1. Florang, Jesse Edward EdD, MSE, LIMHP, PLADC


Help young patients maintain mental and overall health by using Orem's self-care deficit theory to guide interventions.


Article Content

Cyberbullying-a form of bullying that takes place over digital devices-is a growing phenomenon impacting adolescents during a crucial time of social, cognitive, and emotional development. According to, cyberbullying includes "sending, posting, or sharing negative, harmful, false, or mean content about someone else." In the past year, 15% of high-school students reported being cyberbullied; 55.2% of LGBTQ students indicated that they've experienced cyberbullying.

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This behavior is associated with negative mental health outcomes, including depression, anxiety, substance abuse, and suicidal behavior. In fact, recent research highlights the high prevalence of cyberbullying among adolescents admitted to inpatient psychiatric facilities. Unmistakably, cyberbullying has created new mental health and safety concerns for the adolescent population. For this reason, all nurses working with adolescents should have continuing education on the impact of cyberbullying on these at-risk patients.


This article presents Dorothea Orem's self-care deficit theory as a framework for nurses to identify, support, and treat adolescent victims of cyberbullying.


What does cyberbullying look like?

Cyberbullying can occur on several different public and private platforms, but generally takes place through email, messaging, websites, or social media sites. Various methods of cyberbullying exist, including posting embarrassing photos or videos on social media, harassment, "flaming" (sending direct messages or insults on a public platform), "doxing" (posting private or identifying information on the internet without an individual's consent), or exclusion.


At a time when adolescents are seeking independence, cyberbullying has created new stressors with which some teenagers are unable to appropriately cope. Although somewhat similar to traditional bullying, there's no option of fighting the aggressor or running for safety. Although cyberbullying can be perpetrated anonymously, most victims report that they know their attackers and have also experienced some form of traditional bullying. In these situations, cyberbullying is often viewed as an extension of traditional bullying.


Healthcare providers should be prepared to identify signs and symptoms of cyberbullying that may go unnoticed during current physical and mental health assessment procedures. By successfully identifying an adolescent experiencing cyberbullying, we can help develop an appropriate treatment plan specifically designed to develop independent self-care skills. Symptoms of cyberbullying may take the form of depression or anxiety. Warning signs may include isolation, withdrawal, loss of motivation, change in routine, truancy, poor grades, loss of appetite, or changes in social activities. Additional signs of cyberbullying may include secretive or obsessive online behavior and/or mood changes revolving around access to technology.


Where we've gone wrong

Unfortunately, previous attempts to help adolescents cope with cyberbullying have led to some unintended negative consequences, such as adolescents lacking the confidence that it can be stopped. For example, a person with little knowledge about cyberbullying may tell an adolescent to report it to an adult. But parents and school officials are often unprepared and/or lack the knowledge necessary to appropriately intervene when cyberbullying is reported (see Tips for parents and school officials).


What happens when the adolescent tells an adult and the cyberbullying continues? Furthermore, what happens when the adolescent reports cyberbullying and adults take away his or her access to social media in an attempt to protect the adolescent? Much of the younger generation's social interactions occur online so, in a sense, reporting cyberbullying to an adult has led to victims feeling like they're being punished and essentially cut off from social interaction. If reporting cyberbullying to an adult leads to loss of social media access, adolescents will be less likely to seek adult assistance.


Adolescents may also be told to just ignore cyberbullying. But what happens when they can't ignore it? Additionally, the difficulty of removing or deleting information online makes ignoring cyberbullying unrealistic, especially with the ability to save, forward, and download negative social media posts. Even if adolescents do attempt to ignore cyberbullying, their peers still have access to a permanent piece of social media that casts them in a negative light. And in cases where adolescents have their social media access taken away, not only do victims feel like they've been penalized, but also that their social media reputation remains tarnished.


Negative interventions that promote dependence and/or hopelessness include:


* telling adolescents to ignore cyberbullying


* encouraging adolescents to rely solely on adult intervention


* instructing adolescents to delete all their social media accounts


* advising parents/guardians to remove adolescents' access to technology and social media


* minimizing the impact that cyberbullying has on emotional development and mental health


* accepting that cyberbullying is just a part of adolescence


* avoiding accepting that cyberbullying is a school, home, and healthcare problem.



Self-care deficit theory

Dorothea Orem's self-care deficit theory contains three core parts: self-care, self-care deficits, and nursing systems or interventions.


Self-care entails deliberate actions necessary for healthy functioning and cognitive development. When individuals are unable to meet their own self-care needs in specific areas, these areas become self-care deficits. According to Orem's theory, nursing professionals must help patients identify and prioritize unmet self-care needs and then select appropriate methods to help them overcome or compensate for their self-care deficits.


When applying this theory to cyberbullying, nursing interventions should aim to help adolescents meet their self-care needs and foster self-care independence in coping with cyberbullying. As discussed earlier, previous attempts to help adolescents cope with cyberbullying have created more dependence on adults, in contrast to the goal of Orem's theory, which seeks self-care independence. By following Orem's self-care deficit theory, nursing professionals can encourage deliberate actions designed to help adolescents and groups of adolescents change conditions in themselves and their environment.


How do we start?

But how do nurses intervene in something we've never experienced and may not fully understand ourselves? First, we get further education and pass that education on to our patients and their families. For example, although many nurses have never experienced diabetes, we have the knowledge necessary to help patients further their understanding of this chronic condition, practice self-care skills, develop individualized plans, connect with community support and resources, and acquire the tools necessary to monitor their health independently. There are times when these patients may need further outpatient or inpatient help to overcome self-care deficits, but ultimately the goal is to teach the skills necessary to be independently successful. A similar nursing approach should be utilized for cyberbullying.


