DNP 815 Week 7 Case Report: Application of Theory 

Sample Paper: Case Report: Application of Theory

Grand Canyon University: DNP-815

Suicide in Adolescence

Suicide in adolescence is the second most cause of death between the ages of 14-17 (Centers for Disease Control and Prevention (n.d.).  With the development of technology and the increase of social media, bullying can take many forms.  It does not necessarily have to be confined in face-to-face situations; social media has opened the door to innovative ways of bullying through the Internet.  Social media also can influence the young minds of adolescents.  Because of this, depression has increased throughout the years, resulting in more suicides (Centers for Disease Control and Prevention (n.d.).  The purpose of this case report is to address the problem of depression in adolescence and increasing suicide rates, by discussing how to assess for depression and provide treatment options and/or resources.

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Literature Review The following resources helped introduce the assessment of depression process with the use of an established questionnaire.  Allgaier, Pietsch, Frühe, Sigl-Glöckner, & Schulte-Körne (2012), in Screening for depression in adolescents: Validity of the patient health questionnaire in pediatric care, researches the appropriateness and validity of the Patient Health Questionnaire-9 (PHQ-9) and Patient Health Questionnaire-2 (PHQ-2) that is traditionally used to assess depression in adults, to be used to assess adolescents with depression. 

The study states that the PHQ-9, which was derived from the Primary Care Evaluation of Mental Disorders interview, is the gold standard for assessing Depressive Disorders in adults.  The results confirmed the appropriateness of the PHQ-9 and PHQ-2 to be used to assess depression in adolescents.  This was validated with results, charts, and data, which showed that PHQ-9 was more specific and sensitive to the detection of depression, as opposed to the PHQ-2. Arroll, et al. (2010), in Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population, further looked at the validity of the Patient Health Questionnaire-9 (PHQ-9) and Patient Health Questionnaire-2 (PHQ-2) to be used in the Primary Care setting. 

The intention is to identify depression earlier than seeing a Psychiatrist or Psychologist.  The study shares that about 50% of primary care providers miss the diagnosis of depression without the proper screening tool.  The study utilized a 3-arm randomized controlled population.  Sensitivity and specificity were calculated comparing the results of the screening tests with a reference standard.  The results concluded that using the PHQ-9 determined depression diagnosis with much more sensitivity than the PHQ-2.  The study provided data and tables to illustrate the findings.

Furthermore, Lowe, Lipps, Gibson, Jules, & Kutcher (2018), published Validation of the Kutcher adolescent depression scale in a Caribbean student sample, which addresses the reliability of the Kutcher Adolescent Depression Rating Scale (KADS) because adolescent depression detection has been limited within the Caribbean adolescent population.  This study was completed with a sample from elementary schools in Jamaica and Barbados.  Not only was KADS used for the study, but also the Adolescent Depression Rating Scale (ADRS), the Revised Children’s Anxiety and Depression Scale (RCADS), and state and trait anxiety visual analogue scales, as references to compare. ADRS and RCADS is currently the gold standard and more widely accepted in the Caribbean because it has been proven to have consistent validity and reliability.  The study suggested that the KADS assessment had an acceptable range of concurrent validity, and it correlated with the ADRS and RCADS.  

The study included flow charts, data, and tables to illustrate the effectiveness of KADS. Case Description with Applied Theories Adolescent depression has increased in the past years.  According to the National Institute of Mental Health (NIMH) (n.d.), in 2016, an estimated 3.1 million adolescents aged 12 to 17 in the United States had at least one major depressive episode. This number represented 12.8% of the U.S. population aged 12 to 17.  And according to the Centers for Disease Control and Prevention (n.d.), the second leading cause of death in adolescents (aged 15-19), is suicide.  The NIMH continues to add that 19% received treatment with a therapist, 19% received treatment with a therapist along with medication, only 2% received medication treatment alone, and an overwhelming 60% of adolescents did not receive any treatment at all.  Knowing that adolescents are at school majority of their weekday time, it might be best to have depression being assessed at the school level by a school nurse and assist in having treatment options offered and delivered earlier than seeking help at a doctor’s office.

