The Self-Harm Patient: The Need for Change in the Nursing Approach

Self-harm, self-mutilation, or self-injury, the behavior is becoming more prevalent in society, especially among women. This maladaptive coping skill is helping distressed patients to overcome the immediate emotional pain but leaves them physically and emotionally scarred in the long-term. The requirements of female patients with maladaptive coping skills have changed the nurses’ approach and care plan. Nurses must advocate for both physical and psychological treatment to better serve these patients. Other significant changes would be the adaptation of a psychosocial identification system and an out-patient follow-up program.
From the general population of people seeking medical attention, it is “estimated that one in 600 adults self-harm and require hospital treatment.” (Rayner & Warner, 2003). The behavior predominately manifests in female patients in their mid-teens to mid-twenties but can do so at any age. The behaviors breach social class lines and affects people with varying types of support systems. Judith Reece (2005), best describes the behavior;
As a radical response to feelings of total powerlessness and loss of self, a symbolic resistance to the power structures found within society which negates and silences women. (p. 564)
According to Gillian Rayner & Sam Werner (2003), the ratio of injury is 2:1 compared to the male counterparts within the same age range. (p. 306). Patients most commonly use overdose and cutting for self-mutilation. (Tanner, 2007). Whichever method is utilized it causes a rush of endorphins and initiates the pain response sensation to distract them from emotional duress.
The first contact patients receive from medical staff often sets the tone for the entire treatment. Judith Reece (2005) explains that “what the self-injuring woman appears to need is simply to be accepted, and more importantly listened to.”(p. 568). Self-harm patients already feel the stigma from society both with regard to their mental health level and their behavior. They are often ashamed of what they are doing, but feel cutting (or other chosen behavior) is their only option. Nurses must curtail the feelings they have about the behavior. They must involve themselves with the patients in order to gain acceptance within the eyes of the patient. The relationship building process will help the patient to be more willing to participate in care and further future care relationships, such as emotional/mental therapy. The relationship may seem to be easily attainable for the nurse. However it has shown to be a large contributing factor for care refusal, second to the lack of understanding of the behavior in general. According to Gill Tanner (2007) “the prevalence of misinformation about patients who self harm can lead for example to staff withholding analgesia, local anaesthesia or treatment from them.” (p. 21). Nurses are often working with large numbers of patients and may feel overwhelmed. “Advocacy is important to patients, particularly those with mental health problems who are often marginalized or even dismissed as timewasters.” (Tanner, 2007)
Nurses must advocate for multiple avenues of treatment. Treatment should not stop with mere physical treatment of the exterior wounds. The nurse should refer the patient to psychiatric services and be part of the care to assist the patient in a more positive exchange. This would further the relationship the nurse would gain with the patient; inhibiting the patient from internally regressing and negating further treatment options.
Patients with habitual self-harming behavior have an increased response to care when self-harm care principals are initiated rather than suicide watch. (Cook, Clancy & Sanderson, 2004). To better categorize patients, a “psychosocial risk assessment” should be done. (Cook, Clancy & Sanderson, 2004). The assessment would include negotiation of risk factors: age, gender, race, social status and history, health history, substance usage, level of stress and coping strategies. (Cook, Clancy & Sanderson, 2004). Along with this information, the nurse should take into account the means by which care was sought, the current presentation of the patient, the patients regard to the behavior, their mental health and their social situation. (Cook, Clancy & Sanderson, 2004) The assessment would allow a better understanding of the current emotional stance of the patient. The assessment would allow the nurse to separate the habitual self-harm patients from those at risk of suicide. This would allow the nurse to practice the self-harm principles; privacy, confidentiality, note taking, resources and the patient perspective (Cook, Clancy & Sanderson, 2004). The patient would most benefit from a private room, allowing a less stressful environment and one-on-one treatment. Confidentiality, note taking, resources/education are nursing standards. However the final principle of patient perspective is the most difficult. It requires the nurse to step back from the caring and into the understanding. This requires the nurse “recognizing that stopping may not be a desired goal.” (Cook, Clancy & Sanderson, 2004). Empathy becomes the greatest tool the nurse has to assists with the needs of the patient. This may be a directive for specially trained staff, which should involve both psychiatric and medical treatment.
The biggest deficit for self-harm patients is care outside the hospital. A program allowing for home-health visits for these patients in an out-patient follow-up program needs to be initiated. This care can and should be done by nursing staff specially trained and under the directive of a psychiatrist. This would allow for the continued building of the relationship begun during medical treatment and would give these patients stability in care. These visits would allow the patients continued success in governing their feelings and have the added ability for medical staffing to see changes within the patients. The programs should include the social network of the individual, teaching them what to do to be supportive and to help them with their own feelings. The nurse would teach the support network these guidelines from Dr. Gibson (2007) from the National Center for PTSD:
- Take the self-harm seriously by expressing concern and encouraging the individual to seek professional help.
- Don’t get into a power struggle with the individual-ultimately they need to make the choice to stop the behavior. You cannot force them to stop.
- Don’t blame yourself. The individual who is self-harming initiated this behavior and needs to take responsibility for stopping it.
- If the individual who is self-harming is a child or adolescent, make sure the parent or a trusted adult has been informed and is seeking professional help for them.

