Assessment following self-harm: nurses provide comparable risk assessment to psychiatrists but are less likely to admit for in-hospital treatment
- School of Health and Sport Sciences, University of the Sunshine Coast, Sippy Downs, Queensland, Australia
- Correspondence to Margaret McAllister
University of the Sunshine Coast, Maroochydore, QLD 4558, Australia;
Implications for practice and research
▪ The major role that mental health nurses have in conducting self-harm assessments, including risk assessment and planning care pathways, should continue.
▪ There are differences between nurses and psychiatrists in the judgements regarding the management of a client who is at risk of self-harm repetition.
▪ Research is required to understand the reasons for the differences in clinical management.
▪ It may be that these differences relate more towards how novice or expert the clinician is, rather than their disciplinary base (whether nurse or doctor).
▪ If differences are due to expertise, then clinicians could benefit from a shared approach to education on self-harm understanding, assessment and management.
Self-harm is a major global public health issue and is associated with a risk of self-harm repetition, suicide, worsening mental health problems and demand on services. The prevalence of self-harm is estimated to range from 10% and 20%, numbers vary according to whether the data are assessed through self-reporting and whether the populations are clinical or community.1 2
The study, part of the Manchester self-harm project, aimed to compare risk assessment practices between psychiatrists and mental health nurses. The research objectives were to determine the predictive value of risk assessments for subsequent self-harm, the factors that informed nurses and doctors' practice, the immediate management of patients assessed as being high risk and the clinical management of those identified as high risk.
The study was a prospective cohort of hospital presentations (in three Manchester health services) of self-harm from 2002 to 2006. All individuals who received a psychosocial assessment during the 4-year period were included in the sample. Data were collected from the audit of emergency department patient record systems, using wide search terms to produce a maximum capture of possible episodes of self-harm, sociodemographic data, methods of self-harm, clinical information, risk assessment and follow-up arrangements. The collected data were analysed using SPSS and Intercooled STATA, calculating sensitivity, specificity and positive predictive value of risk assessments by nurses and psychiatrists separately and associations between risk factors and an assessment of high or low risk.
The positive predictive value of risk assessments for self-harm repetition was 25% among nurses and 23% among psychiatrists. There was strong agreement on factors associated with high risk by both professions, and, following assessment of high risk, psychiatrists were much more likely than nurses to admit people for inpatient treatment.
This sample consisted of mostly junior psychiatrists and mostly experienced liaison nurses, and this could be one explanation for differences found, but it may not be the only explanation. In order to explore and explain the inconsistencies in quality in self-harm risk assessment found between the two professions, demographic data such as age, years of experience, position and training among the nurses and psychiatrists should have been collected because any of these variables could help to explain the differences found.
Previous studies have compared nurses and doctors' assessment of self-harm using case scenarios or questionnaires and risk assessment protocols. These protocols may not be those used in clinical practice,3 and differences found under experimental conditions might not be found in actual practice, thus limiting external validity. However, the strength of this study is that it compared clinicians' working practices related to self-harm assessment.
The finding suggested psychiatrists were more likely than nurses to admit a high-risk patient, and this contrasts with the findings of other studies,4 which have found no differences. This study involved experienced liaison nurses; other studies involved newly trained nurses who were closely supervised by a psychiatrist. The reasons for these different management approaches should be further studied. The authors suggest that the difference may be explained by the fact that nurses are said to be more concerned about preventing iatrogenic problems or nurses being less able to admit to hospital and thus more likely to consider other options.
The methods used to gather this data were suitable and well explained. The definition of self-harm was very clear and is a contribution to the literature.