Applying Watson’s Theory of Caring would assist in understanding the role of the school nurse to the adolescent student.  Watson’s theory focused on the human and nursing paradigm, where the goal is to balance and bring harmony between health and illness experiences.  This holistic approach to caring would prove beneficial to those dealing with depression.  While assessing a student on their possible depressive state, the school nurse can employ the Theory of Caring by assisting the student in recognizing their own emotional state of being and thereby giving the student a sense of capacity for actual self-healing (Ozan, Okumuş, & Lash, 2015). Furthering the relationship between school nurse and adolescent student, the use of Hildegard Peplau’s Theory of Interpersonal Relationships.  Peplau’s theory focuses on the three relationship stages of the school nurse and the adolescent student: (1) orientation, (2) working, and (3) termination.  Within orientation, the school nurse and the student are just getting to know and understand each other.  This is when the assessment of depression occurs and whether or not the student should be followed in regards to receiving possible treatment for depression.  If the student has been deemed to be in a depressive state, that is when the working relationship occurs.  The school nurse and the student begin to build a relationship built on trust, honesty, and openness. 

The student should feel that their emotional situation is recognized but at the same time understand that there are ways to assist in this emotional state.  During termination, the student has been given management skills and coping mechanisms, tools to deal with situations in school, life, family, and anything that might disrupt the progress of growth and healthy living mentally (Delaney, Shattell, & Johnson, 2017). Synthesized Literature Findings When creating a program that will help identify adolescent students at risk for depression and suicide, utilizing several nursing theories can be used to accomplish this goal.  Beginning with Watson’s Theory of Caring, the nurse becomes involved with the student to begin defining the relationship of school nurse and student.  With Peplau’s Theory of Interpersonal Relationships, the relationship begins with assessing the student’s risk of depression. 

Using the Patient Health Questionnaire-9 (PHQ-9) as an assessment tool to be used with adolescents was shown to have a sensitivity of 85.0% and specificity of 79.4% (Allgaier, Pietsch, Frühe, Sigl-Glöckner, & Schulte-Körne, 2012).  This was further solidified with Arroll, et al. (2010), who also used the PHQ-9 which resulted with 74% sensitivity and 91% specificity.  In both studies, the PHQ-9 was proven to be the better assessment tool for depression than the PHQ-2.  Because the PHQ-2 was limited to just 2 questions, details involving further assessment was found with the PHQ-9 that would not be discovered otherwise.  Allgaier, Pietsch, Frühe, Sigl-Glöckner, & Schulte-Körne (2012), continue to discuss that the PHQ-9 was determined to have a Cronbach’s alpha coefficient of .82.  This reliability shows that this questionnaire can be utilized not only in primary care for adults, but also with adolescents.

Case Summary Adolescent depression will only increase with the age of technology.  Bullying is far more easier to reach than just the arm length of a swinging fist.  A student can emotionally scar another student with just a simple click on a keyboard and social media post that can disseminate like wild fire to the masses.  School staff, especially nurses, can assist in identifying these students who are possible victims of bullying or at risk for depression or emotional assistance.  With over 60% of adolescents with depression not receiving any type of support whether psychological or pharmaceutical, is a staggering percentage that needs to be addressed (Centers for Disease Control and Prevention, n.d.).  School nurses are with adolescents almost every day and some visit the nurse office often. 

Signs and symptoms of depression in adolescents can take many shapes or forms.  Thus, using a depression assessment tool when a student comes into the office despite for what reason, can possibly clue in to students who may need help and are unable to really voice it or recognize they need the help. Intervention A useful intervention for most mood disorders is the utilization of cognitive based therapies.  Cognitive theory basically suggests that automatic thoughts of negative affect and depressed mood are what the mind cognitively distorts (Rnic, Dozois, & Martin, 2016).  Cognitive behavior therapy (CBT) is a type of psychotherapy that addresses emotional problems by boosting the person’s self-worth and happiness by modifying the initial negative thoughts, emotions, and/or behaviors.  

For example, when this author sees a rose, the hurtful memory of being forced into the bushes to take a picture and receiving several minor nicks on arms and legs from the thorns becomes apparent.  With CBT, this author can now change that negative thought process and remember that roses are beautiful and fragrant.  Keles & Idsoe (2018) did a meta analysis of group cognitive behavior therapy interventions for adolescents and had remarkable results.  It showed that the randomized controlled trials supported group CBT is effective for treating depression among adolescents.  It was also noted that it is more cost effective because it is group therapy and that it can be utilized outside of the clinic (Keles & Idsoe, 2018). Implementation Knowing that the PHQ-9 would be the most effective at detecting depression in adolescents, this questionnaire would be the basis of educating school nurses on how to use the tool. 

