This is part eight of my series on what psychiatric nurses do. You can read the other parts of the series here.
Self-harm is an unfortunate reality of mental health care. Many of the patients on psychiatric inpatient wards self-harm in one way or another, despite the efforts of all the staff to prevent it. Cutting, burning, scalding, swallowing dangerous substances, inserting objects under the skin, taking numerous small overdoses, head-banging, etc. Patients will find ways to self-harm no matter what you do.
I remember the first time I had to deal with a serious self-inflicted injury. A male patient had cut his wrist in his sink using a razor blade. There was blood all over the floor, in the sink, on the bed, up the walls, and his arm was covered and pumping ever more blood out. I never thought I’d be squeamish in this long-anticipated situation, but I was surprised by how freaked out I was! I panicked and asked a more experienced nurse to deal with him while I cleaned up his bedroom.
Dealing with self-harm is also challenging on a personal level. With the above incident, I found it incredibly difficult not to get angry with the patient for causing so much trouble for me and my colleagues and for putting himself and others at risk in this way. It’s hard when the same people self harm over and over and you have to deal with the consequences when you’re already very busy. Especially when they said they wouldn’t and you gave them your trust. There was a patient on the ward I was on a short while ago who would take small Paracetamol overdoses virtually every time she went off the ward, despite assuring you she wouldn’t. Each time we knew it wasn’t enough to be seriously harmful, but we still had all the extra work of ringing doctors, hospital visits, paperwork, etc. It’s hard to be patient sometimes.
When a patient self-harms it’s basically the psyche nurse’s job to pick up the pieces. Call an ambulance or doctor, clean up the wound, put on a temporary dressing, escort the patient to A&E if necessary, and do the reams of paperwork it causes. It’s difficult – psyche nurses, bizarrely, are not trained in dressing wounds, stitching or anything like that. Other than a lesson in very basic wound care and aseptic technique at uni, I never had any sort of tutelage in wound care or dressing. Wound care tends to be left to the junior doctors, who instruct nurses on when to change the dressings and how.
There tends to be a dispute among psyche nurses about the proper way to deal with self-harming. Balancing risk and promoting responsibility is a balancing act and all nurses have different opinions. Some argue that self-harm is a coping strategy, albeit a maladaptive one, and that patients should be allowed to utilise it in a safe manner. Others take the opposite view and believe self-harm should be prevented at all costs and every single possible risk should be eliminated. Actual practice tends to fall somewhere in the middle. Obvious risks are eliminated as much as practicable. Known cutters are supervised when shaving and searched for sharp objects when returning from leave; burners aren’t allowed cigarette lighters and supervised when smoking, etc. But risks can never be completely eliminated and at some point the patients have to take responsibility for themselves. It all comes down to care-planning and risk assessment. For example, a well-known patient to the ward I was on would self-harm by inserting staples and metal pins under their skin. There was no way we could stop them without massively infringing on their right to autonomy and it being a massive drain on staff resources. So they were given access to dressings and a doctor would periodically check their wounds for signs of infection.
Suicide attempts are one of the most challenging parts of the job of a psyche nurse. They’re not common, and most are not serious attempts, but are often made to sabotage care, make a point, etc. It’s unfortunate but true that some patients will use the threat of suicide as a way to get what they want, even making serious attempts but at times that they know someone will find them. Again, dealing with this sort of behaviour is very challenging, and is a major reason so many nurses become cynical (myself included). However very occasionally someone will make a genuine, real attempt to commit suicide, usually when off the ward. It’s never happened to me. In fact I only ever knew one patient who successfully committed suicide after being discharged, and I was a student. He drowned himself in a lake after convincing the whole team he was well enough to go home.
The job of the nurse is obviously to prevent suicide as much as possible. Hourly checks of the ward are done by all staff in turn, but those patients who are perceived to be a high suicide risk can be monitored more frequently, to the point where a member of staff can be within arms reach. They will be monitored until staff are satisfied the risk has decreased, and as a team the nurses and sometimes doctors will decide to reduce the observation levels. It’s a lot of responsibility and sometimes we will be wrong. The media love to vilify us for getting it wrong when someone manages to commit suicide under our care, but we’re not faultless and we’re not psychic.
Next time I’ll discuss the AWOL procedure and observations in more detail.