Creating a Nursing Sensitive Indicator for Behavioral Health Nurses on Patient Self Harm/Suicide Behavior APNA National Conference November, 2012 Debra Saldi, MS, BSN, RN, LMHP, NCC, COC Disclosure Speaker has no conflict of interest, commercial support or off-label content in presentation ACH Behavioral Services ACH Immanuel, Omaha, NE ACH Mercy, Council Bluffs, IA ACH Lasting Hope Recovery Center, Omaha, NE Saldi 1
Objectives Understand the components in nursing sensitive indicator development to support patient safety and quality care. Implement a nursing sensitive indicator in an acute psychiatric care setting that creates evidence based care through change process and measurement for impact on excellence in nursing care. Discover how to copyright new practices as intellectual property when evidence based care is created, particularly with potential publishing opportunities. Why is this important? Suicide is second leading cause of death among 25-34 year olds, third among 15-24 year olds, increased suicide rates among older men (www.cdc.gov/violenceprevention 2010) Intentional care of self harm patients saves lives Therapeutic relationship between caregivers and patients is the key component to instill hope and healthy behaviors Rationale By collecting and trending nursing processes in the care of persons who exhibit self harm behaviors and the resulting treatment team interventions, self harm events and events with injury will be reduced. Differentiating between self harm and suicidal behaviors by determining patient intent greatly impacts treatment planning and intervention Saldi 2
Creation Process Identification of need for nursing sensitive indicator Organized team to explore possibilities Shared draft with NDNQI for feedback Phased development with creation, pilot, validity testing Copyrighting process as intellectual property at www.copyright.gov Publishing opportunities with creation of tool and nursing research of tool implementation Definitions of Self Harm Non-suicidal Self Injury: persons who exhibit self injurious behavior do not intend to end life, but intend to reduce internal distresses such as anxiety, flashbacks, or depressed mood. Examples include hair pulling, picking at previous injuries, self burning, and cutting / scratching with minimal blood loss, head banging, and swallowing or inserting items Suicide Gesture: persons who exhibit suicidal gesture behaviors are highly unlikely to cause severe injury or death. Example: wrapping item around neck without anchor, choking self, etc. Suicide Attempt: persons who exhibit suicidal behaviors may result in severe injury or death with the intent being to kill oneself. Examples: attempting to hang self, jumping from high location, overdosing on lethal amount of medication, and severe cutting in location with potential high blood loss. Nursing Sensitive Indicators Risk Assessment On admission Every shift When changes in patient presentation occur Treatment Planning on admission, daily and episodic updates Interventions in place prior, during and after event Reassessment Treatment Plan Update after every event Saldi 3
Data Collection Event date and time Patient age Patient gender Status of admission Medical Record Number (not patient identification number) Self harm type Severity of injury level code Repeat self harm event this month? Assessments and intervention in place at the time of the event Interventions in response to the event Checklist for incident report, clinical documentation, and all data elements completion Implementation Phase Incident reporting system built with indicator content to eliminate double / triple documentation Validity and reliability process Data collection phase for impact to care Low incidence to test process Education and training for differentiation identification Voice of our patients Self Harm vs. Suicide Wednesday - Self harm vs suicide - Mentalhealthhelpuk - YouTube Saldi 4
Case Study #1 24 y/o female with a severe trauma history. While she has had a history of suicide attempts she also has a history of self harm. One of her coping skills is head banging. She states this helps her cope with hearing voices and flashbacks. Case Study #2 15 y/o male who has been hospitalized with suicide ideation with plan to hang himself. He also has some evidence of cutting himself on inner arms with healing lacerations. During rounds he is in his room bleeding from scratching his lacerations. When asked he did not know why he self injured. Case Study #3 67 y/o male hospitalized with serious suicide attempt by overdose. He has recently retired, lost his wife of 40 years and is having many medical conditions that limit his ability to socialize. Upon environment rounds, a sheet is found knotted and under his mattress. He states, I want to die. Saldi 5
Future Implications Psychiatric care for self harm and suicidal behaviors based first on safety and then on therapeutic approaches for alternative ways of coping Case Study #1 Tool is means to excellence in care, but therapeutic intervention is key to saving lives Nursing research is next phase and copyrighted Self harm and suicide are admission criteria for inpatient level of care which necessitates safe and focused intervention strategies Contact Information: Debra.Saldi@Alegent.org Saldi 6