1. Considering risk in an acute mental health ward
Colin Smith, Senior Charge Nurse
Merrick Pope, Specialist Nurse
Dr Debbie Cooper, ST6
Dr Jane Cheeseman, Consultant

2. Managing self harm Aim:
“Reduce incidence of inpatient self-harm in Balcarres female ward by 50% by January 2017.”

3. Vignette
A 22-year-old woman was raised in a series of social care environments. She has a history of childhood neglect. She describes a history of cutting since the age of 14, approximately every three weeks. She has been admitted to hospital following a significant injury, requiring surgical intervention. Mental health admission occurred subsequently. Whilst in the ward, self harm has escalated in frequency and severity. Increasing interventions such as restricting time off ward, constant observations and use of a single room do not seem to have helped. How can the clinical team approach this risk?

4. The dilemma Safe practice Patient centred Promoting autonomy
Focused hospital stay
Cost
MHA/Restraint/Observation
Staff anxiety/concern
Staff responsibility for safety
Longer hospital stay
Increasing intervention e.g. Restraint, MHA, restriction of time off ward etc., often assoc with increased DSH and risk. However, at these points it is especially difficult to change approach, despite a recognition that picture worsening.

5. The Context Moving to new site What is self harm? Ward experience
Critical incident reviews and learning
Mental Welfare Commission report
SPSP ‘test site’

6. Self harm
Definition: ‘self-poisoning or self-injury, irrespective of the apparent purpose of the act’.
10% those presenting with self-harm admitted to hospital.
What is the aim of admission?
Association with mental disorder
Stigma
Risk of suicide

7. King’s article Self harm Inner experiences Ward environment
Relationships
Sensation regulation
Life events
Suicidal intent
Communication
King’s article

8. Evidence base - management
Observation level
No clear relationship between observation level and self harm (Bowers 2007).
No reduction in self harm week following enhanced observation (Stewart 2009).
Review of cases undergoing NHS negligence action found 79% involved use of constant obs at time of event (Gournay 2009).
Locked doors
Self harm increased where doors locked for more than 3 hours (Bowers 2008)
Environment
Location (Low 1997)
Peak time 9pm (Nijman 2002)
Length of stay approaching 1 year (Neuner 2008)

9. Ward Experience
Increased self harm at concentrated periods over past 2-3 years
Inpatient suicide
Patient distress and harm
Staff sickness and work-related stress
Staff knowledge, skills and confidence
Impact of ‘restrictive’ care
Cost implications and length of stay

10. SPSP MH DATA

12. Staff perspectives

14. Critical incident reviews – NHS Lothian
Demographics
Authorised reports available 12 cases
Four events occurred in in-patient setting
75% cases involved female patients
Method:
Method
Number of cases
Asphyxiation 4
Jumping from height 3
Penetrating blade 2
Overdose
Inhalation of noxious gases 1

15. Key themes emerging from critical incident reviews
Risk assessment/observation education
Specialist approach (personality disorder)
Reflecting where traditional care approaches increase risk.
Improving access to learning from events
Communication at transitions

16. The dilemma
Focused hospital stay
Promoting autonomy
Safe practice
Patient centred
Cost
Staff responsibility for safety
MHA/Restraint/Observation
Longer hospital stay
Staff anxiety/concern
Increasing intervention e.g. Restraint, MHA, restriction of time off ward etc., often assoc with increased DSH and risk. However, at these points it is especially difficult to change approach, despite a recognition that picture worsening.

17. Advancing change Reducing inpatient self harm

18. Advancing change Driver diagram
Number of cases
-Rates of self harm
% Completed training
- GBV
- Self harm
- Personality Disorder
- Care planning
- Risk assessment
Pre- and post staff attitude questionnaire
% Attendance
Patient Feedback
Risk Panel
Education
Care Planning/Risk assessment
Traffic light system
MBT
Reflective Practice
Patient Council
Focused use of constant observations
Staff/Culture change
Patient expectations
Reduce number of self harm incidents by 50% by January 2017
Secondary Drivers
Measures
Aim
Primary Drivers
Countermeasures – increased DSH or increased ‘near miss’ critical incidents

19. Creating a culture change - Education
Gender based violence training
Personality disorder training
Care planning
Risk assessment
Mentalisation Based Therapy
Measures:
Number of staff completing training and implementing practice
Pre and post questionnaire
PD/Self harm survey

20. Risk Panel
Clinicians present case to a body of experts to seek advice in complex/risky case.
Opportunity for reflection
Share expertise
Second opinion
Share positive risk taking
Maximise communication
Impact on length of stay
Cost?
Looking to seek expertise from panels set up in England. Coordinating times to discuss.

21. Summary
Self harm is a common inpatient problem with a number of consequences
Keen to achieve improvements in care
Culture/Attitude change
Target use of resources (inc constant obs)
Consider risk panel
Good time for change
New hospital
SPSP
Hospital initiatives

22. Questions for today Views on our approach thus far? Advice/pointers?
Value of ‘risk panel’?
Who to have on such a panel?

23. References
Bowers L, Whittington R, Nolan P, Parkin D et al. The City 128 Study of Observation and Outcomes on Acute Psychiatric Wards. Report to the NHS SDO Programme SDO programme London.
Stewart D, Bowers L, Warburton F. Constant special observation and self-harm on acute psychiatric wards: a longitudinal analysis. General-Hospital Psychiatry 200; 31:
Gournay K, Bowers L. Suicide and self harm in in-patient psychiatric units: a study of nursing issues in 31 cases. Journal of Advanced Nursing 2000; 32 (1):
Bowers L, Whittington R et al. The relationship between service ecology, special observation and self harm during acute in-patient care: the City-128 study. British Journal of Psychiatry 2008; 293 (5):
Low G, Terry G, Duggan C, MacLeod A, Power M. Deliberate self harm among female patients at a special hospital: an incidence study. Health Trends 1997; 29 (1): 6-9
Nijman H, Joost M, Campo A. Situational Determinants of Inpatient self-harm. Suicide and life threatening behaviour. The American Association of Suicidology 2002; 32 (2):
Neuner T, Schmid R, Wolfersdorf, Spiebl H. Predicting inpatient suicides and suicide attempts by using clinical and routine data? General Hospital Psychiatry 2008; 30: