The Experiences of Service Users
New 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 emanate from a recent qualitative study into Accessing Help for Self-Harm and Suicidal Behaviour in the Emergency Department. The new study was commissioned by 3TS as part of their ongoing commitment to Suicide Prevention and Self Harm research. It was carried out by a team of mental health researchers from the Mental Health Nursing Team at the School of Nursing and Midwifery, Trinity College Dublin.
The research 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 those participants reported presenting with suicidal ideation without self-harm. The remainder presented following self-harm which comprised overdose and/ or self-cutting.
Variability in experiences, positive & negative
“Overall, an important primary point to note from this study is the significant variability in the experiences of participants. Some, with more than one presentation to different EDs, reported positive experiences in one ED and negative experiences in another. Participants who presented more than once to the same ED also reported variability, with some experiences largely positive whilst others were negative” said Dr Louise Doyle, Associate Professor of Mental Health Nursing at the School of Nursing and Midwifery, Trinity College Dublin.
National Care Programme
“In some cases this may be explained by the operationalisation of the National Care Programme (NCP) for the management of self-harm in the ED. Our study notes that where participants were treated by staff from this programme their experiences were generally much more positive. However, this programme is not in operation in all hospitals and in those hospitals where it is in place, the hours of delivery vary. Almost all participants, however, identified that their experience in the ED could be improved” said Dr Doyle.
Call for dedicated mental health emergency department
Speaking about the research, Noel Smyth, Chairman of 3TS said “We believe that this study is important. It represents the very personal experiences of many people who attend our Emergency Departments each year seeking both emergency physical and mental health care at a time of crisis. Whilst in no way undermining the hard work and care offered by the great medical health care teams in our hospitals, it does highlight the need for the provision of specialised Suicide and Self-Harm care services in the Emergency Departments. More so, the research highlights the particular need for a Mental Health Emergency Department which should run alongside every A&E in Ireland. This remains to be one of 3ts’ main lobbying goals and we intend to pursue enhanced Emergency Mental Health services in our hospitals with our new Government as per the findings of this study.”
A full copy of the Research can be viewed here
Key Findings and Recommendations
Back to Basics
The 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 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
A lack of understanding around self-harm/suicidal ideation and some mental health diagnoses (particularly personality disorders) was reported by participants. This lack of understanding and education has been shown in the research study to influence negative perceptions of this patient group and consequently can lead to negative interactions and treatment.
Recommendation: There is not an expectation that non-mental health staff in the ED 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, creating a sense of ‘otherness’ which 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 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.
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.
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. But the research also suggests the need for a possible volunteer service where a person can sit with someone in distress who is 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 but they identified the way in which these questions were asked was important. Many cited that having to repeat their experience/symptoms to a number of staff in the ED as 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. In addition, a number of participants reported that they sometimes hide or fail to disclose their suicidal thoughts and feelings while in the ED and 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 ED
Just under half of the participants presented to the ED with suicidal ideation, without any actual self-harm requiring physical treatment. Many of these participants felt that the ED was not the appropriate environment for them but often presented or were referred there because 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 and many 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 study, the Trinity College team along with charity 3Ts 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.
For further press information, please contact: Breffni Burke 086 856 3739
3Ts have put together a page with some helpful tips to help people attending A&E with self harm or suicidal behaviours. Read more here.