Lynda Holt

Chapter Contents

Introduction

Adolescents represent only a small percentage of the total number of patients seen in Emergency Departments (EDs). Their care, however, needs to be specialized and related to their individual stage of development. This chapter will highlight the common areas of adolescent development, such as risk-taking behaviour, and explore them in relation to ED attendance. Sensation-seeking, leading to potentially deviant behaviour such as violent acts, substance misuse and self-harm, will also be considered, as will the generic effects of illness and injury on adolescents. The impact of caring for adolescents on ED nurses will also be examined. Optimum care environments and appropriate nursing skills will be discussed with regard to the quality of service offered to adolescents attending ED.

Adolescent development

The research on adolescent development is vast (Erikson 1965, Croghan 2005, Lerner & Steinberg 2009). An understanding of adolescent development is essential for ED nurses in their daily practice. Adolescence is a period in the life span where the individual, previously dependent on parents and carers for his values and identity, becomes independent and, in this move towards independence, attempts to establish a new and personal identity. The key factors in this process appear to relate to the onset of puberty, i.e., the physical and emotional changes leading to sexual maturity (Bickley & Szilagyi 2003, Tortora & Grabowski 2003), and the need for independence (Smetana 2011).

Cognitively, adolescents are capable of abstract thought and understand many variables within a situation. They should also be able to understand the consequences of their actions (Bernardo & Schenkel 1995). It is a period where group identity is vital, a time of experimentation with self-image, and a time to question fundamental family values. Adolescents are pushing for independence, testing the boundaries of their existing life and, importantly, hoping to find boundaries that will aid the development of their future identity (Croghan 2005, Damon & Lerner 2008).

Caring for the adolescent in the ED

As a client group, adolescents are considered difficult to care for by the majority of nurses (Holt 1993). In the ED, many causes of adolescent attendance can be viewed as self-inflicted, e.g., as a result of alcohol or substance testing, which may render ED nurses less compassionate towards the patient. Although less an issue than before due to the ageing nursing workforce, caring for adolescents presents a particular challenge, as many nurses are just emerging from adolescence themselves. To the adolescent, these nurses may represent a more realistic role model, enhancing the opportunity for health education. This is particularly pertinent to ED nurses because there is a greater likelihood of interaction with this age group at a time when they are physically and emotionally vulnerable.

Providing ED nurses with a better idea of the process of adolescence may equip them more satisfactorily to meet their patients’ needs, which will enable them to recognize normal behaviour instead of reacting to it (Holt 1993).

Nurses are generally less aware of teenagers’ needs than those of other age groups. In the ED, adult care is the most familiar and, because of the associated anxiety, paediatric care is more often discussed or taught. An understanding of adolescent development could help nurses in EDs to provide holistic care. It would also enable nurses to rationalize behaviour such as rebellion, non-conformity, antagonism and paranoia, which is frequently demonstrated in hospital, but is arguably the normal behaviour for an adolescent whose independence has been threatened by illness or injury.

Hospital staff, particularly in EDs, are quick to meet the physical needs of these patients, such as maintaining a safe environment for the drunken teenager or arresting haemorrhage in a patient with slashed wrists, but often with little regard to their emotional needs (Kuykendall 1989). An understanding of these needs, however, could reduce the risk of confrontation and diminish any perceived power struggle. The question for ED nurses is how far these needs can be facilitated within an ED without compromising the care or well-being of others in the environment. When young people are asked why they do not use health services they admit to feeling intimidated by both the service and the service providers, they dislike the times and locations, and are concerned about confidentiality and trust (Croghan et al. 2004, Croghan 2005).

As with all patients, initial assessment is the key to forming a therapeutic relationship, and the adolescent’s response to illness and possible treatment can be quickly gauged, as well as existing coping strategies. Privacy has an important effect on the adolescent because of the significance of self-image; for instance, a wound assessment takes seconds but can cause great embarrassment. Ensuring privacy increases self-esteem and reinforces the adolescent’s importance as an individual. Independence is often threatened by hospitalization, even a short period in ED. Including the patient in the care planning and decision-making reduces non-compliance and aggressive behaviour. Separation is greatly underestimated as a stress for the adolescent. While they demand peer belonging and demonstrate independence, most need and want parental support. Parents themselves often underestimate the support needed and the fears of adolescents. This may be because of swift medical and nursing intervention aimed at promoting physical well-being. While ED nurses are quick to include the parents of a sick child, perhaps, because of the demonstrated independence of adolescents, this inclusion is often overlooked.

