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Self harm in all of its forms is one of the greatest dangers that face vulnerable adolescents, promoting unhealthy cycles, and increasing the risk of suicide and from the perspective of a school nurse, the problem is very evident. Whilst providing duties to young people with, or prone to, psychological, emotional or mental help problems it is clear that self harm is an ever increasing issue. There is evidence that would suggest that the rates of self harm within the UK are the highest in Europe (Mental Health Foundation, 2006, a) and as such, this act should be considered one of our nations significant health concerns. Self harm is a complicated and very challenging problem to face and as such a deep understanding of self harm is vital to combating it.
In reviewing literature we must interpret a comprehensive volume of information relating to a given topic. In this instance the topic at hand is self-harm, and as such we are required to study and absorb as much of the available information in order to digest it into new insights and to provide evidence to inform our practical decisions. In this specific review the aim is to use the available literature to identify the most prominent and prevalent challenges that could face a school nurse in the treatment and management of youths that self harm.
The act of self-harm has become all the more common amongst adolescents (Fortune and Hawton, 2005) (Laukkanen et al, 2009), wherein as many as one in 15 youths undertake self harm at one point or more in their lives (Mental Health Foundation, 2006, a). Self harm involves many types of personal injury, from poisoning to starving, though cutting is the predominant method of self injury (Lakkanen et al, 2009) and because of this, I have ensured to differentiate cutting, from other means of self harm within this review. The primary approach of this review is to attempt to identify the most prominent literature relative to this topic within the UK. Unfortunately there is only a small pool of literature governing the topic of self harm in youths; even foreign literature on the topic is just as underdeveloped and lacking, often using differing terminology, such as “self-Mutilation” (Derouin and Bravender, 2004).
A further category of self harm that requires specific definition is the term Deliberate self harm, otherwise known as DSH. Whilst it is most frequently used in UK literature pertaining to the subject, it has been regarded as controversial, because of the mental connotations behind the disorder. (NICE, 2004). People who commit self harm, tend to not feel comfortable with the use of the word ‘deliberate’, as it disrupts the notion that the act is voluntary, which a lot of sufferers disbelieve (Royal College of Psychiatrists, 2007). In recognising different perspectives on the matter, the term ‘deliberate’ should no longer be used in relation to self harm, to give an enlightened view of the topic within this literature review.
When discussing young people or adolescent in this report, the terms will refer to any young person between 12 and 18 years of age. The average age of onset for self harm is 12 years (mental health foundation, 2006, a), however children as young as five years old have been reported to self harm (Bywaters and Rolfe, 2002). The cases of children that young performing self harm is very uncommon, and the rate tends to increase rapidly with age throughout adolescence (Hawton et al, 2003).
Gathering literary sources was done by utilising a search of CINAHL (Cumulative Index to Nursing and Allied Health Literature), a database for nurising based literature reviews. It is particularly suiting as it relaties specifically to nursing and allied health literature (Aveyard, 2010). In order to get the most comprehensive list of resources, several terms were used within the search; Cut* “self-harm” “self-mutilation”, “Adolescent” and “School nurse” in order to provide a wide range of literature related to the topic. Recent papers, such as those published within the last five to ten years were used. In order to gather enough information, the limit was extended to ten years, as there was simply not enough sources within a five year bracket. When performign these searches, the search terms were often linked in order to provide the best set of results. Other databases were used, using a similar method as this to good results. They included The British Nursing Inde, and PsychINFO.
It is often emphasised how important it is to combine search strategies (Greenhalgh and Peacock, 2005), within literature reviews. Despite the advantage electronic searches provide, it is still possible to miss key sources of literature. (Montori et al, 2004). Every step to ensure the best quality of literature is provided should be taken, and as such within this review, any appropriate cited references have been thoroughly checked and sourced. In following various searches, the extracts from the articles were read for relevance to the review. They were also regarded to see if they met the inclusion/exclusion criteria and for general relevance and importance. The critical apraisal skills programme was used to great effect in ascertaining the quality of certain articles (Aveyard, 2010). Further articles that did not meet criteria at this stage were disregarded from the study. As could be expected, all literature that had been collated showed similarities in their findings and themes. These have been used to link the findings in a systematic manner for the purpose of this review (Pope et al, 2007). Prevelance, rates, reasons to harm, the factors behind harming, suicidal intentions and intervention are all themes which need to be studied and examined for the problems and considerations faced by a medical professional when encountering them.
One thought that is unanimous within studies concerning self-harm is that the act itself is much more than simply attention seeking behaviour. (Mental Health Foundation, 2006, a). This is supported by the instances in which youths attempt to hide their attempts behind long sleeved tops, or by cutting in areas of the body that are hidden from view, such as the inner thigh or the axilla (Freeman, 2002). Because of this, many acts of self-harm do not come to the attention of the healthcare services, so it is almost impossible to discern the true scale of the matter.
