Cyberbullying Help Young Patients Maintain Mental and Overall Health by Using Orem’S Self-Care Deficit Theory to Guide Interventions

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Caring for adolescents experiencing cyberbullying Help young patients maintain mental and overall health by using Orem’s self-care deficit theory to guide interventions.

By Jesse Edward Florang, EdD, MSE, LIMHP, PLADC

Cyberbullying—a form of bullying else.” In the past year, 15% of high- that takes place over digital devices— school students reported being cyber- is a growing phenomenon impacting bullied; 55.2% of LGBTQ students adolescents during a crucial time of indicated that they’ve experienced social, cognitive, and emotional devel- cyberbullying. opment. According to StopBullying. This behavior is associated with nega- gov, cyberbullying includes “sending, tive mental health outcomes, including

posting, or sharing negative, harmful, depression, anxiety, substance abuse, ZANA UKR / SHUTTERSTOCK false, or mean content about someone and suicidal behavior. In fact, recent

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research highlights the high prevalence What does cyberbullying look like? of cyberbullying among adolescents Cyberbullying can occur on several admitted to inpatient psychiatric facili- different public and private platforms, ties. Unmistakably, cyberbullying has but generally takes place through email, created new mental health and safety messaging, websites, or social media concerns for the adolescent population. sites. Various methods of cyberbullying For this reason, all nurses working with exist, including posting embarrassing adolescents should have continuing edu- photos or videos on social media, ha- cation on the impact of cyberbullying on rassment, “flaming” (sending direct these at-risk patients. messages or insults on a public plat- This article presents Dorothea Orem’s form), “doxing” (posting private or self-care deficit theory as a framework identifying information on the internet for nurses to identify, support, and treat without an individual’s consent), or adolescent victims of cyberbullying. exclusion. www.NursingMadeIncrediblyEasy.com May/June 2019 Nursing made Incredibly Easy! 35

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. At a time when adolescents are seeking withdrawal, loss of motivation, change in independence, cyberbullying has created routine, truancy, poor grades, loss of new stressors with which some teenagers appetite, or changes in social activities. are unable to appropriately cope. Although Additional signs of cyberbullying may somewhat similar to traditional bullying, include secretive or obsessive online there’s no option of fighting the aggressor behavior and/or mood changes revolving or running for safety. Although cyberbully- around access to technology. ing can be perpetrated anonymously, most victims report that they know their attack- Where we’ve gone wrong ers and have also experienced some form Unfortunately, previous attempts to help of traditional bullying. In these situations, adolescents cope with cyberbullying have cyberbullying is often viewed as an exten- led to some unintended negative conse- sion of traditional bullying. quences, such as adolescents lacking the Healthcare providers should be pre- confidence that it can be stopped. For ex- pared to identify signs and symptoms of ample, a person with little knowledge cyberbullying that may go unnoticed dur- about cyberbullying may tell an adoles- ing current physical and mental health cent to report it to an adult. But parents assessment procedures. By successfully and school officials are often unprepared identifying an adolescent experiencing and/or lack the knowledge necessary to cyberbullying, we can help develop an appropriately intervene when cyberbully- appropriate treatment plan specifically ing is reported (see Tips for parents and designed to develop independent self-care school officials). skills. Symptoms of cyberbullying may What happens when the adolescent take the form of depression or anxiety. tells an adult and the cyberbullying Warning signs may include isolation, continues? Furthermore, what happens

Tips for parents and school officials

• Increase social media involvement, • Don’t maximize or catastrophize the impact of awareness, and knowledge, and be aware cyberbullying. of current trends. • Reinforce helping strategies that don’t include • Monitor adolescents’ time spent online at punishment (removing technology or deleting home or in class. social media accounts). • Monitor adolescents’ mood, looking for • Create a positive culture among students sudden shifts that revolve around technol- where everyone is prepared to intervene when ogy, such as withdrawal, isolation, loss of cyberbullying occurs. motivation, change in routine, change in • Develop cyberbullying action plans and safety friends, refusal to communicate, change in plans. social activities, change in diet, and change • Advocate for cyberbullying policy development in hygiene. (schools, legal, healthcare, and social media • Ask about cyberbullying, foster open com- providers). munication, and acknowledge that you • Teach, practice, role play, and model understand the circumstances and severity. appropriate cyber-regulation skills. • Don’t ignore, minimize, or avoid addressing • Reward appropriate responses to issues related to cyberbullying. cyberbullying.

For more information, see the StopBullying.gov factsheet Parents and Providers: Partnering with Healthcare Providers to Respond to Bullying at www.stopbullying.gov/sites/default/files/2017-10/ parents-and-providers-partnering-with-healthcare-provider-fact-sheet.pdf.

