Nursing Interventions: Self-harm and Violence

by Brenda Marshall, EdD, MSN, RN

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    00:01 Potential for self-harm is always in our minds on a psychiatric unit.

    00:07 This is a level of safety, safety for the patient that we must always be aware of.

    00:15 It may be reflective of that person's thought process of wanting to die by suicide or to cause self-harm as the only solution to their current problem.

    00:30 I usually say suicide is a permanent solution to a temporary problem.

    00:37 And so, we need to find other solutions that will help this person get through this current problem.

    00:46 And the best way to start is providing that safe environment.

    00:50 You may be getting tired of hearing me say provide a safe environment, but safety is our priority in psychiatric nursing.

    00:59 We want to make sure that we are actively listening to all of our patients.

    01:04 That we're not giving advice. We are not telling people what they should do.

    01:09 Leave should at the door and embrace what I hear you saying is.

    01:17 When you are able to repeat what a person is saying without judgment, that person may, or the first time, actually be hearing their own words.

    01:29 We then want to assist them in identifying thoughts and feelings that what make them feel more insecure or perhaps increasing their desire to harm themselves in some way or to kill themselves.

    01:45 Now, for some people, they say, why would we want them to be more aware of those thoughts or feelings that increase their feelings of desire for self-harm or killing themselves? Well, if you are not aware of those thoughts, then there's no way that we can combat them.

    02:07 If we don't know that we have a bacterial infection, there's no way we're going to know what kind of antibiotic is going to help us to combat it.

    02:18 If we start thinking about the idea that these diagnoses and these feelings are the symptoms of a much deeper diagnosis, then knowing those feelings gives us the arsenal for us to be able to help them to avoid this potential for self-harm.

    02:44 And if they have that increased desire to hurt themselves or to kill themselves, and they can tell us I'm having those thoughts again, then we can help them engage in better coping mechanisms.

    02:58 And that allows us then to discuss those strategies.

    03:02 How to reduce those behaviors of hurting themselves and how to increase the behaviors that will allow them to engage in positive coping skills.

    03:15 It's very important for us to have this therapeutic communication.

    03:18 This therapeutic communication is what opens the door for our patients to notify us whenever they are having thoughts of self-harm.

    03:28 With many of my clients, I actually have them fill out a paper with a promise me that if they are thinking of killing themselves, before they do anything, they will call me, 911, tell their parents that they will not worry alone because if they do not share that with someone, no one can intervene.

    03:54 We want to make sure that each of our patients, when they are no longer in our units, understand that there are community resources for them.

    04:04 Not every nurse works in a hospital.

    04:07 Some of us are going to be working in the community, some of us will be working in doctor's offices.

    04:13 Our patients have a potential for self-harm and if we can identify what the community resources are that are available, and educate our clients, educate their families, educate our in-patients on that - the idea that there is support for them in the community, we are helping reduce that potential for self-harm.

    04:40 The risk for violence for patients with psychiatric disorders, that is another very common nursing diagnosis you might be using.

    04:50 And that might be reflective of the client's emotional instability that can result in anger or frustration. And also reflects their poor coping skills.

    05:02 So, what's the first thing we want to do? You're right, provide a safe environment.

    05:10 We also want to encourage that person to express their feelings, and to express their feelings and feel as though they are in a safe environment.

    05:22 Because of the risk for violence, we have to establish clear limits.

    05:27 Boundary setting is very important. You are not to go behind the nurse's desk.

    05:34 If you are in the room and you were part of the community meeting and you start having these very angry moments, tell somebody, remove yourself, work with someone to reduce that anger.

    05:51 We want to offer them choices so that they have an alternate non-violent behavior.

    05:57 When those frustrations occur, when those feelings of anger occur, they need to know that maybe they need to go for a run if they are able to go for a run if we're in the community. Maybe they need to just be able to talk to someone.

    06:16 They need to have an alternate non-violent behavior that they can utilize.

    06:22 Also, we want to develop plans for strategies, alternate strategies, that will be able to help them remove themselves.

    06:30 And if necessary, for us to remove them from the presence of others if we feel that violence is impending or if it occurs.

    06:41 And we don't do this in secret. We will talk to our clients.

    06:47 We will say, I notice that there are times that your anger gets ahead of you.

    06:53 And this is what's going to happen if in the community meeting, we see that your anger starts building, we're going to have one of the techs coming in and walking you out.

    07:06 Not because we are ashamed of you, but because we want to protect you and everyone else.

    07:12 Because that tech will take you out and will help you walk in the hallways and allow you to verbalize your anger or frustration.

    07:21 Because getting angry in community meeting is not appropriate and we want to help you move towards your recovery.

    07:30 So, we share the plans with the client.

    07:33 In many places, if you are working in a psychiatric hospital or in a psychiatric unit, we have a code that we can call.

    07:44 And that code will bring in specifically trained individuals who can help diffuse a violent situation.

    07:53 If you have that in your hospital, do not step into a violent situation.

    08:00 Safety is not just safety for the client. In psychiatric nursing, safety is also safety for us.

    08:06 It's safety for our environment. It's safety for the other people in the environment.

    08:11 And so, if a person does become violent, we need to be able to take that person out of the situation and not put our own lives at risk in doing so.

    About the Lecture

    The lecture Nursing Interventions: Self-harm and Violence by Brenda Marshall, EdD, MSN, RN is from the course Psychiatric Assessment (Nursing).

    Included Quiz Questions

    1. “I will avoid asking clients about the reasons why they self-harm so that I do not trigger them to harm themselves.”
    2. “I need to avoid providing advice or judgment to clients, and focus on active listening instead.”
    3. “I should engage clients in discussions on positive coping skills that can hopefully replace self-harm.”
    4. “I should always ask clients to notify staff if they experience thoughts of self-harm.”
    1. “I’m glad you told me. Is it okay if I sit with you and talk about ways to keep you safe and things we can try to make the thoughts go away?”
    2. “You shouldn’t think like that! You should focus on all the good things that you have in your life, and you’ll feel better.”
    3. “Thank you for telling me. For your safety, I will need to put you in soft restraints until you feel better.”
    4. “You should take your medication, so you stop having those thoughts.”
    1. Have another staff member take the client to walk around the unit and remind the client that rude language is not tolerated in group therapy.
    2. Stop the group therapy session, and begin discussing appropriate and inappropriate behaviors, using the client as an example.
    3. Escort the client back to their room, initiate seclusion and discuss inappropriate behavior.
    4. Encourage the client to sit at the back of the room and refrain from speaking.
    1. Go out from the client's room and call a code using the facility-specific coding guidelines.
    2. Remove any moveable furniture and other hazards from the client’s room while encouraging the client to stop yelling.
    3. Call out for a nurse to prepare a sedative, initiate four-point restraints, and close the client’s door to ensure confidentiality.
    4. Leave and lock the client’s room, and return when the client has stopped acting violently.

    Author of lecture Nursing Interventions: Self-harm and Violence

     Brenda Marshall, EdD, MSN, RN

    Brenda Marshall, EdD, MSN, RN

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