The Journal of School Nursing
2021, Vol. 37(1) 41-50
© The Author(s) 2019
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DOI: 10.1177/1059840519889679
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Mitzi C. Pestaner, MSN, RN, JD , Deborah E. Tyndall, PhD, RN , and Shannon B. Powell, PhD, RN, CNE
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.
mental health, integrative reviews, school nurse role, safety/injury prevention
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 Disease Control and Prevention [CDC], 2019). As suicide rates continue to rise among older high school adolescents, a similar 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 adolescent 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 promote education for students and/or school staff on risk factors and warning signs, screening to identify those at risk for 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 behavior, improve the attitudes of students (Robinson et al., 2013), and decrease suicidal ideations, attempts, and completed 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 professional for MH services (Cowell, 2019).
The National Association of School Nurses (NASN) published 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 communities. The Framework includes principles of standards of practice, care coordination, quality improvement, community/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 recommended strategies to address those obstacles.
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 treatment of adolescent behavioral health/MH. However, it is unclear how SNs are contributing to the implementation of school-based suicide interventions.
The initial aim of this review was to examine the empirical literature regarding the role of the SN in suicide interventions within the context of increasing suicide rates among adolescents in the United States. Studies were limited (n = 4); therefore, we expanded our search to include quality improvement projects. This resulted in six (n = 6) articles. The final aim of the review was expanded 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 NASN (2016) Framework 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 behavioral health/MH of students.
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 conducted to explore the role of the nurse in school-based suicide 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 thorough exploration of the phenomenon under review (Whittemore & Knafl, 2005).
The search targeted research studies and quality improvement projects in peer-reviewed journals written in English with the following inclusion criteria: (1) school-based suicide 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 combination 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 prevention OR intervention AND schools AND nurses. A search was conducted for articles that were published between February 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 Preferred 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 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 = 2); the SN did not participate in the intervention (n = 69), the intervention was not conducted in a school setting (n = 6), the article was not research or quality improvement (n = 39), or the outcome was not related to suicide or reducing suicide risk or competencies relating to suicide (n = 13), leaving 20 articles for discussion and further evaluation.
Whittemore and Knafl (2005) note the complexity of evaluating the quality of diverse primary sources. Two reviewers (M.P. and D.T.) reviewed the remaining 20 articles independently and then collaboratively. Exclusion and inclusion criteria 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 articles describing international studies (n = 1). Fourteen articles were excluded because the involvement of the SN was unclear (n = 3), the SN did not participate in the intervention (n = 3), the article was descriptive in nature or described a protocol (n = 4), or the outcome was not related to suicide or reducing suicide risk (n = 3), leaving six articles for analysis (see Figure 1).
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 verification (Whittemore & Knafl, 2005). The data were reduced by identifying and categorizing the school nursing role in suicide interventions and outcomes according to the components of the principles outlined in the NASN (2016) Framework 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 consensus was attained. One of the researchers (S.P.) has expertise 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 recognize 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.
The six articles selected for this integrative review include four quantitative studies and two quality improvement projects. Four of the articles described studies or projects conducted in urban (n = 2), suburban (n = 1), and urban/rural (n = 1) public school settings. Interventions were conducted in elementary (n = 1), middle (n = 3), and high (n = 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 posttraining behaviors (Condron et al., 2015; Johnson & Parsons, 2012).
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 = 4), the care coordination principle (n = 3), the quality improvement principle (n = 2), the leadership principle (n = 1), and the standards of practice principle (n = 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 = 3) and outreach (n = 3). SNs conducted screenings (Allison et al., 2014; Biddle et al., 2014; Condron et al., 2015) resulting 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 members of the Student Assistance Program (SAP), SNs initiated the use of two validated screening tools for MH during routine physical exams (Allison et al., 2014). One study examined the impact of the SAP team on educational outcomes for students at risk for suicide. While not statistically significant, suicide rates were lower for those who participated in the SAP (Biddle et al., 2014).
SNs were participants alongside teachers, MH professionals, and social workers in gatekeeper training aimed to improve identification of at-risk youth and referrals for services (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 intervention 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).
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 examined. 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 outcomes were classified under the components collaborative communication (n = 1), interdisciplinary teams (n = 1), and student-centered care (n = 1). As members of an SAP, SNs demonstrated care coordination by communicating with school support staff, parents, and community-based professionals (Allison et al., 2014; Biddle et al., 2014). This collaborative communication resulted in increased awareness of students with MH treatment or psychosocial needs.