However in one study 13 .2% of adolescents reported to have purposefully harmed themselves within their lives (Hawthorn and Rodam, 2006). There have been many studies on the matter, but it is difficult to compare results due to varying age groups and conditions. Two facts seem t o be agreed upon however, and they are that cutting is the most prevalent type of self-harm (Laukkanen et al, 2009) and that in all likelihood the true scale of the problem goes unrecorded. The latter could be due to several reasons; between youths hiding the fact they perform self-harm and that parents who have no fears in regards to their children, are less likely to give consent to permit these studies recording data. (Hintikka et al, 2009).
With all reports agreeing that the situation as a whole reflects merely the tip of an iceberg, and that findings do not cover the majority of acts that go unnoticed by the medical services, health professionals require a greater understanding of the topic, in order to tackle the problem when they do encounter it. As School Nurses are often the first to contact youths who self harm (McDougal, 2003), it is even more vital to provide an understanding and means to address this problem. Whilst establishing a professional where pupils feel comfortable in disclosing their behaviour , it is also vital to promote awareness in the school and community at large of the dangers of this self-harming behaviour (Hackney, 2009). However the root of the problem lies in identifying those who are prone to cutting and other acts of self harm, and understanding why they choose to take this step.
Why Adolescents Self-Harm
There appear to be many reasons offered as to why adolescents choose to harm themselves including to feel more alive, to distract from the reality of their situation, and to even gain relief from the pressures that surround them (Mental Health Foundation, 2006, a). It can be used as a means of dealing with emotional extremes of anger, sadness or depression (Mental Health Foundation, 2006, a), or even as a means of expressing negative emotions such as self-loathing or loneliness. Whatever the cause, the reason behind it is often that the adolescent’s mind finds it easier to deal with physical pain and trauma than the emotional pain that is the root of the problem (Medical Health Foundation, 2006, a). Physically, there are endorphins released during the act of cutting which serve as to calm the person down (Starr, 2004). In doing this, the anxiety is reduced and not only is the adolescent satisfied emotionally, but also potentially addicted physically. Adolescents often feel that between studies and their family, they have no control over their own life; and as such cutting can be a means of exerting control over themselves physically. (Derouin and Bravender, 2004). However in certain circumstances, it can be used to exert control of those around the youth, such as friends, family, and other loved ones. (Freeman, 2002).
With this in mind, it is understandable why youths take to self harm as a means of resolving their emotional issues, as it has been recorded that most youths who have undertaken the act, hold it in a positive light (Griesbach, 2008). However it is only a temporary solution and an often dangerous one at that. Any gratification gained from the act itself does nothing to relive the underlying problem (Mental Health Foundation, 2006), and as such cannot be expected to resolve itself. Those who choose to self harm, tend to do so because of a complex combination of reasons and experiences, rather than a single, governing event (Fox and Hawton, 2004). As such, it can often be difficult for a Nurse to address these issues as a collective when dealing with those who self-harm.
Factors associated to Self Harm
Girls are more prone to internalise their problems than boys and as such, certain pieces of literature believe that girls are far more likely than boys to resort to self harm (Hawton et al, 2002). In contradiction to this, certain texts would state that in a study of admissions to an accident and emergency department, almost as many boys were admitted as girls, for the act of self harm (Lilley et al, 2008). As such, it is important to acknowledge that the differences between genders, may not reflect the likelihood of cutting as any greater than the other.
There a re also emotional factors tied to self harm, tha t include feelings of loneliness, isolation, depression, frustration and worthlessness (Griesbach, 2008). These feelings in and of themselves often a re enough to cause concern that a youth could self harm, however combined with other factors such as separation from loved ones (through arguments or neglect), bullying or even abuse could amplify the risk of self-harm (Griesbach, 2008). It is just as important when considering these factors, that not everybody who has suffered neglect or abuse will self-harm, and that those that have will often handle things in a less destructive manner (Turp, 2002).
Other behavioural factors have been linked to those who self-harm, which include aggressive tendencies, poor educational performance, substance abuse, and most commonly depressive moods (Laukkanen et al, 2009). There are also those who suffer from stress, or who feel as if they have little control over their life. (Griesbach, 2008)
Family and Relationships
Whilst behavioural problems can be tied to the reasons behind self-harm, often it is those closest to the adolescent that promote these issues, knowingly or otherwise, such as a parental figure providing either overprotection, or a lack of care (Marchetto, 2006). There are many psychosocial issues that may impart negative emotions, stress, or pressures upon a youth, with serious family and relationship problems being the more common (Laukkanen et al, 2009). With this to consider, a school nurse must realise that even the most superficial act of self harm could be linked to a very deep and complex series of psychosocial problems. Young people often feel uncomfortable opening up about such backgrounds, regardless of family circumstance (Griesbach, 2008) and consequently it can be difficult for a school nurse to uncover the true cause of self-harm with a patient. This difficulty in opening up must be considered when assessing a youth suspected of self harm in order to best establish a relationship with the patient and thus a level of trust (Griesbach, 2008).
