[Preventing suicidal crisis and suicide]

Suicide is not the inevitable outcome of a suicidal crisis. The people concerned are most often sensitive to preventive actions, which can prevent them from committing self-destructive acts. Preventing the suicidal crisis and suicide requires the involvement of healthcare professionals. It is also everyone's business.

A nurse practitioner-led intervention for runaway adolescents who have been sexually assaulted or sexually exploited: Effects on trauma symptoms, suicidality, and self-injury

BACKGROUND

Adolescent victims of sexual assault and exploitation suffer significant mental health distress including PTSD, self-harm, suicidal ideation, and attempts.

OBJECTIVE

This longitudinal observational study investigated the Runaway Intervention Program's influence on trauma responses at 3, 6, and 12 months for adolescents who have run away at least once and have been sexually assaulted or exploited.

PARTICIPANTS

Runaways (n = 362) received nurse practitioner (NP) home and community visits, intensive case management, and optional empowerment groups.

SETTING

An urban Midwestern city's hospital-based Children's Advocacy Center.

METHODS

Trauma responses were measured by the UCLA PTSD-RI index, past 30 days emotional distress scale, and self-harm, suicidal ideation, and suicide attempt questions. Repeated Measures ANOVA assessed trauma response changes over time. Growth curve analyses using intervention doses determined which aspects of the intervention predicted change.

RESULTS

From program entry to 3 and 6 months, mean values decreased significantly for emotional distress (-0.67, -.91) self-harm (-.30, -.55), suicidal ideation (-.45, -.57), suicide attempts (-.58, -.61), and trauma symptoms (-11.8, -16.2, all p < .001) all maintained at 12 months. In growth curve models, NP visits independently predicted declines in emotional distress (-.038), self-injury (-.020), suicidal ideation (-.025) and attempts (-.032), while empowerment groups predicted trauma symptoms (-.525) and all others except suicide attempts.

CONCLUSIONS

The program, especially NP community visits and empowerment group elements, decreased trauma responses in runaway youth with a history of sexual assault. Given high rates of PTSD and emotional distress among runaways, the Runaway Intervention Program offers promise for improving mental health outcomes.

'Our Care through Our Eyes'. Impact of a co-produced digital educational programme on nurses' knowledge, confidence and attitudes in providing care for children and young people who have self-harmed: a mixed-methods study in the UK

OBJECTIVES

(1) To determine the impact of a digital educational intervention on the knowledge, attitudes, confidence and behavioural intention of registered children's nurses working with children and young people (CYP) admitted with self-harm.(2) To explore the perceived impact, suitability and usefulness of the intervention.

INTERVENTION

A digital educational intervention that had been co-produced with CYP service users, registered children's nurses and academics.

SETTING

A prospective, uncontrolled, intervention study with preintervention and postintervention measurement, conducted at a large acute NHS Trust in the UK.

PARTICIPANTS

From a pool of 251 registered children's nurses and 98 participants were recruited to complete the intervention (response rate=39%). At follow-up, 52% of participants completed the postintervention questionnaire, with 65% (n=33) of those reporting to have completed the digital educational intervention.

PRIMARY OUTCOME MEASURES

Attitude towards self-harm in CYP was measured using a 13-item questionnaire; knowledge of self-harm in CYP was measured through an adapted 12-item questionnaire; confidence in different areas of practice was measured through Likert Scale responses; self-efficacy for working with CYP who have self-harmed was measured through an adapted version of the Self-efficacy Towards Helping Scale; clinical behavioural intention was measured by the Continuing Professional Development Reaction Questionnaire. Semistructured interviews were undertaken with a purposive sample of participants.

RESULTS

For those who completed the intervention (n=33), improvements were observed in knowledge (effect size, ES: 0.69), confidence, and in some domains relating to attitudes (effectiveness domain-ES: 0.49), and clinical behavioural intention (belief about consequences-ES:0.49; moral norm-ES: 0.43; beliefs about capability-ES: 0.42). Qualitative findings suggest participants experienced skill development, feelings of empowerment and reflection on own practice.

CONCLUSIONS

The effect of the intervention is promising and demonstrates the potential it has in improving registered children's nurse's knowledge, confidence and attitudes. However, further testing is required to confirm this.

