Mental Health Nursing

148 Acute Mental Health Nursing
progress. It has recently been found that in no fewer than 85% of suicides
by mental health patients, risk was assessed as being low or absent (DoH,
2001). This is testimony to the challenge presented by risk assessment,
which is certainly not an exact science, but it also underlines that in some
cases the classic phenomenon of ‘false improvement’ may have occurred,
with patients appearing to have improved in mood, leading to relaxation
of vigilance by staff. In other cases, the risk level fluctuates from day
to day, even hour to hour, while in still others impulsivity, perhaps due
to mental illness or substance misuse, may lead to a sudden, spontaneous
suicide.
Care planning
The Care Programme Approach (CPA) (DoH, 1990; revised 2000a) was
developed in response to major incidents of harm which illustrated the
need for systematic care planning by multidisciplinary teams and agencies,
coordinated by a consistent keyworker and seeking to actively
involve the patient and relatives and carers. Effective use of the CPA
with patients assessed as at-risk is a key aspect of risk management,
ensuring that an individual member of staff, such as a named nurse in a
ward setting, maintains an overview of the care process, that the expertise
of different clinicians is employed, that communication about risk is
optimised, and that the care plan is implemented and reviewed appropriately.
In addition, the crucial post-discharge period, when the patient
is at most risk of self-harm (DoH, 2001), can be prepared for; for example,
by ensuring the ‘in reach’ of community staff before the patient
returns home.
Clinical interventions
An individualised care plan should be formulated to take account of the
patient’s specific needs. Self-harming behaviour should be seen
as a symptom of other mental health problems rather than a problem in
itself, and the reasons for the behaviour should be sought and addressed.
Therefore, any underlying depression should be treated with appropriate
and effectively monitored medication and, in some cases, electro-convulsive
therapy. This should be followed with specific interventions as part of a
treatment package directed at addressing risk triggers. These would
include the use of problem-solving therapy, cognitive behavioural therapy,
supportive counselling, and assistance with practical issues such as
finance, housing or relationships.