Participants reported that they often responded to young people at known risk of self- harm or suicide who presented with feelings of wanting to hurt themselves: “the kids will come to you and say ‘I don’t feel safe’, which [means] ‘I don’t feel safe that I’m not going to harm myself’” (P29); “she came to me one afternoon [and said] ‘I feel terrible, I feel unsafe, I feel like I'm going to go and harm myself. I don’t feel that I can keep myself safe’” (P18). This aspect of persistent intensity was conceptualised as high stakes.
In the Cambridge English Dictionary, the term high stakes is defined as “the
potential for serious risk of loss if there is no success in an endeavour” (high stakes, n.d.). The term high stakes reflected participant awareness that a failure to intervene effectively could result in significant consequences for the young person, including school disengagement and suicide. In high stakes clinical scenarios participants needed to be able to respond effectively to volatile crisis situations:
It all became too much for him and he decided that this particular day he’d had enough… he had written a [suicide] note and it was found. He was going to run out in front of a bus in front of the school and kill himself. So the school psychologist was called, she then called me, he then did a runner [tried to run away], and we literally held on to each of his arms. We had 10 minutes before the end of the day. [The] school bell was going and we were right out the front of the school. Student Services were trying to get hold of dad to say we need you to come and collect your son and take him to a doctor or
Emergency Department. I used every single skill and tactic that I could, to try, rather than dragging him back physically into Student Services, to preserve his dignity but also to protect the other children as well. Because he was really distressed, he was crying, he was sobbing, he was dribbling, he was just – yeah. (P21)
96
Typically these situations occurred in the context of a school-based Risk
Management Plan which identified the participant as a safe individual when the
student was feeling distressed with thoughts of self-harm or suicide. Although the number of students on a Risk Management Plan varied, in many schools a significant number of students were monitored for this purpose: “we’ve got about 45 [students on Risk Management Plans]” (P29); “we’ve got 15 students on a Risk Management Plan, purely for suicidal disclosure” (P31). Students on Risk Management Plans were subject to much closer monitoring than other students:
We need to be aware of where they are at all times. It’s down to the teacher to mark their roles... [If the] student’s not here… the teacher will inform myself, the school psychologist and administration staff, whoever they get hold of, [to] say ‘this student is not where they’re meant to be’. Then one of us would follow that up and find out where they are. Obviously it’s a big school, you can’t go searching because you could be walking around one half of the school, they could be walking around the other half. So you check the usual [places]. [For example] I know this girl sometimes goes to the toilet or the arts [studio]. If within five or 10 minutes you can’t ascertain where they are, it’s a [phone] call to [the] parents, saying ‘your child isn’t in class. Please can you call their mobile?’ That normally ascertains where they are. (P29)
Some participants worked in schools that had been disproportionately impacted by suicide: “in my initial three years at the school we had two students suicide, an ex- student suicide [and] four parents suicide. It was very pointy-end [acute]” (P18). According to Department of Education (2018b) policy, school staff have primary responsibility for locating students at known risk of suicide or self-harm who are unaccounted for. As employees of the Department of Health many nurse participants reported that they undertook this role in partnership with school staff, because they perceived that they were best-placed to respond in case an assertive medical response was required: “we’ve had attempted suicides at the school, during school time.
We’ve had self-harming at the school, during school time” (P17). Another participant reflected on the impact such events had on other students if they inadvertently
at school which have [caused] a few ongoing issues with other students who have either found them or brought them in [for care] to Student Services” (P4).
Not surprisingly, suicide risk intervention was a commonly reported task, and often necessitated the participant keeping the young person under direct observation until a parent came to collect them: “there are situations where you have to sit with someone until you have a parent [come to collect them] because I don’t think they’re safe. That’s a really common one” (P29). One participant was interviewed in a park and explained that they had been in the same park with a suicidal student only the week before:
A friend came to tell me she was really worried about [the student] because of a text message she’d received [from her]. [The student’s] mum’s got GPS [global positioning system] tracking [for her daughter], so she’d worked out [the girl] was here. I came down to find her and just sat with her… [I was] glad to find her [lying] in the foetal position. [I] just sat with her, [together] with her friend. She didn’t want to talk. She said she hadn’t harmed herself, she said she hadn’t taken anything [overdosed]. (P19)
Managing young people at risk for suicide who were angry was not uncommon and could present a significant challenge in an uncontained space such as a school:
When they're angry and you can't rationalise with them, you can't get them into a position where they're safe. They’re not listening to anything you say, so they're a ‘difficult student’. They’d be a ‘difficult patient’ in hospital because they would be ranting and raving and throwing things. [They would be] trying to escape [from the hospital] just as much as they are at school. (P23)
[She said] “Yes, I have a plan [for suicide].” [I said] “How [are] you going to do it?” [She said] “I’m going to throw myself in front of the train.” I [said] “oh, okay… you live in [suburb with train station], you catch the train home every day. Why [are] you going to throw yourself in front of the train? Because your dad’s a train driver and you want to get back at him”. … [I] said “don’t let her leave [alone]” … She trashed [destroyed] my office. When
98
she realised that I’d cottoned on to what was happening [realised] she was…very angry. (P6)
While managing crises that occurred at school was a common task for many participants, experienced participants also recognised that young people often required support for events that occurred outside of school. As with crises that were precipitated at school, these situations were unanticipated, necessitated putting other priorities to one side, and typically took up a great deal of time:
I had a student nurse a few weeks ago. Monday morning I wanted to do her induction. By quarter to nine [in the morning] I had two girls in the health centre and we went right into it on Monday morning, the full [crisis intervention]. I couldn’t turn them away because it was a crisis, things had happened over the weekend… [For] that student nurse induction happened later on in the day and even the next day. I think she was amazed by how the kids come down and [say] “I need to tell you something” and then it comes out. (P7)
A key source of stress was the unpredictability and fluctuating nature of mental health risks presented by young people participants provided care to:
With teenagers, the risk assessments are at that very moment. Five minutes later those risk assessments could be out the door [irrelevant] and totally different because they might have a break-up with a partner or best friend argument. My biggest concern is that they escalate to the point where they self-harm or they’re thinking about killing themselves. (P17)
Young people who concealed their suicidality or the degree of their suicidality were also a source of stress: “my main concern is that they might lie to me… because they may be hiding how bad [suicidal] they are, [when they deny suicidality] yet they’ve got a plan [to suicide]” (P6). Some participants were concerned that despite being vigilant, the distress of students in their school community might go undetected: “the sort of young boys that slip under the radar [go unnoticed], and then suddenly they write a suicide note in the middle of the night. They always worry me a bit” (P28).
Many participants sought to keep the young person safe from harm in and out of school, but the majority of participants were highly aware that circumstances beyond their control could easily impact this: “safety for them [is my main concern] ... [but] I can only deal with the situation that’s in front of me. If the kid decides to go home with bad thoughts and decide to do something [such as self-harm or suicide], that’s difficult” (P11). The combination of wicked problems and persistent intensity defined the clinical workload. The work was further complicated by the level of autonomy
and isolation participants had in the role.