Exploring the Knowledge and Skills of Emergency Department Advanced Clinical Practitioners who Assess and Treat Children Presenting with Self-Harm: A Phenomenological Study

Self-harm is an increasingly prevalent occurrence amongst young people, with rising numbers presenting to emergency departments (EDs) each year. Due to medical workforce challenges, growing numbers of Advanced Clinical Practitioners (ACPs) are now assessing and treating these young people, yet the educational requirements necessary to prepare them for this undertaking are not defined.

The purpose of this study was to explore the experience of ACPs, to determine the specific knowledge and skills they use in their practice. Employing a hermeneutic phenomenological approach, in-depth interviews were conducted with a purposive sample of eight clinicians from three English NHS Trusts. Participants included: ACPs, Paediatric Emergency Medicine (PEM) Consultants, a Paediatric Emergency Nurse Consultant and a specialist Child and Adolescent Mental Health Service (CAMHS) practitioner; all of whom had experience of seeing children with self-harm.

Template analysis of the transcripts resulted in the finding of two important integrative themes: Engagement, and Risk Assessment. The knowledge and skills associated with these themes were deemed pivotal to the effective care of children who have self-harmed. They enabled the assessment, and directed interventions pertinent to five elements of practice: ‘Looking for Injuries or Potential Poisoning’; ‘Pursuing Safeguarding and Social Concerns’; ‘Interpreting Emotional State’; ‘Identifying Suicidal Intent’; and ‘Deliberating Professional Practice Issues’.

Congruent with existing literature, all clinicians reported a lack of formal training specific to the care of children who have self-harmed. This lack of training was attributed to the participants’ varying opinions about elements of the risk assessment, particularly regarding the impact of a child’s maturity on their risk. It was also attributed to practitioners being unaware of the need to use a validated alcohol screening tool with this client group.

Despite the lack of training, the experience of participants resulted in their pursuit of a range of safeguarding concerns, assessment of mood, and overt enquiry about suicidal ideation, in the assessment of young people. These practices were well supported by the literature. However, the ED clinicians were unaware of child psychological development principles, such as attachment theory; the knowledge of this was deemed important for the assessment of parental support and family relationships, which influence further influence risk.

There was a universal perception that a young person’s engagement in the clinical consultation represented a lower risk of immediate harm. Conversely, young people who were unable or unwilling to engage, were perceived to be at higher risk. No evidence was found to confirm or refute this opinion.

Further analysis of the data revealed an emotional impact on clinicians who engage with these young people and their families. Therefore, opportunities to debrief and regular access to clinical supervision are recommended, to facilitate learning from incidents and protect emotional well-being.

Whilst most previous studies have recommended ‘training’ per se for ED clinicians who assess and treat young people who self-harm, this study has resulted in specific recommendations for ACP education, based on the knowledge and skills required to initiate engagement and conduct an overall risk assessment of a young person. These should be considered when any curricula are developed or revised for these health professionals, and be subject to further scrutiny in order to evaluate any clinical or professional benefit.