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Managing deliberate self-harm: the A & E perspective
DEFINING DELIBERATE SELF-HARM
Managing deliberate self-harm: the A & E perspective S. Greenwood,
P. Bradley
Self-harm can be defined in its broadest terms as any self-induced act that results in personal harm. These can range from failure to give attention to one’s own emotional or physical needs, through to the more familiar forms of self-harm, for example, self-laceration, burning or injury through taking toxic substances (Harrison 1994). A definition and a description of the range of physical self-harm which is more pertinent to the A & E setting has been provided by Burrows 1992 (see Table 1).
People who self-harm can be divided into three subgroups. This paper reports on a retrospective survey of the Accident and Emergency (A & E) treatment of patients who have deliberately harmed themselves. Reasons for self-harm are identified, and current management in A & E is discussed. Suggestions are made for providing these patients with highquality holistic care instead of treating only their physical injuries.
Cultural In a number of African tribes (Abiji, Bantu, Kikuyu and Xoruba) self-injury is fundamental to their cultural and religious beliefs. Further examples include Shiites practising selfflagellation during the festival of Hussein, and Buddhists resorting to auto-castration as a consequence of their beliefs (Ferry 1994).
Mental illness and personality disorder INTRODUCTION The number of patients presenting to Accident and Emergency (A & E) departments as a consequence of deliberate physical self harm has significantly increased over the last few years. Unfortunately, it is all too common for them to have only their physical injuries addressed, as opposed to their emotional and psychological needs. Are we as health care providers delivering the care and support they need, and more importantly, are we adequately educated to do so?
Susan Nurse,
Greenwood, Peter Bradley,
Enrolled A & E
Consultant, A & E Department, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ. UK Accident and Emergency
I. 2. 3. 4. 5. 6. 7. 8. 9.
Laceration, incision and scratching. Self-biting: hands, limbs, tongue, lip. Amputation: fingers, toes, breast, ears. Auto-castration. EnucleatiorUgouging of eyes. Piclcing: wounds, ulceration or sutures, Burning: cigarette burns, self-incendiarism. Insertion damage: wire, nails, pins, pens etc. Ingestion damage: swallowing corrosive chemicals, batteries,
This accounts for the vast majority of patients attending A & E departments. An important group of these patients are those who repeatedly harm themselves. They often describe a history of physical or sexual abuse in childhood (Draucker 1992). A graphic account by a survivor of self-harm describes her first experience of deliberate physical self-harm. ‘I saw my brother’s razor on the bathroom sink one night and I just thought to myself, if I cut myself, punish myself, it will all be all right. So I cut my wrist. As I watched the blood flow I felt no pain. I just felt clean,
pins, razor blades etc.
I
I
Reproduced
with kind permission
Nursing (I 997) 5. 134-l 36 0 Pearson Professional I997
of the Editor, British Journal of Nursing
Managing deliberate self-harm
Self-inflicted wounds (50 patients) 40% discharged 25% referred to acute psychiatrist IO% review in A & E 20% other types of follow-up Self-poisoning (33 I patients) 16% discharged IO% referred to acute psychiatrist 70% admitted to hospital with subsequent 4% other types of follow up
released, almost detached from what I had just done. It was like screaming out without opening my mouth’ (Harrison 1994).
psychiatry
I35
assessment
Three common reasons for people committing deliberate physical self-harm have been described by Allen (1995):
deliberate physical self-harm. All of these acts of self-harm were self-inflicted wounds, usually to the upper limbs. Of the 50 patients who had deliberately self-harmed, 40% were discharged without any follow-up. This is in stark contrast to the percentage of patients who had taken overdoses (16%) (Table 2). In a separate audit of A & E notes belonging to patients presenting with physical deliberate self-harm, only in a small minority was there any evidence that the doctors or nurses had made any attempt to make an assessment of the patient’s emotional or psychiatric needs. There was also little documented evidence that a mental state examination had been performed or their suicidal risk assessed. In the majority of these patients, their physical wounds were treated and they were discharged with no formal psychiatric follow-up.
1. To manage moods or feelings. 2. As a response to beliefs or habitual thoughts. 3. To communicate or manage interactions with other people.
WHY IS DELIBERATE SELF-HARM SO POORLY MANAGED?
Learning disability Lea in 1984 described that some people with severe learning disabilities who have grossly impaired communications skills may use selfinjurious behaviours to gain attention and establish communication with other people.
THEMSELVES?
This is illustrated by a personal account of deliberate self-harm published in Survivors Speak Out (Penbrooke 1994). ‘Sometimes I cut myself because I need to feel something. At these times I withdraw into myself. At other times my feelings are so chaotic, vivid and overwhelming, that I have to cut them out of me. It is impossible for me to talk or ask for help when the urge to cut is overwhelming.’