A high proportion of children can be diagnosed with mental disorders. With mental health problems such as anxiety, depression and even eating disorders being strongly linked to those who self-harm (Hintikka et al, 2009), these high proportions become all the more concerning. According to The Mental Health Foundation (2006, b) One in ten children have a mental health disorder, coupled with the strong links between self harm and these disorders gives cause for concern as to how much goes unrecorded. Depression has even been recognised as a major factor behind self harm (Derouin and Bravender, 2004), which is becoming even more common with girls who choose to cut. (Hintikka et al, 2009). However there is often a stigma attached to mental health issues that a school nurse will have to overcome when addressing these problems. Often establishing a heightened awareness of these disorders within the community will remove some of the stigma related to these disorders, and in turn will encourage youths to be more open and healthy with their thoughts (Hackney, 2009).
Some adolescents however, have been discovered to have self-harmed for years by successfully hiding their injuries, and have shown no signs of a mental disorder (Derouin and Bravender, 2004) that stimulates the necessity to cut. Even if mental problems are not to blame however, the act of self harm is a sign that something is wrong within the youth’s life; self harm often being the outward response to unfavourable circumstances (Griesbach, 2008).
Peer pressure is an all too common part of adolescence. In regards to self-harm, this combined with curiosity and risk taking behaviour will often act as encouragement to “try it” (Derouin and Bravender, 2004). It is important for a school nurse to understand the presence of peer pressure, and be mindful of it when assisting those who have to overcome self-mutilation. Indeed it is necessary to be mindful of all outside social developmental issues when a school nurse attempts to break the cycle of cutting with a patient. (Derouin and Bravender, 2004).
Whilst those who choose to self cut or self mutilate often are not intending to attempt suicide, there can often be a risk. Often they are simply attempting to release extreme anxiety or inner pain, (Derouin and Bravender, 2004). However, there are difficulties when addressing this problem as a school nurse. Those who choose to cut are often less likely to be at risk of suicide than those who harm in a different manner; often their only aim is to release tension, and they are more in control of the damage they are inflicting than other methods. (Griesbach, 2008). However, evidence supports the notion that those who self-harm, will repeatedly self-harm, and in turn this increases their risk of suicide, intended or not (Cleaver, 2007).
It is important to remember that in general young people will see suicide, and self-harm as two very separate things. Unfortunately for a school nurse, the characteristics of those who self-harm and those who intend to commit suicide are often shared (Hawton and James, 2005). Thus it can be a very challenging experience for a School Nurse to identify pupils who self harm who are at risk of suicide in a medium or a short term. It is vital for School Nurses to recognise the differences between the two, and intervene at the earliest possible opportunity, for every case of self-harm. Whilst Suicide is a rare event (NICE, 2004), it is still the third most common cause of death in the adolescent age group. As such any discovery of self-harming should be fully assessed for needs, emotional, psychological and social factors that are specific to the individual case (NICE, 2004) so as to better assess the problem at hand.
There is some debate as to the best method to stop repeated self-harm, and unfortunately there is a lack of good evidence to support one method over another (NICE, 2004). Randomise Control Trials (RCT) are often the premier choice of researching and comparing differing interventions (Harner and Collinson, 2005). There had been positive results found within the realm of group therapy. Wood (2001) found promising results from a study into developmental group psychotherapy, recording a clinically significant difference to favour group therapy above other forms of aftercare and upon this evidence a first line of treatment should be prescribed as group therapy. Unfortunately in contrast to this a recent repetition of the study failed to yield any positive results to suggest that group therapy was a superior treatment (Hazell et al, 2009). As we can see there is a great difficulty in assessing the value of any research into treatment, and the importance of repeating the tests for grounded evidence.
Young people say that they wish to be helped in a way that feels comfortable for them. This is understandable, as they are often discussing a private matter. Private support groups, one on one sessions and drop in services are viewed as particularly helpful (Griesbach, 2008). One of the most important factors is overcoming the negative attitude associated with the disorder; something that is even possessed by the nurses who treat it (Cleaver, 2007). As such it is important to treat the patient with respect and to listen to their problems, even if their roots do not stem from self-harm, but from daily, or emotional issues. Many who have self harmed state that had this service been available to them in the first place, they would not have started their disorder (Mental Health Foundation, 2006, a)
Preventative measures must be taken to address self-harm in all of its forms. A school nurse is positioned at the forefront of these preventative measures, and often can find themselves in the best possible position to assist the youth. However; self harm is a very large, and very complex problem for a school nurse to address, with evidence suggesting nurses to feel overwhelmed and under supported when tackling the issue (Cook and James, 2009). With this in mind, the further education of school nurses to equip them to deal with these issues cannot be disregarded (NICE, 2004).
