Research Study "Accessing Help for Self Harm and Suicidal Behaviour in the Emergency Department Phase 1: The Experiences of Service Users"
Back to Basics
This research study highlights the need for a ‘back to basics’ approach in providing care to people who present to the ED with self-harm and suicidal ideation. This is not to suggest that people presenting in suicidal distress or after self-harm need a ‘basic’ approach – they need and deserve specialised treatment from the MH team. But that the back to basic approach is about the basics of humanness and empathy approach means interacting with people with empathy, compassion and understanding. ED staff are not expected to have a high level of knowledge about mental health nor to engage in counselling with those who present. But kindness and empathy were identified by participants as extremely important and very much appreciated by participants.
Recommendation: In response the Research Team believe that the basic principles of Make Every Contact Count (MECC) should transfer to those presenting with mental health issues.
Lack of Understanding
Participants reported a lack of understanding around self-harm and suicidal ideation and around some mental health diagnoses (particularly personality disorders). The research finds that this lack of understanding and education has an influence on negative perceptions of this patient group. This consequently can lead to negative interactions and treatment.
Recommendation: There is not an expectation that non-mental health staff in the ED must have an in-depth understanding of this. However, there is a requirement to have a basic understanding. To take self-harm as an example, there needs to be a basic understanding of self-harm and the purpose it can serve for individuals (i.e. a manifestation of emotional distress, a way of dealing with overwhelming emotions). Just as importantly, there needs to be an understanding of what self-harm is generally not – e.g. “attention-seeking”. Further ED Staff training is required in this instance.
Participants also reported a feeling of being treated ‘differently’ to those presenting with physical health problems. This created a sense of ‘otherness’ which they felt stigmatised individuals. The literature has shown that ED staff worry about ‘what to say’ to patients presenting with self-harm or suicidal ideation. Examples are included in the study of ED staff saying things that were perceived as unhelpful – albeit well-intentioned – e.g. “why would someone so young and pretty do this to yourself?” or “you have a good job and a caring family, why would you want to end your life?”
Recommendation: The study, however, demonstrates that ‘what not to say’ is just as important, and that further ED Staff Training is required in this instance.
“All I want is to be treated with compassion, to be seen as a person, something more than just my injuries because they represent what is going on inside my mind”
National Care Programme
One of the most important findings of this study is that when participants were seen by staff who were part of the National Care Programme on self-harm in the ED, usually a Clinical Nurse Specialist in Self-Harm, their experiences were generally better. However, this programme is not run in every hospital, including two hospitals as part of this study which accounted for 18 out of the 62 presentations. In other hospitals, some participants may have presented outside of the time when staff from the Care Programme were on duty (generally 9am-5pm).
Recommendation: The inclusion of Clinical Nurse Specialists in Self-Harm in every hospital to include outside of 9-5 hours. The study shows that assessment, treatment and follow-up were all generally better when patients were cared for by staff as part of the programme.
Recommendations adopted by NCPSH: Since Phase 1 of this research was published, it has helped inform the National Clinical Programme for Self-Harm & Suicide-related Ideation (published February 2022). Research recommendations that have been adopted in the NCPSH include:
- Tickbox & checklist approach to assessment ineffective for clinicians & unsatisfactory for patient.
- Need to deal with emotional needs as well as physical.
- Important that assessor gives perception of being relaxed, unhurried & has a good understanding of patient’s needs.
- ED unsuitable for suicidal ideation – noisy, stressful, long delays between registering & assessment are especially difficult.
- Feeling of being in the wrong place, yet unaware of any suitable alternatives
Presenting Alone / Distress Volunteer Service
Approximately one-third of participants in this study were unaccompanied when they presented to the ED. This cohort generally found the experience more difficult. They found the long waiting time distressing and lonely and felt more inclined to leave the ED without being seen. Those who did have family members or friends with them reported that they were encouraged by them to stay and be assessed.
Recommendation: Where possible, those attending A&E should bring a companion with them. The research also suggests the need for a volunteer service where a person can sit with someone in distress while they are waiting to be seen (if they are amenable to this).
Sensitivity, Privacy & Dignity
Participants understood the need for assessment and for questions to be asked. However, they identified that the way in which these questions were asked was important. Many cited that having to repeat their experience/symptoms to a number of staff members in the ED was very distressing. Furthermore, while standardised assessments are important, participants noted that it was equally important to allow room for personal narratives and perspectives rather than relying on a mechanical ‘tick box’ assessment. A number of participants also reported that they sometimes hide or fail to disclose their suicidal thoughts and feelings while in the ED. They identified the need for sensitively uncovering suicidal thoughts. This is likely to be done by a mental health professional in the ED.
Recommendation: The need for a space which affords privacy and dignity outside of the busy, noisy and very public nature of the ED environment was commented upon repeatedly.
This should also extend to providing a safe environment without the means to self-harm. We would favour the idea of a specified Emergency Mental Health facility which should run alongside the Hospital’s ED.
Alternative Referral Option to Emergency Department
Just under half of the participants presented to the ED with suicidal ideation, without any actual self-injury requiring physical treatment. Many of these participants felt that the ED was not the appropriate environment for them but they often presented or were referred there because of a lack of other crisis options.
Recommendation: The need for a specialised Mental Health Emergency Department which operates alongside each ED in Ireland.
Discharge and Follow-up
There were very mixed experiences around discharge and follow-up. Many of the participants reported being discharged with no clear plan for further treatment or referral. For some participants, a promised referral and/or follow-up phone call did not materialise and they had to try to make contact themselves. It was also noted that family members were left unsupported in a number of cases and were not provided with sufficient guidance about how to care for their family member. Participants who had poor experiences in the ED reported that this would negatively impact their decision to present to the ED again if experiencing a mental health crisis.
Recommendations: Some good examples occurred when participants were provided with a plan on discharge, were informed of the next steps in terms of onward referral, and were followed up with a phone call from the Clinical Nurse Specialist from the Care Programme in the days after discharge.
There is a need for improved co-ordination of patient care between the ED, the GP and mental health services (if appropriate).
In undertaking this research, the Trinity College team, along with the 3Ts charity, hope that these findings can help inform the direct improvement of care and treatment provided to people presenting to the ED with self-harm and suicidal behaviour. We are gratified that some key recommendations have already been included in the National Care Programme for Self-Harm and we look forward to the findings of Phase 2 in due course.