Discussion

Walsh and Rosen (1988) present an excellent table spanning fifty years (from 1935 to 1985) of researchers attempts to differentiate self-injury (and associated behaviours) from suicide (pp 16–19). Regrettably, though, it appears as if little attention to resolve the controversy surrounding terminology has occurred since then. Hence, the dividing line between self-injury and suicide remains blurred, causing confusion and misunderstandings both within and outside the field. A major shift forward however, is the abandonment of the qualifiers ‘deliberate’ by the Royal College of Psychiatrists, and ‘intentional’ from the NICE self-harm guidelines, demonstrating that change is possible when people are prepared to listen.

By drawing attention to the issue of terminology in this chapter, my hope is that it will generate further discussion between professionals and researchers in the field and lead to eventual resolution of this contentious issue, which has existed for far too long. Perhaps a useful starting point to reduce the confusion would be for researchers to clarify to their target audience exactly what topics they are studying. This is particularly important if the ambiguous terms ‘self-harm’ or ‘parasuicide’ are used. It would make life a lot easier and perhaps fewer misunderstandings would arise if articles (academic or otherwise) carried headings such as: Self-harm (includes self-poisoning and self-injury, excludes alcohol and illicit drugs) for example.

‘Safe self harm – is it possible?’

This was the title of a debate that took place at the Royal College of Nursing (RCN) Congress in April 2006, the aim of which was to discuss the nurse’s role in enabling patients to self-harm safely.

Consultant nurse, Chris Holley, leading the ‘safe self harm’ pilot scheme introduced at South Staffordshire and Shropshire Healthcare NHS Foundation Trust prior to the congress, opened the debate.

The controversial proposal at RCN Congress that nurses should endorse safe self-injury for some hospital patients whipped up media frenzy, questioning nurses’ duty of care to prevent self-harm, and accusations of potentially placing patients at increased risk of suicide. These are a handful of headlines that appeared in the press before and after the debate (some of which err on the side of sensationalism; others present a more objective perspective):

• Hospitals to allow self-harm (Lister, S., TimesOnline, March 22, 2006)
• Hospital allows patients to harm themselves (Daily Mail, March 22, 2006)
• Hospital lets its patients self-harm in pilot scheme (Nicholas, C., Scotsman.com, March 26, 2006)
• Self-harmers to be given clean blades (Templeton, S.K., Sunday Times, February 05, 2006).
• Self harm on the NHS (Myall, S., The People.co.uk, March 26, 2006)
• Nurses want to help self-harm patients (Kirby, J., icBirmingham, April 26, 2006)
• Nurses back supervised self-harm (Triggle, N., BBC News 24, Tuesday, 25 April 2006).

Facts speak louder than words

Chris Holley and her colleague Rachel Horton, in the text that follows, enable us to look beyond the controversial headlines of public journalism, to the authentic picture that activated the initiation of the pioneering safe self-injury initiative, and which resulted in so much media controversy.

The safe self-injury initiative
By Chris Holley and Rachel Horton

At South Staffordshire and Shropshire Healthcare NHS Foundation Trust, mental health professionals have been exploring practice to improve the patient experience. They had recognised that they were nursing patients inconsistently, some of whom had a long history of self-injury, and who would describe their behaviour as making themselves feel safe and human again. The nurses had polarised views about how to care – some felt safe to allow patients who self-injure to continue cutting themselves, as they were aware that the patient would feel relief afterwards. On the other hand, some staff felt that they had a duty to prevent such individuals from harming themselves, having a duty to protect from harm. The result was a poor experience of care for both the patients and staff alike. The staff team tended to split between those who would want to search a patient’s room to remove any potentially dangerous implements – and those who would use the ‘turning a blind eye approach’ whilst a patient self-injured, knowing that they would feel better afterwards.

The Nursing and Midwifery Council (NMC) were consulted for advice as some nurses recognised that they were in an ethical and professional dilemma. Despite the lack of formal guidelines for harm minimisation, the NMC’s advice was that whatever method of care was used, it needed to be a consistent approach across the whole care team. A Self Harm Consensus Seminar was held in Stafford in January 2005 to gather opinion from experts across the country; and the RCN Institute, along with mental health trusts in Newcastle-upon-Tyne and South Staffordshire, carried out research to explore nurses’ attitudes towards patients who self-harm. A self-harm focus group was established to explore a process for improving practice in this area, including developing guidelines for working with self-harm/injury which explores the different functions behind self harm/injury for different patients.

The background

A safe self-injury care plan was eventually agreed to use with a patient who had used self-injury for the past 20 years to manage her difficult and distressing thoughts and feelings. She had been cutting her knees in a controlled way which had not caused her serious harm and was not described as an attempt to end her life; it was to bring her relief. The staff team recognised her cutting as an effective coping mechanism, but struggled with their code of professional conduct. The patient recognised that during previous hospital admissions when she has been unable to cut herself, and therefore being denied the opportunity to utilise her safe and trusted coping strategy, it had resulted in her using alternative/more dangerous forms of self-harm. This had the potential to increase the risk of serious and/or long-term harm – even accidental death.

When not allowed to use the safe coping strategy of cutting herself, the service user became so desperate that she eventually cut herself with whatever she could find – a broken cup . . . or even a piece of (dirty) glass found on a walk in the hospital grounds. Her need to cut was so desperate, at this point, that her cutting was not controlled or safe. She therefore became ‘at risk’ because of a nursing protocol which was supposed to ensure (ironically) patient safety.

