Patients' Experiences of Emergency Hospital Care Following Self-Harm: Systematic Review and Thematic Synthesis of Qualitative Research

Suicide risk following ED presentation with self-harm varies by hospital

BACKGROUND

Patients presenting to Emergency Department (ED) with self-harm are recognized to be at high risk of suicide and other causes of death in the immediate period following ED presentation. It is also recognized that there is a large variation in the management and care pathways that these patients experience at EDs.

AIMS

This study asks if there is a significant variation in mortality risk according to hospital attended and if this is explained by differences in care management.

METHODS

Population-wide data from the Northern Ireland Registry of Self-Harm from April 2012 were linked with centrally held mortality records to December 2019, providing data on self-harm type and ED care. Cox proportional hazards models analyzed mortality risk, coded as suicide, all-external causes and all-cause mortality.

RESULTS

Analysis of the 64,350 ED presentations for self-harm by 30,011 individuals confirmed a marked variation across EDs in proportion of patients receiving mental health assessment and likelihood of admission to general and psychiatric wards. There was a significant variation in suicide risk following attendance according to ED attended with the three-fold range between the lowest (HRadj 0.32 95% CIs 0.16, 0.67) and highest. These differences persisted even after adjustment for patient characteristics, variation in types of self-harm, and care management at the ED.

CONCLUSIONS

This study suggests that while the management of self-harm cases in the ED is important, it is the availability and access to, and level of engagement with, the subsequent management and care in the community rather than the immediate care at EDs that is most critical for patients presenting to ED with self-harm. However, the initial care in ED is an important gateway in initiating referrals to these services.

Acute paediatric inpatient care of children and young people admitted with self-harm or eating disorders: A single centre evaluation

In the United Kingdom, the prevalence of children and young people (CYP) accessing acute paediatric inpatient care with mental health problems is increasing, with self-harm and eating disorders particularly prevalent. This study evaluated CYP experiences of being in receipt of acute paediatric inpatient care following either self-harm or crisis stemming from an eating disorder to inform domains for a person-centred outcome measure (PCOM). A series of stakeholder engagement events were conducted between April and July 2015 where creative approaches were used to explore stakeholder experiences of care and to identify outcome domains that were subsequently prioritised using a Nominal Group Technique. Data were analysed using inductive thematic approach, with significance scores calculated for domain statements. Ninety-six stakeholders (15 CYP, eight parents and carers, and 73 professionals) participated. Findings showed five priority PCOM domains: privacy and surveillance; holistic care; making choices, appropriate communication; working together to achieve care goals; and respect and empowerment. This single centre evaluation highlights the need for a PCOM to be developed for this patient group that comprehensively reflects stakeholders' expectations in order to inform improvements to quality of acute paediatric care.

Aboriginal and Torres Strait Islander youth suicide mortality and previous mental health, suicidality and service use in Queensland, Australia, from 2001 to 2021

BACKGROUND

The current study aimed to compare current suicide rates, trends, previous treatment, suicidality and mental health diagnoses for First Nations and non-Indigenous young people who died by suicide.

METHODS

Age-specific suicide rates (ASSRs) were calculated per 100,000 persons/year using suicides aged 10-19 years in the Queensland Suicide Register. Rate Ratios (RRs) and 95 % CIs compared ASSRs for First Nations and non-Indigenous youth dying by suicide in Queensland, Australia, from 2001 to 2018. Risk ratios (RiskR) with 95 % CIs compared characteristics between First Nations and non-Indigenous youth suicides. Joinpoint regression was used to identify any changes in trends and annual percentage change (APC) in suicides with 95 % CIs.

RESULTS

The First Nations youth ASSR was 24.71 deaths per 100,000 persons/year, 4.5 times the non-Indigenous ASSR (95 % CI = 3.74-5.38, p < 0.001). Both non-Indigenous and First Nations suicide trends were stable with no joinpoints (APC: 0.3 %, 95 % CI: -1.6-2.2, p = 0.78; APC: 0.9 %, 95 % CI: -0.2-2.1, p = 0.11). Less than a quarter (23.9 %) of First Nations young people had ever received mental health treatment, significantly fewer than non-Indigenous youth (RiskR = 0.80, 95 % CI = 0.71-0.90, p < 0.001). Similarly, in the three months preceding their death, only 14.5 % of First Nations young people had received mental health treatment (RiskR = 0.89, 95 % CI = 0.83-97, p = 0.015).

LIMITATIONS

Reported mental illness, suicidality and help-seeking could be underreported due to concealment from family or police.

CONCLUSIONS

The current study finds no change in the gap between the First Nations and Non-Indigenous youth suicide rates nor evidence of decrease in the First Nations youth suicide rate. There is a need for alternative approaches to Indigenous youth suicide prevention, such as assertive outreach models outside of traditional triage and mental health systems to proactively build trusting relationships with young people in communities to identify young people needing support.

Opening the black box of registration practice for self-harm and suicide attempts in emergency departments: a qualitative study

BACKGROUND

The World Health Organization has called for improved surveillance of self-harm and suicide attempts worldwide to benefit suicide prevention programs. International comparisons of registrations are lacking, however, and there is a need for systematically collected, high-quality data across countries. The current study investigated healthcare professionals' perceptions of registration practices and their suggestions for ensuring high-quality registration of self-harm and suicide attempts.

METHODS

Qualitative interviews (N = 20) were conducted among medical secretaries, medical doctors, nurses, and registration advisers from psychiatric and somatic emergency departments in all regions of Denmark between September 2022 and March 2023. Content analysis was performed using NVivo.

RESULTS

Despite great efforts to standardize and assure the quality of registration in Denmark, almost all the healthcare professionals perceived registration practice as inconsistent and unreliable. Codes are often misclassified or unused due to insufficient time, non-standardized training, or insufficient information. The interview informants suggested that coding guidelines should be simplified and made more visible, alongside technical solutions in the electronic health record system.

CONCLUSION

The study findings resulted in eight overall recommendations for clinical practice that aim at improving the registration of patients presenting with self-harm or suicide attempts. This would be expected to help improve surveillance and prevention programs.

What Do My (Online) Friends Think? A Topic Modeling Approach to Identifying Patterns of Response to Self-Injurious Behaviors on Reddit

OBJECTIVE

Approximately 17% of adolescents and young adults will engage in non-suicidal self-injury (NSSI) at least once in their lifetime, leading the World Health Organization to identify self-injury as one of the top five public health concerns for adolescents. Despite the widespread prevalence of this behavior, NSSI continues to be heavily stigmatized in both medical and community settings, deterring many engaged in NSSI from seeking informal support from friends and family as well as formal psychological or psychiatric treatment. In contrast to the low rates of in-person help-seeking for NSSI, online support groups are highly utilized by those engaged in NSSI. Thus, an empirical study of responses to frequent, voluntary disclosure of NSSI on social media is needed to better understand how these communities meet the needs of those who self-injure.