The adolescent patient needs to assert his independence, but is not yet ready to cope with the implications of this. In ‘crisis’ situations, as a visit to an ED is often perceived, the ED nurse may be in a position of setting boundaries for the patient. This is not a negative action as it provides the security the adolescent indirectly seeks. All too often, however, on a busy shift, in a packed waiting room, antagonistic behaviour is allowed to escalate into confrontation, often because cues for boundaries have not been recognized by ED nurses inexperienced in adolescent development. Consistency among staff is essential. Boundaries for acceptable behaviour should be decided as a matter of policy, and this should be made clear to patients on admission while respecting their independence and individuality. In addition, Knight & Rush (1998) argue that waiting rooms should be made more ‘user-friendly’ for adolescents, ideally incorporating separate waiting and treatment areas.

Illness or injury often induces developmental regression, forces the adolescent out of his peer group and imposes a fear of rejection. Even in a short admission to ED, nurses need to work towards reducing this anxiety. It is paramount for adolescents to be cared for by staff who are comfortable with them, and can behave as adults, listening to them and respecting their needs. Adolescents are not children and, especially at times of high stress, do not respond well to being railroaded by ED personnel who are threatened or irritated by their behaviour.

Personal fable

Despite the upheaval and trauma of adolescence during this life phase, mortality is at its lowest, with the top cause of death being accident-related (Department of Health 2004). An important cause of accident in adolescence is risk-taking behaviour, not just risky sports, but minor law infringement such as failure to wear a safety belt, exceeding speed limits and experimentation with alcohol and illegal substances (Bellis et al. 2005).

A possible explanation of this is the concept of personal fable (Elkind 1967, Pahlke et al. 2010), a belief that despite risk-taking behaviour they will not be affected by life’s difficulties. This has both a positive and a negative function, and represents normal cognitive development. Positively, it allows goals to be believed in and attainable, such as dreams of success. Its negative function is that it induces risk-taking behaviour. Normally, consequences of actions are considered, but personal fable gives the security of invulnerability to consequences. This is not unique to adolescents; witness, for example, smoking and lung cancer in older people (Winkenstein 1992).

Personal fable affects not only conformity with perceived authority, but also with chronic illnesses, such as diabetes. Thinking of himself or herself as the centre of attention, the adolescent comes to believe that it is because he or she is special and unique (Alberts et al. 2007).

It is important for ED nurses to understand this concept in order to intervene in the risk-taking behaviour that can result in an ED attendance. Personal fable is there to protect the self-concept at the vulnerable time of adolescence. It allows conformity with peers despite negative consequences; for instance, the diabetic patient who presents in ED with hypoglycaemia because he has been drinking to conform with peers. The patient can ‘blot out’ the likely hypoglycaemic attack because being the same is more important. Education and support from ED nurses who understand that this behaviour is not intended to be self-destructive, but is normal adolescent experimentation, can reduce the risk of further occurrence. This perception of invulnerability may contribute to the statistic that the largest cause of adolescent death is from risk-taking – in cars, with fire arms, in water and with toxic substances. Sensitive questioning helps adolescents expose their personal myth, recognize their irrationality and induce a change in behaviour.

Risk-taking behaviour

Most common behaviours evolve from experimentation with alcohol, solvents or drugs, but it can be hard for the busy ED nurse to accept the drunk who is abusive as ‘normal’ when his behaviour is disruptive and difficult to contain. The majority of adolescents who attend ED with drug- or alcohol-related problems are not abusive, and are there because of an injury or illness related to their risk-taking behaviour. These individuals often present with their peer groups and engage in sensation-seeking behaviour, which can appear threatening to ED nurses. Adequate staffing levels and nurse skill mix, with appropriate back-up such as security officers and an incident alarm, should be available. Sensation-seeking is a normal need for experimentation and new experiences, and adolescents are prepared to take physical and social risks to attain these (Barker 1988). Despite risk-taking and sensation-seeking, most adolescents maintain conventional modes of behaviour and deviants are in the minority. EDs frequently treat adolescents as a result of risk-taking behaviour. A non-judgemental attitude is not always easy to foster, and the ED nurse must be aware of her own vulnerability and biases, as well as understanding adolescent development. This enables the nurse to treat adolescents in an appropriate manner, reduces the risk of confrontation or resentment, and respects the adolescents’ rights as individuals.