SNs were often described as members of an interdisciplinary team. Disciplines SNs collaborated with included social workers, counselors, MH professionals, and/or teachers lending to an interdisciplinary perspective and approach. As members of interdisciplinary teams, SNs collaborated with other professionals in school-based suicide interventions for at-risk students (Allison et al., 2014; Biddle et al., 2014; Hooven et al., 2012). In one project, in-school or 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 incorporates the nursing process in providing care for students within the quality improvement principle (NASN, 2016). Interventions and outcomes were classified under the evaluation component (n = 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 gatekeeper 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 initiating and developing prevention programs in the school within the leadership principle (NASN, 2016). Interventions and outcomes were classified under the components advocacy (n = 1) and change agent (n = 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 gatekeeper instructor and provided training to school staff within the school district (Johnson & Parsons, 2012).
Standards of practice principle. School nursing practice maintains 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 = 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 recognize at-risk behavior, approach at-risk students, and make referrals (Walsh et al., 2013).
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 (Allison et al., 2014). In another study, posttraining behaviors were evaluated and found that professional role was predictive of identification of at-risk youth (Condron et al., 2015). However, prediction of the SN role on identification of atrisk 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 suicide 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.
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, Haddad, & Tylee, 2011; Ravenna & Cleaver, 2016) and the nursing shortage in schools may limit collaboration with other MH providers (Cowell, 2019). While NASN recommends 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 = 1,062) did not employ any nurses. Additionally, results from a 2015 NASN SN survey (n = 7,293) found the majority (61%) of respondents 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.
MH competencies. SNs are well equipped to recognize warning 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 = 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 providing MH care (Ravenna & Cleaver, 2016). Specifically, SNs may not have access to suicide risk assessment tools to use for screening students (Nolta, 2014). Additionally, when there are insufficient MH services to address needs, the effectiveness of screening is questionable (Robinson et al., 2013). Further, there may be a potential for harm if adequate support is not available for at-risk students (Heilbron, Goldston, Walrath, Rodi, & McKeon, 2013). Lack of referral services has also been reported as an obstacle to implementing screening of at-risk students (Singer, 2017) and policies relating to nonsuicidal self-injury (Berger, Hasking, & Reupert, 2015).
Role confusion. SNs are critical to the MH team (NASN, 2018). Yet, SNs are often not recognized as part of the school-based MH team (Bohnenkamp et al., 2015). Research on school-based suicide prevention programs has shown that SNs are often not involved (Katz et al., 2013). Nursing practice in school settings may be viewed as the professional role that attends to physical injury or disease processes (King, 2014) hampering their ability to collaborate with other school staff members on MH needs of students (Bohnenkamp et al., 2015). Further, some nurses may lack an understanding of their role in MH screening or as a member of the MH team in school settings (Cowell, 2019).
The NASN (2018) position statement guided our recommendations for future research and strategies to build capacity for the Framework principles of school nursing practice (Table 2). Research aimed to clearly identify SN interventions and measure direct outcomes could increase evidence of school nursing practice within the quality improvement principle of the Framework. A first step might be for SNs to participate in the NASN (2019a) Outcome Challenge by identifying a data point and outcome measure for suicide intervention. For example, SNs could track students who are identified as at risk for suicide (data point) and collect data on referrals (outcome measure) initiated to in-school or community services (e.g., school counselor, MH professional). The results of these referrals could be investigated to determine direct links between SNs and student outcomes related to suicide. Research is also needed on the impact of interprofessional collaboration on addressing MH needs of students (Cowell, 2019). Participating in the Outcome Challenge and tracking data related to SN participation within interdisciplinary teams would empirically demonstrate the impact of the SN. Collection of these data points would assist researchers in examining SN interventions and outcomes to further advance the science and inform school nursing practice.
Research is also needed on the barriers impeding SN participation in suicide prevention and how nurses can advocate for policies that would decrease these barriers. For example, increasing accessibility of SNs could support the ability of individual nurses to build practice capacity within the care coordination principle of the Framework. Policies that support more funding for full-time SNs to decrease the student/nurse ratio is needed. Improving caseloads and accessibility of SNs should be considered as research has found identification of at-risk for suicide adolescents is positively correlated with time spent with those trained in identifying at-risk students (Condron et al., 2015). Research has also shown that school-based suicide prevention programs are cost-effective when compared to the estimated cost of over US$1 million for one suicide (Ahern et al., 2018). Investing in SNs for prevention and intervention of suicide is worthwhile to students, schools, families, and communities. Participating in the NASN (2019b) National School Health Data Set: Every Student Counts! initiative can help demonstrate the value and need for more SNs.