METHOD

The current project used latent Dirichlet allocation to identify frequent and favored themes in response to self-injury content in the largest self-injury group on Reddit (over 100,000 members). Reddit, the 9th most visited website in the world, is a chat-based social media platform that has 430+ million active users and billions of site visits, with current estimates suggesting that ∼63% of the U.S. population are Reddit users.

RESULTS

Identified themes included: (1) recovery encouragement; (2) provision of social and instrumental support; and (3) daily realities of living with NSSI. Responses that encouraged recovery received more upvotes on Reddit than any other type of comment.

CONCLUSION

These results can inform evidence-based, person-centered, dimensional treatments for NSSI.

Re-imagining crisis care: experiences of delivering and receiving the Assured brief psychological intervention for people presenting to Emergency Departments with self-harm

Background

Risk of suicide is increased immediately following emergency department (ED) attendance for self-harm. Evidence suggests that brief psychological interventions delivered in EDs are effective for self-harm. The Assured intervention comprises an enhanced biopsychosocial assessment in the ED, collaborative safety planning and three rapid solution focused follow-up sessions.

Aim

We addressed the following research questions: What were ED mental health liaison practitioners' and patients' experiences of the Assured intervention? What were the barriers and facilitators? What might the mechanisms be for improving experiences and outcomes?

Methods

We conducted a feasibility study of the Assured intervention in four EDs in Southeast England. Semi-structured interviews were conducted with 13 practitioners and 27 patients. Interviews were transcribed, coded line-by-line in Nvivo and thematically analysed using an inductive approach. Inter-rater reliability was calculated with a kappa coefficient of 0.744.

Developing a clinical decision support system software prototype that assists in the management of patients with self-harm in the emergency department: protocol of the PERMANENS project

BACKGROUND

Self-harm presents a significant public health challenge. Emergency departments (EDs) are crucial healthcare settings in managing self-harm, but clinician uncertainty in risk assessment may contribute to ineffective care. Clinical Decision Support Systems (CDSSs) show promise in enhancing care processes, but their effective implementation in self-harm management remains unexplored.

METHODS

PERMANENS comprises a combination of methodologies and study designs aimed at developing a CDSS prototype that assists clinicians in the personalized assessment and management of ED patients presenting with self-harm. Ensemble prediction models will be constructed by applying machine learning techniques on electronic registry data from four sites, i.e., Catalonia (Spain), Ireland, Norway, and Sweden. These models will predict key adverse outcomes including self-harm repetition, suicide, premature death, and lack of post-discharge care. Available registry data include routinely collected electronic health record data, mortality data, and administrative data, and will be harmonized using the OMOP Common Data Model, ensuring consistency in terminologies, vocabularies and coding schemes. A clinical knowledge base of effective suicide prevention interventions will be developed rooted in a systematic review of clinical practice guidelines, including quality assessment of guidelines using the AGREE II tool. The CDSS software prototype will include a backend that integrates the prediction models and the clinical knowledge base to enable accurate patient risk stratification and subsequent intervention allocation. The CDSS frontend will enable personalized risk assessment and will provide tailored treatment plans, following a tiered evidence-based approach. Implementation research will ensure the CDSS' practical functionality and feasibility, and will include periodic meetings with user-advisory groups, mixed-methods research to identify currently unmet needs in self-harm risk assessment, and small-scale usability testing of the CDSS prototype software.

DISCUSSION

Through the development of the proposed CDSS software prototype, PERMANENS aims to standardize care, enhance clinician confidence, improve patient satisfaction, and increase treatment compliance. The routine integration of CDSS for self-harm risk assessment within healthcare systems holds significant potential in effectively reducing suicide mortality rates by facilitating personalized and timely delivery of effective interventions on a large scale for individuals at risk of suicide.

Pathways and transitions for patients admitted to an emergency department after self-harming events

The frequency of people presented in emergency departments (EDs) after self-harming events is increasing. Previous studies have shown that the complexity of the disorders of patients admitted to the ED after self-harming events can be overwhelming for ED healthcare professionals (HCPs) to handle. The objective of this study was to observe and investigate the pathways for patients admitted to the ED after self-harming events to either transition or discharge. Participant observation and interviews were selected as the methods to generate insight into the pathways of patients admitted to the ED after self-harming events. The data were analysed using interpretative phenomenological analysis. A sample size of 20 patients was analysed, and a total of 213 h of observation took place during the data collection. Three main themes appeared: (1) patients' mental stress versus high expectations, (2) uncertainty about how to address the self-harming event and (3) a system of chaos. Patients admitted to the ED after self-harming events struggle with difficult mental stress. Despite this, they face high expectations that they will fit in and cooperate in the ED. The healthcare system is organised with unclear responsibilities and without systematic ways to care for self-harm patients and so provides chaotic patient pathways. There is a need for improved cross-sectional competencies, mutual agreements and systematic communication for discharge, transitions and follow-up care between those involved in the patient's pathway and care.

The experience of being in acute emergency care following an overdose with suicidal intent: A hermeneutic phenomenological study

INTRODUCTION

Nurses working within Emergency Departments are frequently required to care for individuals impacted by suicidal behaviour.

LITERATURE REVIEW

Published research into the experience of such individuals in emergency care, is limited. Studies identified do not distinguish between self-harming and suicidal behaviour and do not reveal the lived experience in depth.

AIM AND METHODOLOGY

This research reveals the lived experience of being in emergency care following an overdose with suicidal intent, through the collection of data while patients are still in hospital. Sixteen semi-structured interviews were conducted with patients on a medical admission ward. The research uses an interpretive hermeneutic phenomenological approach.

ANALYSIS

A thematic analysis indicated six key themes: The fear of death and dying, The hospital - a place of safety, Loved ones a reason to live, Feelings of hopelessness, Eclipsed as a suicidal patient, and the Impact of human relationships.

DISCUSSION

The findings are discussed and contextualized within wider literature: The fear of death, hopelessness, the role of stigma and shame, including anticipatory stigma, and the impact of kindness and relationships. Implications for practice are outlined, informing how care can be enhanced by nursing staff.

Young adults looking back at their experiences of treatment and care for nonsuicidal self-injury during adolescence: a qualitative study

BACKGROUND

Nonsuicidal self-injury (NSSI) is associated with stigma, and negative attitudes among healthcare professionals toward NSSI have been reported. A person-centered approach that focuses on how individuals with lived experience of NSSI perceive the treatment and care they receive is invaluable in reducing barriers to help-seeking and improving treatment and mental healthcare services. The aim of the current qualitative study was to explore the perceptions of young adults when they look back upon their experiences of psychiatric treatment for NSSI during adolescence.

