Research ProposalTask 4

AbstractObjective: This study will explore the sensitive and timely subject of adolescent self-harm and suicide and the ability of RN’s to assist in screening for warning signs and to utilize tools that currently exist that could identify adolescents who are the most at risk. The main objective of this study is to explore the nurse’s perception and the use of suicide risk assessment and screening tools that might help break the suicide cycle.

Background: The third leading cause of death today in the US for Adolescents is suicide and those who have engaged in self-harm behaviors such as cutting and burning themselves are at the greatest risk to carry through with a suicide intent. Despite these alarming facts many adolescents are treated and released from emergency rooms or other facilities following serious self-harm attempts with no mental health intervention.

Review of Literature: A review of the literature surrounding self-harm and suicide among adolescents shows a strong correlation between those who have received mental health care and those who have not been treated. The literature suggest that not all young people who are involved in self-harm have gone on to commit suicide however there is a high incident of self-harm among those who eventually have gone on to complete suicide. Self-harm activities have seeped into the music, poetry and culture of America and even jewelry is widely available with razors and other objects that are used to commit self-harm.

Research Question: The main research question that will be addressed is if nurses are aware of and using the assessment tools that are available that can help to identify those adolescents who are most at risk of suicide who are engaging in self-harm behaviors. Can a nursing intervention be used to identify at risk teenagers and are they being properly used are important questions?

Methods: The study will involve triangulation or “mixed” research to study the prevalence and early detection of adolescent suicide and self-harm. A stratified cross sectional design will be used to gather information for the study. Data for this study will be gathered over the internet for a sampling of RN’s regardless of their specialty. It is the opinion of this researcher that all nurses should be aware of assessment tools and be prepared to use them when an adolescent has any signs that might indicate that they are at risk of or engaging in self-harm. This applies to school nurses, hospital nurses, ER nurses, as well as those involved in home health or anywhere that young people can be found. Data will be analyzed via Chi-square testing to identify if the appropriate tools are being utilized through a quantitative study.

Implications for Nursing:

Nursing staff play a unique role in assessing people upon admission to hospitals or when they need attention at school or in an emergency room. Early nurse assisted recognition of self-destructive behavior can help reduce the near pandemic rate of suicide that presently exists in this country. Additional research and methods to identify those most at risk might be useful and better training on how to assess the existing tools without bias or prejudice is a skill that must be taught to nurses who are beginning their careers or who are currently practicing nurses.

Table of Contents

TOC o “1-3” h z u HYPERLINK l “_Toc366110986” Abstract PAGEREF _Toc366110986 h 2

HYPERLINK l “_Toc366110987” Introduction PAGEREF _Toc366110987 h 6

HYPERLINK l “_Toc366110988” Research Proposal PAGEREF _Toc366110988 h 6

HYPERLINK l “_Toc366110989” Problem Statement PAGEREF _Toc366110989 h 6

HYPERLINK l “_Toc366110990” Review of Literature PAGEREF _Toc366110990 h 7

HYPERLINK l “_Toc366110991” Barriers to the success of a program PAGEREF _Toc366110991 h 10

HYPERLINK l “_Toc366110992” Best practices PAGEREF _Toc366110992 h 10

HYPERLINK l “_Toc366110993” Factors that influence the prevention of adolescent suicide and self-harm PAGEREF _Toc366110993 h 11

HYPERLINK l “_Toc366110994” Barriers to the success of the program PAGEREF _Toc366110994 h 11

HYPERLINK l “_Toc366110995” Best practices PAGEREF _Toc366110995 h 11

HYPERLINK l “_Toc366110996” Research questions PAGEREF _Toc366110996 h 12

HYPERLINK l “_Toc366110997” Research Design PAGEREF _Toc366110997 h 12

HYPERLINK l “_Toc366110998” The appropriateness of triangulation research approach for this study PAGEREF _Toc366110998 h 13

HYPERLINK l “_Toc366110999” Role and Bias of Researcher PAGEREF _Toc366110999 h 13

HYPERLINK l “_Toc366111000” Sampling Techniques PAGEREF _Toc366111000 h 14

HYPERLINK l “_Toc366111001” Appropriateness of Sampling Technique PAGEREF _Toc366111001 h 16

