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Integrative Literature Review

The Role of the School Nurse in Suicide Interventions: An Integrative Review

Mitzi C. Pestaner, MSN, RN, JD1 , Deborah E. Tyndall, PhD, RN1 , and Shannon B. Powell, PhD, RN, CNE1

Abstract

Suicide rates among children and adolescents have continued to rise over the past decade indicating the need for school-based suicide prevention programs. School nurses (SNs) are well positioned to assist in assessment, early identification, and intervention of at-risk students. This integrative review aimed to (1) critically examine the role of the SN in school-based suicide interventions, (2) explore potential barriers preventing the SN from participating in suicide interventions, and (3) recommend strategies to build capacity for principles of school nursing practice in suicide intervention. The National Association of School Nurses’ Framework for 21st Century School Nursing Practice was used to categorize interventions and outcomes related to suicide prevention. Findings demonstrate a lack of reported nursing interventions directly linked to student outcomes and suggest obscurity in the role of the SN. Recommendations for future research and strategies to build capacity for principles of school nursing practice are provided.

Keywords

mental health, integrative reviews, school nurse role, safety/injury prevention

Background

Suicide among adolescents has continued to rise over the

past decade. In 2011, for ages 15–24, suicide rose from the

third to the second leading cause of death (Centers for Dis-

ease Control and Prevention [CDC], 2019). As suicide rates

continue to rise among older high school adolescents, a sim-

ilar negative trend is being noted in the younger adolescent

population. For children of ages 10–14, suicide rose from

being the fourth leading cause of death to third in 2008 and

became the second leading cause of death in 2014 (CDC,

2019).

Contributing to these rates is the finding that only 20% of adolescents in the United States receive services for mental

health (MH) and substance use needs (U.S. Department of

Health and Human Services, 2017). Research demonstrates

that there is a significant increase in suicide and suicide risk

behaviors, such as suicide ideation and attempts, during

adolescence (Hooven, Walsh, Pike, & Herting, 2012). In

2017, the CDC conducted the Youth Risk Behavior Survey

and found that 17.2% of high school students had seriously considered suicide, 13.6% had made a plan, and 7.4% had made one or more suicide attempts (Kann et al., 2018).

Factors contributing to suicidality in children and adoles-

cent populations are complex. In a recent systematic review

of 44 studies, psychological factors (e.g., depression, drug

use), stressful life events (e.g., peer conflicts), and

personality traits (e.g., impulsivity) were identified as the

three main contributing factors (Carballo et al., 2019). In

addition to these main factors, suicidality has many features

that add to the complexity of identifying risk. Features for

consideration include suicidal ideations, intentions, and

behaviors of adolescents which are associated with

increased risk (Miller & Eckert, 2009). Of particular concern

are behaviors categorized as self-injurious, or nonsuicidal

self-injury, most commonly self-cutting without suicide

intent (P. Wilkinson & Goodyer, 2011). While the intent for

suicide may be lacking, nonsuicidal self-injury is associated

with future suicide attempts (P. Wilkinson & Goodyer,

2011).

Since children and adolescents spend a large amount of

their time in schools, the school can be an ideal setting for

implementation of suicide prevention programs (Ross,

Kolves, & De Leo, 2017). Currently, there are a variety of

school-based suicide prevention programs being used to pro-

mote education for students and/or school staff on risk fac-

tors and warning signs, screening to identify those at risk for

1 East Carolina University College of Nursing, Greenville, NC, USA

Corresponding Author:

Mitzi C. Pestaner, MSN, RN, JD, East Carolina University College of

Nursing, 4165-N Health Sciences Building, Greenville, NC 27858, USA.

Email: [email protected]

The Journal of School Nursing 2021, Vol. 37(1) 41-50 ª The Author(s) 2019 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1059840519889679 journals.sagepub.com/home/jsn

suicide, or responding to those displaying suicidal behaviors

(Miller, Eckert, & Mazza, 2009). The overall goals of these

programs are to increase knowledge and help-seeking beha-

vior, improve the attitudes of students (Robinson et al.,

2013), and decrease suicidal ideations, attempts, and com-

pleted suicides (Katz et al., 2013). In a systematic review of

16 school-based suicide prevention programs, school nurses

(SNs) were involved in only 2 (12.5%) of these programs (Katz et al., 2013). Yet, SNs are often the first health-care

provider to see at-risk children and adolescents (Bains &

Diallo, 2016) and have been regarded as the gateway pro-

fessional for MH services (Cowell, 2019).

