The acute incident was a case of ‘deliberate self-harm’ (DSH), admitted to an A & E unit. DSH incorporates deliberate non-habitual acts of self-harm that are not fatal, and may or may not involve attempted suicide (Repper, 1999). Emergency departments provide the main ‘entry point’ for such patients (NICE, 2004). The patient in this case had slashed his wrists in several places, severing a key artery. He was bleeding profusely, and in a semiconscious state on arrival. There was a history of psychopathology dating back several years. He was unmarried, lived alone, and had recently undergone treatment and observation at the forensic mental health unit of a local NHS Hospital Trust. Reppers (1999) review of the relevant literature on the management of self-harm patients in A & E units highlights several key issues for nursing care. It is essential that the qualified nurse is cognisant of the relevant Codes of Professional Conduct specified by the Nursing Midwifery Council (NMC, 2002), including ethical concerns such as respect, confidentiality, and trust. This is particularly crucial when dealing with self-harm patients because research suggests that emergency department nurses often hold negative attitudes towards this type of patient (McAllister et al, 2002). Furthermore, self-harm patients have reported dissatisfaction with the care provided by nurses and other health care staff.
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The empirical literature on the management of self-harm patients in A & E highlights the value of problem-solving approaches to patient care (Repper, 1999). The basic problem-solving model incorporates five principles, outlined in Table 1. These tenets are consistent with protocols for effective decision-making, for both individuals and groups (Janis & Mann, 1977). They are also consistent with NICE/DOH guidelines for caring for the mentally ill (NICE, 2004, Clinical Guideline 16). NICE guidelines recommend immediate assessment of risk, and mental, physical, emotional stability, once a patient arrives at A & E. Staff are then required to account for underlying emotional factors that may have precipitated the self-harm episode, as well as evaluating the seriousness of the injury, before deciding the most appropriate treatment for the patient. Reesal et al (2001) highlight some of the key principles of management that are relevant to nurses working with mental health patients. These relate to assessment, phases of treatment, psychiatric management, goals of treatment, psychotherapeutic management, the management of medication and self-harm/suicide, and medical-legal issues (also see DOH, 1999; NICE, 2004). Nurses need to conduct a comprehensive psychosocial assessment, in full cognisance of the biological, psychological, and social context, and also precipitating and perpetuating factors. Mental health problems can often be long-term/chronic, rather than short/acute, and self-harm is no exception. An underlying condition like depression can be conceptualised in terms of three treatment phases – response, remission, and relapse. Principles of psychiatric management dictate that consent must be obtained prior to treatment. A good psychiatric-patient rapport is essential, and treatment must involve a multidisciplinary team, of which nurses are an essential part. Goal setting is paramount as it facilitates the development of a treatment plan and allows the patients progress to be evaluated more accurately. Psychotherapy can be based on any one of several models (e.g. cognitive-behavioural, interpersonal, dynamic).
Recovery must be closely monitored – patients who have not recovered within 2 months may require a change in treatment modality. Some knowledge of pharmacology is essential for effective medication management, but it is usually up to a psychiatrist to prescribe the necessary medication. In managing suicide/self-harm cases, it is important for the nurse to establish whether the patient “feels desperate, hopeless, helpless, or is tired of struggling with life. Has the patient not wanted to go on living? Is there active suicide ideation? How strong are the thoughts? How frequent, persistent, and irresistible are they? Is there a plan? Do the means and opportunities exist? How impulsive is the patient?” (Reesal et al, 2001, p.25S). Since self-harm episodes are generally unpredictable, there are bound to occur irrespective of psychosocial assessments and psychiatric management. Salient issues for inpatient management (see Table 2) include safety, crisis intervention, diagnosis, patient response to treatment, level of depression, inability to live effectively at home, and the level of social support (i.e. friends, family). Medical-legal issues include confidentiality, risk assessment, information sharing, truth telling, and liability. Some of these are considered later in this essay. Overall, patients must believe they are receiving equity, justice, and consideration, and that clinical management is set up to facilitate good quality care. Ethical and legal issues in the management of mental health patients are outlined in the Nursing and Midwifery Council’s codes of conduct (NMC, 2002), the National Service Frameworks (NSF) Modern Standards and Service Models for mental health patients (DOH, 1999), and the National Institute for Clinical Excellence (NICE, 2004).