Not all adolescent risk-taking is because of a low perception of danger. Some revolves around deliberate self-harm. This is usually a cry for help from adolescents who cannot cope with the pressures of growing up. Self-poisoning is the most common reason for hospital treatment (Cook et al. 2008). Only the minority of adolescents take this route, and of these the majority are not clinically depressed. This course of behaviour is not just a result of the strains of adolescence, identity confusion, anger and guilt; it is a way of getting back at those seen as responsible for the torment, such as parents, teachers and peers. Adolescent patients often demonstrate this by a blasé attitude towards their actions. Despite low suicide intent, the danger of real harm is great because of low risk awareness. The prevalence of mental health problems among adolescents is estimated at 10–20 %, while the incidence of suicide among young men continues to increase and is linked to lifestyle behaviours such as alcohol and drug misuse, and mental health problems (Marfé 2003). Gunnarsdottir & Rafnsson (2010) found that frequent visits to the ED were significantly associated with suicide and fatal poisoning. However, up to 60 % of those who later commit suicide have attended the ED the year before the suicide but did not present themselves as cases of self-harm (Gairin et al 2003). Box 19.1 outlines the risk range for suicide among young people.

It is vital that nurses are able to distinguish between normal behaviour and abnormal distress. This can only be achieved by listening to and hearing the adolescent. Nothing should be taken at face value, as the superficial self-confidence and frequent mood changes common to teenagers can mask real and needy patients, as well as making them difficult to nurse. It is recognized that the ED is not the ideal place for in-depth discussion, but it may be the only opportunity available to the adolescent. An understanding of why the event occurred is essential before discharging the patient. The adolescent practice of ‘dumping distress’ on others via self-harm must be controlled and appropriate coping strategies learned in order to prevent further real harm. The ED nurse has a key role to play by providing constructive advice and follow-up arrangements where appropriate, not by punitive intervention (see also Chapter 15).

Substance misuse

Within the past 30 years, the worldwide drug culture has evolved dramatically, stemming from two developments. First, the major consumer generation has shifted sharply towards the young, especially adolescent and young adult males; and second, the availability of drugs has become much more widespread (Emmett & Nice 1996). While substance misuse is clearly a problem for young adults as well as adolescents, for convenience the subject will be addressed in this chapter.

In addition, the growth of the rave scene in Britain and designer drugs such as ecstasy, which appear to have become accepted by many as an integral part of relaxation and pleasure, have resulted in a culture in which substance misuse is no longer perceived as an antisocial activity, but where penalties for use and supply are severe (Box 19.2 and Table 19.1). While the ED nurse will be aware that alcohol is a major causative factor in attendances, there has been a marked increase in attendances as a consequence of other substance misuse.

The mild, moderate and severe effects of drugs of abuse are outlined in Tables 19.2–19.4(pages 283-284).

Overdose

About 80 % of people who present to EDs following self-harm will have taken an overdose of prescribed or over-the-counter medication (Horrocks et al. 2003). A small additional percentage will have intentionally taken a dangerously large amount of an illicit drug or have poisoned themselves with some other substance. The pattern of the type of drug taken in overdose has changed in recent years, largely with changes in their availability (National Collaborating Centre for Mental Health 2004).

Poisonings can be categorized into three groups: accidental, intentional and iatrogenic. Accidental poisoning most commonly occurs among young children, although death is relatively uncommon. Intentional ingestion includes recreational drug use and suicide attempts. Iatrogenic poisoning usually results from unanticipated drug interactions (Zull 1995). In cases of intentional poisoning the ED nurses should ascertain which drugs have been taken by asking the patient or attending friends or relatives (Box 19.3). The Children Act gives children under the age of 16 the right to refuse consent to treatment (Department of Health 2001). Castledine (1994) stressed the importance of establishing a good relationship with the patient, but in all cases a patient must consent if care is to be given or he can sue for assault and battery. Castledine (1994) suggested that if a patient is mentally confused due to the physical effects of illness or as a consequence of mind-altering drugs, the ED nurse could proceed to treat on the basis of urgency and necessity. Careful recording of the patient’s details and the nursing and medical staffs’ actions are important in such cases.

Conclusion

Adolescent attendance patterns highlight the need for ED nurses to understand the normal processes through which adolescents pass. Nurses can appear judgemental and less sympathetic towards a patient perceived as being responsible for his own illness (Stockbridge 1993). ED nurses can be affected by the apparent lack of compliance from adolescent patients. This can lead to paternalistic or confrontational behaviour that destroys the therapeutic relationship and exacerbates conflict. Adolescents cannot be treated wholly as adults as they lack the emotional maturity to cope with independence and still need the emotional support of parents and other carers. ED attendance is often a result of normal adolescent behaviour and ED nurses should be equipped with the knowledge necessary to provide appropriate support and education. An environment that provides boundaries, privacy and protected independence, with support, and peer support if appropriate, should be developed.

It is important to remember that psychological distress can be just as great as physical illness or trauma. ED nurses have a responsibility to consider the needs of young people as individuals. Perhaps an alteration of attitude is more important than a vast financial outlay in the improvement of adolescent care.

References