Regardless of where you work, you're likely to care for some patients who engage in SIB. As a nurse, you must provide fair and ethical care to all patients, including those who harm themselves. But trying to help these patients modify their behavior can be frustrating for nurses and other caregivers. This article addresses how to identify signs and symptoms of SIB and how to intervene effectively.

What's SIB?

Although people may engage in SIB for any combination of reasons, the primary one is to cope with their emotions and to feel better. These emotions may occur individually or in combination, or one may follow another. The emotion may be different from episode to episode.

No one knows how many ED or healthcare provider visits for "accidental" injuries are self-injury cases in disguise, or how many cases aren't reported. SIB may result in more severe effects than the person intended, sometimes requiring medical treatment, including surgical repair. Possible complications from SIB include wound infections, scarring, being shunned, and difficulty focusing on school or employment tasks.

Many manifestations of SIB

Communicating with those who engage in SIB is extremely difficult and challenging for caregivers. When you're planning approaches and care, always consider that your patient with SIB may have been abused or neglected in childhood.

* They may want to exert control over their bodies or a situation because they feel a lack of control.

* They may attempt to cause self-harm to receive nurturing missing from their past. For example, people who received little attention from their primary caregiver when they were children may gain a feeling of satisfaction from nurturing a wound.

Avoiding triggers

For people who engage in SIB, certain triggers may lead to SIB. Triggers can be anything-for example, a smell, clothing, or the sound of a person's voice-that reminds them of upsetting events in their past or causes stress. Lacking effective coping skills, they turn to SIB to relieve emotional pain.

The trigger may spur memories or exacerbate self-hatred or the need for control. A person may try to resist SIB for hours or days before finally giving in to the desire and engaging in self-harm. Others may respond to a trigger immediately and engage in SIB with little or no warning. (See Two pathways to SIB.)

Some triggers may be part of routine nursing care. For example, we remove patients' street clothes and put them in a flimsy gown, or we might knock quickly, then walk in on patients while they're in bed or in the bathroom. Although we can't completely avoid these actions, we can be more sensitive to the likely effects on these patients and prepare them in advance. For example, explain tests and procedures and ask what these patients need to feel prepared and supported.

Improving your assessment skills

How should you assess and care for these patients? First, let go of assumptions. For example, don't assume that an apparent self-injury was a suicide attempt, or that you know what a patient hoped to gain by a self-injury.

Many nurses are afraid to ask the patient, "Were you feeling like you wanted to hurt yourself, or were you feeling suicidal?" It's okay to ask this. You need to understand the behaviors' meaning to the patient to address the situation properly. It may help to start by simply asking, "What did this injury mean to you?"

Every day, some people live with thoughts of self-harm and some live with suicidal thoughts. People may experience either or both thoughts concurrently without acting on them. Assess each patient individually for these thoughts.

Some ways of asking about SIB are more effective than others. When patients have difficulty talking about their feelings, you can ask them to express themselves in the third person. For instance, ask them, "If your injuries could speak for you, what would they tell us?" Using open-ended questions or statements encourages the patient to provide more explanation. Consider these examples:

* "Tell me about your scars."

* "Tell me what happened."

* "What was happening before you injured yourself?" (This can help you identify the patient's triggers.)

* "Did you feel like you wanted to hurt yourself or kill yourself?" (If necessary, explain the difference.)

* "Are you safe now?"

* "Are you thinking about hurting yourself now?"

Throughout the physical assessment, be alert for injuries on patients' arms, legs, abdomen, breasts, or any other body part.

* While auscultating heart and lung sounds, look for injuries and scars.

* Ask questions such as, "Do you have any wounds, cuts, bruises, or burns?"

* If you see an injury, ask, "Do you have any other wounds?" Remember that patients may be hiding other wounds. You can say, in a matter-of-fact way, "I need to assess your wounds so we can be sure to provide the proper care and avoid infection."

How to intervene effectively

Consider these issues during your assessment to help plan effective nursing care.

* Are there patterns or frequencies of harm? This may provide clues to when a patient is likely to self-harm again.

* Does the patient respond to triggers and know what they are? This knowledge allows staff to remove or decrease triggers when possible, or be available for support.

* How severe is the self-harm, and is the harm in dangerous areas? (For example, did the patient insert objects into body cavities or self-injure close to arteries?) Suicidal patients require one-to-one observation; even if the patient denies being suicidal, if the self-harm was severe or dangerous, this patient may also need one-to-one observation. Organizations often have specific assessment forms or protocols for this purpose.

Here are some approaches that you can take in acute care and ED situations:

* Remain matter-of-fact and calm instead of overreacting. Validate patients' feelings with comments such as, "I'm sorry that you're having a difficult day."

* Encourage patients to express their feelings. Be empathetic rather than sympathetic: Listen and attempt to understand the emotions without feeling sorry for the patient or getting personally involved, which violates professional boundaries.

* Don't punish or restrain patients because doing so reinforces patients' beliefs that they deserve punishment.

* Avoid asking why the behavior occurred, and don't add to shameful feelings by criticizing patients.

* Be respectful of the patient's personal space. Because many people who engage in SIB have been abused, they may be uncomfortable with touch and physical closeness. Tell the patient before touching him or her and explain what you're doing throughout your assessment and during any procedures or nursing care. Keep private parts draped or covered.

* Although you can't stop or limit every trigger, be alert to each patient's particular triggers, and be available to lend support when triggers can't be avoided.

* Because many patients who engage in SIB have a history of being abused, it may be beneficial to arrange for same-sex or opposite-sex caregivers (depending on the patient's history) to avoid potentially triggering tests or procedures.

* Provide as much consistency in caregivers and routine as possible. For example, if at all possible, arrange schedules to avoid giving the patient a different caregiver every 4 hours, or a new one every day.

* Don't make promises you can't keep. Broken promises reinforce negative self-concepts and discourage trusting relationships.

* Praise every alternative to SIB and every attempt to avoid self-harm.

* Encourage patients to focus on their strengths and healthy coping options. They must learn to see themselves as survivors, rather than as victims, and learn more healthy coping behaviors. They can't do this without our encouragement.

Be prepared

The more you understand about SIB, the better able you'll be to provide therapeutic nursing care for patients with SIB. Use the information discussed here to keep patients safe and to improve their coping skills and quality of life in the future.

HOW THE PATTERN DEVELOPS

Ms. S had an experience that demonstrates the spring pathway (wind-up response) situation. She was in a group of people when a young male patient made an inappropriate sexual remark. This spurred Ms. S to remember past abuse. She spent the next half hour becoming tense, obsessing about her feelings, and feeling guilty for any role she thought she played in her past abuse. As these feelings overwhelmed her, she searched for something with which to cut herself.

In contrast, the switch pathway spurs the person to quickly engage in SIB as though turning on a light switch. The person may be unaware of what led to the SIB.

An example of the switch (quick response) pathway came from Ms. B as she explained some of her scars. She pointed to a recent scar on her arm and explained that she was shopping when a man brushed past her backside. She explained that she initially only vaguely recalled the situation, but after pondering it, she realized that when the man brushed past her, she immediately felt out of control. As a result, she went to the nearest bathroom and cut herself before she knew what had happened. Later Ms. B said her feelings may have related to being sodomized as a child.

In both cases, the self-injuring led to a feeling of relief, but the relief was rapidly replaced by guilt about the self-injury.

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