During a subsequent admission to hospital, in order to improve the service user’s experience of in-patient services, a comprehensive assessment was completed which included liaising with other professionals involved in her care; researching case notes – and many discussions with the patient. Her needs were identified and a care plan was negotiated and written in collaboration with the patient which recognised and promoted the need for consistency in practice; sharing responsibility; clear boundary setting and empowerment of the patient. Discussions and agreement of the way forward took place between the patient, nursing, medical and management teams.

The change in practice

The patient was empowered, and involved in defining the team approach, in defining the care plan. She was allowed to cut herself with boundaries in place; she had been checked as having the capacity to make informed decisions about her care, and a very comprehensive specific care plan was developed. The care plan was signed by the patient and by all of the professionals involved in her care – something that had not been done before – the contentious nature of the care being provided warranted a totally ‘signed up’ approach by the team. The care plan, of course, was regularly reviewed, and the result was that the staff team worked confidently and consistently; the patient was happy with her care, without feeling judged.

The care plan included planned 1:1 sessions to explore and encourage the principles of harm reduction; to provide support, and the opportunity to discuss her thoughts and feelings. Staff agreed not to intervene and prevent her from cutting her knees unless she requested this. The lady concerned was used to cutting her knees with glass. Staff agreed not to remove her piece of glass from her room unless she requested this. She had agreed to be responsible for ensuring the glass was kept securely in her room, in a locked drawer, and that she would limit her self-injury to the privacy of her own room – to reduce the risk of distress to other patients on the ward.

The patient agreed to assess her wounds (in the same way that she would do so at home) and dress them independently if she felt that they did not require nursing or medical intervention, and nursing staff agreed to provide her with the necessary equipment to facilitate this – like dressings, antiseptic, etc. She also agreed that she would be responsible for requesting assistance from nursing staff following an act of self-injury if she felt this to be necessary, and nursing staff agreed to assess her wounds and treat them accordingly – or request medical assessment if required.

The patient had stated that she did not wish to receive treatment at the local Accident and Emergency Department agreeing that, in some circumstances, this may not be possible and that medical staff may advise that this is necessary. Therefore, an agreement was made that she would receive medical treatment on the ward, whenever possible. The patient requested that information regarding her self-injury would not be shared with her family without her expressed consent. During this process, she was able to identify factors that would be an indication that she was at an increased risk of more serious harm. She identified that cutting her face was such an indicator and that she would be responsible for informing staff of such risks. At this point, the staff would review her care plan, ensuring that she would be involved with all decisions made regarding any changes.

So what was the impact upon the nursing team delivering this comprehensive care plan?

Honest and open communication between the patient and professionals resulted in an atmosphere of mutual respect and a sharing of renewed attitudes and values. The nursing team were able to openly acknowledge that to witness a patient bleeding from a wound that has been inflicted upon themselves does not naturally lend itself to a calm response; some would find it quite traumatic. The team shared their knowledge and skills; communicated more regularly and supported each other better; debriefed and learnt from each incident – and, as a result, are now a stronger team.

Royal College of Nursing debate and the media

As a result of being involved in informing the Royal College of Nursing debate at RCN Congress in April 2006 (this can be viewed on line at www.rcn.org.uk) South Staffordshire and Shropshire Healthcare NHS Foundation Trust has been the subject of much media attention, only some of it accurate, receiving – in addition to the media calls (“Are you handing razor blades to your patients?”) – many calls from mental health practitioners across the country who have welcomed the promotion of this approach which has been used in silence by numerous practitioners before us. We need to be open/share information about innovative/new approaches to working with those selected patients who we are aware self injure in order to make them feel safe – in order to improve the patient experience – rather than making it an abusive experience in in-patient settings.

© 2007 Chris Holley and Rachel Horton

Used with permission

Harm minimisation is about accepting the need to self-harm as a valid method of survival until survival is possible by other means.
—Pembroke (2007:166)

About the authors

Chris Holley, RMN; Cert. Couns.; DN (CPN); M.Sc.

Chris Holley is a Consultant Nurse in Sexual Abuse and Women’s Issues employed by South Staffordshire and Shropshire Healthcare NHS Foundation Trust, leading their Sexual Abuse Service. She also has the Lead for women’s mental health issues within the Trust. South Staffordshire and Shropshire Healthcare NHS Foundation Trust is also the pilot site for the DH exploratory exercise into the development of guidelines for people who self harm in in-patient settings, and has presented her work internationally.

Rachel Horton is a mental health nurse (RMN) with seven years experience of working in acute in-patient settings, including the perinatal setting. She, together with a service user, compiled the care plan used at South Staffordshire which acknowledged the service user’s need to injure herself at times. She has presented her innovative work at conferences locally.

Key points

• Self-injury has become the focus of much media attention, with reports implying that the UK is the self-harm capital of Europe.
• The magnitude of the problem of self-injury is impossible to determine due to the absence of official statistics, inconsistency over definitions and terms, discrepancies over reported estimates, and because many episodes go unreported or undetected.
• Inaccurate media reporting and judgemental attitudes by the media towards people that self-injure has the potential to increase stigma and prejudice rather than reduce it.
• The UK National Inquiry among young people that self-harm identified that much work still needs to be done to establish the occurrence of self-harm, and to develop knowledge to ascertain appropriate interventions in the prevention of self-harm, and continuance of self-harm once it has become a regular pattern of behaviour.
• Concrete statistics are needed to support claims that self-injury is on the increase among young people.
• Internet sites displaying graphic images of self-injury wounds and scars have become the target of vigorous condemnation.