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Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. consider this Ted, 37, comes to the ED with his daughter, • reinforce that you want to help her and not Harper, 17, and reports that his other daughter, isolate her further by removing access to Emma, 15, is unable to get out of the car because technology or recommending the deletion of she’s having trouble breathing and has been her social media accounts. crying all day. Emergency responders assist • obtain further information about the cyberbul- Emma into the ED and begin routine questions. lying that’s occurring and make appropriate Following the standard assessments and routine reports depending on the type of cyberbullying. care, physical concerns are quickly ruled out. • help Emma and her family develop an individu- Upon further review, it’s determined that Emma alized action plan on how to respond next time is most likely experiencing a panic attack due to she experiences cyberbullying, including cop- severe anxiety. As the assessment continues, it ing and reporting skills. becomes evident that Emma has also been expe- • assist her with identifying supportive people riencing depression for the last few months and whom she can safely talk to about cyberbullying. you overhear her sister say the cause is due to • aid her in identifying specific places she can go some “stupid stuff going on online.” where she feels safe from cyberbullying. To assist the family in developing an individu- • educate her father and sister about how to alized treatment plan aimed at Emma’s self-care support Emma. deficits regarding her ability to cope with cyber- • provide referrals to a counselor and/or a physi- bullying, ensuring that she and her family have cian who understands cyberbullying and will the skills and information necessary to foster help Emma develop independent self-care self-care independence after they leave the ED, through the implementation of social and cop- you: ing skills. • acknowledge that cyberbullying is a legiti- • refer Emma and her family to community mate concern and assure Emma that you resources, agencies, organizations, or groups want to help. that provide support to adolescents. when the adolescent reports cyberbully- cyberbullying, their peers still have access ing and adults take away his or her to a permanent piece of social media that access to social media in an attempt to casts them in a negative light. And in protect the adolescent? Much of the cases where adolescents have their social younger generation’s social interactions media access taken away, not only do vic- occur online so, in a sense, reporting tims feel like they’ve been penalized, but cyberbullying to an adult has led to vic- also that their social media reputation tims feeling like they’re being punished remains tarnished. and essentially cut off from social inter- Negative interventions that promote action. If reporting cyberbullying to an dependence and/or hopelessness include: adult leads to loss of social media access, • telling adolescents to ignore adolescents will be less likely to seek cyberbullying adult assistance. • encouraging adolescents to rely solely Adolescents may also be told to just on adult intervention ignore cyberbullying. But what happens • instructing adolescents to delete all when they can’t ignore it? Additionally, their social media accounts the difficulty of removing or deleting • advising parents/guardians to remove information online makes ignoring cyber- adolescents’ access to technology and so- bullying unrealistic, especially with the cial media ability to save, forward, and download • minimizing the impact that cyberbully- negative social media posts. Even if ing has on emotional development and adolescents do attempt to ignore mental health www.NursingMadeIncrediblyEasy.com May/June 2019 Nursing made Incredibly Easy! 37

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. • accepting that cyberbullying is just a further their understanding of this chronic part of adolescence condition, practice self-care skills, develop • avoiding accepting that cyberbully- individualized plans, connect with com- ing is a school, home, and healthcare munity support and resources, and ac- problem. quire the tools necessary to monitor their health independently. There are times Self-care deficit theory when these patients may need further Dorothea Orem’s self-care deficit theory outpatient or inpatient help to overcome contains three core parts: self-care, self- self-care deficits, but ultimately the care deficits, and nursing systems or goal is to teach the skills necessary to interventions. be independently successful. A similar Self-care entails deliberate actions nursing approach should be utilized for necessary for healthy functioning and cyberbullying. cognitive development. When individu- It’s clear to see why many adolescents Provide als are unable to meet their own self-care feel so hopeless once they experience adolescents needs in specific areas, these areas cyberbullying. They don’t have the power with the skills become self-care deficits. According to to stop it or the skills to cope with it, and Orem’s theory, nursing professionals the adults in their life don’t have the and resources must help patients identify and priori- knowledge to understand it or at times to seek out tize unmet self-care needs and then even acknowledge it. Patient-centered, supportive select appropriate methods to help them recovery-focused nursing care should overcome or compensate for their self- acknowledge that cyberbullying has hap- people and care deficits. pened, recognize cyberbullying’s nega- problem- When applying this theory to cyber- tive impact, and teach the self-care skills solve through bullying, nursing interventions should necessary to respond to cyberbullying aim to help adolescents meet their self- and restore overall health. Fostering self- difﬁ cult care needs and foster self-care indepen- care independence doesn’t mean that situations. dence in coping with cyberbullying. As adolescents need to face cyberbullying discussed earlier, previous attempts to alone; rather, we should provide them help adolescents cope with cyberbullying with the skills and resources necessary to have created more dependence on adults, seek out supportive people and problem- in contrast to the goal of Orem’s theory, solve through difficult situations. which seeks self-care independence. By Positive nursing interventions to pro- following Orem’s self-care deficit theory, mote self-care independence include: nursing professionals can encourage • Educate adolescents and families deliberate actions designed to help ado- about cyberbullying and its negative lescents and groups of adolescents outcomes. change conditions in themselves and • Deliver individualized, patient- their environment. centered, and recovery-focused care. • Teach adolescents the skills necessary to How do we start? improve conditions in themselves and But how do nurses intervene in something their environment. we’ve never experienced and may not • Instruct adolescents in positive, thera- fully understand ourselves? First, we get peutic coping skills to improve self- further education and pass that education esteem and self-perceptions (see Positive on to our patients and their families. For coping skills). example, although many nurses have • Guide adolescents to implement con- never experienced diabetes, we have the structive actions and deliberate planned knowledge necessary to help patients activities to promote overall health.

