A Service User With Suicidal Thoughts Nursing Essay

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Introduction:
Service User’s may be admitted to or transferred to an Acute unit in a psychiatric setting due to a heightened increase of episodes of mental illness’ where their mental illness can encumber their thought process and functioning. Thus the function of the acute unit to provide a safe, holistic and therapeutic environment, assessing the Service User’s problems and needs while facilitating the individual’s unique and personal journey to recovery (Anthony 1993) and enabling a restoration, to an optimum level of mental health, through the use of "complex organisation" (Bowers et al 2005) of knowledge, skills and education.
For the purpose of this assignment this student will look at acute unit nursing Intervention from the perspective of an inpatient setting, whereby the Service User has Suicidal Thoughts with or without intent (Holsworth et al 2001).
Initially clarification is needed to identify those at a higher risk of suicidal thoughts in an acute unit setting and establishing what the acute unit is, once established there will be prominence given to the psychiatric nurse’s role in the acute unit setting while therapeutically interacting with a patient with suicidal thought.
Those at a greater risk of Suicidal Thoughts in an Acute Unit Inpatient Setting:
Suicide from the Latin verb suicidium, sui caedere, "to kill oneself" (Kumar & Mandal 2010) is the act of voluntarily or intentionally taking one’s own life, suicide is not an illness but a term to describe the act of taking one’s own life. In our society there are a number of social groups whom are more prevalent to ST, these can include: older adults, adolescence, those who have had major loss or change in life. The acute units’ are multi-faceted, necessitated by a number of bio psychosocial factors (World Health Organisation (WHO) 2000) including impaired mental health such as: Depression 30%), Schizophrenia (14%) and Substance Misuse (30%) (Suicide Ireland 2010). Deteriorating mental health from an earlier high level of functioning, loss, minimal psycho-social supports may give an individual feelings of worthlessness, despair, shame & hopelessness all accumulating in the service user wanting to "end it all" or at least think about "ending it all." Qin & Nordentoft (2005) report, following on from their longitudinal study that psychiatric in patients are at an increased "risk" of suicide than the general populace, however, as Bowers (2010) highlights, there has been relatively few "studies" pertaining to suicidal tendencies in a hospital setting.
The Role of the Acute Unit:
With the advent of a "Vision for Change" (Department of Health and Children 2006a) and reforms in Mental Health Laws within an Irish context; saw the demise of the old regional asylums and the introduction of new Psychiatric Units in general hospitals throughout Ireland, coupled with psychiatric specific stand-alone private and public hospitals. Whether an admission is "voluntary" or "involuntary" (Mental Health Commission 2001) to a psychiatric acute unit there is an increased risk of suicidal thoughts, indeed Qin and Nordentoft (2005) assessed the historic association between suicidal thoughts and hospitalisation determining that suicidal thought peak immediately following admission.
An acute unit, irrespective of it been a locked or an open ward (Van Der Merwe et al, 2009), and dependent on local policies, should be a place of safety, though this is not always the case (Jones et al 2009) offering full therapeutic interventions to the service user, while allowing for assessment of service user needs and providing basic health care needs (Bowers et al 2005). Though highlighted by O’Rourke and Hammond (2005) no single "agency" functions exclusively in the provision of mental health care, psychiatric nurses are at the forefront of service user contact, therefore there is a greater onus on the psychiatric nurse to provide safe, holistic care enabling recovery, however, this must be done in conjunction with the Multidisciplinary Team and nursing colleagues.
The acute unit by its very nature is a stressful environment not only for service user’s but also for the staff working within the acute unit milieu. High turnover of service users and the intensity of service user’s demands can be factors contributing to this stressful environment. Challenging situations within the acute unit may hinder the psychiatric nurses’ ability to provide best practice in the delivery of care (Currid 2008).
The role of the Psychiatric Nurse:
According to Videbeck (2008a) there were two early theorists who "shaped" the role of psychiatric nursing, Peplau and Mellow, initially focusing on interpersonal dimensions and psychosocial domains respectively. However, Bowers (2005) identified the role of psychiatric nurses within an acute unit as:
"… to collect and communicate information, give and monitor treatment, tolerate and manage disturbed behaviour, provide personal care, and manage the environment."
As providers of nursing care, psychiatric nurses’ are present in a multifaceted environment, with a role that not only facilitates and encourages an integrated method of care, these roles are not only multi-dimensional but also encompass a knowledge base built on a recognition of signs and symptoms of mental ill health, interpersonal communications, self- awareness, irrespective of what Nursing Model is in situ within the acute unit.
From a nursing perspective ethical quandaries can be both emotionally and physically draining (Neville 2004). Nurses may have to carry out interventions that go against the service user’s wishes whilst dealing with challenging and emotional behaviours from a service user.
