Self harm in adult inpatient psychiatric care: A national study of incident reports in the UK

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Abstract

Background

We know little about the nature of self harming behaviour within inpatient psychiatric services. The few studies in this area have mainly investigated the correlates self harm, or have been restricted to forensic services, within single hospitals.

Objectives

To describe the demographic characteristics of those who self harm, and the characteristics of self harming behaviour within adult psychiatric wards across the UK.

Methods

Analysis of 500 reports of self harm within inpatient services across England and Wales, randomly selected from a total of 14,271 reports collected by the National Patient Safety Agency.

Results

Most episodes of self harm were by women, and did not put the service user's life at risk. The most common form of self harm involved breaking the skin. Women were more likely to use methods of restricting their breathing, whilst men were more likely to use outwardly aggressive methods. Self harm was often a private act, which took place in bedrooms, bathrooms and toilets, and during the evening hours. Taking into account the numbers of beds within each service nationally, there were more episodes of self harm within forensic services. The most common interventions for self harm were verbal de-escalation, and manual restraint. The most common antecedents to self harm were a distressing psychological state, conflict behaviours (behaviours which threatened staff, or service user safety), and conflict with staff.

Conclusions

Self harm within inpatient care constitutes a wide range of behaviours, and it may be useful for clinicians to discuss the particular meaning of the methods of self harm used with service users. In general, self harm is a private act, suggesting that most acts of self harm are not intended to have an impact on others. More research into the social nature of self harm, and the meaning of different self harming behaviours (particularly outwardly aggressive methods of self harm such as headbanging), would help to increase our understanding of these acts, and develop more appropriate ways of supporting service users. Future research should also investigate how staff behaviour may contribute to self harm. The development of a reporting system which requires a detailed account of incidents would aid future research in these areas.

Introduction

The development of appropriate services to support those who self harm is a global concern (Chen et al., 2011, Madge et al., 2008). People who are at risk of serious self harm are often admitted to inpatient psychiatric services (Bowers et al., 2005). Rates of self harm within inpatient services vary considerably; studies within the UK have found that between 4% (Bowers et al., 2003) and 70% (Swinton et al., 1998) of service users will self harm during an admission. The underlying factors contributing to these variations are currently unknown. Self harm has significant financial costs, estimated at around four million pounds per year in England (Flood et al., 2008). Preventing self harm within inpatient services is difficult; restrictive containment measures such as constant observation, or asking service users to remain in their nightclothes, are often used, and can be detrimental to service user emotional wellbeing (Breeze and Repper, 1998, Langan and McDonald, 2008). Some staff have expressed dissatisfaction with these practices, stating they are an infringement of people's rights, an invasion of their personal space, and make service users feel uneasy. However, staff also recognise that there are currently few alternative methods of managing self harm (O’Donovan, 2007). Self harm can have a powerful emotional impact on nurses (Carlen and Bengtsson, 2007, Wilstrand et al., 2007), who frequently report that they find the behaviour difficult to understand (Thompson et al., 2008, Wilstrand et al., 2007). Those who self harm are often perceived as manipulative, or attention seeking (Wilstrand et al., 2007), and negative attitudes amongst clinical staff, towards people who self harm, are well described in the literature (McHale, 2010).

We know little about the nature of self harming behaviour within adult inpatient psychiatric services. The few studies in this area have mainly focused on the correlates self harm, in order to identify risk factors (Beer et al., 2010, Callias and Carpenter, 1994). Those which have examined self harm in more detail, are restricted to forensic services, within single hospitals (Beasley, 1999, Burrow, 1992, Mannion, 2009). This study presents a national picture of self harm across all adult inpatient services in the UK. A greater understanding of the nature and circumstances of self harm will aid the development of appropriate interventions, and may reduce negative attitudes amongst staff, as well as alleviate some of the difficult emotions that arise when working with those who self harm.

Section snippets

Method

This paper presents a prospective documentary analysis of incident reports describing episodes of self harm within inpatient services in the UK.

The reports

There was substantial variation in the amount of information provided in the reports, which ranged from one line, to over 350 words in length. Most reports provided basic demographic information, and detailed the location, time and method of self harm. Other useful information however, was often not provided.

Characteristics of those who self harmed

Almost three times as many episodes of self harm were by women (n = 292, 65%) than men (n = 106, 24%). In 11% of reports (n = 50) the gender of the service user was not specified. The mean age

Discussion

To our knowledge, this is the first national study of self harming behaviour within inpatient services. Most episodes of self harm were by women, and taking into account the numbers of beds within each service nationally, there were more episodes of self harm within forensic services. Self harm was often a private act, which took place during the evening hours. The most common methods of self harm involved breaking the skin. Women were more likely to restrict their breathing, whilst men were

Limitations

This study differentiates between acts of self harm and attempted suicide using the clinician's classification of the incident. We have reported data on attempted suicides elsewhere (Bowers et al., 2011). Some consider these to be distinct behaviours, with different underlying motivations, which should be studied separately. Others however, feel this should not be the case, as it is not possible to determine intent (James et al., 2011). This is an ongoing debate amongst researchers, and the

Conclusions

Self harm within inpatient care constitutes a wide range of behaviours, and it may be useful for clinicians to discuss the particular meaning of the methods of self harm used, with service users. In general, self harm is a private act, suggesting that most acts of self harm are not intended to have an impact on others. More research into the social nature of self harm, and the meaning of different self harming behaviours (particularly outwardly aggressive methods of self harm), would help to

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