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Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. • Provide referrals to counselors and therapists in the community who’ll help Positive coping skills build a social support system conducive It’s essential to provide adolescents and to self-care independence. families with the strategies necessary to • Help adolescents develop action plans develop independent self-care regarding and safety plans in response to negative cyberbullying. emotions associated with cyberbullying Social skills (see Action and safety plans). • Relationship skills • Offer appropriate bystander skill train- • Communication skills ing to adolescents and families. • Bystander skills Putting it all together • Cyber-regulation (what’s appropriate online Cyberbullying is a new phenomenon that and how to handle negative interactions) infringes on basic adolescent needs. Un- Coping skills like typical adolescent turmoil, when it • Internal: for example, meditation, counting comes to cyberbullying, adolescents are backwards, or positive reframing unable to utilize their inborn “fight or • External: for example, exercise, music, read- flight” response. According to Maslow’s ing, or painting hierarchy of needs, safety is a basic need Supportive people that humans must have to be healthy and • Identify people who are safe for the adoles- reach their full potential. According to cent to talk to about cyberbullying: for exam- Maslow, safety must be established be- ple, a teacher, principal, school counselor, or fore adolescents can fully develop their social worker; friend; family member; pastor; psychological needs, including relation- coach; physician; or mentor ships, friendships, love, and belonging. If Supportive places adolescents don’t feel safe, healthcare • Identify specific places an adolescent can providers must be prepared to provide go and feel safe from cyberbullying to utilize interventions designed to ensure safety. self-care strategies Due to its high prevalence among teenagers, cyberbullying should be added Primary nursing interventions should to all initial nursing assessments. If we include the identification and implemen- don’t directly ask, adolescents may not tation of coping skills, the development of tell us. By updating healthcare assess- action and safety plans, recognizing sup- ments and nursing screening tools to portive people, and utilizing safe places. include cyberbullying, we can acknowl- Adolescents experiencing cyberbullying edge that cyberbullying is occurring, pro- may find it helpful to use a journal to mote a safe environment, and pinpoint identify, implement, and practice coping where self-care deficits exist. skills. To facilitate safe environments, healthcare providers must be willing to gather A healthy future specific information related to cyberbully- Orem’s self-care deficit theory provides a ing, which may pose immediate safety framework for nurses to help adolescents concerns for adolescents similar to abuse cope with cyberbullying to reduce the or neglect. Before self-care deficits can be likelihood of developing negative mental rectified, adolescents must feel safe. Once health outcomes, such as depression, cyberbullying is addressed and adoles- anxiety, substance abuse, and suicidal cents feel safe, appropriate nursing inter- behavior. Through assessment and ventions can help them reach independent identification of self-care deficits, we can self-care. teach our adolescent patients how to www.NursingMadeIncrediblyEasy.com May/June 2019 Nursing made Incredibly Easy! 39

Helping adolescents develop action plans and/or safety plans is one nursing intervention to help foster independent self-care. Although these plans are similar, they serve a different purpose in pre- paring adolescents to appropriately handle negative situations. You can help adolescent patients and their families fill out these simple templates to provide a road map to appropriate self-care strategies. Having a pre-established plan will ultimately help adolescents make independent self-care decisions and remain safe during negative online interactions. An action plan is an individualized plan that details specific action steps an adolescent will take in the event he or she experiences/witnesses cyberbullying. This proactive approach serves as a self- care tool when negative online interactions occur. Sample action plan

