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ItemMental health nurses’ decision making for people presenting to the emergency department with deliberate self-harm( 2012)BACKGROUND: The management of deliberate self-harm presentations in Australia has increasingly become the responsibility of the hospital Emergency Department (ED). Assessment in Victoria is primarily the responsibility of mental health nurses who are based in the hospital EDs. They assess the presentation and implement appropriate disposition of these patients. The dispositional outcome depends on an assessment of the risks associated with the presentation and the principles of managing the patient in the least restrictive environment. In most cases the dispositional outcome and subsequent treatment is unremarkable and successful. When there is a suicide, there has been a tendency in the media to at times apportion blame to the clinicians for failing to prevent the patient killing themselves. The underlying assumption is that there is a “gold standard” and that clinicians should agree on dispositions for similar types of presentations. This assumption is not supported by research. The proposition that there is agreement in dispositional decision making throughout the industry is not examined in existing research. It is this gap that the present study sets out to explore. AIMS: 1. To investigate variations in patient disposition decisions, following deliberate self-harm risk assessment by Australian mental health nurses. 2. To explore the demographic factors of clinicians that may affect dispositional decision making for deliberate self-harm risk assessment. 3. To explore the clinician’s reasoning processes, leading to their dispositional decision making. CONCEPTUAL MODEL: A conceptual model of the safety and risk factors related to deliberate self harm presentations was developed and was informed by a literature review. This model was based on the demographic characteristics of the patient, level of social connectedness and intellectual functioning. This differed from the widely accepted model that utilises diagnostic categories and demographics. From this model a series of vignettes was developed. Two vignettes were designed to test the model (one that had very high safety factors and one with very low safety factors). A further seven cases were constructed with varying levels of perceived risk and safety. These vignettes were distributed to experts in the field to test for content validity and were found to be representative of typical deliberate self-harm presentations to EDs. METHODS: A cross sectional survey was administered to mental health nurses who were members of the Australian College of Mental Health Nurses. Questions were asked about the demographics of the participant along with a series of questions about the vignettes. Participants were asked about their perceptions of the deliberate self-harm intent of the subject and the disposition that the participant believed was appropriate for that vignette. For each of the questions, reasons for the decision were sought. RESULTS: The survey achieved 210 completed responses 56 of these were from the conference. Outcome was based on agreement and explanation. The quantitative results showed a significant agreement on deliberate self-harm intent across all but one of the vignettes by participants. The two test vignettes achieved agreement on disposition giving confidence in the model. The remaining seven vignettes, designed to balance safety and risk factors, showed poor levels of agreement for disposition. No demographic data consistently explained this variation. In the qualitative analysis the reasons given for dispositional decision in some cases were as conflicted as the decisions themselves. Often the same justification was given for treatment in the community and for a decision to hospitalise. CONCLUSION: Agreement was reached across clinicians on the assessment of deliberate self-harm intent. Only in one vignette was the null point included in the confidence intervals. There was a lack of agreement as to appropriate disposition between clinicians. This finding indicates a high level of subjectivity in dispositional decision making and suggests that for the same presentation different clinicians would make different dispositional decisions. The current work has highlighted individual differences between clinicians assessing in isolation, further research is indicated to investigate the effect of team dynamics on decision making. The findings of such research may prove useful as a tool for testing the formative and normative functions of peer supervision within a team environment. This may help understand the dynamics of decision making within the team and assist that team work towards understanding the dynamics at work in dispositional decision making.