It's clear to see why many adolescents feel so hopeless once they experience cyberbullying. They don't have the power to stop it or the skills to cope with it, and the adults in their life don't have the knowledge to understand it or at times even acknowledge it. Patient-centered, recovery-focused nursing care should acknowledge that cyberbullying has happened, recognize cyberbullying's negative impact, and teach the self-care skills necessary to respond to cyberbullying and restore overall health. Fostering self-care independence doesn't mean that adolescents need to face cyberbullying alone; rather, we should provide them with the skills and resources necessary to seek out supportive people and problem-solve through difficult situations.


Positive nursing interventions to promote self-care independence include:


* Educate adolescents and families about cyberbullying and its negative outcomes.


* Deliver individualized, patient-centered, and recovery-focused care.


* Teach adolescents the skills necessary to improve conditions in themselves and their environment.


* Instruct adolescents in positive, therapeutic coping skills to improve self-esteem and self-perceptions (see Positive coping skills).


* Guide adolescents to implement constructive actions and deliberate planned activities to promote overall health.


* Provide referrals to counselors and therapists in the community who'll help build a social support system conducive to self-care independence.


* Help adolescents develop action plans and safety plans in response to negative emotions associated with cyberbullying (see Action and safety plans).


* Offer appropriate bystander skill training to adolescents and families.



Putting it all together

Cyberbullying is a new phenomenon that infringes on basic adolescent needs. Unlike typical adolescent turmoil, when it comes to cyberbullying, adolescents are unable to utilize their inborn "fight or flight" response. According to Maslow's hierarchy of needs, safety is a basic need that humans must have to be healthy and reach their full potential. According to Maslow, safety must be established before adolescents can fully develop their psychological needs, including relationships, friendships, love, and belonging. If adolescents don't feel safe, healthcare providers must be prepared to provide interventions designed to ensure safety.


Due to its high prevalence among teenagers, cyberbullying should be added to all initial nursing assessments. If we don't directly ask, adolescents may not tell us. By updating healthcare assessments and nursing screening tools to include cyberbullying, we can acknowledge that cyberbullying is occurring, promote a safe environment, and pinpoint where self-care deficits exist.


To facilitate safe environments, healthcare providers must be willing to gather specific information related to cyberbullying, which may pose immediate safety concerns for adolescents similar to abuse or neglect. Before self-care deficits can be rectified, adolescents must feel safe. Once cyberbullying is addressed and adolescents feel safe, appropriate nursing interventions can help them reach independent self-care.


Primary nursing interventions should include the identification and implementation of coping skills, the development of action and safety plans, recognizing supportive people, and utilizing safe places. Adolescents experiencing cyberbullying may find it helpful to use a journal to identify, implement, and practice coping skills.


A healthy future

Orem's self-care deficit theory provides a framework for nurses to help adolescents cope with cyberbullying to reduce the likelihood of developing negative mental health outcomes, such as depression, anxiety, substance abuse, and suicidal behavior. Through assessment and identification of self-care deficits, we can teach our adolescent patients how to appropriately cope with cyberbullying, aid in the creation of action and safety plans, and provide professional referrals to assist them with developing self-care independence.


consider this

Ted, 37, comes to the ED with his daughter, Harper, 17, and reports that his other daughter, Emma, 15, is unable to get out of the car because she's having trouble breathing and has been crying all day. Emergency responders assist Emma into the ED and begin routine questions. Following the standard assessments and routine care, physical concerns are quickly ruled out.

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Upon further review, it's determined that Emma is most likely experiencing a panic attack due to severe anxiety. As the assessment continues, it becomes evident that Emma has also been experiencing depression for the last few months and you overhear her sister say the cause is due to some "stupid stuff going on online."


To assist the family in developing an individualized treatment plan aimed at Emma's self-care deficits regarding her ability to cope with cyberbullying, ensuring that she and her family have the skills and information necessary to foster self-care independence after they leave the ED, you:


* acknowledge that cyberbullying is a legitimate concern and assure Emma that you want to help.


* reinforce that you want to help her and not isolate her further by removing access to technology or recommending the deletion of her social media accounts.


* obtain further information about the cyberbullying that's occurring and make appropriate reports depending on the type of cyberbullying.


* help Emma and her family develop an individualized action plan on how to respond next time she experiences cyberbullying, including coping and reporting skills.


* assist her with identifying supportive people whom she can safely talk to about cyberbullying.


* aid her in identifying specific places she can go where she feels safe from cyberbullying.


* educate her father and sister about how to support Emma.


* provide referrals to a counselor and/or a physician who understands cyberbullying and will help Emma develop independent self-care through the implementation of social and coping skills.


* refer Emma and her family to community resources, agencies, organizations, or groups that provide support to adolescents.



Positive coping skills

It's essential to provide adolescents and families with the strategies necessary to develop independent self-care regarding cyberbullying.


Social skills


* Relationship skills


* Communication skills


* Bystander skills


* Cyber-regulation (what's appropriate online and how to handle negative interactions)



Coping skills


* Internal: for example, meditation, counting backwards, or positive reframing


* External: for example, exercise, music, reading, or painting



Supportive people


* Identify people who are safe for the adolescent to talk to about cyberbullying: for example, a teacher, principal, school counselor, or social worker; friend; family member; pastor; coach; physician; or mentor



Supportive places


* Identify specific places an adolescent can go and feel safe from cyberbullying to utilize self-care strategies



INSTRUCTIONS Caring for adolescents experiencing cyberbullying



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