Nonsuicidal Self-Injury

Nonsuicidal self-injury (NSSI) is a serious and prevalent problem within the adolescent population. NSSI is associated with a variety of psychiatric diagnoses and behavioral concerns. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition, has recognized NSSI as its own separate diagnosis. Although there are unique differences between NSSI and suicidal behaviors, a link exists between these behaviors. It is crucial that pediatric nurse practitioners who provide care for adolescents possess a thorough understanding of NSSI. In this continuing education article, NSSI will be discussed in terms of epidemiology, diagnosis and co-morbidity, risk factors, relationship with suicidal behaviors, and implications for practice.

Identifying the Signs of Self-Harm in Students

Self-harm in adolescents is not a new phenomenon. However, the number of adolescents who participate in self-harming behaviors is growing. It can be difficult to detect those who self-harm due to the secrecy that surrounds the act of self-harm itself. This article focuses on providing assistance to school professionals in the identification of signs of self-harm in adolescents and how to deal with this growing epidemic.

Managing young people with self-harming or suicidal behaviour

This literature review aimed to determine the risk factors being used to identify children and young people who are at increased risk of engaging in self-harm and suicidal behaviour, so that optimal care can be provided for this patient group in children's medical ward settings. The two main themes that emerged were mental and neurodevelopmental disorders, and external factors. Management strategies to aid healthcare professionals in caring for this patient group were also identified. The review concludes by highlighting the need to provide healthcare professionals with continuing education about the mental health problems of children and young people, including risk factors and management strategies.

Prevalence of self-neglect in the caseloads of public health nurses

BACKGROUND

The extent of self-neglect on public health nurses' (PHNs) caseloads in Ireland is unknown. People who self-neglect may be vulnerable or hidden and, as a consequence, difficult to profile. PHNs in Ireland profile their areas to identify the nursing needs of their population.

AIM

This paper aims to: collate caseloads on self-neglect on the basis of a review of community profile and health need assessments (CPHNA) and identify the geographical and demographic factors within which self-neglect cases were found.

METHOD

A retrospective review of the CPHNA of student PHNs (n=88) was undertaken from 2010 to 2014 in a university in Ireland. In all, 88 community profiles were manually reviewed.

RESULTS

A total of 374 self-neglect cases were identified-79 cases were aged between 18-64 years and 295 were over 65 years. The range of self-neglect cases per profiled area was between 0 to 25. The geographic and demographic factors linked to self-neglect across profiles were higher rates of older people, deprivation, disadvantage, and cultural factors.

CONCLUSION

This retrospective review illustrates that self-neglect is a prominent feature in PHN caseloads, which has not been identified previously. Early identification is important to promote the mental health and wellbeing of self-neglecting clients.

'Our Care through Our Eyes': a mixed-methods, evaluative study of a service-user, co-produced education programme to improve inpatient care of children and young people admitted following self-harm

INTRODUCTION

Within Europe, the UK has one of the highest rates of self-harm, with a particularly high prevalence in children and young people (CYP). CYP who are admitted to paediatric hospital wards with self-harm are cared for by registered children's nurses who have been identified to lack specific training in caring for this patient group. This may impede the delivery of high quality care. Therefore, this study aims to co-produce, implement and evaluate an education programme for registered children's nurses to improve their knowledge, attitudes and confidence when caring for CYP admitted with self-harm.

METHODS AND ANALYSIS

This mixed-methods evaluative study will involve a three-stage design. Stage 1: A priority-setting workshop will be conducted with 19 registered children's nurses. A Delphi technique will be used to establish consensus of information needs. Stage 2: An online educational intervention will be co-produced with 25 CYP and 19 registered children's nurses based on the priorities identified in Stage 1. Stage 3: The intervention will be implemented and evaluated with 250 registered children's nurses at a single hospital. Online Likert scale questionnaires will be administered at baseline and postintervention to assess levels of knowledge, attitudes and confidence in caring for CYP who self-harm. Descriptive and inferential statistics will be used to analyse the data. Statistical significance will be assessed at the 5% (two-sided) level. One-to-one qualitative interviews will also be undertaken with approximately 25 participants to explore any perceived impact on clinical practice. An interpretive descriptive approach will guide qualitative data collection and analysis.

