A Nursing Times reader replies to the negative comments drawn from a news story on patients who self-harm and the nurses who lack the skill to treat them.
This comment is in response to “Nurses lack the skills to treat self-harm”
Researchers from the University of Nottingham argue that not all nurses have received sufficient training to support or help individuals who self-harm, leaving these patients with a negative view of the care they receive from those employed to treat them.
Some nurses and other healthcare professionals, often working in emergency departments, have negative and sometimes discriminatory attitudes towards this vulnerable group of patients who they may perceive as attention-seeking or manipulative and dismiss them as time wasters.
Some of the comments following this article support these negative views of nurses. which are unfortunately far from rare and which I have also witnessed throughout my professional practice. Such unacceptable attitudes identify a necessity for further education and training to further understanding of the underlying psychopathology of self harm and how best to offer consistent, compassionate and constructive care to meet their complex and specific needs and to eliminate stereotyping, stigmatisation and discrimination that also impacts upon the attitudes of the public towards individuals with this and other mental health disorders.
You were a normal healthy individual until a series of disasters radically affected your life. You now feel pushed to survive on the fringes of society, with no family, your one-time close friends, mostly married, are scattered around the globe, and you no longer seem able to fit into any social group.
When you correspond with your friends or contact them for an occasional chat they appear preoccupied and too busy with their families and their own affairs to show much interest. You had a steady permanent job which you loved but because of illness in the family, before the last member died, you gave it up to help at home as there was, at the time, no other alternative and nobody else to help.
After a prolonged period as a carer you make several attempts to re-enter employment but despite your professional qualifications, higher degree and many years of experience, these were unsuccessful. Desperate for some type of job you eventually accepted a series of jobs which proved unsuitable and unsustainable as you sank further and further into depression after the gap left by the death of your loved ones.
Despair led you to seek help, and you underwent a course of psychotherapy which lasted a number of years. Once again, with the help of a careers advisor, you made a desperate attempt to return to work and submitted, what was considered by your advisor and others, an excellent CV. However, with age against you and rising unemployment, after more than 50 refusals, you ended up exhausted, demoralised and with diminishing self-esteem which pushed you into putting your whole life under scrutiny.
On the brink of financial disaster, there seemed to be no other recourse but to apply for a job seekers allowance, and then on the advice of a psychiatrist, incapacity benefits even though this was totally against your will and your principles, and despite that fact that you didn’t feel physically ill, just very downcast, prone to depressive episodes, feelings of guilt for your inability to find a job and a social outcast. At the time you were at least consoled by the fact that this would only be a solution for the short term.
This also gave rise to feelings of extreme frustration at not being able to move on, especially after investing your resources in a higher degree in your professional field, and at a time when you had felt at the peak of your career and with ambitions to climb the ladder. Time out at this point, to reflect on the future was needed, even in the knowledge that the longer the break the harder it was to re-enter the labour market. Retraining was not an option because of age and the further personal financial costs involved.
Now imagine the effects this had on you and what led you to seek support in A&E
One cannot predict the date and time of a crisis. The psychotherapeutic support you continue to receive is only available during office hours and by appointment. Despite reassurances there are other organisations there to help in times of crisis, this is not always so in practice.
The only alternative emergency service readily available appears to be the A&E of the local hospital whose purpose is to serve the public 24 hours a day for any medical emergencies, including mental health crises. You realise these departments are overloaded and you don’t wish to bother them or “waste their time”. You grit your teeth and tell yourself that you must pull yourself together as you have heard others say so often when referring to individuals with mental health difficulties.
You have nobody else to confide in as you fear how others may react or change their attitude towards you if they think you are “mentally unstable” and may even perceive you as a danger to society. It’s getting later and later and the problems and the crisis grow out of all proportion until you feel you must take action. The extreme distress and the inner pressure you feel increases and increases until you think you will burst - like the cover blowing off a pressure cooker.
You may find yourself trapped in a dark tunnel with no way out and may even lose the will to live. Eventually, seeing no way out of this most terrible and devastating situation, there are many different “coping” strategies you might try such as, nevertheless, calling a friend even if it’s just for a chat (but nobody around), drinking a cup of tea or coffee, smoking a cigarette, watching TV, listening to music, going for a walk or jog, doing some sport (depending on the time of day) or physical exercise, crying, screaming (not always appropriate), scratching, beating yourself, banging your head against a wall, having a hot bath, going to bed, drinking alcohol, taking drugs, medication, an overdose or harming yourself.