Framework for 21st Century School Nursing Practice

The National Association of School Nurses (NASN) pub-

lished the Framework for 21st Century School Nursing

Practice in 2016 to explain and further elaborate on the key

components of SN practice. The aim of the Framework is to

guide SNs to practice student-centered care and focus their

efforts on the inclusion of students, families, and commu-

nities. The Framework includes principles of standards of

practice, care coordination, quality improvement, commu-

nity/public health, and leadership. These principles often

overlap, and all are embedded in the standards of practice,

a vital component related to evidence-based, quality care

(NASN, 2016). Researchers have used the Framework to

examine the impact of nurse-led interventions upon student

health and education outcomes (Best, Oppewal, & Travers,

2018). In contrast, our review examined the role of the SN in

school-based suicide interventions and reported outcomes

related to decreasing child and adolescent suicide, identified

potential barriers impeding SN participation, and recom-

mended strategies to address those obstacles.

NASN Position Statement

NASN’s position statement (2018) regarding the role of the

SN in the behavioral health/MH of students states that

“behavioral health, which encompasses MH, is as critical

to academic success as physical well-being” (para 1). The

position statement further supports the value of the role of

the SN in managing the MH needs of students. Suicide rates

in adolescents are rising, and SNs are well positioned to have

a participatory role in prevention, identification, and treat-

ment of adolescent behavioral health/MH. However, it is

unclear how SNs are contributing to the implementation of

school-based suicide interventions.

AIM

The initial aim of this review was to examine the empirical

literature regarding the role of the SN in suicide interven-

tions within the context of increasing suicide rates among

adolescents in the United States. Studies were limited (n ¼ 4); therefore, we expanded our search to include quality

improvement projects. This resulted in six (n ¼ 6) articles.

The final aim of the review was expanded to (1) critically

examine the role of the SN in school-based suicide interven-

tions, (2) explore potential barriers preventing the SN from

participating in suicide interventions, and (3) recommend

strategies to build capacity for principles of school nursing

practice in suicide intervention. The NASN (2016) Frame-

work for 21st Century School Nursing Practice was used as a

guide in determining how each intervention and outcome

identified in the articles should be classified in terms of the

nursing role. Additionally, recommendations to enhance

practice were explored within the context of the NASN

(2018) position statement on the role of the SN in the beha-

vioral health/MH of students.

Method

The methodology described by Whittemore and Knafl

(2005) was used for this integrative review. The stages of

this method include problem identification, literature search,

data evaluation, data analysis, and presentation. Following

identification of the problem, a literature search was con-

ducted to explore the role of the nurse in school-based sui-

cide interventions. Due to the lack of research studies, the

authors expanded the inclusion criteria to include quality

improvement projects that described involvement of the

SN in interventions to prevent suicide. Integrative reviews

allow for a diversity of methodologies creating a more thor-

ough exploration of the phenomenon under review (Whitte-

more & Knafl, 2005).

Literature Search

The search targeted research studies and quality improve-

ment projects in peer-reviewed journals written in English

with the following inclusion criteria: (1) school-based sui-

cide interventions and/or prevention programs; (2) outcomes

including suicide, suicidal ideations, suicidal attempts, and

nonsuicidal self-injury for children or adolescents; and (3)

SN involvement with the intervention. A comprehensive

search, using multiple databases (i.e., PubMed, CINAHL,

PsycINFO, and ProQuest), was conducted in consultation

with a research librarian. Multiple search terms in combina-

tion were used, including suicide OR suicide attempts OR

self-harm OR suicidal ideation OR self-injury OR suicidal

behavior OR self-injurious behavior AND child OR youth

OR adolescent OR children OR adolescents AND preven-

tion OR intervention AND schools AND nurses. A search

was conducted for articles that were published between Feb-

ruary 2009 and February 2019.