Professionally psychiatric nurses’ have a Duty of Care to keep the Service User’s "safety needs first and foremost" (Schultz & Videbeck, 2009) whilst been mindful over their own perceptions, thoughts and unease talking about Suicide. The psychiatric nurse must be aware of the "Misconceptions of Suicide" such as persons with suicidal thoughts give no warning of their intent. As highlighted by Engin et al (2009)
"The prediction and prevention of suicide is one of the most difficult and important problems for the psychiatric nurses"
Bowers (2010) identified the time immediately following admission as that of "heightened suicide risk" this was confirmed in Stewarts’s (2011) study into patient characteristic and behaviours associated with self- harm and attempted suicide.
There is no easy way to establish if a service user has or is experiencing suicidal thoughts; the direct route is to ask the service user. However the psychiatric nurse must be mindful of a number of intrinsic factors that may affect an ambiguous response, such as the service user’s current mental state, insight and judgement, currant medications, indeed particular care must be given to those on SSRI’s as the service user may feel more energised (Sudak 2005). It also must be noted that up to 25% of suicidal patients when asked will deny suicidal thoughts (Robins 1981).
Through the use of a systematic, problem solving approach, a psychiatric nurse may be able to identify, prevent, implement procedures and evaluate outcome. A service user with suicidal thoughts offers an intrinsic risk not only to the service user, but possibly to other service users and staff, therefore a risk assessment is needed. According to Videbeck (2008b) many people with suicidal thoughts may send out either indirect or direct "signals" of their aspirations to harm themselves, these "signal" should not be unheeded irrespective of how inconsequential they may seem. Suicidal thoughts may not always be expressed verbally, other indicators of suicidal thoughts can also include, giving away personal possessions, changes in dietary and sleeping habits, displaying calmness after a phase of agitation.
Assessment of Suicide Risk:
Keeping in line with the admission process to the psychiatric acute unit, the service user should have already been questioned on their suicidal thoughts; this will help identify potential risks factors of suicidal thoughts. Suicide risk assessment is a detailed and thorough process of information gathering that requires the psychiatric nurse to be knowledgeable in communication techniques that are direct and intentional, coupled with active listening.
When a service user admits to suicidal thoughts, it is imperative for the psychiatric nurse to establish and evaluate the prospective lethality. Again this must be done through the use of a direct questioning approach. The psychiatric nurse needs to establish if the service user has a plan, if so what is it, is it specific, what means are available to the service user to carry out the plan, where and when are they likely to carry out their plan, is there a correlation between carrying out the plan and a significant date (Neuner et al. 2010), event or pact with another person, also history must be checked directly or through the use of collateral from previous service user notes, family member or primary carers’. Detailed and affirmative answers to these questions will be a significant marker to the high probability that the service user will attempt suicide
The primary intervention is to keep the service user safe and at a later stage when the crises have de-escalated, introduce coping strategies that will help the service user cope with their emotions. The psychiatric nurse must take control of the situation by the removal of potentially harmful objects, following local policies and procedures. From an Irish context the service user may be prevented from leaving the approved centre under Section 23(1) of the Mental Health Act 2001 (Department of Health and Children 2001). Again dependant on local policies special observations (Cleary et al. 1999) are enacted, these may consist of one to one special nursing observations or 15 minute observations, moving the service user’s room closer to the nursing station and checking the service users’ room and possessions for any possible items that may facilitate completion or self- harm.
In some clinical areas the use of a "no suicide contract" may be introduce, whereby the service user agrees to approach staff if their suicidal thoughts return, however these contracts will not guarantee the service users safety (McMyler & Pryjmachuk, 2008). These should be time specific; when the agreed time expires another one should be instigated, repeating the process for as long as is required. Encouragement should be offered to encourage the service user to approach staff to vent any feelings of anger that they have as this might provide temporary relief. It must be noted that a member of staff must be available for this interaction to take place.
It is of paramount importance to document all interactions with a service user experiencing suicidal thoughts, both from a subjective and objective perspective (Simpson & Stacey 2009) not only will this provide a document for the continuum of car but it will also communicate to all other members of the MDT the current situation, what has been identified and possible future risk, in the misfortunate event of a completed suicide it may also be needed in a court of law.
Careful consideration should be given to the administration of medication, ensuring that service user is fully compliant with all charted medication and encourage them to take PRN medication (Mullen & Drinkwater 2011) if so desired or other therapeutic options if available, such as a low stimulus environment.
