Emergency tools for dealing with self-harming patients

A pilot scheme aims to train emergency department staff to deal better with patients who have self-harmed

AS A crisis nurse in the emergency department of a big city hospital, Rose Lynch has first-hand experience of treating people who arrive at the facility following deliberate self-harm.

Between them, Lynch and the other crisis nurse at Cork University Hospital (CUH), Sylvia Quinlan, see all individuals after they come through the emergency department having attempted suicide or engaged in self-harm, from overdoses to attempted hangings, gunshot injuries to drownings.

Lynch, who has worked in the role since September 2001, says that sometimes such patients can feel ignored, dismissed and embarrassed in the emergency department.

“If there is a serious endeavour to kill themselves and they are left sitting there for an hour, they feel no one cares,” she says.

“Sometimes they say they feel dismissed or they have heard someone saying, ‘Here they are in again’.”

Consultant psychiatrist at CUH, Dr Eugene Cassidy, says that emergency department staff sometimes don’t find it easy to address the needs of patients who self-harm.

“My own experience of emergency department staff is [of] an extremely positive and compassionate group who work under tremendous pressures.

“Individuals who have presented following self-harm have specific needs, which are mental health needs, which the emergency department don’t always feel able to deal with.”

But it is hoped a new training programme, which targets all non-mental health emergency department staff, including doctors, nurses and care staff, will change that.

The pilot programme, which will run in a number of hospitals in Cork and Kerry, including CUH and the Mercy University Hospital, Cork and will be delivered by senior psychiatric nurses, aims to improve the skills, knowledge and confidence of staff in dealing with patients who have self-harmed or who are suicidal.

It is a joint project between the National Suicide Research Foundation (NSRF) and Cassidy, and is funded by the National Office for Suicide Prevention.

Lynch, one of the trainers, says one aspect of the programme involves providing staff with information on suicide and supplying them with a set of questions to help broach difficult subjects such as whether the patient feels suicidal or not.

“We’re encouraging the staff to talk to the patients about what they have done. If people open up and respond to empathy, they are more likely to engage,” she says.

“Sometimes it’s like the elephant in the room. No one talks about it. It’s important to see the human side,” says Lynch, who describes the incidence of self-harm as “huge”.

Over the past 12 months she has noticed an increase in the number of men who are cutting themselves.

“The cutting is much more violent than in women . . . a lot of anger is turned in on themselves.”

The need has never been greater to develop a response to patients who engage in deliberate self-harm.

According to figures from the National Registry of Deliberate Self Harm, there was a 96 per cent increase in the rates of self-harm presentations to emergency departments among men in Cork city between 2007 and 2010 and a 35 per cent increase in women.

Nationally, in 2010 (the most recent figures available) there were almost 12,000 presentations at emergency departments due to deliberate self-harm, involving 9,630 individuals – with a 25 per cent increase in the numbers of men who engaged in self-harm between 2007 and 2010, and a 10 per cent increase in the numbers of women who engaged in self-harm over the same period.

“It’s a significant problem nationally and it’s a significant problem here in the region,” says Cassidy.

“Having presented at an emergency department having self-harmed is the single biggest risk factor for future completion of suicide,” he says.

The programme also seeks to maximise the number of individuals who receive a detailed mental health assessment and follow-up treatment.

According to statistics from the registry, 17 per cent of people who presented at emergency departments nationwide, following deliberate self-harm in 2010 left before they had received a psychiatric assessment.

Director of research at the National Suicide Research Foundation (NSRF) Dr Ella Arensman says there is international evidence that people who self-harm are still not being treated appropriately in emergency departments.

“Either they don’t receive the attention and the care that is required, or there is also evidence that staff may even give out statements that could be embarrassing or painful to the patients,” says Arensman.

“If people are treated in a negative way by emergency department staff, it can result in the patient leaving the emergency department without being assessed,” she says.

“The risk of repeated self-harm is higher in those who leave without being assessed.

“We just want people to be more aware of risk factors and also to feel more comfortable in working with people who have self-harmed.”

Arensman says it is hoped that the programme will lead to a reduction in the number of cases of self-harm and suicide in the region.

“If there is greater awareness among emergency department staff of the signs of high risk of repeated self-harm, especially patients using highly lethal methods of self-harm, this will contribute to both a reduced risk of self-harm and of suicide.

“If we see that following training, people have more knowledge, have a more positive attitude and have greater confidence in working with people who have self-harmed, then we have a case to roll it out nationally.”