Table 4

NICE quality standards for self-harm compared with the study results and potential implications for practice

NICE quality standards (QS34)Study results (N=102)Potential implications for practice based on patient/carer recommendations
1People who have harmed themselves are cared for with compassion and the same respect and dignity as any service user.People experienced significant levels of stigmatising attitudes throughout the assessment process.Given the levels of stigmatising attitudes reported by participants and elevated risk of suicide associated with self-harm and clinical populations (eg, autism spectrum condition, obsessive compulsive disorder, post-traumatic stress disorder, personality disorders),42 staff education that also considers reflexivity, culture, and socioeconomic factors may be helpful. Training may be more effective if tailored towards staff groups (eg, acute staff, liaison psychiatry staff), co-designed and delivered by people with relevant lived experience.
2People who have self-harmed have an initial assessment of physical health, mental state, safeguarding concerns, social circumstances and risk of self-harm repetition or suicide.Participants felt initial assessments were focused on their mental state without attention to their distress or reasons for self-harm.Emphatic care at initial stages may help to encourage people to stay for further assessment. Clear communication about the purpose of initial assessment and roles of each staff member may clarify the process and expected outcomes.
Long waiting times were compounded by the continued use of having to wait until the patient is ‘medically cleared’ prior to assessment.Trained support workers or mental health volunteers could ease transitions by providing support, check-ins and soothing aids, where needed. Joint working between acute and liaison staff from initial stages could help with patient flow, engagement, and experience.43
3People who have self-harmed receive a comprehensive psychosocial assessment.Participants were unsure of the purposes of the assessment. People hoped for help but often felt let down by the lack of therapeutic engagement and aftercare. The way the assessment was carried out affected how the person felt afterwards.Clear communication about the process, purpose and expectations for the assessment may help people to understand the process. Care and sensitivity could help people feel safer during this vulnerable stage. Collaborative assessments that focus on building a therapeutic relationship could engage people in the process and build up trust in mental health services.44
4People who have self-harmed receive the monitoring that they need while in the healthcare setting, to reduce self-harm repetition risk.Empathetic check-ins from staff or support workers helped to encourage people to stay for assessment and provide reassurance about the process. However, monitoring from security guards was experienced as perceived as coercive and affected engagement with the assessment process.Our results suggest that the use of security guards to monitor patients may harmfully impact levels of engagement and help-seeking. Other ways to check-in and monitor patients at risk may be helpful such as trained support workers and staff. Where detainment may be necessary, staff training in mental health, robust legal justification and clear communication over the roles of the personnel involved may help to improve patient and staff experience.
5People who have self-harmed are cared for in a safe physical environment while in the healthcare setting to reduce self-harm repetition.Participants described poor experiences of waiting for lengthy periods of time in unsafe healthcare environments.Environments that are separate from the emergency department may be beneficial for physical and psychological safety. Having the opportunity to wait in separate environments or quite rooms could allow some recovery and distance from the noise and intensity of the emergency department, which may facilitate greater engagement in the process.
6People receive continuing support for self-harm have a discussion with their healthcare professional about the potential benefits of psychological interventions specifically structured for people who self-harm.Follow-up care was a major source of disillusionment for participants. There was little discussion of psychological therapies for people who have harmed themselves during the psychosocial assessments. Long waiting times to access psychological therapies were common. Participants were desperate for help at the time of the assessment and for more therapeutic engagement.Our results suggest that greater communication and transparency over psychological therapies and waiting times may be helpful. Therapeutic assessments and enhanced availability of psychological therapies delivered by the liaison psychiatry team may be beneficial for some patients and carers.
7People receiving continuing support for self-harm and moving between mental health services have a collaboratively developed plan describing how support will be provided during the transition.Poor transitions while in the emergency department and linking between services (eg, primary care, secondary care) left many participants feeling distressed and abandoned. Some participants were unclear of the role of care plans that had directives for ‘do-not-assess’, when attending the emergency department for self-harm.Our findings suggest that assessments should be offered for every hospital presenting self-harm episode and plans updated. Co-designed advance directives with accessible crisis may provide more control and understanding over assessment/treatment options for some patients.44
Given the challenges in accessing specialist services, emergency department presentations for self-harm provide an important opportunity for intervention at a time of crisis for the patient. Good-quality, compassionate assessments and collaboratively developed safety plans may help to ease acute distress and prevent repeat self-harm.45 Training in clinician–patient communication may help to provide a shared understanding of patient issues, reduce miscommunication and thereby enhance therapeutic engagement and quality of care.46 47
  • NICE, National Institute for Health and Care Excellence.