Management of Self-harm Patients in AE

circumspection of Self-harm Patients in AEThe acuate incident was a case of meditate self-harm (DSH), admitted to an A E unit. DSH incorporates deliberate non-habitual serves of self-harm that ar not fatal, and may or may not allow in attempted suicide (Repper, 1999). Emergency departments provide the main entry microscope stage for much(prenominal) patients (NICE, 2004). The patient in this case had slashed his wrists in some(prenominal)(prenominal) places, severing a get a line artery. He was bleeding profusely, and in a semiconscious state on arrival. There was a level of psychological medicine dating back several years. He was unmarried, lived alone, and had recently bear up underne interference and honoring at the forensic mental wellness unit of a topical anaesthetic 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 c be. It is inhering that th e measure up protect is cognisant of the relevant work come forths of Professional Conduct specified by the nursing Midwifery Council (NMC, 2002), including honourable concerns much(prenominal) as respect, confidentiality, and trust. This is contingently pivotal when dealing with self-harm patients because research suggests that exigency department admits often hold nix attitudes towards this type of patient (McAllister et al, 2002). Furthermore, self-harm patients read reported dissatisfaction with the make do provided by nurses and some otherwise(a) wellness c are supply.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 mystify incorporates five principles, outlined in put off 1. These tenets are consistent with protocols for impressive decision-making, for both individuals and groups (Janis Mann, 1977). They are also consistent with NICE/ universal time guideposts for lovingness for the ment all toldy ill (NICE, 2004, Clinical Guideline 16). NICE guidelines recommend nimble assessment of insecurity, and mental, physical, turned on(p) stability, once a patient arrives at A E. Staff are then required to account for underlying emotional factors that may possess precipitated the self-harm episode, as well as evaluating the seriousness of the injury, in front deciding the most appropriate treatment for the patient. Reesal et al (2001) highlight almost of the key principles of management that are relevant to nurses working(a) with mental wellness patients. These relate to assessment, phases of treatment, psychiatric management, goals of treatment, psychotherapeutic management, the management of practice of medicine and self-harm/suicide, and medical-legal issues (also see DOH, 1999 NICE, 2004). Nurses destiny to study a comprehensive psycho kindly assessment, in full cognisance of the biological, p sychological, and social context, and also precipitating and perpetuating factors. genial health problems can often be long-term/chronic, rather than short/acute, and self-harm is no exception. An underlying condition bid depression can be conceptualised in terms of three treatment phases response, remission, and relapse. Principles of psychiatric management dictate that accede must be nurseed forward to treatment. A well-behaved 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 growing of a treatment plan and allows the patients progress to be evaluated more accurately. psychotherapy can be found on any one of several models (e.g. cognitive-behavioural, interpersonal, dynamic).Recoery must be closely monitored patients who have not acquire within 2 months may require a change in treatment modality. Some knowledge of pharmacology is essential for sound medication management, exactly it is usually up to a psychiatrist to prescribe the necessity medication. In managing suicide/self-harm cases, it is authorised 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 overwhelming are they? Is there a plan? Do the means and opportunities last? How impulsive is the patient? (Reesal et al, 2001, p.25S). Since self-harm episodes are ecumenicly unpredictable, there are limitation 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 i nclude confidentiality, gamble assessment, info sharing, faithfulness telling, and liability. Some of these are considered later in this essay. Overall, patients must debate they are receiving equity, justice, and consideration, and that clinical management is set up to facilitate undecomposed spirit care. Ethical and legal issues in the management of mental health patients are outlined in the Nursing and Midwifery Councils codes of conduct (NMC, 2002), the home(a) expediency 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 strain 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 and so officeholder on nurses to get word that decisions about a ll 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 fussy A E unit. Due to time constraints and hectic work routines, nurses may be unable to check adherence to standards. Senior nurses may affirm more on their clinical experience in certain instances, whereas junior nurses learning it easier to consult colleagues for clarification, rather than locate and check practice standards. epoch guidelines will help ensure that this patient receives good quality health care, nurses and other health professionals will ultimately state for clinical decisions. It is therefore essential that staff are satisfactoryly trained and resourced to make sure choices that are in the better(p) interests of the patient. Decision theorists Janis and Mann (1977) propose that such assured decision making requires that a viable clinical solution is perceived to be available, to deal with the patients problem, and that there is tolerable time in which to find it. If a nurses is uncertain what to do, perhaps due to inadequate training, lack of guideline information, or un acquainted(predicate)ity with self-harm patients, then he or she may furbish up to ineffectual decision strategies, such as delaying treatment, looking for another nurse to take business, or even discounting the severity of the patients condition. Time constraints can be a serious problem in emergency departments, where patients arrive with serious injuries, and nurses are required to make multiple clinical decisions, in dissipated succession. Severe time limits may induce apprehension or unbalanced behaviour in clinical staff, leading to hasty clinical decisions that cave in to account for all aspects of the patients clinical condition.In 2005 the section of wellness