Seeing Beyond the Patient: Revised

An ecological framework for understanding adolescent suicidal behaviours and its implications for emergency room nurses

As a registered nurse in the emergency department, a population of patients that I encounter daily are adolescents with suicidal acts or thoughts. The nursing of this vulnerable population involves caring for families of children who have ended their own life, managing the medical needs of overdose attempts and providing safety to those adolescents who come to the emergency room with suicidal ideation. By using an ecological approach to health, nurses can have a have more comprehensive understanding of the complex nature of adolescent suicide.

Ecological Theory

Ecological theories of health take into consideration both the individual, their environments, and the effects of overlaying policy (Sallis & Owen, 2015). One of the earliest, modern multiple levels of health theory was proposed by Urie Bronfenbrenner in 1977. His model described multiple levels of influence on the individual behaviour in the micro-, meso-, exo- and macrosystems and how all of these layers of influence interact with each other (Tannenbaum, 2018). Suicide prevention can be viewed through an ecological theory by using a four-tiered model of individual, relationship, community and societal influences that recognizes the complex interplay between levels and outlines risk and protective factors related to suicidal behaviours. (Office of the Surgeon General, National Action Alliance for Suicide Prevention, 2012).

Figure 1. Examples of a Social Ecological Model and Risk and Protective Factors Related to Suicide. Office of the Surgeon General, National Action Alliance for Suicide Prevention, (2012).

Adolescent Suicidal Behaviours and Health Promotion

The Waterloo Wellington Local Health Integration Network (WWLHIN) identifies promoting healthy childhood development as one of its key determinants of health to focus on in the region (Seskar-Hencic, 2011). Suicide is the second leading cause of death from age 14-35 (Statistics Canada, 2017) and for every completed suicide there may be 100-200 unreported additional attempts (Larkin & Beautrais, 2010). By using an ecological framework for understanding suicide, healthcare providers can better understand the nature of this complex illness and design protective interventions aimed at promoting resilience with considerations at all levels (Office of the Surgeon General, National Action Alliance for Suicide Prevention, 2012).

Individual Level

When examining adolescent suicidal behaviour at the level of the individual there are multiple factors that should be considered due to the complex nature of identifying those at risk. Depression, hopelessness and substance abuse are seen as the most significant risk factors associated with adolescent suicide (Ayyash-Abdo, 2002). Gender in adolescent suicidal behaviour is a paradox, although statistically more females attempt suicide, completion of suicide is more common amongst males (Langhinrichsen-Rohling, Friend, & Powell, 2009). Gender identity in adolescents is also a key determinant in identifying at-risk youth as those who belong to sexual minorities are more likely to think about or attempt suicide (Russell & Joyner, 2001). These individual factors in isolation are not known to be causative factors for suicide in adolescents but demonstrate the need for a multilevel ecological approach to understand adolescents who may be at risk (Ayyash-Abdo, 2002).

Identifying individual risk factors may be the most obvious in emergency department settings as they are easily reported and clinically assessed. The important consideration for emergency department nurses is to view the patient outside of this layer and consider the interaction with all layers of the environment. Routine health promotions strategies that target individuals, seek to change individual behaviour (McLeroy et al, 1988) and in the emergency setting this could include referral to drug cessation programs, specialized mental health treatment, or support groups for GLBTQ youth with the goal of increasing the adolescent’s individual protective behaviours.

Relationships

Interpersonal relationships with family, friends, teachers and acquaintances directly affect behaviour and health as they provide support and mediate life stress (McLeroy et al, 1988). Adolescents are particularly vulnerable on this level with almost one third of those who attempt suicide report feeling isolated or having broken up from a relationship before the attempt (Ayyash-Abdo, 2002). As adolescents have a crucial need for close friendships, the loss of these interpersonal relationships is significant, as is family dysfunction and parental psychopathologies which are both correlated with higher suicide attempts by adolescents (Ayyash-Abdo, 2002). Nurses in the emergency department should consider these risk factors when assessing adolescents at risk for suicidal behaviours. Assessment of their perception of loss and interactions with family supports could help to identify those at risk. Targeted health promotion activities such as therapy that includes parental support have shown to be of benefit in reducing depressive thoughts in adolescents and the coping abilities of the family unit (Rotheram-Borus, 2000).