HYPERLINK l “_Toc366111002” Participants PAGEREF _Toc366111002 h 16

HYPERLINK l “_Toc366111003” Data Collection Methods PAGEREF _Toc366111003 h 17

HYPERLINK l “_Toc366111004” Instrument PAGEREF _Toc366111004 h 18

HYPERLINK l “_Toc366111005” Research Procedure PAGEREF _Toc366111005 h 18

HYPERLINK l “_Toc366111006” Data Analysis PAGEREF _Toc366111006 h 19

HYPERLINK l “_Toc366111007” Rationale for Analysis Chosen PAGEREF _Toc366111007 h 22

HYPERLINK l “_Toc366111008” Interpretation of Analysis Results PAGEREF _Toc366111008 h 22

HYPERLINK l “_Toc366111009” Conclusion PAGEREF _Toc366111009 h 23

HYPERLINK l “_Toc366111010” References PAGEREF _Toc366111010 h 25

HYPERLINK l “_Toc366111017” Appendices PAGEREF _Toc366111017 h 29

HYPERLINK l “_Toc366111018” Appendix A PAGEREF _Toc366111018 h 29

HYPERLINK l “_Toc366111019” Consent form PAGEREF _Toc366111019 h 29

HYPERLINK l “_Toc366111020” Appendix B PAGEREF _Toc366111020 h 30

HYPERLINK l “_Toc366111021” A screenshot of the Online Survey Tool (available online at http://www.surveymonkey.com/s/MP29GZN) PAGEREF _Toc366111021 h 30

Introduction

Teenage mortality is an important public health issue because the majority of these deaths are preventable. Suicide is the third leading cause of death among adolescents and it is believed that 14 to 24 percent of teenagers have engaged in self-harm (NIH, 2008). Every two hours in the United States someone under the age of twenty four successfully commits suicide leaving behind a family and a community that is left to wonder why this has happened and also if there were measures that might have been able to prevent the death from happening (ASS, 2013). The purpose of this study is to explore how nurses and other professionals can recognize signs of self-harm and interrupt a cycle that might lead to suicide. Research into how nurses and professionals are coping with this pandemic will be explored. An important question will be how assessment tools can identify at risk youths. Nurses from many fields work with adolescents; these include those who work in clinics, in hospitals, in schools and in psychiatric units. This proposal intends to provide an outlook on how this pandemic can be mitigated through the involvement of nurses and others who work with adolescents. This study will explore the sensitive and timely subject of adolescent self-harm and suicide and the ability of RN’s to assist in screening for warning signs and to utilize tools that currently exist that could identify adolescents who are the most at risk. The main objective of the study is to explore the nurse’s perception of the efficiency of suicide risk assessment and screening tools in breaking the suicide cycle.

Research Proposal

Problem Statement

Adolescent suicide and self-harm are serious sources of concern for public health workers. One of the main problems that have been noted is the general lack of knowledge by nurses on the appropriate assessment tools to be used for identifying at risk teenagers. This research seeks to fill this knowledge gap by seeking the opinions of registered nurses on the current state of the assessment tools and any possible modifications or improvements that should be included. As noted earlier on, teenage mortality is an important public health issue because the majority of these deaths are preventable. Suicide is the third leading cause of death among adolescents and it is believed that 14 to 24 percent of teenagers have engaged in self-harm (NIH, 2008). There is therefore a need for better suicide and self-harm assessment tools to be developed to help in breaking the suicide cycle.

This research will seek to uncover the reason there are so many cases of adolescent suicide and self-harm and why this is a reaching a near pandemic level world- wide. The rate of attempted suicide and cases of self-harm continues to increase on a yearly basis. Although suicide is a potentially preventable problem there do not appear to be enough early are not interventions available. Suicide ranks as the third leading cause of death for youth between the ages of 10 and 24 and 4,600 lives are lost each year due to suicide. (“Suicide Prevention,” 2013)Currently there is speculation as to what the risk factors are but there is no conclusive evidence as to why so many young people are taking their lives. Factors such as bullying, lack of support in the family and peer groups and drug use all appear to be causative factors but there is still a lack of empirical evidence as to how to deal with this growing problem.