Suicide is most often a spontaneous event. With these programs in place, the rate of suicide could dramatically be affected. Helping these patients manage their feelings more effectively diminishes the chances of high stress spontaneous harmful behavior. With these adaptations to the nursing approach and plan of care, self-harm patients would be more successfully co-operative during in-house care. Out-patient care programs would allow ultimately for decreased care of these patients by hospital staff, freeing the staff to assist other patients and freeing the patients of the maladaptive coping behavior.


References
Cook, SH., Clancy, C., & Sanderson, S. (2004). Self-harm and suicide: care, interventions and policy. [Electronic Version] Nursing Standard, 18(43), 43-52, 54. Retrieved January 25, 2008 from CINAHL database (2004164849).
Gibson, L. (2007, May) Self-Harm. Retrieved February 2, 2008 from http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_self_harm.html
Kirby, J. (2006, April). Nurses want to help self-harm patients. Retrieved February 2, 2008 from http://icbirmingham.icnetwork.co.uk/0100news/0100localnews/tm_objectid=16994348&method=full&siteid=50002&headline=nurses-want-to-help-self-harm-patients-name_page.html
Rayner, G. & Warner, S. (2003). Self-harming behaviour: from lay perceptions to clinical practice. [Electronic Version] Counseling Psychology Quarterly, 16(4), 305-329. Retrieved January 25, 2008 from CINAHL database (2004137871).
Reece, J. (2005). The language of cutting: initial reflections on a study of the experiences of self-injury in a group of women and nurses. [Electronic Version] Issues in Mental Health Nursing, 26, 561-574. Retrieved January 25, 2008 from CINAHL database (2009003979).
Tanner, G. (2007). Managing wounds in patients who self harm. [Electronic Version] Emergency Nurse, 15(6) 20-25. Retrieved January 23, 2008 from CINAHL database (2009694673).




