Continuum of Self-Protective Responses

Protection and survival are fundamental needs of all living things. On a continuum of self-protecting responses, self-enhancement and growth-promoting risk taking are the most adaptive responses, whereas indirect self-destructive

Theories of self-destructive behavior overlap with those of self-concept (see Chapter 17) and disturbances in mood (see Chapter 18). To think about or attempt destruction of the self, the person must have low self-regard. Low self-esteem leads to depression, which is always present in self-destructive behavior. The range of self-protective responses is shown in Figure 19-1.

The levels of behavior in the continuum may overlap. For instance, the girl who learns and excels at gymnastics is building her self-esteem and projecting a positive self-concept. However, if she tries movements she is not prepared for and does not take safety measures, her behavior becomes self-injurious or indirectly self-destructive. Similarly, a diabetic man who has never complied completely with his prescribed diet and medication regimen may become discouraged and intentionally take an overdose of insulin. The nurse must be alert to subtle shifts in mood and behavior of patients when assessing maladaptive self-protective responses.

It has been estimated that one half of patients do not comply with their health care treatment plan. This level of noncompliance or nonadherence is the same for those with physical illnesses and those with psychiatric illnesses. Noncompliance accounts for 125,000 deaths annually and contributes to 10% to 25% of hospital and nursing home admissions.

People who do not comply with recommended health care activities are generally aware that they have chosen not to care for themselves. They usually have a reason for noncompliance, such as not having symptoms, not being able to afford the treatment they need, not understanding the treatment, or not having time. Patients also may minimize the seriousness of their problems. Many chronic illnesses are characterized by long periods of stability, during which the person may not be aware of discomfort. This reinforces the noncompliant behavior.

The most prominent behavior associated with noncompliance is refusal to admit the seriousness of the health problem. This denial interferes with acceptance of treatment. Another aspect of noncompliance is that guilt about not following health care recommendations also may interfere with obtaining regular care.

Noncompliant people are also struggling for control. Serious illness is often seen as an attack on the person and a betrayal by the body. Patients need to reassert their control and prove that they are still master of their fate. Most chronically ill people need to test the limits of their control and the validity of the prescribed self-care regimen. The following clinical example illustrates the problem of noncompliance with a prescribed health care regimen.

Nature of the Assessment

Most people who commit suicide have visited a primary care provider, emergency department (ED), or psychiatric outpatient service in the weeks before their death. Errors in recognition and inadequate assessment likely contribute to a number of these deaths. Adequate screening, protection of the patient, and acceptable treatment could prevent these occurrences (Reid, 2010).

Suicidal patients often present initially in the ED. About 666,000 people visited EDs for nonfatal, self-inflicted injuries in 2008 (Centers for Disease Control and Prevention, 2011). As many as 1 in 10 people who end their lives by suicide are seen in the ED within 2 months of dying, but many of them are never assessed for suicide risk (Pompili et al, 2011).

Psychiatric evaluation of suicide attempters in the ED should include the use of a standardized tool to evaluate suicide ideation and suicide risk (Pompili et al, 2009). After completing the assessment, the nurse should document the following (Scott and Resnick, 2009):

• That a suicide risk assessment was conducted

• Risk factors found to be present

• Interventions taken to address the risk factors

• Level of risk determined (minimal, moderate, or high)

• Factors that might protect the patient against suicide

Directly questioning the patient about suicidal thoughts and plans will not cause the patient to take suicidal action. Rather, most people want to be prevented from carrying out their self-destruction. Most patients are relieved to be asked about these feelings (Crawford et al, 2011).

In asking about suicide, nurses can begin with general questions, such as the following:

• “Have you ever felt that life was not worth living?”

• “Did you ever wish that one morning you would just not wake up?”

These can be followed by more specific questions, such as

• “Have you been thinking about death recently?”

• “Have you ever thought about harming yourself?”

If the patient has had thoughts of death, self-harm, or suicide, the nurse must then ask more focused and direct questions about the method, plan, and means. A tool used in one inpatient setting is presented in Figure 19-2. Other suicide assessment tools also are available (Young and Erwin, 2008; Hermes et al, 2009).

QUALITY AND SAFETY ALERT

• It is essential that nurses have a systematic way of evaluating a patient for the risk of suicide.

• This requires the use of a standardized suicide assessment tool and safety plan.

• Merely asking a patient if he or she is suicidal does not meet the standard of care.

• Suicide assessments should occur regularly at critical points during hospitalization, including on admission, at discharge, and during changes in medications, treatments, mental status, and level of precautions.