Increasing SNs’ competency in the care of students with MH needs has the potential to enhance the ability of nurses to assimilate the standards of practice principle of the Framework into practice. SNs have expressed feeling doubtful about their competency and needing more education about MH issues (Jönsson, Maltestam, Tops, & Garmy, 2019). While training nurses on MH topics has been shown to increase confidence and knowledge in providing MH care (Blair, Chhabra, Belonick, & Tackett, 2018; Bullock, Libbus, Lewis, & Gayer, 2002; Higson, Emery, & Jenkins, 2017), more research is needed on how increased competency influences nursing practice and outcomes. Interprofessional education is an important way in which to develop collaboration among SNs, teachers, and other school professionals (Bohnenkamp et al., 2015). Interprofessional education would not only promote increased efficacy regarding MH issues but promote a collaborative working relationship with other school professionals.
Valid screening tools and resources can enhance the ability of the SN to integrate the community/public health principle of the Framework into practice. The NASN (2018) position statement reflects the expertise of SNs in conducting screenings and referring at-risk students for MH services. Thus, providing SNs with appropriate screening tools will enhance their ability to conduct these assessments (Nolta, 2014) and refer at-risk students for services. While not included in this integrative review, we found one international study in which SNs incorporate a screening tool for suicidal behavior during student physical health screenings (de Wilde, de Looij, Goldschmeding, & Hoogeveen, 2011). Findings indicate that questions about recent suicidal thoughts were most predictive of subsequent actions by SNs when compared to self-report of other emotional or behavioral problems. These findings support the need for validated screening tools to appropriately identify at-risk students in school settings. More research is needed on appropriate screening tools for use in schools to identify students at risk for suicide or MH disorders.
Removing role obscurity has the potential to enhance the ability of the SN to incorporate the leadership principle of the Framework into practice. Using the NASN (2018) position statement as a guide, SNs should be proactive in identifying themselves as instrumental in suicide interventions by making others aware of their expertise in assessing and intervening among those with MH needs. Following the scope and standards of practice component, which notes the “evolving boundaries” of the practice of school nursing (NASN, 2016, p. 51), SNs should become involved in developing policy, whether it is for advocating for changes at the district, local, statewide, or national level. Advocating for school-based suicide prevention programs using a teambased approach, including the SN, is critical (Bohnenkamp et al., 2015). It is incumbent on the SN to clarify ways in which their strong assessment and leadership skills can positively impact the health and academic success of students by engaging in preventative and interventional initiatives such as suicide prevention.
There were several limitations in conducting this integrative review on the role of the SN in suicide interventions. We comprehensively searched the literature using a rigorous method, but it is possible that some research may have been overlooked. We attempted to maintain a high level of rigor in classifying interventions within the principles of the framework, and while the literature has objectively defined the principles and their components, there may have been some level of subjectivity in our classifications. While it is certainly possible that many SNs have key roles in suicide interventions, we found this lacking in the literature.
Suicide rates in adolescents are rising, and SNs are well positioned to have a participatory role in prevention, identification, and treatment of adolescent behavioral/MH. However, this integrative review revealed a lack of empirical evidence supporting the role of the SN in school-based suicide interventions. Interventions and outcomes were classified according to the NASN (2016) Framework for 21st Century School Nursing Practice, but due to role obscurity or lack of clearly defined roles, they were limited in scope. Future research aimed to directly link SN interventions with outcomes related to suicide is warranted. Barriers that impede SNs from participating in school-based suicide interventions also need further investigation. Eliminating these barriers would support the role of the SN and build capacity for the Framework principles of school nursing practice.
We would like to thank Dr. Martha Engelke for her invaluable feedback and Dr. Gina Firnhaber for her consultation during the literature search.
Mitzi C. Pestaner, Deborah E. Tyndall, and Shannon B. Powell contributed to acquisition, analysis, or interpretation; critically revised the manuscript; and gave final approval. Mitzi C. Pestaner and Deborah E. Tyndall contributed to conception or design and drafted the manuscript. All authors agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Mitzi C. Pestaner, MSN, RN, JD https://orcid.org/0000-0001-9299-8389
Deborah E. Tyndall, PhD, RN https://orcid.org/0000-0001-9030-2464
Shannon B. Powell, PhD, RN, CNE https://orcid.org/0000-0003-2957-1774
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Mitzi C. Pestaner, MSN, RN, JD, is a PhD student at East Carolina University College of Nursing, Greenville, NC, USA.
Deborah E. Tyndall, PhD, RN, is an assistant professor at East Carolina University College of Nursing, Greenville, NC, USA.
Shannon B. Powell, PhD, RN, CNE, is an assistant professor at East Carolina University College of Nursing, Greenville, NC, USA.
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: pestanerm13@students.ecu.edu
