Nonsuicidal self-injury: NPs must make patient safety the priority

July 26, 2016

Significant gaps in the knowledge of EBP are evident as new diagnostic criteria are recognized and evolve in clinical practice. An example of this EBP knowledge gap is the diagnosis of nonsuicidal self-injury (NSSI) that was identified in 2013 as a separate diagnosis in Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).

Evidence-based practice (EBP) is now the standard of care for clinical practice in all medical and nursing disciplines. However, significant gaps in the knowledge of EBP are evident as new diagnostic criteria are recognized and evolve in clinical practice. An example of this EBP knowledge gap is the diagnosis of nonsuicidal self-injury (NSSI) that was identified in 2013 as a separate diagnosis in Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Once NSSI was identified as a separate diagnosis, the first essential step was to explore the ‘background knowledge’ for NSSI so that an in-depth understanding of the criteria for diagnosis of NSSI is available for practitioners in clinical practice. Hornor describes this essential ‘background knowledge’ for the diagnosis, risk factors, and nursing implications for NSSI in the May/June issue of the Journal of Pediatric Health Care. In this July issue of Contemporary Pediatrics, Westers and Muehlenkamp’s article entitled, SOARS model: Risk assessment of nonsuicidal self-injury, further enlightens the diagnosis of NSSI through the use of the newly created SOARS patient assessment tool. The authors provide practitioners a unique set of critical questions that demonstrate sensitive and caring ways to query adolescents about NSSI behaviors as part of a routine screening during healthcare visits. I highly recommend incorporating the SOARS assessment tool with the authors specific questions into the electronic health record for routine use during adolescent visits. 

The gap in EBP exists in the evidence-based treatment plan for the diagnosis of NSSI. To date, “no empirically supported treatment targeted specifically for NSSI yet exists.” Rigorous research studies involving collaborations among researches and clinicians are needed to clearly identify the best clinical evidence for successful treatment of NSSI. Westers and Muehlenkamp support brief office-based interventions followed by a referral for treatment. Hornor writes that adolescents who report NSSI must be linked to appropriate mental health services.1 As primary care nurse practitioners caring for adolescents, I support Hornor’s position that we must refer adolescents with NSSI behaviors for mental health treatment.

There is one additional controversy identified by Westers and Muehlenkamp concerning adolescents and patient confidentiality: They report from previous work that “…breaking confidentiality about NSSI behavior is often based on the clinical judgment of the medical provider.” As nurse practitioners, our standard of practice requires us to inform our adolescents about confidentiality at the beginning of each visit. Our practice should include a statement that says: “we will maintain confidentiality unless you intend to/or are harming yourself or others.” If our assessment reveals NSSI behaviors, the adolescent is indeed harming himself/herself and I believe we must inform the adolescent of our duty to inform the parent of the behaviors AND make the referral for mental health treatment a priority. Assuring patient safety is our major responsibility for the treatment of an adolescent with a diagnosis of NSSI.

References

1.     Hornor G. Nonsuicidal Self-Injury. J Pediatr Health Care. 2016;30(3):261-7.