Review of Literature

Adolescent suicide and self-harm are serious sources of concern for public health workers. One of the main problems that have been noted is the general lack of knowledge by nurses on the appropriate assessment tools to be used for identifying at risk teenagers. This research seeks to fill this knowledge gap by seeking the opinions of registered nurses on the current state of the assessment tools and any possible modifications or improvements that should be included. As noted earlier on, teenage mortality is an important public health issue because the majority of these deaths are preventable. Suicide is the third leading cause of death among adolescents and it is believed that 14 to 24 percent of teenagers have engaged in self-harm (NIH, 2008). There is therefore a need for better suicide and self-harm assessment tools to be developed to help in breaking the suicide cycle.

This research will seek to uncover the reason there are so many cases of adolescent suicide and self-harm and why this is a reaching a near pandemic level world- wide. The rate of attempted suicide and cases of self-harm continues to increase on a yearly basis. Although suicide is a potentially preventable problem there do not appear to be enough early are not interventions available. Suicide ranks as the third leading cause of death for youth between the ages of 10 and 24 and 4,600 lives are lost each year due to suicide. (“Suicide Prevention,” 2013)

Currently there is speculation as to what the risk factors are but there is no conclusive evidence as to why so many young people are taking their lives. Factors such as bullying, lack of support in the family and peer groups and drug use all appear to be causative factors but there is still a lack of empirical evidence as to how to deal with this growing problem.

While research shows that less than one percent of suicide attempts are successful, the magnitude of suicidal ideation may be tenfold for those who attempt suicide.

Depressed adolescents who isolate and are not close to family or have few friends appear to be at greatest risk. Young people who are bullied also are in great danger of making and following through with threats to commit suicide.

There is evidence to suggest that the use of drugs, such as marijuana can escalate the number of teens who actually carry through with their attempt to commit suicide. Adolescents who have already done self-harm through cutting or burning their body appear to be at a greater risk to follow through with a suicide attempt.

A number of the literary sources reviewed also expounded on home and professional methods and practices that can be put in place to prevent and control the prevalence of suicide and self-harm. Some of the sources that provided the epidemiological causes of self-harm and suicide also went ahead to provide possible solutions to prevent self-harm and suicide among young adults. Best practices identified include psychological treatment, pharmacotherapy, social harmony and a sense of belonging.

Amitai and Apter (2012) unearthed that social harmony; inclusion, and improvement of familial relationships play a significant role in preventing the occurrence of suicide and suicidal occurrences in the family set-up. Albeit the duo acknowledged and lamented on the lack of adequate prevention strategies, they went ahead to propound that strengthening social ties among family members, friends and relatives significantly reduces chances of self-harm and suicidal attempts in basic social set-ups. Bilsker and White (2011) present a study conducted on young adults who self-harm and provide possible means of prevention among different sexes.

Hawton, Saunders, Kate, and O’Connor (2012) and Peterson, Freedenthal, Sheldon, and Andersen (2008) cited psychosocial and pharmacological interventions as strategies that can be engineered towards the prevention of self-harm and suicide. In a study conducted by Hendin, Phillips, Vijayakumar, Pirkis, Wang, Yip, Wasserman, Bertolote, & Fleischmann (2008) social and religious factors were examined in Asia in relation to other continents to provide specific solutions against suicide for the diverse challenges facing young adolescents. This group of sources thus provides possible prevention programs and practices.

There are a number of factors cited as contributing or risk factors for suicidal behavior and self-harm. Demographics are cited to play a critical role in leading to self-harm and suicidal behavior. It is estimated that males are three to five times more likely to have successful suicidal attempts than their female counterparts (Cash and Bridge 2010, and Bilsker and White 2011). Mental illness, depression and psychological disorders are also cited as factors that influences the occurrence of self-harm and suicide (Otsuki, Kim, and Peterson 2010).

The use of drugs and sleeping disorders are also linked to adolescent suicide and self-harm. According to Ours, Williams, Fergusson, & Horwood (2012) the use of cannabis is linked to self-harm and suicidal attempts among certain adolescents. Wong, Brower and Zucker (2011) point out sleeping disorders and effects of having an alcoholic parent as possible causes of self-harm and suicide. The above group of sources thus explicate on the epidemiological causes of self-harm.