METHODS

Twenty-six individuals with lived experience of NSSI who were in contact with child and adolescent psychiatry during adolescence were interviewed. The interviews were analyzed using thematic analysis.

RESULTS

Three main themes were developed: Changed perceptions in retrospect, The importance of a collaborative conceptualization and Lasting impression of the relationship. Participants' perception of themselves as well as the treatment changed over time. The importance of a joint understanding of NSSI and an agreed-upon treatment focus was emphasized. The relationship to the mental health professionals, and experiences of how NSSI was communicated, were salient several years later.

CONCLUSIONS

Healthcare professionals need to communicate about NSSI in a respectful manner and include the perspective of the adolescent with lived experience of NSSI in a joint conceptualization of NSSI and treatment focus.

Mapping clinical interactions in an Australian tertiary hospital emergency department for patients presenting with risk of suicide or self-harm: Network modeling from observational data

BACKGROUND

Reliable assessment of suicide and self-harm risk in emergency medicine is critical for effective intervention and treatment of patients affected by mental health disorders. Teams of clinicians face the challenge of rapidly integrating medical history, wide-ranging psychosocial factors, and real-time patient observations to inform diagnosis, treatment, and referral decisions. Patient outcomes therefore depend on the reliable flow of information through networks of clinical staff and information systems. This study aimed to develop a quantitative data-driven research framework for the analysis of information flow in emergency healthcare settings to evaluate clinical practice and operational models for emergency psychiatric care.

METHODS AND FINDINGS

We deployed 2 observers in a tertiary hospital emergency department during 2018 for a total of 118.5 h to record clinical interactions along patient trajectories for presentations with risk of self-harm or suicide (n = 272 interactions for n = 43 patient trajectories). The study population was reflective of a naturalistic sample of patients presenting to a tertiary emergency department in a metropolitan Australian city. Using the observational data, we constructed a clinical interaction network to model the flow of clinical information at a systems level. Community detection via modularity maximization revealed communities in the network closely aligned with the underlying clinical team structure. The Psychiatric Liaison Nurse (PLN) was identified as the most important agent in the network as quantified by node degree, closeness centrality, and betweenness centrality. Betweenness centrality of the PLN was significantly higher than expected by chance (>95th percentile compared with randomly shuffled networks) and removing the PLN from the network reduced both the global efficiency of the model and the closeness centrality of all doctors. This indicated a potential vulnerability in the system that could negatively impact patient care if the function of the PLN was compromised. We developed an algorithmic strategy to mitigate this risk by targeted strengthening of links between clinical teams using greedy cumulative addition of network edges in the model. Finally, we identified specific interactions along patient trajectories which were most likely to precipitate a psychiatric referral using a machine learning model trained on features from dynamically constructed clinical interaction networks. The main limitation of this study is the use of nonclinical information only (i.e., modeling is based on timing of interactions and agents involved, but not the content or quantity of information transferred during interactions).

CONCLUSIONS

This study demonstrates a data-driven research framework, new to the best of our knowledge, to assess and reinforce important information pathways that guide clinical decision processes and provide complementary insights for improving clinical practice and operational models in emergency medicine for patients at risk of suicide or self-harm. Our findings suggest that PLNs can play a crucial role in clinical communication, but overreliance on PLNs may pose risks to reliable information flow. Operational models that utilize PLNs may be made more robust to these risks by improving interdisciplinary communication between doctors. Our research framework could also be applied more broadly to investigate service delivery in different healthcare settings or for other medical specialties, patient groups, or demographics.

Attitudes toward and experiences of clinical and non-clinical services among individuals who self-harm or attempt suicide: a systematic review

The prevalence of self-harm has increased substantially in recent decades. Despite the development of guidelines for better management and prevention of self-harm, service users report that quality of care remains variable. A previous systematic review of research published to June 2006 documented largely negative experiences of clinical services among patients who self-harm. This systematic review summarized the literature published since then to July 2022 to examine contemporary attitudes toward and experience of clinical and non-clinical services among individuals who self-harm and their relatives. We systematically searched for literature using seven databases. Quality of studies was assessed using the Mixed-Methods Appraisal Tool and findings were summarized using a narrative synthesis. We identified 29 studies that met our inclusion criteria, all of which were from high- or middle-income countries and were generally of high methodological quality. Our narrative synthesis identified negative attitudes toward clinical management and organizational barriers across services. Generally, more positive attitudes were found toward non-clinical services providing therapeutic contact, such as voluntary sector organizations and social services, than clinical services, such as emergency departments and inpatient units. Views suggested that negative experiences of service provision may perpetuate a cycle of self-harm. Our review suggests that in recent years there has been little improvement in attitudes toward and experiences of services for patients who self-harm. These findings should be used to reform clinical guidelines and staff training across clinical services to promote patient-centered and compassionate care and deliver more effective, acceptable and accessible services.

Comparing the Acceptability and Quality of Intervention Modalities for Suicidality in the Emergency Department: Randomized Feasibility Trial

BACKGROUND

Emergency departments (EDs) manage many patients with suicide risk, but effective interventions for suicidality are challenging to implement in this setting. ReachCare is a technology-facilitated version of an evidence-based intervention for suicidal ED patients. Here, we present findings on the acceptability and quality of ReachCare in the ED, as well as a comparison of these measures across 3 potential delivery modalities.

OBJECTIVE

Our aim was to test the feasibility of the ReachCare intervention in its entirety through conducting a pilot study with patients presenting with suicidality to the ED. We tested three different ways of receiving the ED-based components of ReachCare: (1) self-administered on the tablet app using a chatbot interface, (2) administered by an in-person clinician, or (3) administered by a telehealth clinician.

METHODS

In total, 47 ED patients who screened positive for suicide risk were randomly allocated to receive one of three delivery modalities of ReachCare in the ED: (1) self-administered on the patient-facing tablet app with a chatbot interface, (2) delivered by an in-person clinician, or (3) delivered by a telehealth clinician, with the latter two using a clinician-facing web app. We measured demographic and clinical characteristics, acceptability and appropriateness of the intervention, and quality and completeness of the resulting safety plans.

RESULTS

Patients assigned high ratings for the acceptability (median 4.00/5, IQR 4.00-4.50) and appropriateness (median 4.00/5, IQR 4.00-4.25) of ReachCare's ED components, and there were no substantial differences across the 3 delivery modalities [H(acceptability)=3.90, P=.14; H(appropriateness)=1.05, P=.59]. The self-administered modality took significantly less time than the 2 clinician modalities (H=27.91, P<.001), and the usability of the self-administered version was in the "very high" range (median 93.75/100, IQR 80.00-97.50). The safety plans created across all 3 modalities were high-quality (H=0.60, P=.74).

