Management of Self-harm Patients in AE

Management of Self-harm Patients in AE The acute incident was a case of ‘deliberate self-harm’ (DSH), admitted to an A E unit. DSH incorporates deliberate non-habitual acts of self-harm that are not fatal, and may or may not involve attempted suicide (Repper, 1999). Emergency departments provide the main ‘entry point’ for such patients (NICE, 2004). The patient in this case had slashed his wrists in several places, severing a key artery. He was bleeding profusely, and in a semiconscious state on arrival. There was a history of psychopathology dating back several years. He was unmarried, lived alone, and had recently undergone treatment and observation at the forensic mental health unit of a local NHS Hospital Trust. Reppers (1999) review of the relevant literature on the management of self-harm patients in A E units highlights several key issues for nursing care. It is essential that the qualified nurse is cognisant of the relevant Codes of Professional Conduct specified by the Nursing Midwifer y Council (NMC, 2002), including ethical concerns such as respect, confidentiality, and trust. This is particularly crucial when dealing with self-harm patients because research suggests that emergency department nurses often hold negative attitudes towards this type of patient (McAllister et al, 2002). Furthermore, self-harm patients have reported dissatisfaction with the care provided by nurses and other health care staff. The empirical literature on the management of self-harm patients in A E highlights the value of problem-solving approaches to patient care (Repper, 1999). The basic problem-solving model incorporates five principles, outlined in Table 1. These tenets are consistent with protocols for effective decision-making, for both individuals and groups (Janis Mann, 1977). They are also consistent with NICE/DOH guidelines for caring for the mentally ill (NICE, 2004, Clinical Guideline 16). NICE guidelines recommend immediate assessment of risk, and mental, physical, emotional stability, once a patient arrives at A E. Staff are then required to account for underlying emotional factors that may have precipitated the self-harm episode, as well as evaluating the seriousness of the injury, before deciding the most appropriate treatment for the patient. Reesal et al (2001) highlight some of the key principles of management that are relevant to nurses working with mental health patients. These relat e to assessment, phases of treatment, psychiatric management, goals of treatment, psychotherapeutic management, the management of medication and self-harm/suicide, and medical-legal issues (also see DOH, 1999; NICE, 2004). Nurses need to conduct a comprehensive psychosocial assessment, in full cognisance of the biological, psychological, and social context, and also precipitating and perpetuating factors. Mental health problems can often be long-term/chronic, rather than short/acute, and self-harm is no exception. An underlying condition like depression can be conceptualised in terms of three treatment phases – response, remission, and relapse. Principles of psychiatric management dictate that consent must be obtained prior to treatment. A good psychiatric-patient rapport is essential, and treatment must involve a multidisciplinary team, of which nurses are an essential part. Goal setting is paramount as it facilitates the development of a treatment plan and allows the patien ts progress to be evaluated more accurately. Psychotherapy can be based on any one of several models (e.g. cognitive-behavioural, interpersonal, dynamic). Recovery must be closely monitored – patients who have not recovered within 2 months may require a change in treatment modality. Some knowledge of pharmacology is essential for effective medication management, but it is usually up to a psychiatrist to prescribe the necessary medication. In managing suicide/self-harm cases, it is important for the nurse to establish whether the patient â€Å"feels desperate, hopeless, helpless, or is tired of struggling with life. Has the patient not wanted to go on living? Is there active suicide ideation? How strong are the thoughts? How frequent, persistent, and irresistible are they? Is there a plan? Do the means and opportunities exist? How impulsive is the patient?