There is currently strong emphasis on evidence-based nursing practice (NICE, 2004). Clinical decisions, where possible, should be based on good quality empirical research. The NICE Clinical Guidelines No.16, for the care of self-harm patients, are rooted in scientific evidence. It is therefore incumbent on nurses to ensure that decisions about all aspects of patient care comply with these standards. Thus, for example, nursing staff are compelled to consider using an integrated physical and mental health triage scale, establish physical risk and mental state, and offer psychosocial assessment at triage. The problem here concerns the practical realities of guidelines adherence in a busy A & E unit. Due to time constraints and hectic work routines, nurses may be unable to check adherence to standards. Senior nurses may rely more on their clinical experience in certain instances, whereas younger nurses finding it easier to consult colleagues for clarification, rather than locate and check practice standards. While guidelines will help ensure that this patient receives good quality health care, nurses and other health professionals will ultimately responsibility for clinical decisions. It is therefore essential that staff are adequately trained and resourced to make informed choices that are in the best interests of the patient. Decision theorists Janis and Mann (1977) propose that such informed decision making requires that a viable clinical solution is perceived to be available, to deal with the patients problem, and that there is adequate time in which to find it. If a nurses is uncertain what to do, perhaps due to inadequate training, lack of guideline information, or unfamiliarity with self-harm patients, then he or she may resort to ineffectual decision strategies, such as delaying treatment, looking for another nurse to take responsibility, or even discounting the severity of the patients condition. Time constraints can be a serious problem in emergency departments, where patients arrive with life-threatening injuries, and nurses are required to make multiple clinical decisions, in quick succession. Severe time limits may induce panic or frantic behaviour in clinical staff, leading to hasty clinical decisions that fail to account for all aspects of the patient’s clinical condition.
In 2005 the Department of Health published its Patient Led NHS (DOH, 2005). Central to this discourse is the notion of empowerment – enabling patients to have more say in clinical decisions about their care, by providing them with the all relevant information, support, and guidance. This is consistent with the 1983 Mental Health Act which states that patients are provided with all necessary and correct information by an informed health care professional, for example on the nature, purpose and probable effects of treatments, and detention, renewal, and discharge. Thus, the patient in A & E will have to be treated accordingly by nursing staff. The Department of Health has encouraged the faster emergence of best practice guidelines (DOH, 2005), as this is key to successful empowerment. Currently there are no commissioned best practice statements for the care of mentally ill, or specifically those who self-harm. Since the devolution of responsibility from health authorities to local primary and secondary care trusts (DOH, 2002a, 2002b), nurses have assumed greater responsibility implementing national guidelines on mental health. An important part of this empowerment is to liase or network with relevant multidisciplinary professionals, agencies, and local communities. Nurses working in mental health view networking as a major area of responsibility (Rask & Hallberg, 2005). Thus, emergency department staff dealing with this particular will be required to contact social services, and the patients’ GP/PCT, friends, family, employment, and other relevant parties. Where necessary, partnerships can be set up, for example with local primary care or social service units, to arrange particular aspects of care, such as home visits, 24 hour access, and development of care plans.
The NMC Code of Professional Conduct (NMC, 2002) states that nurses are to behave in a way that enhances trust and confidence in the patient. In other words it is incumbent on a nurse to be truthful and keep his or her patients’ confidence (Tschudin, 1992; Rumbold, 1999; Reesal et al, 2001). Yet in reality this may pose a very difficult ethical dilemma. During psychosocial assessment nurses often need to obtain personal information from the patient, information that the patient will not normally share with anyone. Patients may divulge information on the understanding that it would be kept in confidence. However, serious problems arise if a patient expresses an intention to reattempt self-harm, or even suicide. Is it ethical for the nurse to share this information with other staff and relevant authorities? The NMC (2002) Codes of Conduct are inherently contradictory, because on the one hand they require nurses and midwifes to “protect confidential information” (p.11), but on the other hand mandate that staff “must act to identify and minimise the risk to patients and clients” (p.11). Crow et al (2000) argue that effective handling of this dilemma requires an understanding of the patient’s own cultural background and general worldview. It is essential for a patient to sign release forms stating that he or she wishes to be present during information-sharing, and takes responsibility for the clinical consequences of such information.