CONCLUSIONS

Patients rated ReachCare in the ED as highly acceptable and appropriate regardless of modality. Self-administration may be a feasible way to ensure patients with suicide risk receive an intervention in resource constrained EDs. Limitations include small sample size and demographic differences between those enrolled versus not enrolled. Further research will examine the clinical outcomes of patients receiving both the in-ED and post-ED components of ReachCare.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04720911; https://clinicaltrials.gov/ct2/show/NCT04720911.

Review: Systematic review and metasynthesis of qualitative literature on young people's experiences of going to A&E/emergency departments for mental health support

BACKGROUND

There has been an increase in children and young people attending emergency departments for mental health reasons, including self-harm. Patients often report having poor experiences when attending emergency departments for mental health support. However, there has yet to be a review exploring the experiences of young people. Our aim in this study was to synthesise qualitative literature on young people's experiences of going to emergency departments for mental health support.

METHODS

A systematic review and metasynthesis were conducted. Five databases and grey literature were searched for relevant studies. Five articles met study criteria and were analysed using an iterative process of thematic synthesis.

RESULTS

The synthesis yielded four overarching themes: (a) emergency departments' inability to meet the mental health needs of young people, (b) emergency departments exacerbating patient distress, (c) patients feeling like a burden or undeserving of treatment and (d) consequences of poor emergency department experiences.

CONCLUSIONS

These findings (based on a still very limited literature) highlight the role that emergency departments have in relation to being a key point of contact with young people who self-harm. To properly engage with patients, emergency departments need to have the resources to provide compassionate care and follow clinical guidelines regarding assessments.

A systematic review and meta-ethnography to explore people's experiences of psychotherapy for self-harm

BACKGROUND

Self-harm is a major public health concern. Lifetime prevalence is high, and rates of self-harm are rising; however, available interventions do not benefit everyone, and engagement with therapy can be low. Qualitative accounts allow for a greater understanding of what is helpful to individuals. This study aimed to synthesize the experiences of interventions for self-harm, from participants who have participated in these themselves.

METHODS

Participants had self-harmed at least once and undergone an individual psychotherapeutic intervention for self-harm. Papers not written or translated to the English language were excluded. Four databases (Medline, CINAHL, Web of Science and PsycINFO) were systematically searched and each paper was assessed using the CASP quality appraisal tool. A meta-ethnographic approach to the synthesis was taken.

RESULTS

Ten studies encompassing 104 participants were included. Four overarching themes were developed and the importance of recognizing the person beyond the self-harm emerged through a line of argument synthesis. Building a trusted, therapeutic relationship founded on patience and without judgement was essential for the perceived success of therapy, which was unique to each person and often went beyond reducing self-harming behaviours.

LIMITATIONS

Papers included in the study showed a lack of diversity with regard to ethnicity and gender.

CONCLUSIONS

The findings illustrate the importance of the therapeutic alliance when working with self-harm. Clinical implications of this paper include the importance of utilizing key therapeutic competencies which should be considered fundamental to change within psychotherapeutic interventions for self-harm, with the uniqueness of each patient recognized throughout.

Peer Intervention following Suicide-Related Emergency Department Presentation: Evaluation of the PAUSE Pilot Program

The risk for future suicidal behaviours is elevated following suicide attempts, particularly for those with complex needs or those who are disconnected from healthcare systems. The PAUSE program was designed to address this gap using peer workers to provide continuity and coordination of care following suicide-related emergency presentations. This study aimed to evaluate the pilot program's effect on suicidal ideation and hope, and to explore the acceptability and participants' experiences. A mixed-methods design was employed with pre- and post-evaluation questionnaires, including the GHQ-28-SS (general health questionnaire suicide scale), AHS (adult hope scale), and K10 (Kessler psychological distress scale). Participant engagement rates and semi-structured interviews were used to explore program acceptability. In total, 142 people were engaged with the PAUSE pilot between 24 August 2017 and 11 January 2020. There were no significant gender differences in engagement. The suicidal ideation scores decreased, and the hope scores increased after participation in PAUSE. A thematic analysis revealed that participants identified that the key program mechanisms were holistic and responsive support, ongoing social connectedness, and having peer workers who understood their experiences and treated them like people rather than clients. The small number of participants and lack of a control group limited the result generalizability. The findings suggest that PAUSE was an effective and acceptable model for supporting people following suicide-related hospitalisations in this pilot sample.

Experiences of Inpatient Psychiatric Nursing Care among People Who Have Survived a Suicide Attempt

Nurses are front line providers for people who have been hospitalized following a suicide attempt, yet few studies have explored this population's experiences specifically with nursing care in inpatient psychiatric units. The purpose of this study was to hear directly from people who have survived a suicide attempt about their experiences with inpatient psychiatric nursing care following a suicide attempt in order to identify strengths and weaknesses of current practices and elicit suggested improvements. Qualitative in-depth interviews were conducted with people who were previously psychiatrically hospitalized following a suicide attempt (N = 9; M_age=42). Applied thematic analysis was used to identify themes related to positive and negative experiences with nursing care during hospitalization and advice for nurses. Findings demonstrated that positive experiences with nurses related to empathy, friendliness, feeling supported, flexibility, and active listening, while negative experiences centered around feeling stigmatized, invalidated, degraded, and coerced. Advice for nurses included being self-aware of preconceived or stigmatized notions, practicing empathy, listening, and humanity. The results of this study indicate the need for compassionate care, training to reduce nurse stigma, and adequate resources for nurses to mitigate emotional strain and burnout.

Developing a prototype digital risk mitigation pathway for children and young people admitted to acute paediatric NHS care in mental health crisis: Protocol of the Safety Assessment in Paediatric healthcare Environments (SAPhE) pathway study

Background

Globally, there are increasing numbers of Children and young people (CYPs) experiencing a mental health crisis requiring admission to acute paediatric inpatient care. These CYPs can often experience fluctuating emotional states accompanied by urges to self-harm or attempt to end their life, leading to reduced safety and poorer experiences. Currently, in the UK National Health Service (NHS) there are no standardised, evidence-based interventions in acute paediatric care to mitigate or minimise immediate risk of self-harm and suicide in CYP admitted with mental health crisis.

Objective

To outline the protocol for the SAPhE Pathway study which aims to: 1) identify and prioritise risk mitigation strategies to include in the digital prototype, 2) understand the feasibility of implementing a novel digital risk mitigation pathway in differing NHS contexts, and 3) co-create a prototype digital risk mitigation pathway.

Methods

This is a multi-centre study uses a mixed-methods design. A systematic review and exploratory methods (interviews, surveys, and focus groups) will be used to identify the content and feasibility of implementing a digital risk mitigation pathway. Participants will include healthcare professionals, digital experts and CYP with experience of mental health conditions. Data will be collected between January 2022 and March 2023 and analysed using content and thematic analysis, case study, cross-case analysis for qualitative data and descriptive statistics for quantitative data. Findings will inform the experience-based co-design workshops.