Barriers to the success of a programA number of articles cited inadequate research and social disorganization among other factors as the barriers to the prevention of self-harm and suicide. Amitai and Apter (2012) acknowledged and lamented about the lack of adequate prevention methods and practices for self-harm and suicide. The fact that many of these young people are released from the hospital with no mental health steps put into place prior to their release has no doubt contributed to the high level of suicide and an increase in those who self-harm.

Best practicesAmitai and Apter (2012) pointed out social harmony and cohesion and strengthening of social ties as best practices in preventing self-harm and suicide prevalence among adolescents in the domestic set up. The Bullying Statistics website (2009) points out the control of bullying around homes and schools as a way of preventing adolescent suicide and self-harm. Hawton, Saunders, Kate, & O’Connor (2012) and Peterson, Freedenthal, Sheldon, and Andersen (2008) pointed out psychosocial and pharmacological interventions as strategies that can be engineered towards the prevention of self-harm and suicide. These are some of the best practices in controlling and preventing self-harm and suicide among adolescents.

Factors that influence the prevention of adolescent suicide and self-harmAmitai and Apter (2012) pointed out that adolescent self-harm and suicide have adverse social impacts in the social set up and as such, there is need to find prevention methods. Bilsker and White (2011) attach suicide to economic loss and social loss. They introduce an interesting aspect of Potential Years of Life Lost (PYLL) where they opined that there is value lost when a young adult commits suicide hence the need to devise prevention programs to avoid the loss.

Barriers to the success of the programThere are a number of barriers linked to the prevention of self-harm and suicide among adolescents. According to Amitai and Apter (2012), lack of adequate research on the effective prevention methods is the major setback to preventing the prevalence of the near pandemic. Peterson, Freedenthal, Sheldon, and Andersen (2008) stated that self-harm among adolescents has only been recently recognized and as such few randomized studies have been conducted to establish prevention measures.

Best practicesThere are a number of prevention and treatment methods identified to curb the prevalence of self-harm and adolescent suicide. Psychological treatment and pharmacotherapy are examples provided by Hawton, Saunders, Kate, & O’Connor (2012) and Peterson, Freedenthal, Sheldon, and Andersen (2008). Amitai and Apter (2012) on the other hand emphasize the need for strengthening social ties and familial relationship and creating a sense of belonging.

Research questionsThe main research questions that will be addressed are:

1. What is the efficiency of suicide risk assessment and screening tools in breaking the suicide cycle?

2. What is the efficiency of self-harm assessment and screening tools in breaking the suicide cycle?

3. Can a nursing intervention such as the use of appropriate assessment tools be used to identify at risk teenagers and are these being used by professionals who are working with adolescents.

Research DesignIn this proposed study, a triangulation or ‘mixed’ research method will be used as a methodological framework for quantitatively studying prevalence and early detection of adolescent suicide and self-harm. Ideally, the study will be a quantitative research study that intends to use both primary and secondary research methods (triangulation) to accomplish its purpose. As noted by Hawton, Saunders and O’Connor (2012), self-harm and suicide are significant sources of public health problems in our nation’s adolescents with self-harm statistics being high among teenagers and suicide rates being noted as the third most prevalent cause of death among American teenagers (NIH, 2008). The triangulation research design will help us in exploring self-harm and suicide and evaluate how nurses and other professionals can recognize signs of self-harm and interrupt a cycle that might lead to suicide; which is the purpose of this study. Hussein (2009) noted that triangulation is a concept that is defined as the application of several qualitative and quantitative techniques in studying a common phenomenon for the sole purpose of increasing the credibility and validity of the study. The primary research will be conducted by means of an online self-administered survey.