The search resulted in 1,422 articles. An additional search

in Google Scholar with the inclusion of the search term

“nursing research” was conducted, which resulted in an

additional six studies for a total of 1,428 articles. The Pre-

ferred Reporting Items for Systematic Reviews and Meta-

Analyses (Moher et al., 2009) served as a reference for

review of the articles. These articles were reviewed by title

42 The Journal of School Nursing 37(1)

and abstract, and after deleting duplicates, 1,279 articles

were excluded with 149 remaining for full-text review.

These articles were reviewed in detail, and 129 articles were

eliminated because the involvement of the SN was unclear

(n ¼ 2); the SN did not participate in the intervention (n ¼ 69), the intervention was not conducted in a school setting (n

¼ 6), the article was not research or quality improvement (n ¼ 39), or the outcome was not related to suicide or reducing suicide risk or competencies relating to suicide (n ¼ 13), leaving 20 articles for discussion and further evaluation.

Data Evaluation

Whittemore and Knafl (2005) note the complexity of eval-

uating the quality of diverse primary sources. Two reviewers

(M.P. and D.T.) reviewed the remaining 20 articles indepen-

dently and then collaboratively. Exclusion and inclusion cri-

teria were applied, and data were extracted relating to clarity

of the description of the procedure and strength of the

research method. To maintain our focus on the scope and

standards of school nursing practice in the United States and

within the NASN Framework, the reviewers excluded arti-

cles describing international studies (n ¼ 1). Fourteen arti- cles were excluded because the involvement of the SN was

unclear (n ¼ 3), the SN did not participate in the intervention (n ¼ 3), the article was descriptive in nature or described a protocol (n ¼ 4), or the outcome was not related to suicide or reducing suicide risk (n ¼ 3), leaving six articles for analysis (see Figure 1).

Data Analysis

The goals of the data analysis stage include interpreting

primary sources thoroughly and without bias as well as

synthesizing the data in a creative way (Whittemore &

Knafl, 2005). This stage involves data reduction, display,

and comparison as well as drawing conclusions and verifi-

cation (Whittemore & Knafl, 2005). The data were reduced

by identifying and categorizing the school nursing role in

suicide interventions and outcomes according to the compo-

nents of the principles outlined in the NASN (2016) Frame-

work for 21st Century School Nursing Practice. The Best,

Oppewal, and Travers’s (2018) integrative review, which

used the framework in linking SN interventions to student

health and education outcomes, served as a guide. The six

primary sources were reviewed by three researchers (M.P.,

D.T., S.P.) independently and then collaboratively until con-

sensus was attained. One of the researchers (S.P.) has exper-

tise in school nursing and application of the Framework

lending additional rigor to the process.

We critically analyzed each research study or project and

categorized each according to all five principles and

assigned multiple principles as applicable. While we recog-

nize the five principles overlap (Maughan, Bobo, Hoffmann,

& Bland-Slaffey, 2018), we categorized interventions and

outcomes into Framework principles and components based

upon best placement. The data were displayed by organizing

each SN role in suicide intervention and outcome according

to its aligned principle in the form of a table which allowed

the researchers to visualize patterns and common themes.

The last step in the data analysis stage involves synthesizing

the data into an integrated summary (Whittemore & Knafl,

2005). Each researcher reviewed the resulting summary and

discussed it in detail to ensure there was minimal bias and an

honest appraisal of the data.

Results

The six articles selected for this integrative review include

four quantitative studies and two quality improvement proj-

ects. Four of the articles described studies or projects con-

ducted in urban (n ¼ 2), suburban (n ¼ 1), and urban/rural (n ¼ 1) public school settings. Interventions were conducted in elementary (n ¼ 1), middle (n ¼ 3), and high (n ¼ 6) schools. Interventions examined student outcomes related

to suicidal risk (Allison, Nativio, Mitchell, Ren, & Yuhasz,

2014; Biddle, Kern, Thurkettle, Puskar, & Sekula, 2014;

Hooven et al., 2012) or school staff outcomes pertaining to

knowledge (Johnson & Parsons, 2012; Walsh, Hooven, &

Kronick, 2013), confidence (Walsh et al., 2013), and post-

training behaviors (Condron et al., 2015; Johnson & Parsons,

2012).