Ethics and Dissemination

The study received full ethical approval from NHS REC [Ref: 22/SC/0237 and 22/WM/0167]. Findings will be made available to all stakeholders using multiple approaches.

Assessment of suicide risk in mental health practice: shifting from prediction to therapeutic assessment, formulation, and risk management

Suicide prevention in psychiatric practice has been dominated by efforts to predict risk of suicide in individual patients. However, traditional risk prediction measures have been shown repeatedly in studies from high income countries to be ineffective. Several factors might contribute to clinicians' preoccupation with risk prediction, which can have negative effects on patient care and also on clinicians where prediction is seen as failing. The model of therapeutic risk assessment, formulation, and management we outline in this article regards all patients with mental health problems as potentially at increased risk of suicide. It is aimed at reducing risk through use of a person-centred approach. We describe how a move towards therapeutic risk assessment, formulation, and risk management, including collaborative safety planning, could help clinicians develop a more tailored approach to managing risk for all patients, incorporating potentially therapeutic effects as well as helping to identify other risk reduction interventions. Such an approach could lead to enhanced patient safety and quality of care, which is more acceptable to patients.

Teaching trainee psychiatrists a Mentalization-Based Treatment approach to personality disorder: effect on attitudes

AIMS AND METHOD

To evaluate whether a brief training using a Mentalization-Based Treatment (MBT) model improves attitudes of trainee psychiatrists working with patients with personality disorder. Trainee psychiatrists (n = 49) completed the Attitudes to Personality Disorder Questionnaire before and after a training consisting of two 3 h lectures on (a) theory of personality disorder and (b) practical skills using an MBT role-play.

RESULTS

There was a significant improvement on composite scores of attitude, with small to moderate effect size (Wilcoxon signed-rank test Z = 3.961, P < 0.001, r = 0.40).

CLINICAL IMPLICATIONS

Brief MBT-informed teaching oriented to the clinical situation appears to have a positive effect on attitudes towards people with personality disorder.

Acute psychiatric care: approaches to increasing the range of services and improving access and quality of care

Acute services for mental health crises are very important to service users and their supporters, and consume a substantial share of mental health resources in many countries. However, acute care is often unpopular and sometimes coercive, and the evidence on which models are best for patient experience and outcomes remains surprisingly limited, in part reflecting challenges in conducting studies with people in crisis. Evidence on best ap-proaches to initial assessment and immediate management is particularly lacking, but some innovative models involving extended assessment, brief interventions, and diversifying settings and strategies for providing support are potentially helpful. Acute wards continue to be central in the intensive treatment phase following a crisis, but new approaches need to be developed, evaluated and implemented to reducing coercion, addressing trauma, diversifying treatments and the inpatient workforce, and making decision-making and care collaborative. Intensive home treatment services, acute day units, and community crisis services have supporting evidence in diverting some service users from hospital admission: a greater understanding of how best to implement them in a wide range of contexts and what works best for which service users would be valuable. Approaches to crisis management in the voluntary sector are more flexible and informal: such services have potential to complement and provide valuable learning for statutory sector services, especially for groups who tend to be underserved or disengaged. Such approaches often involve staff with personal experience of mental health crises, who have important potential roles in improving quality of acute care across sectors. Large gaps exist in many low- and middle-income countries, fuelled by poor access to quality mental health care. Responses need to build on a foundation of existing community responses and contextually relevant evidence. The necessity of moving outside formal systems in low-resource settings may lead to wider learning from locally embedded strategies.

Suicide and self-harm

Suicide and self-harm are major health and societal issues worldwide, but the greatest burden of both behaviours occurs in low-income and middle-income countries. Although rates of suicide are higher in male than in female individuals, self-harm is more common in female individuals. Rather than having a single cause, suicide and self-harm are the result of a complex interplay of several factors that occur throughout the life course, and vary by gender, age, ethnicity, and geography. Several clinical and public health interventions show promise, although our understanding of their effectiveness has largely originated from high-income countries. Attempting to predict suicide is unlikely to be helpful. Intervention and prevention must include both a clinical and community focus, and every health professional has a crucial part to play.

‘Wasn’t offered one, too poorly to ask for one’ – Reasons why some patients do not receive a psychosocial assessment following self-harm: Qualitative patient and carer survey

OBJECTIVE

Psychosocial assessment following self-harm presentations to hospital is an important aspect of care. However, many people attending hospital following self-harm do not receive an assessment. We sought to explore reasons why some patients do not receive a psychosocial assessment following self-harm from the perspective of patients and carers.

METHODS

Between March and November 2019, we recruited 88 patients and 14 carers aged ⩾18 years from 16 mental health trusts and community organisations in the United Kingdom, via social media, to a co-designed qualitative survey. Thematic analyses were used to interpret the data.

RESULTS

Patients' reasons for refusing an assessment included long waiting times, previous problematic interactions with staff and feeling unsafe when in the emergency department. Two people refused an assessment because they wanted to harm themselves again. Participants reported organisational reasons for non-assessment, including clinicians not offering assessments and exclusion due to alcohol intoxication. Other patients felt they did not reach clinically determined thresholds because of misconceptions over perceived heightened fatality risk with certain self-harm methods (e.g. self-poisoning vs self-cutting).

CONCLUSION

Our results provide important insights into some of the reasons why some people may not receive a psychosocial assessment following self-harm. Parallel assessments, compassionate care and specialist alcohol services in acute hospitals may help reduce the number of people who leave before an assessment. Education may help address erroneous beliefs that self-injury and self-harm repetition are not associated with greatly raised suicide risk.

Experiences of care for self-harm in the emergency department: the perspectives of patients, carers and practitioners

Emergency departments are often the point of entry to the healthcare system for people who self-harm, and these individuals are at high risk of further self-harm and suicide in the post-discharge period. These settings therefore provide a critical opportunity for intervention. However, many studies have identified that the experiences of patients, carers and the emergency department staff themselves is often suboptimal. In this editorial we summarise one such study, by O'Keeffe and colleagues, and consider strategies for improving the experiences of patients and their carers when presenting to the emergency department. We also reiterate the need for wider systemic change in attitudes and approaches towards people who self-harm that are pervasive across the healthcare system and beyond.

A rapid review of emergency department interventions for children and young people presenting with suicidal ideation

BACKGROUND

Suicidal ideation is an increasingly common presentation to the paediatric emergency department. The presence of suicidal ideation is linked to acute psychiatric hospital admission and increased risk of suicide. The paediatric emergency department plays a critical role in reducing risk of suicide, strengthening protective factors and encouraging patient engagement with ongoing care.

AIMS

This rapid review aims to synthesise evidence on interventions that can be implemented in the paediatric emergency department for children and adolescents presenting with suicidal ideation.