The psychiatric nurse must have self-awareness when dealing with a service user with ST. According to Videbeck (2008 c) the psychiatric nurse "must indicate unconditional positive regard not for the act but for the person…" allowing the psychiatric nurse to focus on helping the patient recovery. As the service user is already at a very low ebb, it would be incongruent of the psychiatric nurse to convey feeling of guilt and shame to the service user. Cutcliffe & Stevenson (2008) argued that "the concept of reconnecting the person with humanity is central to psychiatric mental health nursing care". The service user may have an initial resentment against the psychiatric nurse for providing a safe environment, hindering their plan or stopping the act itself.
There are a number of tools that the psychiatric nurse can use in a clinical environment, to try and identify suicidal thoughts including: ASIST: Applied Suicide Intervention Skills Training, BHS: Beck Hopelessness Scale, SIS Suicidal Intent Scale, STORM: Skills-based Training on Risk Management and also in-house tools. Risk assessment is also a main feature of providing psychiatric care as outlined in a Vision for Change (Department of Health and Children 2006b)
"…risk-assessment approaches within mental health settings is essential. Reducing exposure to litigation and financial risk addresses just one narrow aspect of the
risk-management agenda. The recording and analysis of adverse events in clinical risk management must be seen in a wider context of service user safety, staff safety, quality service delivery and clinical governance."
Risk assessment are now conducted on every patient the quality of the risk assessment may depend on the level of the clinicians skills in assessing the risk, or working with the given information, it serves as a valuable tool for assessing a service user with suicidal thoughts, however there are those whom argue that risk assessments may be making less safe for patients (Undrill 2007), Large et al. (2011) conducted a meta-analysis study of factors associated with inpatient suicide and concluded that even though risk assessments have become a key concept in patient safety, argues that there is a" lack of evidence that acting on the results of risk assessment can actually reduce events such as suicide…"
From an Irish perspective the Health Service Executive has adopted the "Australian New Zealand Risk Management Standard (AS/NZS 4360:2004) (HSE 2011) as the Irish process of identifying risk in a clinical and non- clinical environment, due to its variable nature. Under Article 32 of the Mental Health Act 2001 (Approved Centres) (Department of Health and Children 2001) it is a statutory requisite that "approved centres" incorporate a "comprehensive risk management policy" Therefore Irish psychiatric nurses’ must adhere to local policies and guidelines regarding their clinical governance, insuring that a full risk assessment is completed and documented on all psychiatric in patients, and in particular those with suicidal thought.
Conclusion:
Unfortunately, irrespective of what form of risk assessment is used, or what nursing interactions/interventions have taken place, there will be a number of in-inpatient completed suicides. However for those who have had suicidal thoughts and attempts there are a number of coping methods and strategies that can be introduced, which may help the service user cope with their suicidal thoughts, including such therapies such as CBT, DBT, Art Therapy to name but a few. These therapies are delivered by specialists and though some nurses’ may have additional training in these areas not all psychiatric nurses’ do therefore, it is important that psychiatric nurses’ do have an understanding and some basic insight into these therapies (Mathers. 2012).
Due to the very nature of their profession psychiatric nurses’ work within a very dynamic and challenging environment, within this environment the psychiatric nurse must not only adhere not only to local policies and procedures, but also to national ones, regarding documentation, administration of medication, risk management, indeed as suggested by Bowers et al. (2005), that these tasks may be impeding on the nurses’ time to interact with and talk to the service user, therefore, possibly impacting on the psychiatric nurses’ ability to have a therapeutic intervention rather than a superficial one with the service user, an interaction which may have identified possible suicidal thoughts or even helped manage these thoughts, also these interactions may lead to a relationship between the service user and the psychiatric nurse based on trust.
The psychiatric nurse must have a level of self-awareness about them. This awareness
may help the psychiatric nurse deal with their own internal ethical issues, an understanding of the service user who may be more predisposed to suicidal thoughts due to the nature of their mental illness, heightened times were the act of suicide may be attempted, such as immediately after admission (Bowers et al. 2010). The withdrawal of a service user from the general activities on the acute unit, non-conformance with medication or attempting to leave the acute unit without permission may all be precursor’s to attempted suicides.
Planning for discharge or moving to a more open ward, the psychiatric nurse must have involved the full complement of the multidisciplinary team, insuring that all measure of safety and support are in place to facilitate the service user in their recovery process.
Qualitative studies by Cleary (2012) identified "five broad themes…" from a nurses’ perception of good work in an acute setting:
"i) teamwork (ii) interpersonal actions with patients (iii) providing practical and holistic support to patients (iv) patients’ mental health improvements and (v) optimism-pessimism. …"
Though caution is warranted as there are limitations to the study, it must be noted that points ii, iii and iv all pertain to the psychiatric nurse, placing greater emphasis on a patient centred approach to acute unit psychiatric nursing, irrespective of the multi- facetted nature of the acute unit setting.
 
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