† (Reesal et al, 2001, p.25S). Since self-harm episodes are generally unpredictable, there are bound to occur irrespective of psychosocial assessments and psychiatric management. Salient issues for inpatient management (see Table 2) include safety, crisis intervention, di agnosis, patient response to treatment, level of depression, inability to live effectively at home, and the level of social support (i.e. friends, family). Medical-legal issues include confidentiality, risk assessment, information sharing, truth telling, and liability. Some of these are considered later in this essay. Overall, patients must believe they are receiving equity, justice, and consideration, and that clinical management is set up to facilitate good quality care. Ethical and legal issues in the management of mental health patients are outlined in the Nursing and Midwifery Council’s codes of conduct (NMC, 2002), the National Service Frameworks (NSF) Modern Standards and Service Models for mental health patients (DOH, 1999), and the National Institute for Clinical Excellence (NICE, 2004). There is currently strong emphasis on evidence-based nursing practice (NICE, 2004). Clinical decisions, where possible, should be based on good quality empirical research. The NICE Clinical Guidelines No.16, for the care of self-harm patients, are rooted in scientific evidence. It is therefore incumbent on nurses to ensure that decisions about all aspects of patient care comply with these standards. Thus, for example, nursing staff are compelled to consider using an integrated physical and mental health triage scale, establish physical risk and mental state, and offer psychosocial assessment at triage. The problem here concerns the practical realities of guidelines adherence in a busy A E unit. Due to time constraints and hectic work routines, nurses may be unable to check adherence to standards. Senior nurses may rely more on their clinical experience in certain instances, whereas younger nurses finding it easier to consult colleagues for clarification, rather than locate and check practice standards. While guidelines will help ensure that this patient receives good quality health care, nurses and other health professionals will ultimately responsibility for clinical decisions. It is therefore essential that staff are adequately trained and resourced to make informed choices that are in the best interests of the patient. Decision theorists Janis and Mann (1977) propose that such informed decision making requires that a viable clinical solution is perceived to be available, to deal with the patients problem, and that there is adequate time in which to find it. If a nurses is uncertain what to do, perhaps due to inadequate training, lack of guideline information, or unfamiliarity with self-harm patients, then he or she may resort to ineffectual decision strategies, such as delaying treatment, looking for another nurse to take responsibility, or even discounting the severity of the patients condition. Time constraints can be a serious problem in emergency depart ments, where patients arrive with life-threatening injuries, and nurses are required to make multiple clinical decisions, in quick succession. Severe time limits may induce panic or frantic behaviour in clinical staff, leading to hasty clinical decisions that fail to account for all aspects of the patient’s clinical condition. In 2005 the Department of Health published its Patient Led NHS (DOH, 2005). Central to this discourse is the notion of empowerment – enabling patients to have more say in clinical decisions about their care, by providing them with the all relevant information, support, and guidance. This is consistent with the 1983 Mental Health Act which states that patients are provided with all necessary and correct information by an informed health care professional, for example on the nature, purpose and probable effects of treatments, and detention, renewal, and discharge. Thus, the patient in A E will have to be treated accordingly by nursing staff. The Department of Health has encouraged the faster emergence of best practice guidelines (DOH, 2005), as this is key to successful empowerment. Currently there are no commissioned best practice statements for the care of mentally ill, or specifically those who self-harm. Since the devolution of responsibility from health authorities to loca l primary and secondary care trusts (DOH, 2002a, 2002b), nurses have assumed greater responsibility implementing national guidelines on mental health. An important part of this empowerment is to liase or network with relevant multidisciplinary professionals, agencies, and local communities. Nurses working in mental health view networking as a major area of responsibility (Rask Hallberg, 2005). Thus, emergency department staff dealing with this particular will be required to contact social services, and the patients’ GP/PCT, friends, family, employment, and other relevant parties. Where necessary, partnerships can be set up, for example with local primary care or social service units, to arrange particular aspects of care, such as home visits, 24 hour access, and development of care plans. The NMC Code of Professional Conduct (NMC, 2002) states that nurses are to behave in a way that enhances trust and confidence in the patient. In other words it is incumbent on a nurse to be truthful and keep his or her patients’ confidence (Tschudin, 1992; Rumbold, 1999; Reesal et al, 2001). Yet in reality this may pose a very difficult ethical dilemma. During psychosocial assessment nurses often need to obtain personal information from the patient, information that the patient will not normally share with anyone. Patients may divulge information on the understanding that it would be kept