Educating school nurses on (1) what is deemed to be a high-risk score, (2) address the specific issues that the student might consider the factors that lead them to be emotionally vulnerable, and then (3) to begin the process of cognitive behavior therapy.  School nurses will be educated on how to assess, address issues, begin teachings of cognitive behavior therapy and then also refer to the school psychologist and social worker to give more added emotional support and guidance.  Additional resources for adolescents with depression will give those students more options on how to address their issues and with who is most compatible. Evaluation Evaluating whether the proposed case review is effective, it would be best to test it against Kolcaba’s Theory of Comfort. 

Because Kolcaba’s theory is holistic, addressing the pain of a patient (whether it is physical or emotional) is in regards to the three types of comfort: relief, ease, and transcendence.  And these 3 types of comfort are addressed in the four contexts of the holistic experience of: physical, psycho spiritual, socio cultural, and environmental. In order to fully evaluate the effectiveness of cognitive behavior therapy as an effective intervention for students who are at risk for depression and/or suicide, it is best to address Kolcaba’s Theory of Comfort within the three types of comfort themselves.

Relief.  Assessing comfort of with the use of observation charts or comfort scoring. Physical addresses the mood swings, any heart issues or breathing issues induced by depression or anxiety.  Psycho spiritual addressed anxiety and fear.  Socio Cultural addressed relief from feeling alienated.  And environmental addressed relief from environmental stressors such as social media contact.  This area of comfort could be evaluated with an observational checklist that included comfort level scoring and qualitative data retrieved from the patient.

Ease.  Physical addressed ease in pain and distressing symptoms.  Psycho spiritual addressed ease of fear and depression.  Socio cultural addressed ease in alienated feeling.  And environmental addressed ease from environmental stressors not being around the bullies or in contact with bullies via in person or web.  This can be evaluated by the patient verbalizing ease and contentment, and lack of fear or visual reduced anxious behavior.

Transcendence.  Physical addressed rising above pain and distressing symptoms.  Psycho spiritual addressed crying, fear, and depression.  Socio cultural addressed need for rising above the feeling of alienation, and need for support from family or significant other.  Environmental addressed the need to rise above the level of environmental stressors (Chandra, Raman, & Kolcaba, 2016).  This can be evaluated by overall level of depression of the patient was reduced and vocalizing tools in order to overcome emotional obstacles.  Comfort scores and observation checklist can also be utilized by seeing the student motivated to participate in activities, able to commit to active daily living activities, and the student is able to adjust to being alienated and feeling more confidence and self-worth in an otherwise very unwelcoming environment (Chandra, Raman, & Kolcaba, 2016). Kolcaba’s theory of comfort is significant.  It truly does address comfort in most, if not all, aspects nursing.  The need for comfort to be approached in the holistic manner is expressed, and the use of a taxonomic structure to address all constructs of the theory as a whole.  Kolcaba’s theory of comfort is parsimonious, meaning simple at best.  It is all containing and addresses issues thoroughly without use of much resources if any.

Conclusion Writing this conclusion is very difficult.  Just today, I just read an article of a student who was found dead by the custodian in his middle school at 6:30am (Vargas, 2019), apparently from a suicide.  Students are shocked, mourning, and grieving.  There has to be signs some say.  Within the article, counselors state that parents should look for signs of depression, changes in behavior, lack of appetite.  But, most times, adolescents don’t confide in their parents, they usually turn to their friends, but even that can be vague.  Some may come into a school nurse office stating they just don’t feel good. 

Seems benign, the school nurse does a cursory assessment with vitals and find nothing out of the ordinary.  And sends that student back to class after 20 minutes of rest.  What if the school nurse had a simple tool to ask sensitive questions that might not ever get asked?  The student is there, in the nurse office, the nurse can easily hand the student a questionnaire such as PHQ-9.  Most students will pass over the PHQ-9 without understanding the gravity of it, but there might be just student that might actually answer it truthfully and a school nurse will be able to assist that student in receiving services and much needed assistance.

Thus, a school nurse can be armed with the necessary tools to assess an adolescent in an open and non-clinical manner for possible depression.  If a student was found to be at risk for depression, the school nurse will again have the tools to assist that student in developing their own personal cognitive behavior therapy tools.  With the increasing rate of depression and suicide in adolescents, one more added advantage for those students to find help is to have it within the place they are located most of their waking hours like school.  School nurses have the education, compassion, and necessary capacity to be that bridge to help in the mental health of adolescents.

