The Journal of School Nursing2025, Vol. 41(3) 357–369© The Author(s) 2023Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405231180618journals.sagepub.com/home/jsn
AbstractThe rising rate of youth suicide in rural Eastern North Carolina reflects the national trend. Although school nurses have been regarded as the gateway professional for mental health services, their role in suicide prevention is not well understood. The purpose of this study was to explore school nursing practice regarding suicide prevention of school-aged children in one vulnerable region of the United States. Focus groups and surveys were collected from 35 school nurses in six school districts. Findings indicate that suicide protocols inclusive of the school nurse can facilitate their role in suicide prevention. Variation of school nursing practice existed between and within districts. These variations in school nursing practice highlight the need for school districts within the state and across the country to examine their policies and practices for mental health equity. Barriers such as higher caseloads, role disconnect, and lack of specialized training contributed to variations in practice.
Keywordssuicide prevention, school nurses, school nurse role, vulnerable youth, mental health equity, qualitative research
Suicide is a leading cause of death in youth, with recent statistics placing suicide as the second leading cause of death for ages 10–14 and third among ages 15–24 (Centers for Disease Control and Prevention [CDC], 2023a). There was a 2.8% increase in suicide rates for these two age groups between 2018 and 2021 (Stone et al., 2023). Notably, Black youth in these age groups experienced a significant increase in suicide rates of almost 37% (Stone et al., 2023). Another disturbing trend is the suicide rate for youth residing in rural areas. Between 2015 and 2017, children ages 10–19 residing in rural areas died by suicide at a rate of 8.6 per 100,000 in comparison to the 6.1 rate among urban children (Probst et al., 2019). Children residing in rural areas may have access to more lethal means (e.g., firearms) and be subject to mental health stigma which may impede seeking help for emotional distress (Goldman-Mellor et al., 2018). Compounding these racial and rural disparities is the shortage of mental health providers, particularly the short supply of pediatric mental health providers in rural communities (Goldman-Mellor et al., 2018; Probst et al., 2019).
The rate of adolescent suicide in North Carolina (NC) reflects the national trend. Among ages 10–17, the 2021 suicide rates were the highest reported rates in two decades, with sixty-two youth dying by suicide (NC Child Fatality Task Force, 2023). Suicide rates in older teens had the largest increase, with ten percent of high school students reporting attempted suicide (NC Child Fatality Task Force, 2023). Youth in rural NC may be especially vulnerable given the current trends in suicide rates and the lack of mental health providers. As compared to the fifty states in the nation, NC is the state with the second-largest rural population (United States Census Bureau, 2023). Of the 100 counties in NC, 94 have a shortage of mental health providers (NC Rural Health Leadership Alliance, 2021). rural (NC was ranked fourth in the nation for having the most suicides among Black youth with a rate of 3.85 per 100,000 population (Price & Khubchandani, 2019). Of particular concern is the rural eastern part of the state, where all counties have a reported shortage of mental health providers (Rural Health Information Hub, 2022). Further, as the long-term impacts of the COVID-19 pandemic are recognized, suicide prevention is especially relevant for at-risk youth in vulnerable communities (Stone et al., 2023).
As the shortage of providers becomes more dire, schools have pivoted to respond to the need to provide mental health services to children and adolescents (Golberstein et al., 2020). In particular, to identify and treat at-risk students, schools have implemented suicide prevention programs (Katz et al., 2013; Miller et al., 2009; Robinson et al., 2013). School nurses would seem likely collaborators with other school staff in implementing these protocols since they are often the only healthcare provider in schools (Hoskote et al., 2023) or they may be the first point of contact for students in crisis (Shattuck et al., 2022). Yet, in a systematic review of 16 school-based suicide prevention programs, only 2 (12.5%) of these programs reported school nurse collaboration (Katz et al., 2013).
In an attempt to learn more about school nurses’ contribution to suicide prevention, Pestaner et al. (2021) conducted an integrative review and found few studies regarding their role. The review concluded with obscurity of the school nurse role due to limited research and limitations in the collection and/or reporting of data. Limitations in data included the inability to discern school nurse contributions as results were not stratified or details of the contributions were not well described or measured. More recently, Shattuck et al. (2022) found that more than 50% of school nurses in New Mexico reported managing emergencies related to suicidal or self-injurious behavior. However, data to identify whether or not school nurses had access to validated screening tools or data to capture outcomes (e.g., referrals) were not collected. These glimpses into the role, while limited, suggest that school nurses may be contributing to suicide prevention outcomes of students. Nevertheless, the lack of clarity on the school nurse role is concerning since school nurses are well-positioned to collaborate with interdisciplinary teams to address suicide prevention. This gap in knowledge weakens the ability to demonstrate the school nurse’s contribution, or potential contributions, to the mental health of students. Although school nurses have been regarded as the gateway professional for mental health services (Cowell, 2019), their role in suicide prevention is not well understood. Therefore, the purpose of this mixed-method study was to explore school nursing practice regarding suicide prevention of school-aged children in one vulnerable region of the United States.
A sequential, QUAL-qual mixed-method design was used. This design indicates the mixing of one method (qualitative) containing a core component combined with a supplemental component (Morse, 2017). The supplemental component consists of data collection strategies that enhance the core component. The aims of this study were to: (a) describe the role of school nurses in Eastern NC in suicide prevention of students (QUAL—core component), (b) explore facilitators and barriers faced by school nurses in contributing to suicide prevention interventions (QUAL—core component), and (c) determine what percentages of school nurses report suicide prevention interventions (e.g., suicide risk screenings, referrals) during the 2021–2022 school year (qual—supplemental component). Pacing is used to explain the interaction of the core and supplemental components (Morse, 2017). The following illustrates the pacing and data sources collected for the sequential design: QUAL (focus groups) → qual (open-ended surveys).
