When patients self-harm, who tends to it?

[LilaDavis]

Hi everyone!

I'm not currently a nurse (thinking of it) but I work on an inpatient acute ward on the psychology team. Over the past year or so we've had a major increase in patients with PD diagnosis and self-harming behaviors.

I'm curious because the nurses I work with seem to have different attitudes regarding the issue of self-harm. Once they've been notified of/observed a patient self-harming, they will assess the wounds. Assuming they don't need emergency treatment, the approaches are very different. Some nurses will flat out refuse to clean/dress the wounds (unless it's more serious) and will instruct the patient to do so, sometimes under observation. This also includes cleaning their bed area or wherever they have self harmed, if there is blood etc.

Their rationale is that for chronic self-harmers, the aftercare is reinforcing the behavior because they crave that kind of attention/affection. They're not rude or nasty about it, but firmly tell the patient it's their responsibility.

Other nurses will just immediately clean it up and treat. So I'm curious, what happens on your ward? What are your own thoughts?

[LessValuableNinja]

I agree with reinforcing consequences, which include self care. However, I believe the nurse also has responsibility for assessing, reassessing, and providing education on wound care. However, it's important to understand if policy or management preference conflicts with anything I've said.

[Meriwhen, ASN, BSN, MSN, RN]

If a patient self-harms, there are wounds that need to be taken care of. It doesn't matter if these wounds were as a result of self-harming. To leave those wounds unassisted and without any needed treatment is tantamount to neglect. And to leave the patient to take care of the wound themselves is asking for trouble--whose butt do you think will be on the line if there are complications because they and not the nurse treated the wound (hint: it's not the patient's).

So when assessing/treating the wound, take a neutral approach without showing emotion or reaction...and don't make a big deal of it. Don't give them the reaction (attention) that they were hoping for. Take care of the wound and make sure they're safe, then let the MD and the rest of the treatment team know about it.

[oceanblue52]

I agree there is significant liability in letting patients dress their own wounds, even with a watchful nurse. Talk about a lawsuit waiting to happen! I do think it's an interesting idea to let that patient change linens if they are capable to do so. If they are stable and recognize what they did is maladaptive, a nurse should assess and then go in with the patient to watch them change the sheets. If if there are excess body fluids, that's on the staff, never give a sanitizing wipe to a Patient. Other patients are not at all in a state to clean up, and it's on staff to make sure body fluids are properly handled. The staff you work with sound jaded and in need of re-education on the importance of properly cleaning up bodily fluid spills.

[SuburbsGirl]

If patient is doing that on unit, why aren't they on a 1:1?

[Julius Seizure]

I'm not a psych healthcare worker, but in my experience, people who self harm are often already ashamed of what they have done. That doesn't mean that they mustn't help with cleaning up themselves or the surroundings, but I have to wonder at the rationale. Obviously every patient is different, but I wasn't under the impression that self-harm was usually "attention seeking" in the way that you describe the nurses thinking.

[apsychRN]

First, what items are on the unit that a client is able to do that much self harm with before being caught & stopped?

Second, absolutely a nurse should address any and all wounds, especially those that happened under his/her watch or care.

Third, Self harm isn't always about attention. And even if it is, SOMETHING is obviously wrong and that person deserves and should have at least the time and attention of a nurse for as long as it would take to address a wound to see what is going on in that persons mind that they felt the need to harm themselves.

Some people self harm because they are so numb and disconnected they need to feel pain to feel ANYTHING.

Some believe they deserve to feel pain.

Some harm themselves to keep from harming others.

Some People hurt so bad the only way or only thing they know to do is to feel pain physically so as not to few it so much emotionally.

So my point is..if you are the kind of nurse that makes a Psych patient "clean up their own mess & dress their own wounds", you need to move on out of Psych and into another field of nursing that may suite you better. One where you actually don't need to spend time with someone or to walk in their shoes to help them learn healthy coping skills. One where you can just dictate to your patient.

[B52, ADN, BSN, MSN, RN]

I had one patient who removed the plastic thing in the ceiling so he would have access to a light bulb, which he used to make superficial cuts along his arm. After we cleaned him up and bandaged the wounds, he ripped off the bandages and walked around showing everyone his wounds. He wanted to be on a 1:1 because another patient was on a 1:1. He got his wish.

[BeenThere2012, ASN, RN]

I'm not a psych healthcare worker, but in my experience, people who self harm are often already ashamed of what they have done. That doesn't mean that they mustn't help with cleaning up themselves or the surroundings, but I have to wonder at the rationale. Obviously every patient is different, but I wasn't under the impression that self-harm was usually "attention seeking" in the way that you describe the nurses thinking.

It can be attention seeking. Depends on the patient. If they come to a staff member and feel ashamed...that is one thing. If they come to a staff member after telling everyone they were "triggered" by something minor and then want to engage you in endless circles of conversation, then it might be attention seeking. If they don't tell anyone at all and hide it, then probably still struggling with their problem. Have to assess each one individually.

[Orca, ADN, ASN, RN]

Years ago, when I was working on a geropsych unit, I had a patient who managed to open up her arm with a paper clip - while I had a JCAHO inspector on the unit. One thing about it - the inspector saw what I was doing, and she didn't stop to ask any questions.

[Meriwhen, ASN, BSN, MSN, RN]

Years ago, when I was working on a geropsych unit, I had a patient who managed to open up her arm with a paper clip - while I had a JCAHO inspector on the unit. One thing about it - the inspector saw what I was doing, and she didn't stop to ask any questions.

It's kind of amazing what patients will use to harm themselves. I had one adolescent patient break the plastic cap of the hospital-issue shampoo bottle and insert fragments of it under her skin.

Guess who had to pick them out...though I damn well impressed myself with the poker face I kept as I was doing it.

[oceanblue52]

It's kind of amazing what patients will use to harm themselves. I had one adolescent patient break the plastic cap of the hospital-issue shampoo bottle and insert fragments of it under her skin.

Guess who had to pick them out...though I damn well impressed myself with the poker face I kept as I was doing it.

It is pretty amazing. I feel like it's futile sometimes to just keep banning materials because one person is clever enough to make a self harm tool. One hospital I worked at required us to remove under wires from bras, and another had to remove all the springs from the soap dispensers. A third patient who was on a 1:1 somehow got a hold of a rubber band/hair tie and kept smacking her skin with it, which drove staff nuts. Adolescents are the most clever in my experience.