ETHICS AND DISSEMINATION

This study aims to develop, trial and evaluative a service-user, co-produced education programme for acute hospital registered children's nurses to improve the care of CYP admitted due to self-harm. The study has ethical approval from the National Health Services Research Ethics Committee and full governance clearance.

A nurse-led pathway to treat self-harm injuries

Self-harm occurs frequently in psychiatric hospitals and other mental health and outpatient settings. Many patients at the Ayr Clinic are at risk of self-harm and often access the local accident and emergency service for minor injury care. The medical and nursing response to people who repeatedly self-harm, given increasing pressures and dwindling A&E resources, can often be one of impatience, frustration and hostility. A nurse-led pathway was developed by the Ayr Clinic and NHS Ayrshire and Arran to fast-track the assessment and treatment of such injuries and improve health professionals' attitudes towards these patients. This project was winner of the Nursing Times emergency and critical care awrad 2014.

Self-harm in the emergency setting: Understanding and responding

Nurses are the people most consistently and intensely involved in the care of people who present to emergency departments because of self-harm, yet most have received no training or support to provide strategic care. This paper will explore unique features of the emergency context for care and provide practical instruction on how nurses working in the area can respond effectively. As this paper argues there is much that the emergency nurse can provide for the client who self-harms and it describes important steps toward recovery--a respectful human encounter, understanding, support for the person's efforts in coping, optimism and hope that pain will lessen and recovery will take place.

[Emergency departments and deliberate medicinal self-poisoning]

Deliberate medicinal self-poisonings are a frequent cause of admission to emergency departments. These patients are almost always brought to hospital by paramedics rather than by family or private ambulances.

[Emergency departments and demand for psychiatric care]

New organisations have been established in the general hospital to respond to care increasing needs linked to the psychiatrics pathologies. In France, there are different types of organisation within emergency departments, in order to host these patients in the best way. In the context of psychiatric emergency departments, the role of the nurse is critical. This article presents the example of the case of a patient needing psychiatric care admitted to the emergency department.

Use of a safe kit to decrease self-injury among adolescent inpatients: a pilot study

A quasi-experimental pilot study was conducted via a convenience sample of 39 adolescents with a recent history of self-injury who were admitted to an inpatient psychiatric unit. It was postulated that the use of a safe kit would decrease the urge to self-injure during the participant's hospital stay. Participants were screened using the Deliberate Self-Harm Inventory 9 and enrolled in the study after informed consent was received. Patients designed a safe kit, filling it with items that may help them refrain from self-injury when the urge was high. At the end of the hospital stay, participants completed a questionnaire evaluating the use of the safe kit in the context of other coping skills used during their admission. Sixty-two percent (n = 23) of participants used the kit as a means of coping with urges to self-injure. Sixty-one percent of those who used the kit strongly agreed that the safe kit reduced the urge to self-injure. Further research is needed with a larger sample to explore the effectiveness of a safe kit in maintaining safety on an adolescent unit.

Getting it right: caring for people who self-harm

The treatment received in emergency departments by people who self-harm depends to a great extent on the behaviour of staff and how this is perceived by service users. In this article, a long-time service user describes how she was pleasantly surprised by the attitudes of the emergency nurses and doctors who cared for her after she had self-harmed.

Safer self-injury or assisted self-harm?

Psychiatric patients may try (or express a desire) to injure themselves in hospital in order to cope with overwhelming emotional pain. Some health care practitioners and patients propose allowing a controlled amount of self-injury to occur in inpatient facilities, so as to prevent escalation of distress. Is this approach an example of professional assistance with harm? Or, is the approach more likely to minimise harm, by ensuring safer self-injury? In this article, I argue that health care practitioners who use harm-minimisation can be considered to be helping physical injury to occur, although they do not encourage the act. I consider why there are compelling reasons to believe that a patient who self-injures is not maximally autonomous in relation to that choice. However, I then move onto argue that allowing a degree of self-injury may enable engagement with psychotherapy (enhancing autonomy) and behavioural change. In these circumstances, allowing injury (with precautions) may not be harm, all things considered.