in confidence. However, serious problems arise if a patient expresses an intention to reattempt self-harm, or even suicide. Is it ethical for the nurse to share this information with other staff and relevant authorities? The NMC (2002) Codes of Conduct are inherently contradictory, because on the one hand they require nurses and midwifes to â€Å"protect confidential information† (p.11 ), but on the other hand mandate that staff â€Å"must act to identify and minimise the risk to patients and clients† (p.11). Crow et al (2000) argue that effective handling of this dilemma requires an understanding of the patient’s own cultural background and general worldview. It is essential for a patient to sign release forms stating that he or she wishes to be present during information-sharing, and takes responsibility for the clinical consequences of such information. Nurses must take extra care when dealing with patients whose cultural backgrounds denotes different understandings of truth and presents linguistic barriers, â€Å"Frequently, when patients from other cultures are asked if they understand something, they nod yes and smile amicably. However, do they really understand what is being stated.., and does it make sense from their cultural perspective of truth?† (Crow et al, 2000). A break down of trust, through truth telling without consent, may aggravate the patients’ psychological state, precipitating the very outcomes the nurse is trying to prevent. And trust can be difficult to generate if nurses fail to develop a good rapport with patients. Long (1998) points out that nurses are often expected to apply nursing models, such as the Activities of Daily Living (ADL) (Rask Hallberg, 2000), in developing and executing a care plan. Such frameworks of care seem at odds with experiences of someone who wishes to commit self-harm a nd possibly suicide. Normal daily activities would be anything but ‘normal’. Moreover, the application of academic models to such situations creates a sense of detachment from the patient, so that an â€Å"‘I-It’ relationship, takes priority over the person in need of care, and in need of developing a therapeutic ‘I-thou’ relationship† (p.5). RISK ASSESSMENT STRATEGIES NICE (2004) guidelines stipulate that self-harm patients undergo a comprehensive risk assessment. This must include an identification of the fundamental clinical and demographic factors that are implicated in the risk of further self-injury. According to Reesal et al (2001) these may include staff attitudes, the presence of anxiety, agitation, panic attacks, persistent global insomnia, anhedonia and poor concentration, feelings of hopelessness/helplessness, substance abuse (alcohol, drugs), impulsivity, being male and aged between 20-30 years or over 50 years, or female aged between 40 and 60 years, being older, having a history of self-harm or suicide attempts, and/or a family history of self-harm, or suicide attempts. The NICE (2004) also require an identification of depressive symptomatology. Nurses carrying out risk assessments must always use a standardised risk assessment scale. Decisions about referral, discharge and admission are partly based on the outcome of risk evaluation s. Crowe and Carlyle (2003) argue that risk assessment in mental health care reflects a form of clinical governance, driven more by organisational, financial, political, and legal considerations, than by concern for patient welfare. For example, risk assessment forms part of professional standards for nurses, and failure to adhere to this requirement in patient care increases clinician liability if a patient (or their family) decides to sue for negligence (Samanta et al, 2003). The result is that the welfare of the patient may not be accorded the priority it deserves. QUALITY ASSURANCE Central to quality assurance is the notion of clinical governance (Ayres et al, 1999; NHS Executive, 1999; Hungtington et al, 2000). The purpose of clinical governance is to maintain the quality of service delivery. This is particularly crucial in A E units, where critical incidents, such as the mismanagement of a badly injured self-harm patient, can easily lead to death. As Huntington et al (2000) point out, this situation, combined with a proclivity for staff to protect their reputation, can engender a culture of blame, scapegoating, and secrecy, all of which may hinder improvements in the quality of patient care (NHS Executive, 1999). Governance typically entails organisational change, from a ‘blame culture’ to a ‘learning’ orientation. Of course such change is subject to the usual organisational restraining factors that Kurt Lewin (1951) refers to in his model of change. These include excessive staff workloads, a â€Å"not another cha nge† attitudes, and general reluctance to give up ‘tried and tested’ practices, time constraints, and patient inconvenience. The critical issue in an A E is whether staff consistently adhere to professional standards of care, as prescribed by NICE (2004), the Royal College of Psychiatrists, and the