The appropriateness of triangulation research approach for this studyResearchers have always argued that a good research practice often involves the utilization of multiple methods in order to enhance both the validity and reliability the research findings as indicated in the work of (Mathison, 1988).The choice of triangulation as the appropriate research design is inspired by the fact that helps in achieving improved clarity, research completeness and validity as noted by Fielding and Fielding (1986). According to Knafle and Gallo (1995), triangulation technique contributes to the overall quality of a research ‘only to the extent that it facilitates the achievement of some clearly articulated purpose’ (cited in Adami and Kiger, 2005). The convenience of triangulation in nursing research for confirmatory purposes is noted by Adami and Kiger (2005) to be heavily dependent on the principle that research should be a rigorous search for absolute and objective truth. Validity and completeness of findings on how nurses and other professionals can recognize signs of self-harm and interrupt a cycle that might lead to suicide are therefore our motivation for choosing triangulation technique for this study. The overarching objective of this study is to find ways of minimizing mortality and injury due to teenage self-harm and suicide among the American youths. This must be done with the highest level of clarity, validity, and completeness that can only be achieved by means of triangulation.

Role and Bias of ResearcherThe role of the researcher in this study will be to investigate by means of credible sources and latest information, the role of nurse-assisted early detection of adolescent suicide and self-harm in order to interrupt the deadly cycle that leads to suicide. This would be done by the formulation of objective research question and following a research methodology that is accurate, valid and free of any bias.

Bias is defined by Sica (2006) to be a type of systematic error that can ultimately influence scientific investigations and hence distort the overall measurement process. Panucci and Wilkins (2010) noted that the identification and avoidance of bias is the sole responsibility of the researcher. In order to avoid researcher bias, I will ensure that I formulate research questions that are not too leading. As a researcher, I recognize that I will be interviewing nurses who have already had experience with young people who might be prone to self-harm or suicide. It will be necessary to develop a suitable survey to allow for those with different experiences to ensure that the data is without bias. The survey needs to be refined to eliminate bias from those who might have considerable experience with adolescents who have followed through from self-harm, to completion of suicide. A potential bias or error in the survey can be recognized by realizing that individuals with more experience who are interviewed would be more inclined to take adolescents threats more seriously than those with only casual experience who might hear the adolescents concerns but might see them as maneuvers to get attention from parents or school authorities.

Sampling TechniquesThis research will employ a random stratified sampling strategy. The sample population will be stratified according to state of residence, age, gender, and type or nature of nursing career where they are engaged. The respondents will selected from sample pool of willing online participants who will answer to our request form participation in our online survey. The participants will be given an informed consent form (Appendix A). The same questions will be given to all participants. In other words, the sample pool will be derived from various nursing website via their social media portals (Facebook and Twitter accounts) of the following websites:

Facebook WGU- RN to MSN Discussion Group

-www.allnurses.com

-www.nursezone.com

-www.nurse.com

-www.medicalnewstoday.com

-www.internurse.com

-www.medscape.com

-www.nursingtimes.net

-www.nurselinkup.com

-www.nurseweek.com

Additionally, the research will involve professionals who have had experience with adolescents who might have suggested intent to self-harm or commit suicide. A routine Google search will bring up an abundance of websites that are dedicated to helping those who are feeling suicidal. These range from the US Governments Suicide prevention hotline to private groups dedicated to those with specific issues who have volunteers who have survived self-harm or suicidal intent and are now working with others, two such groups are To Write Love On Her Arms and Laura’s Playground have RN’s who actively volunteer to assist adolescents. These websites are dedicated to helping youth who are struggling with suicidal thoughts. Through stratified sampling of professional nurses there will be greater precision as to how to interpret assessments and which set of youth are at greatest risk and how to follow through to help adolescents with self-harm history or who have attempted suicide.

Appropriateness of Sampling TechniqueThe choice for stratified random sampling for this research is inspired by its ability to reduce all forms of human bias in the process of selecting participants to be included in the sample. As a consequence stratified random sample can provide us with a study sample that is highly representative (Daniel, 2011, p.127). This technique also improves the degree of representation of certain groups within a given population (such as nurses who deal with stresses out teens). This means that it ensures that a given strata is not over-represented. This method reduces the sampling error since population statistics estimates are drawn from a known population. Our sampling will be of nurses and professionals working in the field to see if the appropriate tools are being used to identify those who are at the most risk. This would be a stratified sampling that will include professionals who have previous knowledge of adolescents through their own studies, personal lives, and work experiences.

