Nursing Week 4 _ Assignment 2_ IMPROVEMENT AND RESEARCH PROJECT IN PATIENT SAFETY AND QUALITY

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Exploring psychotherapeutic issues and agents in clinical practice

Psychopharmacology

Nonsuicidal Self-Injury A Nurse-Led Quality Improvement Project to Address Self-Harm

Nonsuicidal self-injury (NSSI) is defi ned as deliberate self- infl icted damage to bodily tis-

sue without suicidal intent (American Psychiatric Association, 2013) and fre- quently comorbid with major depressive, posttraumatic stress, and borderline per- sonality disorders. NSSI is highly associ- ated with eating disorder behaviors (e.g., binging, purging, restricting) and greater severity of symptoms (Kierkens & Claes, 2020).

Engagement in NSSI behaviors gen- erally begins in adolescence (Cipriano et al., 2017) and prevalence among youth and young adults has been steadily in- creasing (McManus et al., 2019; Wester

et al., 2018). In our experience, working on a combined hospital inpatient eating and aff ective disorders unit, we have ex- perienced an increase in the number of patients with comorbid NSSI that has led to destabilization of the milieu, de- pleted resources, decreased staff morale, and distraction from other acute patient issues. NSSI leads to longer lengths of inpatient stay, increased staffi ng costs, increased infection risk, and physical scarring (Goldberg-Mellor et al., 2020; Timberlake et al., 2019).

Th e literature suggests limited evi- dence for predisposing genetic factors (Russell et al., 2021) and some consis- tent evidence for abnormalities in com-

ABSTRACT Nonsuicidal self-injury (NSSI) behav- iors, such as cutting, scratching, or more severe injuries, are frequently comorbid with neurodevelopmental, intellectual, trauma, personality, and major depressive disorders, compli- cating treatment and placing added care burdens on hospital nursing staff and advanced practice nurses. Although specifi c psychopharma- cological treatment guidelines and approved medications for NSSI are non-existent, patients are treated with medications approved for co- morbid disorders and behavioral in- terventions targeting intrapersonal (poor emotional self-regulation) and interpersonal (communication of distress) functions. The current ar- ticle describes a nurse-led quality improvement project, using the Plan- Do-Study-Act cycle, in a case exam- ple. Outcomes include improved staff competencies and policies, yet we remain challenged in implementing planned actions that add additional time burdens to already stretched care providers. [Journal of Psycho- social Nursing and Mental Health Services, 60(3), 7-10.]

Deborah Goodman, BSN, RN; Allisyn Pletch, MSN, PMHCNS-BC; Padmini Paul, MSN, PMHNP-BC, ANP-BC; Elizabeth Anderson, BSN, RN; and Karan Kverno, PhD, PMHNP-BC, PMHCNS-BC, FAANP

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munication patterns between limbic and prefrontal cortical areas of the brain with neuroimaging (Brañas et al., 2021), which may contribute to poor emotional and behavioral self-regulation. Th e liter- ature clearly describes NSSI as an abnor- mal behavior that serves specifi c func- tions for an individual. Th e functions may represent aberrant intrapersonal attempts at emotional self-regulation and/or aberrant interpersonal commu- nication of distressing emotions or self- punishment. Th e behaviors may also be a sign of impaired impulse control (Taylor et al., 2018).

Patients who self-harm on our unit are almost always placed on constant observation by physician order, re- quiring staff or a hired sitter at all times, including when in the bath- room. Unit policy requires nurses and clinical technicians to spend ≥1 hour each shift away from their own pa- tients and the milieu, focusing their at- tention on that specifi c patient, which can be draining and demoralizing for staff and isolating for patients. Some of the more serious self-harm occur- rences on the unit can lead to security involvement, seclusion, or restraint to maintain patient safety. Other patients can become aware of these incidences because of the noise, number of in- creased staff and security on the unit, and the nature of the open milieu in the psychiatric inpatient setting.

Our goal for a quality improvement (QI) project was to gather best practices on the treatment of NSSI and build a pi- lot program on our inpatient psychiatry unit. Our initial clinical question was: What are the best practices for preven- tion and intervention among patients with non-suicidal, self-directed vio- lence? Our population was psychiatric inpatients (ages 13 to 80 years) receiv- ing treatment for aff ective and/or eating disorders at a large university teaching hospital. Our long-term goal was to fo- cus staff attention on the issue, educate clinical staff and patients on prevention and coping methods, and prevent NSSI on the inpatient unit.