When preventative measures fail it is good practise to advise people who repeatedly self injure with management techniques such as, how best to deal with scarring, alternative coping strategies, and harm minimalisation techniques (NICE, 2004). This concept is well established in health promotion and has been applied in recent years successfully to both sexual health education and in a reduction of teenage pregnancies (Lesley, 2008). Adolescence is a time for striving for independence, experimenting and taking risks (Lesley, 2008) and this approach of minimising self harm can often be the best approach to tackling those who have already self harmed.
Evidence to suggest an effective treatment is not abundant (NICE, 2004) but to focus on minimising the damage is a pessimistic approach. Certain voluntary organizations advocate the thought “If you feel the need to self harm, focus on staying within the safe limits” (Mind, 2010). Young people want a range of options for self help best suited to them, even if it is something as simple as something to distract themselves from self harm for just a short period of time (Mental Health Foundation, 2006, a). Successful distraction techniques have been known to include using ice instead of cutting, or even marking with a red pen; other means involve simply venting pent up frustration such as by punching a punch bag (Mental Health Foundation, 2006, a) not all reliefs have to be physical, however, and often creative pursuits such as writing, drawing and painting can have a very positive effect (Griesbech, 2008). Often, it is much more constructive to engage in creative rather than destructive behaviour and is even more likely to change behavioural response to self harm (Norman and Ryrie, 2004).
If unavoidable, it is advocated that those who cut use clean, sharp instruments and avoid areas that include veins and arteries (Pengelly, 2008). When advocating this a nurse must consider both the legal and ethical arguments of endorsing any form of self harm (Pengally, 2008). Many do not feel comfortable discussing these minimalisation techniques over the concern that this could be construed as encouragement and leave the nurse vulnerable to backlash (Pengally, 2008). That said, often self harm may be the only control that a young person feels that they have over their lives (Derouin and Bravender, 2004) it is essential for a nurse, when supporting adolescents, to make effective clinical decisions. Ethical dilemmas and diverse situations often arise in this field of medicine and must be balanced with the needs of the patient and community (Bennet, 2008).
Ultimately, when undertaking these decisions, practitioners must consult with the rest of the clinical team and maintain in depth records. Similarly, the decision whether or not to inform the parents raises another ethical question. Inititally, it can damage trust between the nurse and patient in future consultations, however, should a youth be considered mature enough they should be treated as adults and thus given the same level of confidentiality (Hendrick, 2010).
The majority of sources of information within this review is qualitative research which is related to the desire to obtain the opinions of individuals alongside their experiences (Watson et al, 2008). The benefits of qualitative methods are that often a greater wealth of information is obtained, in terms of social and personal experiences and insights than would otherwise be available (Hall, 2006). Unfortunately, there are many criticisms that beset qualitative studies. For instance, many disregard the findings as they are not ecologically valid due to the small sample size (Parahoo, 2006) as such, findings of many studies often only reflect the characteristics of that particular sample as opposed to the diverse population that engage in the act of self harm. Furthermore, it is difficult to justify evidencing qualitative research as often its results are interpretative (Aveyard, 2010) of course, findings can also be affected by the differing assessment methods used to collate the information, such as whether the assessment was done autonomously or if it relied on parental consent.
Harm minimalisation techniques need to be widely available to adolescents who self harm with recognization of the ethical dilemmas, in order to support school nurses within this field of practise. Future literature on the subject also needs to choose its terminology carefully and focus upon one form of self harm rather than generalising. This is the only manner in which a specific treatment can be formulated to address each individual form of self harm allowing nursing to develop appropriate preventative interventions. School nurses should also refer all youths who harm to CAMHS. The presumption that young people that cut are not suicidal or that they do not have mental illness is too high a risk to consider and even though the majority hold neither of these disorders, they can not be overlooked due to the minority that do possess them.
The true extent of self harm or self cutting is very difficult to determine due to the inconsistencies and definition and underreporting that often it goes unnoticed. What can be agreed upon, is that self cutting is an increasing and serious problem among adolescents. School nurses hold a vital role in the management of this disorder and are often at the forefront of any prevention, treatment and education. An understanding of why adolescents self harm and all linked factors are vital for undertaking treatment of a patient. However, this challenge is complex and requires a large amount of training and support; it is very important to avoid any stigma attached to self harming when treating youth, they are often not attention seeking and frequently posess a lot of problems in their lives. Self harm masks underlying emotional, psychological and social trauma and can simply be a youths only outlet to relieve stress and emotional tension. It is undeniable that self harm is a rapidly expanding area of research, however upon reviewing this literature many questions are still left unanswered. There is still the underlying moral and ethical difficulties that a school nurse must consider when supporting those who self harm
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