A grounded theory exploration of deliberate self-harm in incarcerated women

The purpose of this study was to explicate a definition of deliberate self-harm (DSH) and present a model that illustrates the DSH process as experienced by incarcerated women. Grounded theory was used to guide the collection and analysis of data. A circular process of DSH emerged. For the incarcerated women in this study anxiety caused a visceral build-up of tension that reached a critical level necessitating a need to act in some way to gain relief. DSH supplied the mechanism by which overwhelming tension was released. The temporary relief, however, was soon supplanted by the negative consequences of disciplinary detention imposed as a means of punishment that in turn, lead to more anxiety and anger.

IMPLICATIONS

Nurses practicing in corrections need to work towards "decriminalizing" DSH and to develop a prison protocol that gives nurses permission to "just listen" and incarcerated women permission to "just talk" without fear of reprisal.

Self-injury behavior: how can nurses help?

Although historical, religious, and cultural examples provide some understanding of SIB, the importance of further research, especially in adolescent SIB, cannot be underestimated. Nursing research is needed to explore the correlation between SIB and the spiritual needs of adolescents. Shannon (2005) stated that SIB is a common precursor to suicide. If adolescents at risk for this behavior are identified earlier, perhaps fewer teens will be lost to suicide. Although many use self-injury as short-term relief from their problems, it is repetitive in nature. If nurses are able to assist adolescents in interrupting emerging patterns of SIB, future self-injury may be prevented. Adolescents at risk for self-injury behavior are searching for a way to give voice to their pain. When approached with a caring attitude that reflects the love of Christ, when listened to with intentionality, and when nurtured by an authentic presence, self-injurers are relieved to externalize their difficult emotions through verbal means rather than to record their pain with visible stories on their skin. For even when the wounds heal, the scars remain a visible reminder of the hurt hiding within. In essence, the history of the self-injurer is recorded on their skin.

Self-neglect. 2: Nursing assessment and management

This is a two-part unit on self-neglect. Part 1 examined definitions of the phenomenon, its characteristics and risk factors. This article, part 2, discusses nurses' role in the identification and assessment of self-neglect. Due to its complex nature, a multi-agency and multidisciplinary approach is required to meet and protect the needs of vulnerable adults.

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

AIM AND OBJECTIVES

This exploratory study investigates emergency department nurses' attitudes towards patients who engage in deliberate self-harm. It examines their attitudes towards, and triage and care decisions with, patients who self-harm.

BACKGROUND

Emergency department nurses sometimes show unsympathetic attitudes towards patients who present with self-harm and these can contribute to difficulties in assessing and providing appropriate care.

DESIGN

A modified version of the Suicide Opinion Questionnaire was used. A non-probability sample of 43 emergency department nurses from a large Australian hospital participated in the study. Data were analysed using SPSS.

RESULTS

Most nurses had received no educational preparation to care for patients with self-harm; over 20% claimed that the department either had no practice guidelines for deliberate self-harm or they did not know of their existence and one-third who knew of them had not read them. Overall, nurses had sympathetic attitudes towards patients who self-harm, including both professional and lay conceptualizations of deliberate self-harm. They did not discriminate against this group of patients in their triage and care decisions.

CONCLUSIONS

The findings of this exploratory study are important because attitudes can affect care decisions. Recommendations are made for improving the educational preparation of emergency department nurses, for improving awareness and implementation of practice guidelines, and for improving attitudes towards patients with deliberate self-harm. Further research is needed to confirm these results.

'Then I just showed her my arms . . .' Bodily sensations in moments of alienation related to self-injurious behaviour. A hermeneutic phenomenological study

