Accessing Help for Self-Harm & Suicidal Behaviour in the Emergency Department: a two-phase study

Accessing Help for Self-Harm & Suicidal Behaviour in the Emergency Dept: a two-phase research study

Phase 1 Qualitative Research Study by Trinity College for 3TS Reveals Need for Back to Basics Approach to Patient Care

Lack of understanding, labelling and the need for a ‘back to basics’ approach were some of the key findings to emerge from Phase 1 of our qualitative study into Accessing Help for Self-Harm and Suicidal Behaviour in the Emergency Department. 

Phase 1 focused on the experience of the service user attending the Emergency Department with self-harm, suicidal behaviours or an attempted suicide with the final report published in July 2020. Phase 2 of the study focussed on companions i.e. the family, friends or carers who accompany them.  

3TS commissioned these studies as part of our ongoing commitment to Suicide Prevention and Self Harm research. Research was carried out by researchers from the Mental Health Nursing Team at the School of Nursing and Midwifery, Trinity College Dublin, led by Dr Louise Doyle, Associate Professor of Mental Health Nursing.

Phase 1 - A Qualitative Study

Phase 1 focused on the personal experiences of 50 participants who had presented to the Emergency Department (ED) of Hospitals for self harm or suicidal behaviour throughout Ireland within the preceding 5 years. Just under half of participants reported presenting with suicidal ideation without self-injury. The remainder presented following self-harm which comprised overdose and / or self-cutting.

Variability in experiences, positive & negative 

An important primary point to note from this study is the significant variability in the experiences of participants. Some had more than one presentation to different EDs, yet reported positive experiences in one ED and negative experiences in another. Participants who presented more than once to the same ED also reported variability. Some had largely positive experiences and others negative.

“I’d just say, the best advice I could possibly give is actually listen to the person that’s sitting in front of you. They’re not just a number, they’re not just there for the sake of being there. They’re asking for help, we’re crying out for help….” (ED15)

This important research represents the very personal experiences of many people who attend our EDs at a time of crisis seeking both emergency physical and mental health care .  3Ts believe that whilst in no way undermining the hard work and care offered by the excellent medical health care teams in our hospitals, it highlights the need for the provision of specialised Suicide and Self-Harm care services in EDs. Specifically, 3Ts believe this research highlights the need for a Mental Health Emergency Department which should run alongside every A&E in Ireland. This remains one of 3Ts’ main lobbying goals and we intend to pursue enhanced Emergency Mental Health services in our hospitals with  Government as per the findings of this study.

The Experiences & Support Needs of Family/Supporting Adults Who Accompany Someone to the Emergency Department with Self-Harm, Suicide-Related Ideation or Suicide Attempt

Phase 2 Study Findings

72% of families & carers received no suicide prevention guidance after a loved one presented to an Emergency Department.

Background

The Emergency Department (ED) is often the first point of contact for people experiencing self-harm or suicidal thoughts. In Ireland in 2021, there were 11,415 ED presentations for self-harm, with many more presenting with suicidal ideation.

After discharge, families & carers are typically left to manage patient safety — yet few receive guidance on how to do this.

While the National Clinical Programme for Self-Harm & Suicide-Related Ideation (NCP-SHI) highlights the vital role of carers, no Irish study had systematically explored their experiences until now.

This Phase 2 study, conducted by Trinity College Dublin in partnership with 3TS, addressed that gap.

"Families play a critical role — both in the ED & after discharge — but are often left in the dark. Simple steps such as providing a safety plan & clear guidance could save lives."
_{— Professor Louise Doyle, lead researcher}

Headline Findings

• 72% of carers received no information on suicide prevention
• 71% received no guidance on supporting the person after discharge
• 72% said no safety plan was developed for the patient
• Over half felt staff lacked the skills & confidence to care for suicidal patients
• 68% reported that a mental health assessment was carried out — but over one-quarter said no assessment was offered, or the person left before being seen
• The ED environment was often unsuitable: noisy, crowded, with long waits & little privacy

"Tragically, some participants lost their loved one to suicide after the ED visit — and felt this might have been preventable with better services. We believe a dedicated, 24/7 Suicide Emergency Department is urgently needed."

— Noel Smyth, Chairman 3TS

Study Methods

• Design: Exploratory qualitative online survey, co‑developed with two PPI contributors
• Participants: Adults (18+) who accompanied someone to an Irish ED for self-harm, suicide attempt or suicidal ideation within the past five years
• Recruitment: Online & social media platforms via mental health organisations
• Analysis: Content analysis of open-ended responses
• Ethics: Approved by Faculty of Health Sciences Research Ethics Committee, TCD

Sample Profile (n = 239)

• Gender: 88% female
• Age: 18–81 (mean = 43)
• Relationship to Patient: Parents of adults (22%), parents/guardians of minors (21%), siblings (16%)
• Location: Dublin EDs (34%), broader Leinster (24%)
• Presentation Reasons: Suicide attempt (56%), suicidal ideation (52%), self-harm (38%)

Detailed Findings

Patient Assessment in the ED

• 68% reported that a mental health assessment was carried out
• 52% of carers were included, mostly to provide collateral history
• Inclusion led to better understanding, communication & joint decision-making
• Exclusion resulted in gaps in information & reliance on possibly minimised patient accounts

Safety Planning

• 72% reported no safety plan was developed
• Of those with a plan, only 46% of carers were involved
• Carers strongly wanted jointly created safety plans linking to aftercare

ED Environment & Staff Interactions

• Challenges: Long waits, unsuitable physical spaces, focus on medical stabilisation over psychological needs, occasional negative attitudes
• Positive experiences: Some reported compassionate, skilled care — e.g. where Clinical Nurse Specialists (CNS) were involved

Information & Support on Discharge

• 72% received no suicide prevention materials
• 71% received no guidance on how to support the person after discharge
• Desired content: Clear advice on warning signs, support strategies, emergency contacts & follow-up pathways

Carer Recommendations for Improvement

• Improve staff education on self-harm & suicide empathy
• Always treat patients & carers with respect & attentiveness
• Ensure availability of specialist mental health staff in EDs
• Provide sensitivity training & promote non-judgemental communication

Recommendations for Practice

Standardised Assessment & Care Planning

• Fully implement NCP-SHI principles across all EDs
• Guarantee mental health assessments for all self-harm/suicidal presentations
• Involve carers in assessment & safety plan development

Compassionate Staff Interactions & Training

• Promote compassionate, non-stigmatising language in all ED interactions
• Provide ongoing staff education on brief-interaction empathy & suicide awareness

Information Provision & Aftercare Support

• Supply clear verbal & written guidance to carers covering:
  • Warning signs
  • Support strategies
  • Emergency contacts
  • Aftercare pathways
• Format materials in plain English & suitable for varied literacy levels

About the Authors

Prof Louise Doyle
Dr Brian Keogh
Dr Jean Morrissey
Mr Ciarán Carr
Contact: louise.doyle@tcd.ie