published its Patient Led NHS (DOH, 2005). Central to this dis soma is the stamp 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 likely effects of treatments, and detention, renewal, and discharge. Thus, the patient in A E will have to be treated accordingly by nursing staff. The segment of Health has encouraged the faster emergence of scoop out 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 aut horities to local basal 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(ip) area of responsibility (Rask Hallberg, 2005). Thus, emergency department staff dealing with this particular will be required to contact social utilitys, 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 elan 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 usually 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 figure 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 unders tanding of the patients own pagan background and general worldview. It is essential for a patient to sign passing game 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 assorted 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 world 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 miss to develop a good rapport with patients. Long (1998) points out that nu rses are often expected to apply nursing models, such as the Activities of day-after-day Living (ADL) (Rask Hallberg, 2000), in developing and executing a care plan. such(prenominal) frameworks of care seem at odds with experiences of someone who wishes to commit self-harm and maybe suicide. Normal daily activities would be anything but normal. Moreover, the application of schoolman models to such situations creates a sense of detachment from the patient, so that an I-It relationship, takes antecedency over the person in need of care, and in need of developing a therapeutic I-thou relationship (p.5).RISK ASSESSMENT STRATEGIESNICE (2004) guidelines stipulate that self-harm patients undergo a comprehensive risk assessment. This must include an identification of the implicit in(p) clinical and demographic factors that are implicated in the risk of foster self-injury. According to Reesal et al (2001) these may include staff attitudes, the presence of anxiety, agitation, panic att acks, persistent global insomnia, anhedonia and poor concentration, feelings of hopelessness/helplessness, substance abuse (alcohol, drugs), impulsivity, existence 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 regime, goaded 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 neglectfulness (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 considerably lead to death. As Huntington et al (2000) point out, this situation, combined with a tilt 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). presidential term typically entails organisational change, from a blame culture to a learning orientatio n. 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 magnificent College of Psychiatrists, and the National Service Framework for Mental Health (DOH, 1999). Nurse attendance 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 strong 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). Althou gh 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 zone 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 overshadow greater empowerment in th e modern NHS, and but must someway 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 careReferencesAyres, I.L., Cooling, R. Maughan, H. (1999) Clinical governance in primary caregroups. Public Health Medicine. 2, pp.47-52.Crow, K., Matheson, L. Steed, A. (2000) Informed consent and truth-tellingcultural directions for health care providers. daybook of NursingAdministration. 30, pp.148-152.Crowe, M. Carlyle, D. (2003) Deconstructing risk assessment and management inmental health nursing. daybook of move on Nursing. 43, pp.19-27.DOH (1999) National Service Framework for Mental Health Modern Standards Service Models. capital of the United Kingdom Department of Health.DOH (2002a) National Service Framework A Practical Aid to Implementation inPrimary Care. capital of the United Kingdom Department of Health.DOH (2002b) Improvement, Expansion Reform the next 3 Years Priorities and prep Framework 2003-2006. London Department of Health.DOH (2005) Patient Led NHS. London Department of Health.Horrocks, J., House, A. Owens, D. (2004) Establishing a clinical data base forhospital attendances because of self-harm. psychiatric Bulletin, 28, pp.137-139.Huntington, J., Gillam, S. Rosen, R. (2000) Clinical governance in primary careorganisational development for clinical governance. British Medical Journal.321, pp.679-682.Janis, I.L. Mann, L. (1977) Decision Making A Psychological psychoanalysis of Choice,Commitment. sassy York Free Press.Lewin, K. (1951) Field Theory in Social Science. New York Harper Row.Long, A., Long, A. Smyth, A. (1998) Suicide a statement of suffering. NursingEthics. 5, pp.3-15.McAllis ter, M., Creedy, D., Moyle, W. Farrugia, C. (2002) Nurses attitudestowards clients who self-harm. Journal of Advanced Nursing. 40, pp.578-586.NICE (2004) Self-Harm The Short-Term Physical and Psychological Managementand Secondary legal community of Self-Harm in Primary and Secondary CareClinical Guideline 16. London National Institute for Clinical Excellence.NHS Executive (1999) Clinical Governance in the new NHS. London NHSExecutive (HSC 1999/065).NMC (2002) Code of Professional Conduct. London Nursing Midwifery Council.Rask, M. Hallberg, R. (2000) Forensic psychiatric nursing care nursesapprehension of their responsibility and work content a Swedish survey.Journal of Psychiatric Mental Health Nursing. 7, 163-177.Reesal, R.T., Lam, R.W. the CANMAT Depression Work Group (2001) Clinicalguidelines for the treatment of depressive disorders Principles of ManagementII. The Canadian Journal of Psychiatry. 46 (Suppl 1), pp.21S-28S.Repper, J. (1999) A review of the literature on the prevention of suicide throughinterventions in Accident and Emergency Departments. Journal of ClinicalNursing. 8, pp.3-12.Rumbold, G. (1999) Ethics in Nursing Practice (3rd edition). London Balliere Tindall.Samanta, A., Samanta, J. Gunn, M. (2003) court-ordered considerations of clinicalguidelines will NICE make a difference? Journal of the Royal Society of Medicine. 96, pp.133-138.Tschudin, V. (1992) Ethics in Nursing The Caring blood (2nd Edition).London Heinemann.Wilson, J. (1999) Best practice guidelines. British Journal of Nursing. 8, pp.293-294.