The Self-Harm Patient:
Interventions in Nursing

Self-harm, the behavior is becoming more prevalent in society, especially among women. This maladaptive coping skill is helping distressed patients to overcome the immediate emotional pain but leaves them physically and emotionally scarred in the long-term. Direct nursing interventions to decrease the likelihood of repetition of the behavior should include special observation and an out-patient follow-up program.
Intervention #1 Special Observation
Special observation, also called one-to-one care of the patient will disable the ability for repetition of the behavior. This care will enable the staff to be present with the patient to increase the possibility of a cooperative relationship between the patient and the nurse. This would further allow the skilled nurse the ability to initiate the risk assessment and manage the patient as needed.
Disadvantage #1 Infantilizing.
Disadvantages to this nursing intervention are infantilizing (Bowers, 2007) of the patient and a discrimination factor concerning patient stereotyping. According to Bowers (2007), “use of special observation has been portrayed as impersonal guard duty, infantilizing, disliked by patients, directed primarily at protection of the organization from scandal.” (p. 13) Scandal resulting when the patient repeats the self harm while in nursing care. The patient often feels confined by this special observation and refuses to partake in activity. Bowers (2007), claims that intermittent observation works better for the nurses and the patients, allowing the nurses to be “more accessible and visible to patients,” providing “greater reassurance and security” without treating the patient as a prisoner. Research has found that “patients appreciated staff efforts to keep them safe” with intermittent regular checks and was “found to be more cost-effective than other safety measures.” (Mental Health Practices, 2007)
Disadvantage #2 Discrimination with Stereotyping.
Nurses assessing patients can be considered at risk for discriminating against the patients whom self-harm. The risk assessment performed provides the nurses information on which they base the plan of care. However with self-harm psychiatric patients this can increase the likelihood of discrimination. Patients who are considered repeat harmers may automatically be considered for special observation even if they are being seen for an unrelated problem. Care issues or lack there of, can also lead to a view of discrimination. Self-harm patients “are perceived as difficult to deal with.” (Cook, 2004) This has lead to staffing attitudes of the patients being unworthy of treatment, and “many self-harming patients find themselves ignored by health and social care professionals.” (Cook, 2004)
Intervention #1 Out-Patient Follow-Up Program
The biggest need for self-harm patients is follow-up care to reduce the repetition of the behavior. An out-patient follow-up program allowing for home-health visits for self-harm patients by specially trained nursing staff and under the directive of a psychiatrist can decrease the number of visits to seek care due to the behavior. This would allow for continued building of the relationship begun during in-patient medical treatment and would give these patients stability in care. These visits would allow the patients continued success in governing their feelings and have the added ability for medical staffing to assess changes within the patients.
Disadvantage #1 Cost.
Cost and inadequate significance in the reduction in number of repeat hospitalizations is a large disadvantage of this intervention. Cost is a huge factor for patients in seeking care. Although a follow-up program may be advantageous to the patient, the cost may be the largest barrier. Patients may have inadequate insurance that will either not cover home-health visits or only cover part of the cost, leaving the remainder of the cost to be put on an already strained health-care system. One review by Burns (2005) showed that group therapy offered a considerable advantage over standard aftercare. (p. 126) Group therapy is often covered for a set amount of visits, allowing the patient to be free of the cost.
Disadvantage #1 Unsubstantial Reduction in Medical Visits
Burns (2005), also shows following a three-year follow-up program, hospitalizations were down 16% in a set experimental group. (p.124). This number may not be considered beneficial over the cost of the program in relation to the money saved in emergency room and hospitalizations. In the program 147 patients were studied. (p.124). This means that only 23 patients did not repeat the behavior seeking further care. This can be taken in multiple ways, either the patients did not re-harm significantly enough to induce need for further care or there behavior indeed was reduced or stopped altogether. A significant amount of study into this area would need to be followed in order to see the true cost benefit.
In all it seems that the best benefit for the patient and the most cost effective would be to have special observation under intermittent conditions. This would maximize the ability of the nurse to care for multiple patients and still monitor the patient in need providing safety and security. This would also maximize the cost of the observation, as a one-to one- staffing can get costly and create an even bigger nursing shortage. A follow-up program still seems like a plausible means, but more research into the effectiveness would need to be reached in order to gauge the cost effectiveness and the increase in patient outcomes.

References
Bowers, L. & Simpson, A. (2007, July). Observing and engaging. Mental Health Practice, 10(10), 12-14. Retrieved May 5, 2008 from CINAHL database (2009625320).
Burns, J., Dudley, M., Hazell, P., & Patton, G. (2005, March) Clinical management of deliberate self-harm in young people: the need for evidence-based approaches to reduce repetition. Australian & New Zealand Journal of Psychiatry, 39(3), 121-128. Retrieved May 5, 2008 from CINAHL database (2005125726).
Cook, SH., Clancy, C., & Sanderson, S. (2004). Self-harm and suicide: care, interventions and policy. Nursing Standard, 18(43), 43-52, 54. Retrieved January 25, 2008 from CINAHL database (2004164849).
Nurse-led study finds that regular checks reduce self harm. (2007, June) Mental Health Practice, 10(9), 4. Retrieved May 5, 2008 from CINAHL database (2009598980).