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Emergency psychiatric assessments: implications for senior house officer training

  • Alan A. Woodall (a1), Seren Roberts (a2), Gary P. Slegg and David B. Menkes (a3)
Abstract
Aims and Method

In order to examine the opportunities for senior house officers (SHOs) to undertake emergency psychiatric assessments we conducted a retrospective cohort study of such assessments in a district general hospital.

Results

Senior house officers conducted few assessments for self-harm compared with psychiatric liaison nurses (P < 0.001), and were involved in only 40% of emergency referrals where psychiatric opinion was requested. Senior house officers continue to undertake more assessments out of hours than any other group (P < 0.01).

Clinical Implications

Although the introduction of psychiatric liaison nurses has improved capacity and reduced waiting times for emergency assessment, the opportunity for SHOs to undertake emergency assessments has been reduced, particularly with regard to assessment of suicidal risk following self-harm. These results suggest the need for better monitoring of SHO experience, particularly in the light of service developments that have an impact on psychiatric training.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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Bennewith, O., Stocks, N., Gunnell, D., et al (2002) General practice based intervention to prevent repeat episodes of deliberate self harm: cluster randomised controlled trial. BMJ, 324, 12541257.
Dowling, S., Barrett, S. & West, R. (1995) With nurse practitioners, who needs house officers? BMJ, 311, 309313.
Griffin, J. & Bisson, J. I. (2003) Introducing a nurse-led deliberate self-harm assessment service. Psychiatric Bulletin, 25, 212.
Hassan, T. B., MacNamara, A. F., Davy, A., et al (1999) Lesson of the week: Managing patients with deliberate self harm who refuse treatment in the accident and emergency department. BMJ, 319, 107109.
Lepping, P. (2003) Assessment by doctors and nurses of deliberate self-harm. Psychiatric Bulletin, 27, 233.
Morris-Stiff, G., Ball, E., Torkington, J., et al (2004) Registrar operating experience over a 15-year period: more, less or more or less the same? Surgeon Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland, 2, 161164.
National Institute for Clinical Excellence (2004) Self Harm. The Short-term Physical and Psychological Management and Secondary Prevention of Self-harm in Primary and Secondary Care. http://www.nice.org.uk/pdf/CG016NICEguideline.pdf http://www.nice.org.uk/pdf/CG016NICEguideline.pdf
Royal College of Psychiatrists (2003) Basic Specialist Training Handbook. London: Royal College of Psychiatrists. http://www.rcpsych.ac.uk/traindev/postgrad/bst.pdf
Weston, S. N. (2003) Comparison of the assessment by doctors and nurses of deliberate self harm. Psychiatric Bulletin, 27, 57.
Whyte, S. & Blewitt, A. (2003) Deliberate self harm: The impact of a specialist DSH team on assessment quality. Psychiatric Bulletin, 25, 98.
World Health Organization (1992) Tenth Revision of the international Classification Diseases and Related Health Problems (ICD–10). Geneva: WHO.
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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Emergency psychiatric assessments: implications for senior house officer training

  • Alan A. Woodall (a1), Seren Roberts (a2), Gary P. Slegg and David B. Menkes (a3)
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eLetters

response

prathibha rao, senior house officer in psychiatry
14 July 2006

The authors raise an important issue regarding the training of junior doctors. What is also worrying is that it is the same doctors with little experience who are expected to supervise the liason nurses and the senior house officers on approaching the registrar level oftraining.

However, one needs to be careful of accepting the data and the results at face value. Firstly the authors call the study aretrospective cohort study.A cohort study is one where a group of people are selected and followed through in order to assess the prognosis of a disease or the effects of a treatment or exposure. There is no cohort which has been identified and in my view I would say that this is more of a cross sectional survey where a cross section of a population,i.e. all the referrals to the liason department have been investigated for certain different criteria.

The authors mention 144 assessments in 2 months, which is about 20in a day. This to me seems a seriously busy psychiatry department and one would wonder whether it is at all humanly possible for a single SHO to be assessing all the 20 referrals in a day and the impact of it on patient care.

In the case that the SHO assesses all referrals , what then happens to the daily duties of the SHO? Is the SHO then expected to forego his normal daily duties? Does he then get a day off after this very busy on call ? Does it not then affect the training objectives. We already have heard from the colleagues in other specialities about the impact of the on call duties on the training commitments and psychiatry would also be following suit in that case.

It is also noteworthy that the majority of the so called serious mental illnesses have been assessed by the SHOs and the self harm by the liason nurses. To an extent this makes sense as a majority of the self harmers tend to repeat their act and assessment by the same health professional would lead to continuity of care and perhaps a better risk assessment. Obviously this needs to be balanced against the training needs of SHOs and the solution is not straight forward.
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Conflict of interest: None Declared

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Changes due to EWTD and MMC.

Yasir Abbasi, SHO in Psychiatry, Nottinghamshire Healthcare NHS Trust
14 July 2006

Dear Editor,

I read with interest Alan A Woodall et al's paper in the Psychiatric Bulletin (June 2006). It precisely highlights the deficient areas of training at an SHO level i.e. exposure to more acute risk assessments especially suicidal risks after an attempt of self harm. Such concerns were being raised in all the specialities including Psychiatry when the European Working Time Directives (EWTD) was being implemented. There were repeated forewarnings by training bodies about the effect of EWTD on junior doctors training and patient care but to no heed. Finally when it came upon us, more specialist nurses were introduced to help reduce the working hours of doctors. With time these nurses inevitable got more experienced and confident thus required less and less input from junior doctors in making decisions.

But at the same time I believe the introduction of specialist nurses into the position conventionally fulfilled by SHO’s should not act as an obstacle to training. In the Nottinghamshire rotation measures have been introduced to make sure that appropriate amount of training is imparted to trainees. As part of our mid term appraisals we are supposed to have a completed a personal training file, which includes details of the number of patients we see out of hours and a logbook of assessments where we are expected to take the lead for a minimum of 6 patients out which atleast two should be self harm patients with medium risk. Also we are supposed topresent and receive feedback from our educational supervisor on these riskassessments.

This just makes me wonder the way EWTD has been mishandled and what detrimental effects would the Modernising Medical Careers (MMC) which is in full swing at the moment shall have on our training, careers and futurepatient care. I guess no one shall know until the time comes in August 2007.

Declaration of Interest: None

Yours Faithfully,

Dr Y Abbasi, SHO General Adult Psychiatry, Millbrook Unit, Mansfield.Nottinghamshire Healthcare NHS Trust.

References:

DEPARTMENT OF HEALTH (2003) Modernising Medical Careers: The Responseof the Four UK Health Ministers to the Consultation on ‘Unfinished Business Proposals for Reform of the Senior House Officer Grade’. London: Department of Health.

Raja A. S. Mukherjee and S. Rao Nimmagadda Changes to training in medicine and psychiatry: a trainee’s perspective on a possible way forward. Psychiatric Bulletin, Feb 2005; 29: 43 - 45

Nick Brown and Dinesh Bhugra. The European Working Time Directive. Psychiatric Bulletin, May 2005; 29: 161 - 163.
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Conflict of interest: None Declared

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