National Service Framework for Mental Health (DOH, 1999). Nurse attending to a self-harm patient will need to ensure that they are familiar with these guidelines before attending to the patient, or at least have quick assess to relevant information, and/or are supervised by a more experienced colleague with better knowledge of professional standards. This is essential as failure to adhere to professional standards has major legal implications (Samanta et al, 2003; Wilson, 1999). Although clinical governance leaders within acute and community NHS trusts have a responsibility to ensure that nursing staff deliver good quality care, such governance can only be effective wi th adequate resourcing (Huntington et al, 2000). For example, there needs to be clarity from professional bodies about best practice (there are currently no best practice statements for the care of mentally ill/self-harm patients), as well as support from health authorities, and clinical governance leaders at regional office, professional, and local district levels. This essay considers nursing issues in the management of a self-harm patient admitted to an emergency department unit of an NHS Trust. Salient issues for the qualified nurse include ethical dilemmas, associated with conflicting codes of conduct, important management issues relating to assessment, diagnosis, psychological and medical treatment, in-patient care, and medical-legal considerations. Nurses now command greater empowerment in the modern NHS, and but must somehow adhere to strict professional standards, while simultaneously exercising good clinical judgement. Additionally, they must also manage to overcome the unique clinical and psychological circumstances of deliberate self-harm. Support from clinical governance leaders, and adequate training in management, decision making skills, and clinical practice, are essential, if nurses are to delivery high quality patient care References Ayres, I.L., Cooling, R. Maughan, H. (1999) Clinical governance in primary care  groups. Public Health Medicine. 2, pp.47-52. Crow, K., Matheson, L. Steed, A. (2000) Informed consent and truth-telling:  cultural directions for health care providers. Journal of Nursing  Administration. 30, pp.148-152. Crowe, M. Carlyle, D. (2003) Deconstructing risk assessment and management in  mental health nursing. Journal of Advanced Nursing. 43, pp.19-27. DOH (1999) National Service Framework for Mental Health: Modern Standards   Service Models. London: Department of Health. DOH (2002a) National Service Framework: A Practical Aid to Implementation in  Primary Care. London: Department of Health. DOH (2002b) Improvement, Expansion Reform – the next 3 Years: Priorities and  Planning Framework 2003-2006. London: Department of Health. DOH (2005) Patient Led NHS. London: Department of Health. Horrocks, J., House, A. Owens, D. (2004) Establishing a clinical data base for  hospital attendances because of self-harm. Psychiatric Bulletin, 28, pp.137-139. Huntington, J., Gillam, S. Rosen, R. (2000) Clinical governance in primary care:  organisational development for clinical governance. British Medical Journal.  321, pp.679-682. Janis, I.L. Mann, L. (1977) Decision Making: A Psychological Analysis of Choice,  Commitment. New York: Free Press. Lewin, K. (1951) Field Theory in Social Science. New York: Harper Row.   Long, A., Long, A. Smyth, A. (1998) Suicide: a statement of suffering. Nursing  Ethics. 5, pp.3-15. McAllister, M., Creedy, D., Moyle, W. Farrugia, C. (2002) Nurses attitudes  towards clients who self-harm. Journal of Advanced Nursing. 40, pp.578-586. NICE (2004) Self-Harm: The Short-Term Physical and Psychological Management  and Secondary Prevention of Self-Harm in Primary and Secondary Care  Clinical Guideline 16. London: National Institute for Clinical Excellence.   NHS Executive (1999) Clinical Governance in the new NHS. London: NHS  Executive (HSC 1999/065). NMC (2002) Code of Professional Conduct. London: Nursing Midwifery Council. Rask, M. Hallberg, R. (2000) Forensic psychiatric nursing care – nurses  apprehension of their responsibility and work content: a Swedish survey.  Journal of Psychiatric Mental Health Nursing. 7, 163-177. Reesal, R.T., Lam, R.W. the CANMAT Depression Work Group (2001) Clinical  guidelines for the treatment of depressive disorders: Principles of Management  II. The Canadian Journal of Psychiatry. 46 (Suppl 1), pp.21S-28S. Repper, J. (1999) A review of the literature on the prevention of suicide through  interventions in Accident and Emergency Departments. Journal of Clinical  Nursing. 8, pp.3-12. Rumbold, G. (1999) Ethics in Nursing Practice (3rd edition). London: Balliere Tindall. Samanta, A., Samanta, J. Gunn, M. (2003) Legal considerations of clinical  guidelines: will NICE make a difference? Journal of the Royal Society of Medicine. 96, pp.133-138. Tschudin, V. (1992) Ethics in Nursing: The Caring Relationship (2nd Edition).  London: Heinemann. Wilson, J. (1999) Best practice guidelines. British Journal of Nursing. 8, pp.293-294.