METHOD

Six electronic databases were searched for studies published since January 2010: PubMed, Web of Science, Medline, PsycINFO, CINAHL and Cochrane. Outcomes of interest included suicidal ideation, engagement with out-patient services, incidence of depressive symptoms, hopelessness, family empowerment, hospital admission and feasibility of interventions. The Cochrane risk-of-bias tool was used to evaluate the quality of studies.

RESULTS

Six studies of paediatric emergency department-initiated family-based (n = 4) and motivational interviewing interventions (n = 2) were narratively reviewed. The studies were mainly small and of varying quality. The evidence synthesis suggests that both types of intervention, when initiated by the paediatric emergency department, reduce suicidal ideation and improve patient engagement with out-patient services. Family-based interventions also showed a reduction in suicidality and improvement in family empowerment, hopelessness and depressive symptoms.

CONCLUSIONS

Paediatric emergency department-initiated interventions are crucial to reduce suicidal ideation and risk of suicide, and to enhance ongoing engagement with out-patient services. Further research is needed; however, family-based and motivational interviewing interventions could be feasibly and effectively implemented in the paediatric emergency department setting.

Experiences of nursing care for patients who self-harm and suggestions for future practices: The perspectives of emergency care nurses

Self-harm is a major challenge in healthcare systems. Emergency department nurses provide care to numerous patients with self-harm injuries. Accordingly, nurse-patient interactions are vital to improve the physical and psychological outcomes of this complex patient group. Previous studies have proposed the establishment of improved teaching programs to increase the competence of emergency department nurses within mental health care; however, few studies have comprehensively investigated the experiences and suggestions for future nursing practices. Therefore, we gathered in-depth knowledge of Danish emergency department nurses' experiences caring for patients who self-harm and obtained their suggestions on future nursing practices. Ten semi-structured interviews were conducted to capture the nurses' individual perspectives. The scientific theory is based on phenomenology and hermeneutics. Interpretative phenomenological analysis was used, and three themes were identified: (i) importance of having the competences to establish a relationship in the acute phase; (ii) acute care from a biomedical perspective; and (iii) highlighting ideas for improved future practices. The emergency department nurses were aware of the importance of mental health care but found their competence and motivation situated in medical care. The nurses felt that they lacked skills to undertake in-depth mental care for patients who self-harm and that the healthcare system failed to help this group of patients. Based on these findings, rather than aiming at improving nursing skills, we suggest a close collaboration between the emergency and psychiatric departments to improve the quality of care for patients who self-harm. We also recommend organizational changes within the emergency department, such as the introduction of a so-called 'social track'.

Suicide Awareness Training: A Literature Review with Application to Queensland Nurses

Despite decades of strategic intervention, Queensland's suicide rates exceed both national and global rates. This is surely an indicator that not enough is being done to address this cause of death. The authors suggest that this problem may be addressed, in part, by provision of improved suicide awareness training for nurses. The purpose of this review was to support this through examination of the contemporary status of suicide awareness training in Queensland nurses, the efficacy of suicide awareness training in general, and the experiences of nurses, other health professionals, and suicidal patients in healthcare settings. We concluded that while efficacious, suicide awareness training in Queensland nurses is presently inadequate, and that both nurses and patients may benefit from improved suicide awareness training.

Evaluation of the impact and implementation of a national clinical programme for the management of self-harm in hospital emergency departments: study protocol for a natural experiment

BACKGROUND

A National Clinical Programme for the Management of Hospital-Presenting Self-Harm (NCP-SH) was introduced in Ireland in 2014. This involved the development of a model of care to standardise the management of self-harm in emergency departments, to be delivered by dedicated clinical nurse specialists. The core components of the programme were to: ensure an empathic and timely response, conduct a biopsychosocial assessment, involve family members in assessment and discharge planning, and provide a bridge to next care. The overall aim of the programme was to reduce the rate of repeat self-harm. This multistage study will evaluate the impact of the NCP-SH on hospital-presenting self-harm and to identify determinants influencing its implementation.

METHODS

Employing a sequential mixed methods design, the first stage will use data from the National Self-Harm Registry Ireland to examine the impact of the NCP-SH on self-harm repetition, along with other aspects of care, including provision of psychosocial assessments and changes in admissions and postdischarge referrals. A cost-effectiveness analysis will assess the cost per repeat self-harm attendance avoided as a result of the NCP-SH. The second stage will identify the influences of implementation fidelity-adherence to the programme's core components-using a combination of document analysis and semistructured interviews with staff of the programme, guided by the Consolidated Framework for Implementation Research.

ETHICS AND DISSEMINATION

This study has received full ethical approval and will run until August 2023. This study is novel in that it will identify important factors influencing successful implementation of complex programmes. It is expected that the findings will provide important learnings for the integration of mental health services in general hospital settings and will be disseminated via peer-review publications along with reports for clinicians and policy-makers.

First responder, clinician, and non‐clinical support staff knowledge, attitudes, and behaviours towards people presenting for emergency care following self‐harm: a mixed evidence synthesis

This is a protocol for a Cochrane Review (qualitative). The objectives are as follows:

The objectives of this review are threefold, as follows.

Firstly, to assess the content of knowledge, attitudes, and behaviours of first responders, clinicians, and non‐clinical support staff towards service users with SH presentations. 

Secondly, to understand how service user and staff characteristics (e.g. age, gender, sociodemographic background), type of SH presentation (e.g. method, repetition), and contextual factors (e.g. hospital environment, presence of bystanders) affect the knowledge, attitudes, and behaviours of first responders, clinicians, and non‐clinical support staff in providing acute care.

Thirdly, to assess whether clinicians' knowledge, attitudes, and behaviours have evolved over time.

Predicting nonsuicidal self-injury using a variant of the implicit association test

OBJECTIVE

Nonsuicidal self-injury (NSSI) is a severe problem, and its prevalence is increasing. To aid prevention and treatment, there is an urgent need for evidence-based measures to identify individuals at risk for NSSI. Measures that probe past NSSI are most promising, but people are often motivated to conceal NSSI behavior. This problem can be overcome by using implicit measures, which do not require individuals to self-report on their behavior. Yet, prior research typically found weak predictive utility of implicit measures. Based on a new perspective on implicit measures and recent findings in NSSI research, we developed an Implicit Association Test that probes past NSSI (the P-NSSI-IAT).

METHOD

We report two preregistered studies (N = 83; N = 372) in which we tested the utility of the P-NSSI-IAT to detect past NSSI and predict NSSI one month later.

RESULTS

P-NSSI-IAT scores (a) differentiated injury groups from non-injury groups and (b) prospectively predicted NSSI and improved prediction above and beyond risk factors of NSSI.

