The three themes that emerged from this study: (a) Not sure that's part of their job, (b) That's way too personal, and (c) They couldn't help anyway provide a deeper insight into the understanding of youths' perceptions of their health care providers' roles in addressing bullying.
The idea that youths have a limited view of their health care providers' role in preventive health care is concerning. The first focus groups were composed of essentially healthy youths who likely had limited interaction with their providers; however, a fourth group was convened of youths with significant health care needs who had had extensive contact with their primary care and specialty providers. Regardless of group, participants indicated that during primary care visits, neither they nor their nurse practitioners nor physicians routinely brought up bullying, with conversation limited to the general quality of their school life. Nor did the youths indicate that other health care providers, such as school nurses, emergency department personnel, or specialty care providers, initiate conversations about bullying. None of the youths saw this as a deficit in care; they just did not view bullying as a topic that was within their providers' scope of practice but rather something that was the school's purview.
It is interesting to note that the study participants did see a role for health care providers if bullying reached the level of suicide ideation. One participant had experienced a bullied peer who attempted suicide. For others, suicide ideation likely arose to the level of a mental health problem that their nurse practitioners or physicians could address. Another, although unconfirmed, explanation is that youth views on suicide/suicide ideation have been shaped by health care providers implementing screening for depression and suicidal ideation secondary to the 2007 American Academy of Pediatrics recommendations (Shain, 2007) and the 2016 Joint Commission's Sentinel alert (Joint Commission, 2016).
There is little research on the quality of adolescent–health care provider relationships. The results of one landmark study reported by Brown and Wissow (2009), however, show that when sensitive topics are explored in primary care visits, adolescents had a more positive and robust view of the visit. These findings were independent of the characteristics of the participant population. Youths can be helped to gain a fuller appreciation of the role their nurse practitioners and other health care providers can play in helping them address situations that lead to stress, psychological, and physical problems. Prior research indicates that adolescents are more comfortable talking about sensitive topics during primary care visits when they are primed to do so in advance, when providers facilitate an active dialogue designed to elicit adolescent disclosure of personal concerns, when there is adequate time during the visit for this to occur, and when an appropriate level of confidentiality is ensured (Boekeloo et al., 2003, Carlisle et al., 2006, Jacobson et al., 2001). Youths who frequently seek health care at school or specialty clinics often benefit from a long-term trusting relationship with the staff; such visits provide an excellent opportunity for health care providers to initiate discussions around bullying.
Youths' willingness or reluctance to be open about sensitive topics with their health care providers is highly influenced by their degree of trust and knowing, a priori, what pieces of information, and how selected information, would be disclosed to parents. This is a realistic concern, because parents unanimously wish to be informed about any health issue their adolescent may have (Carlisle et al., 2006). Youths will often forego care or avoid discussing sensitive topics if they include illegal behavior (e.g., drug and alcohol use; texting while driving), are in conflict with familial cultural norms (sexual activity, gender identity), or are associated with societal stigma (e.g., serious mental health disorders; Akinbami et al., 2003, Carlisle et al., 2006, Lehrer et al., 2007). Bullying fits none of these categories, especially because the youths in this study did not view the consequences of bullying as rising to the level of a significant mental health problem worthy of their providers' attention. This is congruent with teens' general views on common adolescent mental health issues (Coles & Coleman, 2010). For some youths, a breach of confidentiality would require them to contend with their parents' responses to bullying. This is a legitimate concern, because parents' responses are often uniformed and ineffective and can potentially can aggravate the situation (Sawyer, Mishna, Pepler, & Wiener, 2011).
Recent Pew estimates suggest that at least 93% of youths 12 to 17 years of age are regularly online (Lenhart, Ling, Campbell, & Purcell, 2010), and although adolescent Internet use can present dangers, it also provides an opportunity for screening and health-related education activities (Kachur et al., 2013, Lord and Marsch, 2011, Olson et al., 2009). Across demographic and socioeconomic profiles, youths participating in this study were comfortable with the notion of completing an online bullying screen and even believed that this would afford additional confidentiality over other forms of screening. This is consistent with prior research indicating that adolescents are comfortable with electronic screening, even when used for sensitive topics such as sexually transmitted infection screening (Goyal, Teach, Badolato, Trent, & Chamberlain, 2016) and assessment of risky behaviors (Chisolm, Gardner, Julian, & Kelleher, 2008). Given the widespread use of both general technology and electronic health records, future screening tools would likely be more readily adopted by both patients and providers in an electronic form.
Unfortunately, it was not surprising that youths do not immediately view bullying as a critical issue for health care providers to address. Despite calls in the professional literature declaring youth bullying a professional responsibility for over a decade (Lyznicki et al., 2004, Spector and Kelly, 2006, Storch and Ledley, 2005), there are currently no explicit preventive health care recommendations specific to bullying screening and intervention by pediatric health care organizations (Committee on Injury, Violence, and Poison Prevention, 2009, Committee on Practice and Ambulatory Medicine & Bright Futures Periodicity Schedule Workgroup, 2016; NAPNAP, 2013, Vessey et al., 2013). The incorporation of explicit information pertaining to bullying into professional position statements and practice standards is needed. Although adolescents are well aware that bullying is harmful, those participating in this study believed the role of their nurse practitioners and physicians in addressing bullying to be very limited. Expanding the paradigm for nurse practitioners and other providers to include anticipatory guidance, prevention strategies, and screening specific to bullying will help ensure that more comprehensive mental health care is provided. Moreover, when such developmentally appropriate strategies are routinely incorporated into primary care, youths will more readily recognize that health care practitioners can be valuable allies in addressing bullying.
J Pediatr Health Care. 2017;31(5):536-545. © 2017 Mosby, Inc.