EXEMPLAR PATIENT WITH NSSI At the time of the QI project, the eat-

ing disorders inpatient unit had a female patient, approximately 40 years old, who initially presented with chief complaints of worsening depression with an increase in restricting and purging behaviors. She also had severe NSSI behaviors that in- cluded: scratching, biting, stabbing, head banging, and intentionally avoiding uri- nation. She was diagnosed with major depressive disorder, posttraumatic stress disorder, and anorexia nervosa. She also had dissociative symptoms and borderline personality traits. History was positive for numerous psychiatric hospitalizations over the previous decade for treatment of depression, self-injury, suicide attempts, and disordered eating behaviors. Self- harm behaviors, restrictive eating, and restrictive behaviors always occurred in the context of depressive mood episodes. She had been treated with multiple com- binations of antidepressants (selective se- rotonin reuptake inhibitors, bupropion, trazodone, nortriptyline), lithium, and antipsychotics (olanzapine) with partial success. She had also been treated with electroconvulsive therapy (ECT), with good success.

QI METHOD: PLAN-DO-STUDY-ACT Plan: Development of the Initiative

We created the Self-Injurious Be- havior (SIB) Prevention Committee, a sub-section of the unit’s Comprehensive Unit-Based Safety Program committee. Th e committee comprised nurses of all levels and clinical technicians. Initially, the committee looked into providing patients with a list of feasible and aff ord- able coping strategies to use when they had self-harm urges on the unit. We then took our QI project to the Psychiatry Re- search and Scholarship Committee, the members of which encouraged us to cre- ate an evidence-based practice QI proj- ect from this idea. One of the SIB com- mittee members attended the Institute’s Evidence-Based Practice Bootcamp and led the project. We began by searching the literature for NSSI clinical practice guidelines.

Nonpharmacological Best Practices. Most of the evidence-based treatments were nonpharmacological. Most fre- quently, the function of NSSI appears to be an intrapersonal attempt to soothe distressing emotions (Taylor et al., 2018) and is supported by evidence for the ef- fectiveness of aff ect self-regulation in- terventions, such as dialectical behavior therapy and emotional regulation group therapy. Individuals who express inter- personal distress through NSSI may be more responsive to compassionate care that empowers patients to collaborate in their own treatment (Taylor et al., 2018). Nurses who were nurturing, caring, and nonjudgmental facilitate patient recov- ery. Allowing patients to decide on their own treatment or positive coping skills empowers them to take charge of their own health.

Pharmacological Best Practices. Al- though there are no U.S. Food and Drug Administration–approved medication treatments or guidelines for NSSI, pa- tients are treated with medications tar- geting comorbid disorders (Costa et al., 2020; Kiekens & Claes, 2021). Treatments for highly comorbid disorders that in- volve emotion dysregulation (e.g., eating disorders, major depression, borderline personality disorder) have demonstrated some benefi ts in the treatment of NSSI (Turner et al., 2014). Th ese medications include antidepressants and antipsychot- ics that target the serotonin and dopa- mine systems. ECT has been used with success in the treatment of self-injurious behaviors associated with emotion dys- regulated disorders involving NSSI; however, Rootes-Murdy et al. (2019) found that it was not of benefi t in reduc- ing NSSI in adolescents and young adult women with treatment-resistant depres- sion. ECT has been found to be eff ective for repetitive self-injury in individuals with autism and intellectual impairment (Blum, 2017; Steenfeldt-Kristensen et al., 2020; Wachtel et al., 2018).

Recent studies have focused on the brain’s opioid system. Endogenous opi- oids, such as beta-endorphins, when released in response to stress or injury,

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decrease discomfort and pain. NSSI has been linked to low basal beta-endorphins, low pain sensitivity, high stress reactiv- ity, and high emotional reactivity (Kaess et al., 2021; van der Venne et al., 2021). Opioid antagonists (naltrexone) and opioid partial agonists (buprenorphine) reduce NSSI in persons with NSSI associ- ated with treatment-resistant depression (Serafi ni et al., 2018). Kaess et al. (2021) suggest that it is still too early for a co- herent explanatory framework to guide practice; however, some researchers sug- gest that the eff ects of endogenous opioid release in response to self-injury, and the neuromodulating eff ects of opioids on the dopamine reward pathway, may incentiv- ize NSSI among adolescents and others with low basal endorphins (Serafi ni et al., 2018; van der Venne et al., 2021).