SN Role in Suicide Interventions and Outcomes

The interventions and outcomes contained in the six articles

were classified under the five principles of the NASN (2016)

Framework for 21st Century School Nursing Practice to

reflect the activities of SNs in suicide prevention. Scholarly

articles describing SN roles in suicide interventions were

classified within the community/public health principle (n

¼ 4), the care coordination principle (n ¼ 3), the quality improvement principle (n ¼ 2), the leadership principle (n ¼ 1), and the standards of practice principle (n ¼ 1; see Table 1).

Community/public health principle. School nursing practice may include the assessment of at-risk students and initiating

referrals according to the community/public health principle

(NASN, 2016). Interventions and outcomes were classified

under the components of screening/referral/follow-up (n ¼ 3) and outreach (n ¼ 3). SNs conducted screenings (Allison et al., 2014; Biddle et al., 2014; Condron et al., 2015) result-

ing in early identification of students at risk for suicide for

treatment and referral (Allison et al., 2014; Condron et al.,

2015) and lower suicide rates (Biddle et al., 2014). As mem-

bers of the Student Assistance Program (SAP), SNs initiated

the use of two validated screening tools for MH during rou-

tine physical exams (Allison et al., 2014). One study exam-

ined the impact of the SAP team on educational outcomes

for students at risk for suicide. While not statistically

Pestaner et al. 43

significant, suicide rates were lower for those who partici-

pated in the SAP (Biddle et al., 2014).

SNs were participants alongside teachers, MH profes-

sionals, and social workers in gatekeeper training aimed to

improve identification of at-risk youth and referrals for ser-

vices (Condron et al., 2015). Evaluation of posttraining

behaviors indicated that professional role was predictive of

identification of at-risk youth (Condron et al., 2015). SNs

also assisted with a counselor-led youth/parent suicide inter-

vention by providing follow-up support to students after

screening for suicide (Hooven et al., 2012). Outcomes of

this youth/parent intervention included decreased student

suicide risk factors and increased protective factors (Hooven

et al., 2012).

PubMed

2009-2019

219 Citations

CINAHL

2009-2019

118 Citations

PsycINFO

2009-2019

368 Citations

ProQuest

2009-2019

717 Citations

Other

2009-2019

6 Citations

1,428 Citations Screened

Inclusion/Exclusion Criteria Applied to

Title/Abstract &

Duplicates Removed

1,279

Articles

Excluded

129 Articles Excluded

2 Role of the Nurse Unclear

69 School Nurse not Involved

6 Not Conducted in a School

Setting

39 Not Research or Quality

Improvement

13 Outcome not Suicide

20 Articles

In-depth Full Text Review

Inclusion/Exclusion Criteria

Applied

14 Articles Excluded

3 Role of the Nurse Unclear

3 School Nurse not Involved

1 Not Conducted in US

4 Not Research or Quality

Improvement

3 Outcome not Suicide

6 Articles

Included

149 Articles

Screening Full Text Review

Inclusion/Exclusion Criteria

Applied

Figure 1. Article Selection Process.

44 The Journal of School Nursing 37(1)

We found evidence of outreach, which was demonstrated by

SNs connecting parents and students to in-school and

community-based resources (Allison et al., 2014; Biddle et al.,

2014; Condron et al., 2015). As a result of screening initiated by

SNs, students were referred to the SAP which resulted in one

student being hospitalized for suicidal ideation (Allison et al.,

2014). Biddle, Kern, Thurkettle, Puskar, and Sekula (2014)

examined services used by SNs and other SAP team members

to support students at suicidal risk. They found that services,

such as drug and alcohol assessments, better predicted positive

educational outcomes. In another study, factors associated with

participant behaviors following gatekeeper training were exam-

ined. Findings indicated that participants who spent more time

with students identified more at-risk students and had higher

numbers of students receiving services (Condron et al., 2015).

Care coordination principle. SNs manage care for students and support autonomous decision-making by collaborating with

others and participating as team members within the care

coordination principle (NASN, 2016). Interventions and out-

comes were classified under the components collaborative

communication (n ¼ 1), interdisciplinary teams (n ¼ 1), and student-centered care (n ¼ 1). As members of an SAP, SNs demonstrated care coordination by communicating with

school support staff, parents, and community-based profes-

sionals (Allison et al., 2014; Biddle et al., 2014). This col-

laborative communication resulted in increased awareness

of students with MH treatment or psychosocial needs.