CONCLUSIONS

These initial findings suggest that the P-NSSI-IAT is a promising tool for NSSI risk assessment. Future studies should further examine the predictive utility of this newly developed measure for NSSI behavior.

Consumer and Carer Perspectives of a Zero Suicide Prevention Program: A Qualitative Study

This study explored the experiences of healthcare consumers who had recently attempted suicide, and their carers, following placement on a Suicide Prevention Pathway based on the Zero Suicide framework. Qualitative interviews were conducted with 10 consumers and 5 carers using a semi-structured interview schedule. Interviews were transcribed and thematic analysis was applied to identify prominent themes and sub-themes. Three interrelated themes were identified. The first theme was 'Feeling safe and valued' with the associated sub-theme pertaining to perceived stigmatizing treatment and self-stigma. The second was 'Intersection of consumer and staff/organizational needs' with a related sub-theme of time pressure and reduced self-disclosure. The final theme was 'Importance of the 'whole picture', highlighting the relevance of assessing and addressing psychosocial factors when planning for consumer recovery. Overall, consumers and their carers reported a favorable experience of the Suicide Prevention Pathway; however, there were several areas identified for improvement. These included reconciling the time-pressures of a busy health service system, ensuring consumers and carers feel their psychosocial concerns are addressed, and ensuring that adequate rapport is developed. Key to this is ensuring consumers feel cared for and reducing perceptions of stigma.

Experiences of people seen in an acute hospital setting by a liaison mental health service: responses from an online survey

Background

In recent years the UK has expanded the provision of liaison mental health services (LMHS). Little work has been undertaken to explore first-hand experiences of them.

Aims

The aim of this study was to gain insights into the experiences of users of LMHS in both emergency departments and acute inpatient wards in the UK.

Methods

This cross-sectional internet survey was initially advertised from May-July 2017 using the social media platform Facebook. Due to a paucity of male respondents, it was re-run from November 2017-February 2018, specifically targeting male respondents. The survey featured a structured questionnaire divided into three categories: the profile of the respondent, perceived professionalism of LMHS and overall opinion of the service.

Analysis

Responses to the structured questionnaire were analysed using descriptive statistics and latent class analysis. Free-text responses were transcribed verbatim and interpreted using thematic analysis.

Results

184 people responded to the survey. 147 were service users and 37 were partners, friends or family members of service users. Only 31% of service users and 27% of close others found their overall contact helpful. Latent class analysis identified three clusters − 46% of service users generally disliked their contact, 36% had an overall positive experience, and 18% did not answer most questions about helpfulness or usefulness. Features most frequently identified as important were the provision of a 24/7 service, assessment by a variety of healthcare professionals and national standardisation of services. Respondents indicated that the least important feature was the provision of a separate service for older people. They desired faster assessments following referral from the parent team, clearer communication about next steps and greater knowledge of local services and third sector organisations.

Conclusions

This survey identified mixed responses, but overall experiences were more negative than indicated in the limited previous research. The evaluation and adaptation of LMHS along the lines suggested in our survey should be prioritised to enhance their inherent therapeutic value and to improve engagement with treatment and future psychiatric care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06974-4.

Healthcare staff's views on responding to suicide and self-harm: Part II

PURPOSE

To report on healthcare staff's views of the barriers to preventing suicide and self-harm.

DESIGN AND METHODS

Using a qualitative approach, data were collected through "World Café" discussion forums and written submissions, and analyzed using reflexive thematic analysis.

FINDINGS

Healthcare staff, including psychiatric nurses, perceived that a whole of society approach was needed for suicide and self-harm prevention. Support for those at the front line is needed as well as clear referral pathways and interagency working.

PRACTICE IMPLICATIONS

Formalized support for staff working in healthcare should be given with a flexible and inclusive approach to service delivery adopted.

Experiences of care for self-harm in the emergency department: comparison of the perspectives of patients, carers and practitioners

Background

Each year, 220 000 episodes of self-harm are managed by emergency departments in England, providing support to people at risk of suicide.

Aims

To explore treatment of self-harm in emergency departments, comparing perspectives of patients, carers and practitioners.

Method

Focus groups and semi-structured interviews with 79 people explored experiences of receiving/delivering care. Participants were patients (7 young people, 12 adults), 8 carers, 15 generalist emergency department practitioners and 37 liaison psychiatry practitioners. Data were analysed using framework analysis.

Results

We identified four themes. One was common across stakeholder groups: (a) the wider system is failing people who self-harm: they often only access crisis support as they are frequently excluded from services, leading to unhelpful cycles of attending the emergency department. Carers felt over-relied upon and ill-equipped to keep the person safe. Three themes reflected different perspectives across stakeholders: (b) practitioners feel powerless and become hardened towards patients, with patients feeling judged for seeking help which exacerbates their distress; (c) patients need a human connection to offer hope when life feels hopeless, yet practitioners underestimate the therapeutic potential of interactions; and (d) practitioners are fearful of blame if someone takes their life: formulaic question-and-answer risk assessments help make staff feel safer but patients feel this is not a valid way of assessing risk or addressing their needs.

Conclusions

Emergency department practitioners should seek to build a human connection and validate patients’ distress, which offers hope when life feels hopeless. Patients consider this a therapeutic intervention in its own right. Investment in self-harm treatment is indicated.

Contesting constructs and interrogating research methods: Re-analysis of qualitative data from a hospital-based case study of self-harm management and prevention practices

Discourses of self-harm, and also suicide, are often underpinned by a central tenet: prevention is the priority. This belief is seemingly so inscribed in research that it is rarely interrogated. The present paper re-analyses qualitative data from a hospital-based study of self-harm management and prevention practice. It aims to reflect upon, and disrupt, the authors' latent assumptions about the construct of 'prevention', while reflecting on the research method used. Twenty-five individuals participated in semi-structured interviews: healthcare and affiliated professionals (n = 14); parents and carers (n = 8); and children and young people (aged 9-16 years) who had presented to an emergency department for self-harm, with or without suicidal intent (n = 3). We offer two central discursive considerations: (1) Self-harm prevention is largely an unintelligible concept, having to be reflexively constructed in situ. As such, it is questionable whether it makes sense to discuss the prevention of this amorphous and dynamic phenomenon, which cannot always be disentangled from everyday life; (2) Interviews entail significant biographical work for participants, notably the performance of personal and professional competence for the audience. These interactional dynamics offer a glimpse into the priorities, meanings and needs for participants in relation to self-harm. Together these considerations provide useful insights into how the interview method can serve as both a limiting and illuminating site of knowledge creation.