People committing self-injurious behaviour are often perceived as difficult patients; confronted with unhelpful reactions from nurses, the patients find themselves left alone in their distress. A connection between self-injurious behaviour and feelings of alienation is suggested in the literature. Alienation is described as a state in which the self is perceived as strange, machinelike and not in contact with its emotional and physical needs. On one hand, complex neuro-biological processes are seen as responsible for this; on the other hand, alienation is seen as a means of self-protection when one is exposed to a threatening or traumatic situation. Nursing interventions focus on the nurse-patient relationship and on the handling of self-injuries, but they tend to ignore the client's previous experience. Proceeding from the assumption that patients committing self-injurious behaviour are the experts on their own harm, the purpose of the present study is to get insight into their 'lived experience' and to contribute to the understanding of this vulnerable group. Adopting a hermeneutic phenomenological research perspective, methods of participant observation and qualitative interviewing were chosen to generate data. The database consists of 99 observational sequences, five interviews and a set of email texts written by a self-injuring woman. A thematic analysis as described by Van Manen was done. The main findings are that alienation is experienced in several stages, that nurses can detect early signs of an impending loss of control, and that self-injurious behaviour is an effective strategy to end a painful experience of alienation. Self-injurious behaviour is appropriately understood as a form of 'self-care'.

Measuring nurse attitudes towards deliberate self-harm: the Self-Harm Antipathy Scale (SHAS)

Most mental health nurses engage at some point with clients who harm themselves and these nurses often experience strong negative emotional reactions. Prolonged engagement with relapsing clients can lead to antipathy, and 'malignant alienation'. The study reported here has the aim of developing a brief, robust instrument for assessing nurse attitudes in this area. The Self-Harm Antipathy Scale, developed here on a sample of 153 healthcare professionals, has 30 attitudinal items with six factors. It has acceptable face validity, good internal consistency and some evidence of good test-retest reliability. It discriminates effectively between criterion groups. Overall this is evidence for the complexity of nurses' responses to this client group but such complex attitudes can still be assessed using a relatively brief structured instrument.

Care staff attributions toward self-injurious behaviour exhibited by adults with intellectual disabilities

Challenging behaviours may elicit negative emotional reactions and increase stress within care staff. The Leeds Attributional Coding System (LACS) was used to elicit spontaneous causal attributions of staff toward hypothetical clients with challenging behaviours. It was hypothesized that there would be relationships (1) between staff exposure to challenging behaviours and burnout, and (2) between staff cognitions and burnout. Using a cross-sectional correlational design, 41 care staff took part in a 10 minute interview about two vignettes depicting self-injurious behaviour. Staff also completed measures of demographic information and burnout. Participants made attributions toward self-injurious behaviour that were typically internal to the client, uncontrollable, unstable and specific. There was a significant association between number of clients cared for and emotional exhaustion and personal accomplishment. Staff who made fewer stable attributions had higher levels of burnout. There were no other relationships found between staff cognition and burnout. The LACS can be successfully employed in this context, and may have some benefits over other methods. Future research is required to explore the relationship between cognition and burnout.

Testing the effectiveness of an educational intervention aimed at changing attitudes to self-harm

Nurses' attitudes toward service users who repeatedly self-harm can be negative and may interfere with the user's willingness to engage with services. The effectiveness of an educational intervention aimed at improving nurses' attitudes in this area was tested in this study. The intervention consisted of attendance on an accredited course on self-harm over a period of 15 weeks and the outcome of interest was attitudes as measured by the Self Harm Antipathy Scale. When deployed in a before-and-after design with two non-randomly allocated groups, there was evidence of a 20% reduction in antipathy toward self-harm among course attenders maintained over a period of at least 18 months (compared with a 9% reduction in a comparison group). Three of the six Self Harm Antipathy Scale attitude dimensions showed significant short-term change with some further long-term effects. This is preliminary evidence for the effectiveness of the chosen intervention in reducing overall antipathy toward self-harm clients and enhancing a sense of competence, a valuing of the care process and an awareness of the factors contributing to self-harm.

Pragmatism rules: the intervention and prevention strategies used by psychiatric nurses working with non-suicidal self-harming individuals

Self harm in the absence of expressed suicidal intent is an under explored area in psychiatric nursing research. This paper reports on findings of a study undertaken in two acute psychiatric inpatient units in Ireland. The purpose of the study was to gain an understanding of the practices of psychiatric nurses in relation to people who self harm, but who are not considered suicidal. Semi structured interviews were held with eight psychiatric nurses. Content analysis revealed several themes. For the purpose of this paper the prevention and intervention strategies psychiatric nurses engage in when working with non-suicidal self harming individuals are presented. Recommendations for further research are offered.