Do: Implementation of the Plan Our unit has several inpatient edu-

cational groups each day, led by nurses. Many of these groups provide discussion on positive coping skills and illness edu- cation. Patients are encouraged to attend and participate in groups. Regarding our exemplar patient, NSSI was linked to ex- acerbations in mood symptoms, abnor- mal eating behaviors, and personality vulnerabilities. Th e patient was placed on constant observation at the begin- ning of her hospitalization and intermit- tently throughout her 36-day course of treatment. Her daily inpatient treatment included therapeutic meals and group therapy with other patients with eating disorders, as well as twice daily assess- ment with a nurse and daily meetings with the physician treatment team. She was encouraged to use coping strategies and discuss any urges to harm herself. Despite some response to multiple medi- cation trials, NSSI did not remit until she received (with her consent) a series of ECT treatments.

Study: Analysis of the Outcomes Following the 3-month period of

observation, the SIB Prevention Com- mittee met to analyze our process ob- servations. One problem area, described

by patients and staff , was the constant observation procedure, especially the night shift procedure that includes re- quiring patients who have self-harmed to wear bilateral soft mitts, keep hands above bed covers at all times, and keep the light on throughout the night, with an observing staff member or hired sitter inside or just outside the patient’s room. Th is procedure has met with pushback from staff and patients, who argue par- ticularly about the interruption of sleep with the lights on and door open to their room throughout the night. Many pa- tients with aff ective disorders experience decreased sleep as a symptom, and this has not been addressed appropriately. In addition, we realized that we were not using a standard procedure to monitor NSSI behaviors and assess risk.

Act: Adjustments Made Based on Outcomes

Based on observations, we developed and implemented NSSI competencies for all nursing staff , adopted a screening tool to monitor NSSI risk and response to treatment, and implemented staff train- ing to increase awareness of self-injury pathology and events. We implemented nursing interventions to increase pa- tient awareness of distressing emotions that trigger their urges to self-harm, and nurses collaborated more consistently with patients to improve their preferred coping skills. Each nurse and clinical technician on the unit completed the new NSSI staff competency training. We draft ed a prevention policy to include in the unit admissions packet. Th e new inpatient admissions criteria include a more comprehensive list of personal items not allowed on the unit, including a list of sharps and sharp objects that are encouraged to be left at home, or stored on the unit and used with staff supervi- sion. Th e biggest change in our nursing practice was implementing a symptom monitoring tool to evaluate history of self-harm behavior. Th e tool has brought more attention to patient vulnerabilities and created more informed nursing care. However, our patient admissions process

is already lengthy, and the screening tool added another component to a drawn- out process, resulting in only partial compliance with completion of the tool. In conjunction with the NSSI symptom tool, the unit created a “Hot Board” in the nursing conference room where staff can be made aware of high-risk pa- tients. Th is board is updated on a daily to weekly basis, and functions well as a broad, up-to-date memo. Debriefi ng ses- sions aft er severe NSSI events have been implemented so that staff can reassure patients of continued safety and answer questions without violating patient con- fi dentiality.

CONCLUSION NSSI is a complex behavioral ex-

pression of psychological distress. En- gagement in self-harming behaviors is infl uenced by social and environmental life events, creating greater vulnerability among marginalized and more stressed populations (Arcelus et al., 2016; Lim et al., 2019). Treatment rests on identify- ing the intrapersonal and interpersonal functions of the behaviors and imple- menting evidence-based approaches to modify behaviors. Comorbid disorders and life events that precipitate NSSI be- haviors must be identifi ed and treated with evidence-based, nonpharmaco- logical and pharmacological treatments through collaborative, team-based, patient-centered care.

Our recommendation for the future is to eliminate some part of the admis- sions process and replace it with a NSSI severity and risk tool that can also be used to monitor response to treatment. We intend to continue developing our nursing staff to regularly assess response to pharmacological treatments, follow up on topics discussed in groups, prac- tice coping skills with patients during assessment times, and elucidate patient feedback on their own preferences for educational groups and coping skills.

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From Johns Hopkins Medicine, Psychiatry and Behavioral Sciences, Eating Disorders and Mood Disorders Inpatient Programs (D.G., A.P., P.P., E.A.), and Johns Hopkins University School of Nursing (K.K.), Baltimore, Maryland.

Disclosure: The authors have disclosed no po- tential confl icts of interest, fi nancial or otherwise.

Address correspondence to Karan Kverno, PhD, PMHNP-BC, PMHCNS-BC, FAANP, Johns Hopkins University School of Nursing, 525 N. Wolfe Street, Baltimore, MD 21205; email: [email protected].

doi:10.3928/02793695-20220208-02

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