SNs were often described as members of an interdisci-

plinary team. Disciplines SNs collaborated with included

social workers, counselors, MH professionals, and/or teach-

ers lending to an interdisciplinary perspective and approach.

As members of interdisciplinary teams, SNs collaborated

with other professionals in school-based suicide interven-

tions for at-risk students (Allison et al., 2014; Biddle et al.,

2014; Hooven et al., 2012). In one project, in-school or

Table 1. SN Role in Suicide Interventions and Outcomes.

Authors SN Role in Suicide Intervention Outcomes Framework Principles Components

Allison, Nativio, Mitchell, Ren, and Yuhasz (2014); Condron et al. (2015); Biddle et al. (2014)

Conduct screenings for suicide risk; initiate referrals

Early identification and increased referral; lower suicide rate

Community/ public health

Screening/ referral/follow- up

Hooven, Walsh, Pike, and Herting (2012)

Provide follow-up support after counseling intervention

Decreased suicide risk factors; increased protective factors

Allison et al. (2014); Biddle et al. (2014)

Connect parent/student to in- school and community-based services

MH treatment for suicide risk; identified services which better predicted educational outcomes

Outreach

Condron et al. (2015) Connect at-risk students to services

Increased number of students receiving services

Allison et al. (2014); Biddle et al. (2014)

Communicate with school support staff, parents, and community-based professionals

Increased awareness of students with MH treatment or psychosocial needs

Care coordination

Collaborative communication

Allison et al. (2014); Biddle et al. (2014); Hooven et al. (2012)

Collaborate with various disciplines (e.g., social worker, counselors, teachers, MH professionals)

Interdisciplinary perspective and approach

Interdisciplinary teams

Allison et al. (2014) Provide support service options to parent/student

Parent/student decision-making Student-centered care

Allison et al. (2014) Participate in evaluation of screening tools

Recommendations for utilization of tool

Quality improvement

Evaluation

Johnson and Parsons (2012) Evaluate impact of training on participant knowledge

Increased knowledge level about suicide; reported use of protocol

Johnson and Parsons (2012) Advocate for gatekeeper suicide prevention program

School board approval to implement program

Leadership Advocacy

Johnson and Parsons (2012) Implement suicide prevention program

Trained nonmedical staff in suburban school district

Change agent

Walsh, Hooven, and Kronick (2013)

Participate in school-wide gatekeeper training

Increased perceived competency and knowledge in recognizing and referring at-risk youth

Standards of practice

Clinical competence

Note. SN ¼ school nurse; MH ¼ mental health.

Pestaner et al. 45

community-based service options were provided to parents

and students after collaboration with the SAP team (Allison

et al., 2014). This collaboration led to student-centered care

by facilitating student/parent decision-making.

Quality improvement principle. School nursing practice incor- porates the nursing process in providing care for students

within the quality improvement principle (NASN, 2016).

Interventions and outcomes were classified under the eva-

luation component (n ¼ 2). In one quality improvement project, pediatric and family nurse practitioners, who were

certified SNs, evaluated the effectiveness of two screening

tools which included questions pertaining to suicidality

(Allison et al., 2014). Based upon their evaluation, the SNs

recommended the assessment of student reading and literacy

skills prior to administration of tools. In another quality

improvement project, a SN supervisor implemented gate-

keeper training to nonmedical school personnel (Johnson

& Parsons, 2012). The SN supervisor evaluated participants’

suicide knowledge and the use of the gatekeeper protocol.

Findings showed a significant increase in knowledge about

suicide and use of the protocol 3 months following training.

Leadership principle. School nursing practice includes initiat- ing and developing prevention programs in the school within

the leadership principle (NASN, 2016). Interventions and

outcomes were classified under the components advocacy

(n ¼ 1) and change agent (n ¼ 1). One project described how a SN supervisor received approval for the implementation of

a gatekeeper suicide prevention program by advocating for

the program to school administrators and board members

(Johnson & Parsons, 2012). As a change agent, the SN

supervisor completed training to become a certified gate-

keeper instructor and provided training to school staff within

the school district (Johnson & Parsons, 2012).