Psychosocial Assessment in the Emergency Department

Background: In the United Kingdom, suicide risk is assessed in the emergency department (ED) in a face-to-face assessment with psychiatric liaison practitioners. This study aimed to explore patient experiences of psychosocial assessment after presenting with self-harm/suicidality. Method: A total of 28 patients were interviewed within 2 weeks of ED attendance for self-harm/suicidality. Interviews were transcribed and analyzed using inductive thematic analysis. Results: People described two different experiences. A therapeutic interaction was about the "person" and made people feel their life mattered and instilled hope for the future. This was characterized by: unscripted conversation; warmth promoting disclosure; psychological exploration of feelings; validation of distress; and a coproduced care plan. A formulaic assessment was about the "risk" and made people feel their life did not matter and hopeless about the future. This was characterized by: feeling judged and not worthy of help; a focus on risk and form filling; a trivial treatment plan; and loss of trust in services. Limitations: Our study comprised a single ED and used a non-diverse sample. Conclusion: Psychosocial assessment in the ED impacts on hope for people in crisis. A focus on therapeutic communication that is about the person, as well as the risk, improves patient experience, decreases distress, and instills hope that life is worth living.

'Relieved to be seen'-patient and carer experiences of psychosocial assessment in the emergency department following self-harm: qualitative analysis of 102 free-text survey responses

OBJECTIVES

We sought to explore patient and carer experiences of psychosocial assessments following presentations to hospital after self-harm.

DESIGN

Thematic analysis of free-text responses to an open-ended online survey.

SETTING

Between March and November 2019, we recruited 88 patients (82% women) and 14 carers aged ≥18 years from 16 English mental health trusts, community organisations, and via social media.

RESULTS

Psychosocial assessments were experienced as helpful on some occasions but harmful on others. Participants felt better, less suicidal and less likely to repeat self-harm after good-quality compassionate and supportive assessments. However, negative experiences during the assessment pathway were common and, in some cases, contributed to greater distress, less engagement and further self-harm. Participants reported receiving negative and stigmatising comments about their injuries. Others reported that they were refused medical care or an anaesthetic. Stigmatising attitudes among some mental health staff centred on preconceived ideas over self-harm as a 'behavioural issue', inappropriate use of services and psychiatric diagnosis.

CONCLUSION

Our findings highlight important patient experiences that can inform service provision and they demonstrate the value of involving patients/carers throughout the research process. Psychosocial assessments can be beneficial when empathetic and collaborative but less helpful when overly standardised, lacking in compassion and waiting times are unduly long. Patient views are essential to inform practice, particularly given the rapidly changing service context during and after the COVID-19 emergency.

A Qualitative Account of Young People's Experiences Seeking Care from Emergency Departments for Self-Harm

Many young people who engage in self-harm do not seek help from health services. For those that do, emergency departments (EDs) are a key point of contact. Substantial gaps remain in current knowledge related to young consumers’ experiences and views on optimal treatment of self-harm in the ED. In this study, semi-structured interviews were conducted with thirteen young people (M_age = 21.2 years), who were engaged with care at headspace early intervention centers and had presented to an ED with a self-inflicted physical injury. Participants were asked to describe their experience in the ED and the care they received. Data were analyzed thematically. Three inter-related themes were identified: 1. The ED was experienced through a lens of significant distress, 2. The ED environment and processes were counter-therapeutic, and 3. Staff were perceived to be disinterested, dismissive, and lacking in knowledge. The study highlights the overwhelmingly negative nature of participants’ experiences, and presents recommendations for service and practice improvements, such as the provision of staff training and increased aftercare.

Theorising health professionals' prevention and management practices with children and young people experiencing self-harm: a qualitative hospital-based case study

Self-harm in young people remains a significant concern. Studies of emergency departments have centred on negative professional attitudes. There has been limited interrogation and theorisation of what drives such attitudes, and the contexts that sustain them. Adopting a complex systems lens, this study aimed to explore how systems shape professional and patient interactions. It draws upon interviews with healthcare and affiliated professionals (n = 14) in a UK case study hospital, with primary focus on the emergency department. Data were analysed using a thematic approach and the principles of grounded theory. Four themes emerged, with the first three centralising how professionals' practices operate within: (1) a framework of risk management; (2) expectations of progressing patients through the care pathway; and (3) a culture of specialist expertise, with resulting uncertainty about who is responsible for self-harm. The fourth theme considers barriers to system change. A small number of participants described efforts to enact positive modifications to practices, but these were frustrated by entrenched system structures. The potential detrimental impacts for patient care and professional wellbeing are considered. Future practice needs systemic action to support professionals in treating patients experiencing self-harm, while future research requires more ethnographic explorations of the complex system in situ.

"There Is So Much More for Us to Lose If We Were to Kill Ourselves": Understanding Paradoxically Low Rates of Self-Harm in a Socioeconomically Disadvantaged Community in London

London has unexpectedly low overall rates of self-harm in public health data and contains highly deprived areas with these paradoxically low rates. Qualitative data were collected via interviews and focus groups with 26 individuals living and working in one such area. Using the Stress Process Model, we explore why this ethnically diverse community, which is exposed to multiple, chronic stressors, might nonetheless appear to have low rates of self-harm. Participants described significant impacts of stressors on the mental health of people locally. These were partly buffered by social resources related to community solidarity and a culture of self-reliance. However, identifying oneself as mentally ill through being known to have self-harmed was seen as highly risky, diminishing a person's social status and exposing them to additional stressors from the community and services. Consequently, people tended to hide distress, respond with behaviors less linked to mental illness, and avoid mental health services.

Factors explaining variation in recommended care pathways following hospital-presenting self-harm: a multilevel national registry study

BACKGROUND

People who present to hospital following self-harm are at high risk of suicide. Despite this, there are considerable variations in the management of this group across hospitals and the factors influencing such variations are not well understood.

AIMS

The aim of this study was to identify the specific hospital and individual factors associated with care pathways following hospital-presenting self-harm.

METHOD

Data on presentations to hospitals by those aged 18 years and over were obtained from the National Self-Harm Registry Ireland for 2017 and 2018. Factors associated with four common outcomes following self-harm (self-discharge, medical and psychiatric admission and psychosocial assessment before discharge) were examined using multilevel Poisson regression models.

RESULTS

Care pathways following self-harm varied across hospitals and were influenced by both hospital and individual factors. Individual factors were primarily associated with self-discharge (including male gender, younger age and alcohol involvement), medical admission (older age, drug overdose as a sole method and ambulance presentations) and psychiatric admission (male gender, methods associated with greater lethality and older age). The hospital admission rate for self-harm was the only factor associated with all outcomes examined. The availability of psychiatric in-patient facilities and specialist mental health staff contributed to variation in psychiatric admissions and psychosocial assessments prior to discharge. Hospital factors explained the majority of observed variation in the provision of psychosocial assessments.

CONCLUSIONS

Characteristics of the presenting hospital and hospital admission rates influence the recommended care pathways following self-harm. Provision of onsite mental health facilities and specialist mental health staff has a strong impact on psychiatric care of these patients.