Junior staffing changes and the temporal ecology of adverse incidents in acute psychiatric wards

AIM

This paper reports an examination of the relationship between adverse incident rates, the arrival of new junior staff on wards, and days of the week on acute psychiatric wards.

BACKGROUND

Incidents of violence, absconding and self-harm in acute inpatient services pose risks to patients and staff. Previous research suggests that the arrival of inexperienced new staff may trigger more adverse incidents. Findings on the relationship between incidents and the weekly routine are inconsistent.

METHOD

A retrospective analysis was conducted of formally reported incident rates, records of nursing student allocations and junior doctor rotation patterns, using Poisson Regression. Variance between days of the week was explored using contingency table analysis. The data covered 30 months on 17 psychiatric wards, and were collected in 2002-2004.

FINDINGS

The arrival of new and inexperienced staff on the wards was not associated with increases in adverse incident rates. Most types of incidents were less frequent at weekends and midweek. Incident rates were unchanged on ward-round days, but increased rates were found on the days before and after ward rounds.

CONCLUSION

Increased patient tension is associated with raised incident rates. It may be possible to reduce incident rates by moderating stimulation in the environment and by mobilizing support for patients during critical periods.

Adverse incidents, patient flow and nursing workforce variables on acute psychiatric wards: the Tompkins Acute Ward Study

BACKGROUND

Adverse incidents (violence, self-harm and absconding) can cause significant harm to patients and staff, are difficult to predict, and are driving an increase in security measures and defensive practice.

AIMS

To explore the relationship between adverse incidents on acute psychiatric wards, admissions and nursing workforce variables.

METHODS

A retrospective analysis of officially collected data covering a period of 30 months on 14 acute wards at three hospitals. This data included 69 serious untoward incidents.

RESULTS

Adverse incidents were more likely during and after weeks of high numbers of male admissions, during weeks when other incidents also occurred, and during weeks of high regular staff absence through leave and vacancy.

CONCLUSIONS

It may be possible to predict adverse incidents. Careful staff management and deployment may reduce the risks.

Assessment of risk and special observations in mental health practice: a comparison of forensic and non-forensic settings

The use of special observations in psychiatric practice may be employed as an alternative to more restrictive methods such as the use of seclusion and restraint. From the literature, special observations are used for a complex array of signs and symptoms (and risk behaviours) which include suicidal intent, self-injurious behaviour, hallucinatory experiences, and absconding. This paper reports on research into the use of special observations in both forensic and non-forensic psychiatric settings. A comparative approach was adopted to establish if the perceived risk factors leading to the adoption of special observations were similar in both settings. Three groups of nursing staff were requested to assess 30 patients who were placed on special observations. Before this, nurses were requested to rate the risk factors in terms of their severity on a 7-point Likert scale. The rank-ordering analysis revealed a similarity of identified risk factors and anova (one-way, unrelated) and the Jonckheere Trend Test revealed that there were significant differences between the scores in the forensic and the non-forensic settings. The statistical differences existed for risk factors relating to harm to self and others but not for psychiatric symptomatology.

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

Self-harm in the absence of suicidal intent is an underexplored area in psychiatric nursing research. This article reports on findings of a study undertaken in two acute psychiatric admission units in Ireland. The purpose of this study was to gain an understanding of the practices of psychiatric nurses in relation to people who self-harm but who are not considered suicidal. Semistructured interviews were held with eight psychiatric nurses. Content analysis revealed several themes, some of which will be presented and discussed in this article, namely, the participants' understanding of self-harm, their approach to care, and factors in the acute psychiatric admission setting, which impacted on their care. Recommendations for further research are offered.

Suicide and Documentation: Don’t Let the Pen Kill Your Career

1. Nurses' notes must reflect the assessment performed regarding their patients' risk factors, red flags, and protective supports, especially for suicidal patients. 2. Nursing interventions range from the least-restrictive methods to full restraints, if necessary to prevent patients from harming themselves. 3. Medications, such as antidepressant, antipsychotic, and antimanic agents, as well as benzodiazepines, have been shown to help psychiatric patients cope with depression, psychosis, and mood stability.