Art Over Life Essay

An ode is a form of lyric poetry where the poet reveals his personality. He shares his thoughts, feelings and opinions as we see through his eyes. Keats’s odes were very majestic and full of imagination. The two poems Ode to a Nightingale and Ode on a Grecian Urn are very similar in their structure and message. Keats was tired of the mortal world and could only see the negative things in his life and so he looked for an escape. It wasn’t only his own pain that depressed him, it was the pain of his brother who was dying and we can see evidence of this in this quote; â€Å"The weariness, the fever, the fret. Here, where men sit and hear each other groan. Where palsy shakes a few last grey hairs. † Both Ode to a Nightingale and Ode to a Grecian Urn have similarities in them. In Ode to a Nightingale and Ode the speaker opens with a declaration of his own heartache. He feels as if he is numb and â€Å"as though of hemlock I had drunk,† he then addresses a nightingale he hears singing somewhere in the forest. He says in this opening stanza that he is not envious of the nightingale because it is so happy. Keats appreciated nature and saw it in some ways superior to humans. In â€Å"Ode To A Grecian Urn† Keats imagine what the people on the urn were doing when the picture on the urn was painted. He reflects on the idea of a thing of beauty living on past his lifetime and he rejoices in the fact that the urn will never change. As you can see in both poems Keats’s glee is based on the fact that both the Nightingales song and the people on the Urn will never change and they will live on past his lifetime. This is the same for Keats’s poems; all the beauty within them live on past Keats’s lifetime and generation. Both poems convey immortality one through a living thing and one through a still object. We can almost sense that Keats uses beauty in his poems to escape the harsh life of the mortal world and he sees beauty in things that are not human. This is the case in both of the poems. Beauty is almost compensation for life and Keats fully appreciates beauty and escapes through writing about beauty. He realises then at the end of the Ode to a Nightingale poem that escaping to the nightingale’s world is not as good as the mortal world. He bases this decision on the fact that in the mortal you experience both the good and bad intensely but this is better than no intense feeling at all. There is also a complicated ending in â€Å"Ode To A Grecian Urn† in the part he says â€Å"Beauty is truth, truth beauty, – and that is all ye know on earth, and all ye need to know†.

What Is ‘Creativity’ and How Can It Be Assessed?