Community

How organizations can support behavioural changes and targeting health promotion to create organizational change is a key concept when considering an ecological perspective on health promotion (McLeroy et al, 1988). Adolescents spend a large amount of time in the school setting and a large number of suicide prevention programs are based in schools (Ayyash-Abdo, 2002). Programs aimed at creating support in school setting for at risk groups have shown to have positive affects (Eggert, Thompson, Herting, & Nicholas, 1995). Emergency department nurse’s awareness of programs available in local school boards can be a valuable resource when referring adolescents who present with suicidal behaviours.

The community setting can refer not only the physical, but also the psychological sense of community (McLeroy et al, 1988) and to adolescents this would include traditional as well as social media as nearly one hundred percent of adolescents (age 15-24) use social media daily (Statistics Canada, 2018). Although research into social media use and suicide risk has yet to draw many sound conclusions, the presence of cyberbullying increases the risk of suicide amongst adolescents at two times the rate of those who are not (Luxton, June, & Fairall, 2012) and adolescents who engage in the social media community for more than two hours a day are found to report poorer mental well being, including suicidal thoughts (Sampasa-Kanyinga & Lewis, 2015). When adolescents present to the emergency department with suicidal behaviours, considerations for the effects of social media on the client should be considered. This may include interventions such as assessing the appropriateness of patients having access to social media accounts or the posting of suicidal messaging in group forums. Assessing a client’s history of cyberbullying is an important intervention as fifteen percent of adolescent’s report being cyberbullied within the last year (Statistics Canada, 2018).

Societal Factors

Societal influences on health involves the use of policies, regulations and laws that protect the health of communities (McLeroy et al., 1988). The federal government influences suicide prevention in Canada through multiple programs including; addressing suicide prevention by creating public awareness campaigns to reduce stigma, promoting suicide awareness in schools and workplaces through the Mental Health Commission of Canada’s Opening Minds campaign, creating legislation for psychological well being in the workplace, funding research into suicide prevention, and monitoring suicide trends across Canada (Government of Canada, 2016). The Canadian Public Health Agency supports children through the Community Action Program for Children which address determinants that may affect a child’s risk for suicidal behaviour later in life by providing nutrition, parental coping skills and family violence support (Public Health Agency of Canada, 2015). The Government of Canada also seeks to address health inequity in its support of suicide prevention programs for indigenous youth in Canada, as suicide rates among indigenous youth in Canada are some of the highest in the world (Government of Canada, 2013). Through the National Aboriginal Youth Suicide Prevention Strategy, the government aims to coordinate suicide prevention strategies across all levels of government, including large scale prevention and community-based treatment with an emphasis on the community identifying its own needs (Government of Canada, 2013).

Creation of public policies related to reducing cyberbullying occurs at the societal level of ecological health promotion theory and could include education programs, national policies and the development of laws aimed at targeting cyberbullying (Luxton et al, 2012). Social media and the internet can be used preventatively in order to address suicide prevention in health promotion activities aimed at targeting individuals, schools and by creating larger public health outreach campaigns (Luxton et al, 2012).

The implication for nurses working in emergency department settings is the need to be aware of federal prevention programs that may exist in their communities and methods of engaging youth at risk with these programs. As members of larger professional bodies nurses also have the opportunity to directly influence public policy. Groups such as the Canadian Nurses Association have influence on public policy in Canada and work to ensure policy takes health and well-being on all levels into account when policies are formed (CNA, n.d.).

Conclusion

Nurses in emergency departments often meet patients in a time of crisis, focusing on the individual client and their immediate needs thus failing to consider environmental determinants that affect a client’s risk. Multiple studies have demonstrated that in isolation individual risk factors do not increase risk of suicide therefor demonstrating the importance of viewing suicide and suicide prevention through a broader lens (Perkins & Hartless, 2002). Using an ecological model of health can help health care providers look beyond the individual in crisis and understand the multiple factors associated with adolescent suicide. If considerations into ecological theory are made when treating adolescents with suicidal behaviours, nurses will be better prepared to support their clients by enforcing protective behaviours and focussing on health determinants at all levels of the environment.

References

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