WHAT IS THE SCALE OF THE PROBLEM? In Bradford, we performed a retrospective survey of all the patients who attended the A & E department, from June to October 1996, as a consequence of deliberate self-harm. During this four-month period, 351 patients presented having taken an overdose of a variety of medications. Fifty patients presented with
Doctors and nurses often find it frustrating working with patients who deliberately selfharm (Burrows 1992). This, in part, can be attributed to the belief that their function as health care professionals is to assist the deserving sick. This belief often causes them to deal with the patient in a judgemental manner. This belief contravenes the Code of Professional Conduct (UKCC 1992) which states that nurses should ‘Recognize and respect the uniqueness and dignity of each patient and client, and respond to their need for care, irrespective of ethnic origin, religious beliefs, personal attributes, the nature of their health problems or any other factor.’ Another possible explanation for the poor service these patients receive, is that the majority of patients who deliberately self-harm present to A & E departments ‘out of hours’ (Fig.). At these times it is often difficult to gain access to psychiatric or other support services.
I36
Accident and Emergency Nursing
Fig. Deliberate self-harm -time of presentation to A & E. Y axis -number of patients with deliberate self-harm, X axis - time of presentation to A & E.
patients have to be drawn up by the multidisciplinary team. The current lack of provision of ‘out of services needs to be hours’ psychiatric addressed, for example, by developing an oncall CPN service for the A & E department. In addition, health care professionals need to be regularly updated about the variety of services available to the patient in their locality, for example, self-help groups, voluntary organizations, psychiatric and other support services. An education package should be prepared to service the needs of new staff joining the department or staff temporarily attached to the department, to ensure that a high standard of care is maintained. Finally, all A & E departments should regularly audit the performance of their staff in managing patients who deliberately self-harm.
REFERENCES
THE WAY FORWARD A multidisciplinary team approach is required involving A & E nurses, doctors, psychiatric and other support services. It is imperative that both doctors and nurses within the A & E department are re-educated to dispel their prejudices in order to improve the way in which the patient is assessed and treated. They should also be educated so that they are better able to understand the needs of these patients. Protocols dealing with the assessment, treatment, referral and possible discharge of these
AUen C 1995 Helping with deliberate self harm: some practical guidelines. Journal of Mental Health 4: 243-250 Burrows S 1992 Nursing management of self mutilation. British Journal of Nursing 17: 138-148 Draucker CB 1992 CounseLIing survivors of childhood sexual abuse. SAGE, London Ferry R 1994 Complex causes. Nursing Times 90: 34-35 Harrison D 1994 Understanding self harm. MIND, Peterborough Lea SG 1994 Instinct, environment and behaviour. Methuen, New York Penbrooke LR 1994 Survivors speak out. SSO, London UKCC 1992 Code of professional conduct. UKCC, London
Managing deliberate self-harm: the A & E perspective S. Greenwood,
P. Bradley
Self-harm can be defined in its broadest terms as any self-induced act that results in personal harm. These can range from failure to give attention to one’s own emotional or physical needs, through to the more familiar forms of self-harm, for example, self-laceration, burning or injury through taking toxic substances (Harrison 1994). A definition and a description of the range of physical self-harm which is more pertinent to the A & E setting has been provided by Burrows 1992 (see Table 1).
People who self-harm can be divided into three subgroups. This paper reports on a retrospective survey of the Accident and Emergency (A & E) treatment of patients who have deliberately harmed themselves. Reasons for self-harm are identified, and current management in A & E is discussed. Suggestions are made for providing these patients with highquality holistic care instead of treating only their physical injuries.
Cultural In a number of African tribes (Abiji, Bantu, Kikuyu and Xoruba) self-injury is fundamental to their cultural and religious beliefs. Further examples include Shiites practising selfflagellation during the festival of Hussein, and Buddhists resorting to auto-castration as a consequence of their beliefs (Ferry 1994).
Mental illness and personality disorder INTRODUCTION The number of patients presenting to Accident and Emergency (A & E) departments as a consequence of deliberate physical self harm has significantly increased over the last few years. Unfortunately, it is all too common for them to have only their physical injuries addressed, as opposed to their emotional and psychological needs. Are we as health care providers delivering the care and support they need, and more importantly, are we adequately educated to do so?
Susan Nurse,
Greenwood, Peter Bradley,
Enrolled A & E
Consultant, A & E Department, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ. UK Accident and Emergency
I. 2. 3. 4. 5. 6. 7. 8. 9.
Laceration, incision and scratching. Self-biting: hands, limbs, tongue, lip. Amputation: fingers, toes, breast, ears. Auto-castration. EnucleatiorUgouging of eyes. Piclcing: wounds, ulceration or sutures, Burning: cigarette burns, self-incendiarism. Insertion damage: wire, nails, pins, pens etc. Ingestion damage: swallowing corrosive chemicals, batteries,
This accounts for the vast majority of patients attending A & E departments. An important group of these patients are those who repeatedly harm themselves. They often describe a history of physical or sexual abuse in childhood (Draucker 1992). A graphic account by a survivor of self-harm describes her first experience of deliberate physical self-harm. ‘I saw my brother’s razor on the bathroom sink one night and I just thought to myself, if I cut myself, punish myself, it will all be all right. So I cut my wrist. As I watched the blood flow I felt no pain. I just felt clean,
pins, razor blades etc.