In the case of secondary data, the sources will be derived from peer-reviewed journal articles, books, whitepapers, personal experiences, online and offline articles, newspapers and conference papers. Only the most relevant and most credible sources will be included in this research. In order to choose the most relevant and credible secondary sources, an elaborate strategy aimed at authenticity, credibility, representativeness and meaning was used as described in the work of Scott (1990). All the sources will be evaluated for currency (must be up to date) (Stein, 2002).

ParticipantsThe target audience will be nurses who work in all areas of nursing and are not limited to those who are working with youths. The benefit of working with all nurses, regardless of their chosen field is to determine if the adequate tools are in place to identify if a child is at risk or if better screening needs to be in place. The volunteers who are already working with adolescents appear to be ready and willing to co-operate to help identify how additional methods can be identified to assist with this crisis. Nurses are on the frontline of suicide prevention and identifying adolescents who are at risk. The participants’ gender will be both male and female and can include those who have worked with adolescents and nurses who are working in all fields.

Data Collection MethodsThe primary data to be used in this study will be collected by means of an online survey. The primary data collection tool will be an online survey that will be developed and hosted by SurveyMonkey Audience (www.surveymonkey.com). Survey Monkey is a specialized data abstraction tool that will be used for both data collection and analysis. Our choice of online survey as the primary data collection methods is inspired by the fact that communication researchers have found out that the internet is an excellent domain for carrying out survey research (Wright, 2005). Virtual nursing communities are the latest emerging way of innovative teaching application within the context of nursing education (Giddens et al, 2010). Thousands of individuals regularly take part in nursing-related discussions on almost every type of conceivable interest and issue (Wellman & Haythornthwaite, 2002).

The main aim of the survey will be to gauge the experiences and opinions of registered nurses (RNs) on issues of self-harm and suicide among teenagers. More specifically, it will gauge their awareness on the available screening options that can help in the identification of youth at risk. Their opinions on the adequacy and inadequacy of these screening/ assessment tools will also be sort. The survey will have ten questions. (Appendix B).

Data Description

The questions posed to the participants will include age, gender, state of residence, level of education, years at current job, and knowledge of tools that are available to assess adolescents as well as frequency of use.

InstrumentThe instrument that will be used for data collection is a survey tool. Questionnaires or surveys are specialized instruments used in collecting data during survey research. These tools include a set of rather standardized questions that are meant for exploring a specific topic as well as collecting other information about opinions, demographics, behaviors, and attitudes. In this study, a popular online survey program (Survey Monkey) will be used to gauge the experiences and opinions of registered nurses (RNs) on issues of self-harm and suicide among teenagers. More specifically, it will gauge their awareness on the available screening options that can help in the identification of youth at risk. The use of standardized survey instruments in gauging the perception of care by patient and caregivers is not new (Nicholas et al., 2005). In this study, survey instrument will be used to collect demographic information from registered nurses as well as their perceptions or opinions of the efficacy of suicide risk assessment tools used on teenagers.

Research ProcedureThis research will begin with the design of the online survey. The survey in this study will involve the design and use of online questionnaires. The design of the survey will begin by the development of a collection or bank of question items that will be suitable for answering the required research questions. The design as well as development of the survey instrument will involve six distinct steps or stages. The initial step will involve the examination of any existing models for suicide and self-harm evaluation by physicians and nurses. The second stage will involve the extrapolation of the essential items from the existing models for suicide and self-harm evaluation by physicians and nurses. The third stage will involve the examination of extant literature that reported the application of questionnaires in the evaluation of mental conditions (suicide and self-harm in particular). The fourth stage will involve the development of the criteria that was derived from the existing models for suicide and self-harm evaluation by physicians and nurses. The fifth stage will involve the design and construction of the online questionnaires to be administered to the target audience (Registered Nurses) via the appropriate channels. The fifth step will involve the piloting and revision of the questionnaires. The survey will be deployed only after being granted through the IRB board at Western Governors University (Tappen, 2011).

Data AnalysisThe primary data collection tool will be an online survey that will be developed and hosted by SurveyMonkey (www.surveymonkey.com). SurveyMonkey® is a specialized data abstraction tool that will be used for both data collection and analysis. My choice of an online survey as the primary data collection methods is inspired by the fact that communication researchers have found that the internet is an excellent domain for carrying out survey research (Wright, 2005). Virtual nursing communities are the latest emerging wa