Standards of practice principle. School nursing practice main- tains a high level of performance and competency under the

standards of practice principle (NASN, 2016). Interventions

and outcomes were classified within the clinical competence

component (n ¼ 1). In one study, SNs enhanced their clinical competence by completing gatekeeper training (Walsh et al.,

2013). SNs received the gatekeeper training along with other

in-school participants. Knowledge was assessed after the

training showing an increase in the ability of staff to recog-

nize at-risk behavior, approach at-risk students, and make

referrals (Walsh et al., 2013).

Discussion

SN Role in Suicide Interventions and Outcomes

While systematic reviews have reported on the effectiveness

of school-based suicide intervention programs in general

(Katz et al., 2013; Robinson et al., 2013), our review sought

to examine these intervention programs through the lens of

school nursing. We found the role of the SN in suicide

interventions represented within each of the Framework

principles, but research is limited. While the integrative

review by Best et al. (2018) found direct links between SN

interventions and student health and education outcomes,

our review was not able to discern a direct link between

school nursing interventions and student outcomes related

to suicide.

Outcomes were often reported based on interdisciplinary

team efforts, leading to obscurity of the role of the SN and

how their participation impacted outcomes (Allison et al.,

2014; Biddle et al., 2014; Hooven et al., 2012). For example,

SNs screened at-risk students and referred these students to

the SAP, but it is unclear whether the SNs were involved in

the process of making referrals to community services (Alli-

son et al., 2014). In another study, posttraining behaviors

were evaluated and found that professional role was predic-

tive of identification of at-risk youth (Condron et al., 2015).

However, prediction of the SN role on identification of at-

risk youth was not clear as nurses were grouped with school

administrators, advisors, and bus drivers. Other studies

noted SNs as part of prevention efforts (Hooven et al.,

2012; Walsh et al., 2013), but their role and the type of

support provided is not clearly described.

Furthermore, limited evidence on the role of SNs in sui-

cide interventions hindered our examination of whether or

not the role is in alignment with the NASN (2018) position

statement. We found minimal evidence of SNs collaborating

with others in prevention, assessment, early identification,

and intervention for students at risk for suicide. Thus, we

explored potential barriers hindering school nursing practice

related to suicide intervention.

Barriers for School Nursing Practice

Accessibility of SNs. SNs are easily accessible to students and may be less intimidating for those who need MH support

(NASN, 2018). However, heavy caseloads are barriers to

addressing student MH needs (Pryjmachuk, Graham, Had-

dad, & Tylee, 2011; Ravenna & Cleaver, 2016) and the

nursing shortage in schools may limit collaboration with

other MH providers (Cowell, 2019). While NASN recom-

mends at least one full-time SN accessible daily to students,

Willgerodt, Brock, and Maughan (2018) found that the

majority of SNs are responsible for two or more schools and

18.1% of the public schools surveyed (n ¼ 1,062) did not employ any nurses. Additionally, results from a 2015 NASN

SN survey (n ¼ 7,293) found the majority (61%) of respon- dents reporting the students per nurse ratio at 942 or greater

(Mangena & Maughan, 2015). When SNs manage heavy

caseloads or availability of SNs is limited, time constraints

can be a significant barrier and nursing practice in suicide

prevention efforts may be overlooked.

46 The Journal of School Nursing 37(1)

MH competencies. SNs are well equipped to recognize warn- ing signs of MH issues and qualified to identify behavioral

concerns (NASN, 2018). However, competency may be a

barrier to SNs participating in interventions pertaining to

MH. A lack of training in the care of students with MH

issues has been frequently reported (Bohnenkamp, Stephan,

& Bobo, 2015; Pryjmachuk et al., 2011; Ravenna & Cleaver,

2016) which parallels with the 2015 NASN survey of SNs

(n ¼ 8,006) indicating MH as a top priority educational need (Mangena & Maughan, 2015). Findings from an integrative

review on trends in self-injurious behavior suggest that SNs

may lack competencies to recognize high-risk behaviors (B.

Wilkinson, 2011). Although one study found that 40% of SNs provided suicide emergency management within their

school, they may not be receiving adequate training to do so

(Ramos et al., 2013).

Lack of screening tools. SNs can identify and screen for MH issues and refer students for MH services (NASN, 2018).

However, tools and resources to support assessments and

interventions have been reported as obstacles for SNs in