I
I
Reproduced
with kind permission
Nursing (I 997) 5. 134-l 36 0 Pearson Professional I997
of the Editor, British Journal of Nursing
Managing deliberate self-harm
Self-inflicted wounds (50 patients) 40% discharged 25% referred to acute psychiatrist IO% review in A & E 20% other types of follow-up Self-poisoning (33 I patients) 16% discharged IO% referred to acute psychiatrist 70% admitted to hospital with subsequent 4% other types of follow up
released, almost detached from what I had just done. It was like screaming out without opening my mouth’ (Harrison 1994).
psychiatry
I35
assessment
Three common reasons for people committing deliberate physical self-harm have been described by Allen (1995):
deliberate physical self-harm. All of these acts of self-harm were self-inflicted wounds, usually to the upper limbs. Of the 50 patients who had deliberately self-harmed, 40% were discharged without any follow-up. This is in stark contrast to the percentage of patients who had taken overdoses (16%) (Table 2). In a separate audit of A & E notes belonging to patients presenting with physical deliberate self-harm, only in a small minority was there any evidence that the doctors or nurses had made any attempt to make an assessment of the patient’s emotional or psychiatric needs. There was also little documented evidence that a mental state examination had been performed or their suicidal risk assessed. In the majority of these patients, their physical wounds were treated and they were discharged with no formal psychiatric follow-up.
1. To manage moods or feelings. 2. As a response to beliefs or habitual thoughts. 3. To communicate or manage interactions with other people.
WHY IS DELIBERATE SELF-HARM SO POORLY MANAGED?
Learning disability Lea in 1984 described that some people with severe learning disabilities who have grossly impaired communications skills may use selfinjurious behaviours to gain attention and establish communication with other people.
THEMSELVES?
This is illustrated by a personal account of deliberate self-harm published in Survivors Speak Out (Penbrooke 1994). ‘Sometimes I cut myself because I need to feel something. At these times I withdraw into myself. At other times my feelings are so chaotic, vivid and overwhelming, that I have to cut them out of me. It is impossible for me to talk or ask for help when the urge to cut is overwhelming.’
WHAT IS THE SCALE OF THE PROBLEM? In Bradford, we performed a retrospective survey of all the patients who attended the A & E department, from June to October 1996, as a consequence of deliberate self-harm. During this four-month period, 351 patients presented having taken an overdose of a variety of medications. Fifty patients presented with
Doctors and nurses often find it frustrating working with patients who deliberately selfharm (Burrows 1992). This, in part, can be attributed to the belief that their function as health care professionals is to assist the deserving sick. This belief often causes them to deal with the patient in a judgemental manner. This belief contravenes the Code of Professional Conduct (UKCC 1992) which states that nurses should ‘Recognize and respect the uniqueness and dignity of each patient and client, and respond to their need for care, irrespective of ethnic origin, religious beliefs, personal attributes, the nature of their health problems or any other factor.’ Another possible explanation for the poor service these patients receive, is that the majority of patients who deliberately self-harm present to A & E departments ‘out of hours’ (Fig.). At these times it is often difficult to gain access to psychiatric or other support services.
I36
Accident and Emergency Nursing
Fig. Deliberate self-harm -time of presentation to A & E. Y axis -number of patients with deliberate self-harm, X axis - time of presentation to A & E.
patients have to be drawn up by the multidisciplinary team. The current lack of provision of ‘out of services needs to be hours’ psychiatric addressed, for example, by developing an oncall CPN service for the A & E department. In addition, health care professionals need to be regularly updated about the variety of services available to the patient in their locality, for example, self-help groups, voluntary organizations, psychiatric and other support services. An education package should be prepared to service the needs of new staff joining the department or staff temporarily attached to the department, to ensure that a high standard of care is maintained. Finally, all A & E departments should regularly audit the performance of their staff in managing patients who deliberately self-harm.
REFERENCES
THE WAY FORWARD A multidisciplinary team approach is required involving A & E nurses, doctors, psychiatric and other support services. It is imperative that both doctors and nurses within the A & E department are re-educated to dispel their prejudices in order to improve the way in which the patient is assessed and treated. They should also be educated so that they are better able to understand the needs of these patients. Protocols dealing with the assessment, treatment, referral and possible discharge of these
AUen C 1995 Helping with deliberate self harm: some practical guidelines. Journal of Mental Health 4: 243-250 Burrows S 1992 Nursing management of self mutilation. British Journal of Nursing 17: 138-148 Draucker CB 1992 CounseLIing survivors of childhood sexual abuse. SAGE, London Ferry R 1994 Complex causes. Nursing Times 90: 34-35 Harrison D 1994 Understanding self harm. MIND, Peterborough Lea SG 1994 Instinct, environment and behaviour. Methuen, New York Penbrooke LR 1994 Survivors speak out. SSO, London UKCC 1992 Code of professional conduct. UKCC, London