References : DNP 815 Week 7 Case Report: Application of Theory 

Allgaier, A., Pietsch, K., Frühe, B., Sigl-Glöckner, J., & Schulte-Körne, G. (2012).  Screening for depression in adolescents: Validity of the patient health questionnaire in pediatric care. Depression & Anxiety (1091-4269), 29(10), 906. doi:10.1002/da.21971

Arroll, B., Goodyear-Smith, F., Crengle, S., Gunn, J., Kerse, N., Fishman, T., & … Hatcher, S. (2010). Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. Annals of Family Medicine, (4). 348. Centers for Disease Control and Prevention (n.d.). National center for health statistics: Adolescent health.  Retrieved from https://www.cdc.gov/nchs/fastats/adolescent-health.htm

Chandra, S. M., Raman, K., & Kolcaba, K. (2016). Application of Katharine Kolcaba Comfort Theory in Post Operative Child: Delivering Integrative Comfort Care Intervention by using Theory of Comfort. International Journal of Science and Research (IJSR),5(6), 1714-1720. doi:10.21275/v5i6.nov164670

Delaney, K. R., Shattell, M., & Johnson, M. E. (2017). Original Article: Capturing the Interpersonal Process of Psychiatric Nurses: A Model for Engagement. Archives of Psychiatric Nursing, 31, 634–640. https://doi-org.lopes.idm.oclc.org/10.1016/j.apnu.2017.08.003 Fawcett, J. (2005). Middle-range nursing theories are necessary for the advancement of the discipline. Aquichan , 5 (1), 32-43. Retrieved from https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=21501730&site=ehost-live&scope=site

Keles, S., & Idsoe, T. (2018). A meta-analysis of group Cognitive Behavioral Therapy (CBT) interventions for adolescents with depression. Journal Of Adolescence, doi:10.1016/j.adolescence.2018.05.011

Kolcaba K. (2001). Evolution of the mid range theory of comfort for outcomes research. Nursing Outlook, 49(2), 86–92. Retrieved from https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=107034755&site=eds-live&scope=site

Koehn ML. (2000). Alternative and complementary therapies for labor and birth: an application of Kolcaba’s theory of holistic comfort. Holistic Nursing Practice, 15(1), 66–77. Retrieved from https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=106998146&site=eds-live&scope=site

Krinsky, R., Murillo, I., & Johnson, J. (2014). A practical application of Katharine Kolcaba’s comfort theory to cardiac patients. Applied Nursing Research, 27(2), 147–150. https://doi-org.lopes.idm.oclc.org/10.1016/j.apnr.2014.02.004

Lowe, G. A., Lipps, G. E., Gibson, R. C., Jules, M. A., & Kutcher, S. (2018). Validation of the Kutcher adolescent depression scale in a Caribbean student sample. CMAJ Open, 6(3), E248-E253 National Institute of Mental Health. (n.d.). Major depression.  Retrieved from https://www.nimh.nih.gov/health/statistics/major-depression.shtml#part_155031

Ozan, Y. D., Okumuş, H., & Lash, A. A. (2015). Implementation of Watson’s theory of human caring: a case study. International Journal of Caring Sciences, 8(1), 25–35. Retrieved from https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=103751480&site=eds-live&scope=site

Rnic, K., Dozois, D. J. A., & Martin, R. A. (2016). Cognitive distortions, humor styles, and depression. Europe’s Journal of Psychology, 12(3), 348–362. https://doi-org.lopes.idm.oclc.org/10.5964/ejop.v12i3.1118 Shu Hua NG. (2017). Application of Kolcaba’s Comfort Theory to the Management of a Patient with Hepatocellular Carcinoma. Singapore Nursing Journal, 44(1), 16–23. Retrieved from https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=124789969&site=eds-live&scope=site

Tektaş, P., & Çam, O. (2017). The effects of nursing care based on Watson’s theory of human caring on the mental health of pregnant women after a pregnancy loss. Archives of Psychiatric Nursing, 31(5), 440–446. https://doi-org.lopes.idm.oclc.org/10.1016/j.apnu.2017.07.002

Vargas, V. (March 5, 2019).  Shocking Death of Teen on Orange County Campus Closes Schools.  NBC News.  Retrieved from: https://www.nbclosangeles.com/news/local/Orange-County-teen-death-campus-closed-parents-506739621.html