persistence of psychological distress necessitating enhanced assessment, management and continuity of care beyond the routine 6-week postpartum check. Further research is required to understand long-term outcomes and to refine the findings for specific disease cohorts to be able to respond effectively.

[Non-suicidal self-injurious Behaviour: Insights into a littleknown Patient Population in Plastic Surgery]

BACKGROUND

Despite its high prevalence in adolescents and young adults, non-suicidal self-injury (NSSI) is poorly known and understood in areas other than psychiatry. Due to this lack of knowledge, affected patients often face a lack of understanding as well as rejection and discrimination when seeking help from medical professionals. This not only hampers a lasting improvement of NSSI and the development of a trustful physician-patient relationship but may also lead to traumatisation of affected patients. Based on our patients' data, this article aims to inform interested plastic surgeons about NSSI and thus to support the treatment of affected patients.

PATIENTS AND METHODS

600 patients with scars from NSSI presenting to our outpatient clinic for the first time during the past five years were enrolled in this study. Extensive data collected during the first contact was analysed and compared with the current literature.

RESULTS

95 % of the patients were female; 5 % were male. On average, patients presented 8.4 years after the last NSSI event and with a mean age of 26 years. NSSI scars were most often located on the left forearm (48 %), followed by both forearms (40 %), the left upper arm (20 %), both upper arms (15 %) and both thighs (14 %). In 57 % of patients, scars were only present on one side. A mean of 380 cm2 of the body surface was affected by NSSI scars. 47 % of patients reported having at least one additional diagnosis, with thyroid dysfunction and depression being the most common. 21 % of patients had ongoing psychiatric or psychological therapy at the time of their first consultation in our clinic.

CONCLUSION

Our data provides first insight into a large population of NSSI patients seeking treatment options for their NSSI-associated scars in a plastic surgery outpatient clinic. Most patients were female with scars located on their forearms. A mean of more than 8 years had passed between their last NSSI and their first presentation to our clinic. Our findings offer a data-based approach to a group of patients with a disease pattern that is largely misunderstood in surgical disciplines and needs more attention, especially in the light of its high prevalence and life-long consequences.

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

Emergency departments are often the point of entry to the healthcare system for people who self-harm, and these individuals are at high risk of further self-harm and suicide in the post-discharge period. These settings therefore provide a critical opportunity for intervention. However, many studies have identified that the experiences of patients, carers and the emergency department staff themselves is often suboptimal. In this editorial we summarise one such study, by O'Keeffe and colleagues, and consider strategies for improving the experiences of patients and their carers when presenting to the emergency department. We also reiterate the need for wider systemic change in attitudes and approaches towards people who self-harm that are pervasive across the healthcare system and beyond.

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

Self-harm is a major challenge in healthcare systems. Emergency department nurses provide care to numerous patients with self-harm injuries. Accordingly, nurse-patient interactions are vital to improve the physical and psychological outcomes of this complex patient group. Previous studies have proposed the establishment of improved teaching programs to increase the competence of emergency department nurses within mental health care; however, few studies have comprehensively investigated the experiences and suggestions for future nursing practices. Therefore, we gathered in-depth knowledge of Danish emergency department nurses' experiences caring for patients who self-harm and obtained their suggestions on future nursing practices. Ten semi-structured interviews were conducted to capture the nurses' individual perspectives. The scientific theory is based on phenomenology and hermeneutics. Interpretative phenomenological analysis was used, and three themes were identified: (i) importance of having the competences to establish a relationship in the acute phase; (ii) acute care from a biomedical perspective; and (iii) highlighting ideas for improved future practices. The emergency department nurses were aware of the importance of mental health care but found their competence and motivation situated in medical care. The nurses felt that they lacked skills to undertake in-depth mental care for patients who self-harm and that the healthcare system failed to help this group of patients. Based on these findings, rather than aiming at improving nursing skills, we suggest a close collaboration between the emergency and psychiatric departments to improve the quality of care for patients who self-harm. We also recommend organizational changes within the emergency department, such as the introduction of a so-called 'social track'.

They Told Me "This Isn't a Hotel": Young People's Experiences and Perceptions of Care When Presenting to the Emergency Department with Suicide-Related Behaviour

In Australia, the number of young people presenting to the emergency department with mental health concerns, in particular, suicidal behaviour (defined here as suicidal ideation, thoughts, intent and attempts) is increasing. Little is known about the experiences of Australian young people who present to hospital emergency departments with suicidal behaviour. In this qualitative study, we conducted a series of focus groups with 55 young people aged 16–25 years, with a view to developing a framework for youth suicide prevention for Western Australia. The data were analysed using a general inductive analysis approach. We explored the experiences and perceptions of the care and management of 35 young people presenting to Western Australian hospital emergency departments. Participants described a range of negative experiences relating to the emergency department environment, staff attitudes and their treatment by staff. We argue that adapting ED practices and approaches to young people presenting with suicidal thoughts and behaviours based on these findings will result in lower rates of repeated presentations and admissions to hospital and lower rates of suicide attempts and deaths by suicide.

'A Safe Place Where I Am Welcome to Unwind When I Choose to'-Experiences of Brief Admission by Self-Referral for Adolescents Who Self-Harm at Risk for Suicide: A Qualitative Study

Evidence is lacking on how to manage imminent suicidality in adolescents with self-harm. Brief Admission by Self-referral (BA) is a crisis-management intervention, developed for adults with self-harm at risk for suicide. Structured, individualized and based on responsible autonomy, BA aims to provide a respite while minimizing negative effects of hospitalization. This qualitative interview study illuminates adolescents' experiences of BA, adapted for this target group. Nineteen adolescents aged 14 to 19 years, described BA as helpful for timely rest and recovery to save themselves from impulses to self-harm. The individual contract, which is a prerequisite for access to BA, was perceived to give access to professional support in a safe environment, also among adolescents not using their contract. Being trusted with responsibility to self-admit was also hard work with struggles of self-doubt. Challenges included experiencing distrust from staff and fear of not being able to abstain from self-harm, which BA is conditioned upon. However, this condition was also perceived to induce self-motivation and growth. BA appeared well-adapted to the target group, fulfilling needs of predictability, autonomy, and opportunity for recovery to prevent self-harm. Suggestions for improvement included continually informing staff about important features of BA. To further evaluate benefits and challenges of BA, future research may evaluate clinical and health-economic outcomes and perspectives from parents and caregivers.

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.