If you witness or experience cyberbullying

Who will you report it to? Where are your safe places? 1.______1.______2.______2.______

What are your coping skills? Internal 1.______2.______External 1.______2.______

A safety plan is an individualized plan that details specific steps an adolescent will take in the event he or she feels unsafe. Sample safety plan

If you feel like harming yourself or others

Contact Where are your safe places? 1. 911 1. Hospital/ED 2. 1-800-273-8255 National Suicide 2. Counselor’s office Prevention Lifeline 3. Mental health counselor

What are your coping skills? Internal 1.______2.______External 1.______2.______

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Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. appropriately cope with cyberbullying, Orem DE. Nursing: Concepts of Practice. 5th ed. St. Louis, aid in the creation of action and safety MO: Mosby; 1995. PACER’s National Bullying Prevention Center. plans, and provide professional referrals Cyberbullying. www.pacer.org/bullying/resources/ to assist them with developing self-care cyberbullying. independence. ■ Saleem Punjani N. Comparison and contrast of Orem’s self-care theory and Roy’s adaption model. J Nurs. 2013;3(1):1-5. REFERENCES Seed MS, Torkelson DJ. Beginning the recovery journey CHI Health. Research looks at cyberbullying and ado- in acute psychiatric care: using concepts from Orem’s lescents. 2018. www.chihealth.com/en/about-us/press- self-care deficit nursing theory. Iss Mental Health Nurs. room/publications/microscope/micro-research/research- 2012;33(6):394-398. looks-at-cyberbullying-and-adolescents.html. StopBullying.gov. Facts about bullying. 2017. www. Cyberbullying Research Center. www.cyberbullying.org. stopbullying.gov/media/facts/index.html#stats. Denyes M. Orem’s model used for health promotion: StopBullying.gov. What is cyberbullying. www.stop directions from research. Adv Nurs Sci. 1988;11(1):13-21. bullying.gov/cyberbullying/what-is-it/index.html. Florang JE. Live Alive Mental Health: An Interactive Coping Wagnild G, Rodriguez W, Pritchett G. Orem’s self-care Skill Journal. Columbia; SC: CreateSpace; 2017. theory: a tool for education and practice. J Nurs Educ. 1987;26(8):342-343. Florang JE, Jensen LW, Goetz SB. Cyberbullying and depression among adolescents in an acute inpatient psychiatric hospital. Adolesc Psychiatry. 2018;8(2):133-139. Jesse Edward Florang is an Adjunct Faculty Advisor and Grando V. A self-care deficit nursing theory practice Dissertation Committee Member at Franklin University in Columbus, model for advanced practice psychiatric/mental health Ohio. nursing. Self-Care Dependent-Care Nurs. 2005;13(1):4-8.

Link for Counselors. Cyberbullying guide. 2018. www. The author and planners have disclosed no potential conflicts of linkforcounselors.com/cyberbullying-guide. interest, financial or otherwise. Moore JE, Beckwitt AE. Children with cancer and their parents: self-care and dependent-care practices. Iss Comp Pediatr Nurs. 2004;27(1):1-17. DOI-10.1097/01.NME.0000554599.83607.d7

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INSTRUCTIONS Caring for adolescents experiencing cyberbullying TEST INSTRUCTIONS PROVIDER ACCREDITATION • Read the article. The test for this CE activity is to be taken online at Lippincott Professional Development will award 1.0 contact www.nursingcenter.com/CE/nmie. Tests can no longer be mailed or hour for this continuing nursing education activity. faxed. Lippincott Professional Development is accredited as a • You’ll need to create (it’s free!) and log in to your personal CE Planner provider of continuing nursing education by the American account before taking online tests. Your planner will keep track of all your Nurses Credentialing Center’s Commission on Accreditation. Lippincott Professional Development online CE activities for you. This activity is also provider approved by the California • There’s only one correct answer for each question. A passing score for this Board of Registered Nursing, Provider Number CEP 11749 for test is 13 correct answers. If you pass, you can print your certificate of earned 1.0 contact hour. Lippincott Professional Development is also contact hours and access the answer key. If you fail, you have the option of an approved provider of continuing nursing education by the taking the test again at no additional cost. District of Columbia, Georgia, and Florida, CE Broker #50-1223. • For questions, contact Lippincott Professional Development: 1-800-787-8985. Your certificate is valid in all states. • Registration deadline is March 5, 2021. Payment: The registration fee for this test is $12.95. www.NursingMadeIncrediblyEasy.com May/June 2019 Nursing made Incredibly Easy! 41