Nurses must take extra care when dealing with patients whose cultural backgrounds denotes different understandings of truth and presents linguistic barriers, “Frequently, when patients from other cultures are asked if they understand something, they nod yes and smile amicably. However, do they really understand what is being stated.., and does it make sense from their cultural perspective of truth?” (Crow et al, 2000). A break down of trust, through truth telling without consent, may aggravate the patients’ psychological state, precipitating the very outcomes the nurse is trying to prevent. And trust can be difficult to generate if nurses fail to develop a good rapport with patients. Long (1998) points out that nurses are often expected to apply nursing models, such as the Activities of Daily Living (ADL) (Rask & Hallberg, 2000), in developing and executing a care plan. Such frameworks of care seem at odds with experiences of someone who wishes to commit self-harm and possibly suicide. Normal daily activities would be anything but ‘normal’. Moreover, the application of academic models to such situations creates a sense of detachment from the patient, so that an “‘I-It’ relationship, takes priority over the person in need of care, and in need of developing a therapeutic ‘I-thou’ relationship” (p.5).
RISK ASSESSMENT STRATEGIES
NICE (2004) guidelines stipulate that self-harm patients undergo a comprehensive risk assessment. This must include an identification of the fundamental clinical and demographic factors that are implicated in the risk of further self-injury. According to Reesal et al (2001) these may include staff attitudes, the presence of anxiety, agitation, panic attacks, persistent global insomnia, anhedonia and poor concentration, feelings of hopelessness/helplessness, substance abuse (alcohol, drugs), impulsivity, being male and aged between 20-30 years or over 50 years, or female aged between 40 and 60 years, being older, having a history of self-harm or suicide attempts, and/or a family history of self-harm, or suicide attempts. The NICE (2004) also require an identification of depressive symptomatology. Nurses carrying out risk assessments must always use a standardised risk assessment scale. Decisions about referral, discharge and admission are partly based on the outcome of risk evaluations. Crowe and Carlyle (2003) argue that risk assessment in mental health care reflects a form of clinical governance, driven more by organisational, financial, political, and legal considerations, than by concern for patient welfare. For example, risk assessment forms part of professional standards for nurses, and failure to adhere to this requirement in patient care increases clinician liability if a patient (or their family) decides to sue for negligence (Samanta et al, 2003). The result is that the welfare of the patient may not be accorded the priority it deserves.
QUALITY ASSURANCE Central to quality assurance is the notion of clinical governance (Ayres et al, 1999; NHS Executive, 1999; Hungtington et al, 2000). The purpose of clinical governance is to maintain the quality of service delivery. This is particularly crucial in A & E units, where critical incidents, such as the mismanagement of a badly injured self-harm patient, can easily lead to death. As Huntington et al (2000) point out, this situation, combined with a proclivity for staff to protect their reputation, can engender a culture of blame, scapegoating, and secrecy, all of which may hinder improvements in the quality of patient care (NHS Executive, 1999). Governance typically entails organisational change, from a ‘blame culture’ to a ‘learning’ orientation. Of course such change is subject to the usual organisational restraining factors that Kurt Lewin (1951) refers to in his model of change. These include excessive staff workloads, a “not another change” attitudes, and general reluctance to give up ‘tried and tested’ practices, time constraints, and patient inconvenience. The critical issue in an A & E is whether staff consistently adhere to professional standards of care, as prescribed by NICE (2004), the Royal College of Psychiatrists, and the National Service Framework for Mental Health (DOH, 1999). Nurse attending to a self-harm patient will need to ensure that they are familiar with these guidelines before attending to the patient, or at least have quick assess to relevant information, and/or are supervised by a more experienced colleague with better knowledge of professional standards. This is essential as failure to adhere to professional standards has major legal implications (Samanta et al, 2003; Wilson, 1999). Although clinical governance leaders within acute and community NHS trusts have a responsibility to ensure that nursing staff deliver good quality care, such governance can only be effective with adequate resourcing (Huntington et al, 2000). For example, there needs to be clarity from professional bodies about best practice (there are currently no best practice statements for the care of mentally ill/self-harm patients), as well as support from health authorities, and clinical governance leaders at regional office, professional, and local district levels.
This essay considers nursing issues in the management of a self-harm patient admitted to an emergency department unit of an NHS Trust. Salient issues for the qualified nurse include ethical dilemmas, associated with conflicting codes of conduct, important management issues relating to assessment, diagnosis, psychological and medical treatment, in-patient care, and medical-legal considerations. Nurses now command greater empowerment in the modern NHS, and but must somehow adhere to strict professional standards, while simultaneously exercising good clinical judgement. Additionally, they must also manage to overcome the unique clinical and psychological circumstances of deliberate self-harm. Support from clinical governance leaders, and adequate training in management, decision making skills, and clinical practice, are essential, if nurses are to delivery high quality patient care
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