Assuming for the purpose of this article that you harmed yourself, as you have done several times before under stress and seem unable to stop yourself, you go, or somebody finds you and takes you, to A&E. You may by this time be feeling extremely rough and really don’t want to go there and may (possibly based on previous experience) even have reflected on what type of reception you might get and how long you may have to wait, but there seems to be no other option.
Besides, talking to staff there who may be total strangers may seem to you like an intrusion into your privacy.
Now imagine these two scenarios in A&E
The department appears hectic but the nurse is kind and understanding and takes a few unhurried moments to talk to you and shows a genuine interest, giving you the opportunity to express your concerns. He or she is experienced and empathetic and has an understanding of the subjectivity of psychic pain (ie how the patient describes their own suffering, no matter how strange or unbelievable, rather the nurse’s interpretation of what the patient relates). After a short wait a mental health specialist is called to see you and you have a long talk in which they calm you and reassures you that you are in safe hands. He or she makes an assessment of your current situation, evaluates your risk of further self-harm and decides whether a hospital admission or any other immediate measures are necessary.
The staff are totally indifferent to your arrival, you may be ignored completely or they may be very brisk and businesslike to mask their lack of ability to cope with your situation. At worst, they may express either implicitly or explicitly that you are wasting their time, or they may at least make you feel that way, giving you the impression that they have other more important things to do or other patients to attend to. (Their appearance of busyness may include retreating to the staff room for a chat or to drink coffee or play cards outside their official breaks). You may even be sent away without having a chance to discuss your problems.
Now bear in mind that you, or somebody you care about, could be in this patient’s shoes at any time in your life and require the assistance of nurses in A&E.
- Reflecting on the reception, support and assistance you received in both of the above scenarios, how you would feel, what would you think and how would you react?
- Were your expectations adequately met in either of these scenarios?
- Would you expect to be treated with empathy, understanding and respect or would you feel that you were wasting the staff’s time, were in their way and that they had other patients with greater or more urgent needs than you?
- Would you like to feel that somebody professionally competent and experienced in looking after patients with DSH was willing to take the time to listen to you and talk through your problems with you whilst acknowledging your reasons for your distress which led you to harm yourself?
- Would you like to feel that you were in a safe and secure environment where you could trust the person you were talking to and confide in them in the knowledge that any information you give would be passed only to others directly involved in your care, and with your consent?
- Would you expect to receive constructive practical support and advice with the offer of a follow up appointment if required?
- Did this encounter with the emergency services relieve you immediate distress?
- If you felt that you were not respectfully or fairly treated, and that your immediate needs were not being met what would you like to have seen done differently?
- What effect did this encounter with the emergency services have on your condition?
- How would you relate these experiences to others who might be in a similar situation?
- How would you answer the questions on a survey of service provision for those who self-harm?
- What advice would you give to others in a crisis about where to attend if they appear to be in danger of harming themselves or following an episode of deliberate self harm?
- If, after imagining yourself in both of these scenarios, your experience of the standard of care you received did not meet your expectations, what recommendations would you make to improve the quality of the emergency services for the care of individuals who have harmed themselves?
Would it not be better for everybody concerned if a consistent attitude and treatment policy were adopted by nursing staff nationwide to treat patients like the person in this example, who I imagine is quite realistic and typical of quite a few people presenting to A&E, in essence no different to any other patient, with the dignity and understanding he or she merits.
An understanding needs to be shown of what may have led him/her to such desperate, and possibly attention seeking measures, in order to provide the appropriate support in an emergency situation and in the longer term. A satisfactory and mutually agreed follow up must be ensured rather than merely dismissing them with a list of names and addresses which may not lead anywhere.
With the appropriate training and experience, far greater satisfaction may be derived from a job well done with compassion, empathy and understanding than all the stress unleashed by anger when confronted by a patient one is unable to cope with and who is deemed to be wasting the nurses’ time.
Nurses on the general register have to be prepared to care for patients with a wide and increasing variety of conditions and act according to their code of professional conduct and ethics as well as adhering to local or national policies and guidelines such as NICE.
No patient should ever be confronted with an attitude of arrogance by healthcare personnel nor should they be told, or led to believe, that they are wasting their time. Such attitudes are a sign of ignorance.
Confidence in the ability to support this group of patients with their often highly complex needs can be highly rewarding, but is best achieved by undergoing the appropriate training, in what is considered by many as a fascinating area of study of personality, human behaviour and psychopathology. Such training should be a requisite for all nurses on the general register.
Although deliberate self harm is often considered to be a voluntary act it is associated with impulse control disorders. It may also be triggered during a dissociative or psychotic episode which sometimes occurs in individuals who have an underlying personality disorder or serious mental health disorder.