Creativity refers to intuitive solutions that are of genuine value. A characteristic seen as most desirable, linked to problem solving and expertise (Garnham and Oakhill,1994). Additionally, Weisberg(1993) believed intended originality is involved with creative thinking. Despite its difficulty to define, creativity has been studied in diverse disciplines, often in conjunction with intelligence testing. According to Mooney(1963), the study of creativity arises from 4 perspectives; creative people, creative processes, products of creativity and creative places.The psychometric approach attempts to predict creative achievement and identify the products of creativity. Several established tests have been administered to creative people, to explain differences between intelligence, as measured by IQ and creativity tests. Guilford(1956) derived a hypothesis regarding this difference, differentiating between convergent and divergent thinking. Convergent thinking seeks to find the correct ans wer to specific problems, a strategy for solving most well-defined problems.Conversely, divergent thinking requires flexibility and originality, leading to many possible solutions which aid solving ill-defined problems. Guilford identified the process of divergent thinking as important for creativity, since involving indirect and productive thinking. However, research has indicated only slight correlation between performance on divergent thinking tasks and other measures of creativity.Additionally, its mixes creativity with intelligence or originality therefore is difficult to establish. The autobiographic and biographic approaches focus on the products of creativity. Unlike above, assumptions that intelligence and creativity correlate are ignored, as they are based on observation. Wallas(1926) proposed a four stage account of creative insights. Beginning with; perception, preparatory work on a problem; incubation, internalisation of problem into the unconscious mind.Followed by the most crucial stage, inspiration, the solution begins to appear in conscious awareness, in the form of flash of insight. Intimation occurs, feelings of the solution about to emerge; sensitivity is crucial in order to avoid distraction. Finally, verification is when the solution is applied and elaborated, ensuring the problem is solved. Wallas considered creativity to be a legacy of the evolutionary process, allowing humans to adapt to rapidly changing environments. What Is ‘Creativity’ and How Can It Be Assessed? Creativity refers to intuitive solutions that are of genuine value. A characteristic seen as most desirable, linked to problem solving and expertise (Garnham and Oakhill,1994). Additionally, Weisberg(1993) believed intended originality is involved with creative thinking. Despite its difficulty to define, creativity has been studied in diverse disciplines, often in conjunction with intelligence testing. According to Mooney(1963), the study of creativity arises from 4 perspectives; creative people, creative processes, products of creativity and creative places.The psychometric approach attempts to predict creative achievement and identify the products of creativity. Several established tests have been administered to creative people, to explain differences between intelligence, as measured by IQ and creativity tests. Guilford(1956) derived a hypothesis regarding this difference, differentiating between convergent and divergent thinking. Convergent thinking seeks to find the correct ans wer to specific problems, a strategy for solving most well-defined problems.Conversely, divergent thinking requires flexibility and originality, leading to many possible solutions which aid solving ill-defined problems. Guilford identified the process of divergent thinking as important for creativity, since involving indirect and productive thinking. However, research has indicated only slight correlation between performance on divergent thinking tasks and other measures of creativity.Additionally, its mixes creativity with intelligence or originality therefore is difficult to establish. The autobiographic and biographic approaches focus on the products of creativity. Unlike above, assumptions that intelligence and creativity correlate are ignored, as they are based on observation. Wallas(1926) proposed a four stage account of creative insights. Beginning with; perception, preparatory work on a problem; incubation, internalisation of problem into the unconscious mind.Followed by the most crucial stage, inspiration, the solution begins to appear in conscious awareness, in the form of flash of insight. Intimation occurs, feelings of the solution about to emerge; sensitivity is crucial in order to avoid distraction. Finally, verification is when the solution is applied and elaborated, ensuring the problem is solved. Wallas considered creativity to be a legacy of the evolutionary process, allowing humans to adapt to rapidly changing environments.

Literary Analysis of The Play of Romeo and Juliet - 710 Words

Romeo and Juliet Literally Essay Romeo and Juliet is a play written in the late 1500s by William Shakespeare. Romeo and Juliet, two star crossed lovers make their way to be together as they face challenges from their society, parents etc. In the beginning of the play the prologue introduces the tragic end of their love and thus bringing peace to their rival families. In act 2 scene 5 Friar Laurence a wise character in the play marries Romeo and Juliet in hope ending the rivalry between their families. But before holding the nuptial of Romeo and Juliet Friar Lawrence with a basket full of herbs compares his herbs to Romeo and Juliet’s love situation. Can the play of Romeo and Juliet be related to how the nature of plants work? In fulfilling the answer of this question Shakespeare explores this question in his famous play of Romeo and Juliet. 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