Six school districts were selected to obtain a representative sampling of the region. Across these six counties, there is a racially and ethnically diverse population including White (53.5%–72.1%), Black (30.5%–40.5%), and Hispanic (2.4%–16.3%) residents (US Census Bureau, 2022). Seventy-three percent of the schools within these six districts receive Title 1 funding (NC School Report Card, 2023). All study protocols were approved by the Institutional Review Board at East Carolina University [UMCIRB 19-002869] and by each school district. After receiving approvals, we contacted lead school nurses with an email invitation describing the study. We scheduled focus groups with full-time school nurses in conjunction with their regularly scheduled school nurse staff meetings to gain advantage of when they would be collectively gathered. School nurses who agreed to participate signed an informed consent and completed a demographics survey prior to the start of the focus groups. Semi-structured questions elicited responses regarding the role of school nurses in suicide prevention and facilitators or barriers contributing to their role. Six focus groups, lasting one hour and including five to eight participants were conducted by DT and MP. Five of the focus groups were conducted in person in private meeting spaces located at either schools or training facilities. One focus group was conducted via Zoom© video conferencing per the request of the district. Participants received a $50 debit card incentive. Fluctuating COVID-19 county infection rates required consideration of district protocols and researcher judgment, resulting in focus groups occurring over a period of 6 months from October 2021 to April 2022.
School nurses who participated in focus groups received an open-ended survey at the end of the school year to gather additional information regarding their role in suicide prevention. Survey questions were developed based on findings from focus group data and targeted two types of suicide prevention interventions (a) school nurse suicide risk assessment and referral, and (b) suicide risk assessment based on interdisciplinary collaboration. Since school nurses did not track these interventions, they were asked to use memory to respond to the following prompts for the 2021–2022 school year: (a) How many times did you refer students to the school counselor or school social worker because you were concerned about a student’s risk for self-harm? and (b) How many times did you collaborate with a school counselor or school social worker for a student suicide risk assessment? Participants were asked to describe these situation(s) using a free text option. Surveys were distributed via Qualtrics© and took appropriately 15 min to complete. Participants who completed surveys were entered into raffles to receive one of twelve preloaded debit cards with values of $25 or $50.
Audio-recordings of journal data were uploaded and transcribed verbatim by Rev.com into Microsoft® Word documents and were labeled with sequential identifiers (e.g., District A) to ensure confidentiality. The authors used firstand second-cycle coding (Saldaña, 2015) to code separately and then collaboratively until consensus was obtained. Inductive content analysis was used to generate codes into categories in order to make meaning of the data (Elo & Kyngäs, 2008). In fall 2022, the team revisited each district to complete member checking with participants. Participants were presented with schematics representing researcher-generated categories of the role of school nurse in suicide prevention for the district. Participants were asked to score their level of agreement with each category using a 5-point Likert scale ranging from 5 (strongly agree) to 1 (strongly disagree). Categories were collapsed and data abstracted to best represent the main findings. Deductive content analysis was used to compare focus group data with survey data to test the main categories (Elo & Kyngäs, 2008). Numerical values were used to better understand the school nurse role in suicide prevention and to generate additional meaning of their experiences (Sandelowski, 2001). The findings of each qualitative component were brought together to examine the point of interface (Morse, 2017).
A total of 35 school nurses participated in the study (Table 1). School nurses were female, mostly White/European (89%), and between the ages of 35–54 (69%). Most participants (94%) held a bachelor’s degree and were nationally certified (77%). Participants had at least 4 years of school nurse experience with 57% having 11 years or more. The majority of participants (77%) had a 1–2 school caseload, with 63% serving less than a thousand students and 14% serving greater than 1500 (Table 2). Participants served populations including Head Start/PreK/Nursery (31%), Elementary (69%), Middle/ Junior High (43%), High School (34%), Special Education (6%), and Alternative (9%).
Suicide Risk Assessment and Referral. Focus group data indicated consistency among the six districts in that school nurses were responsible for medical assessment of selfinjurious behaviors (e.g., drug overdosing, cutting behaviors). For some school nurses, this was likely the only time they would get involved with suicide intervention because it was “seen as a health issue.” Participants were comfortable with this role of medical assessment as this aligned with the traditional role of school nursing. However, there was less comfort in mental health assessment and one participant described an occurrence when a student with mental health needs was overlooked:
There have been so many times they try to come to my office. They will complain and I get a history, give them a hug, get them back to class. And I missed it! I end up feeling like I completely failed in helping that kid because it wasn’t even on my radar with the others sitting out there waiting to be seen in the office. All I know is there was nothing measurable in my assessment. But I mean, it is frustrating. (District D)
Although participants were less comfortable with assessing mental health, they acknowledged their pivotal role in student safety. School nurses were often the first point of contact for distressed students who presented with psychosomatic complaints. Participants used previous experiences, knowledge of warning signs, and/or their nursing intuition to identify “red flags” as they didn’t have access to validated screening tools.
If it’s a gut feeling that we feel like this child needs some help and it depends on what they’re saying…just looking at their body movements…and even if it’s warranted or not, if it’s beyond us we’ll turn them over to counseling…If we had a screening tool, we could be more in tune and we could ask better questions…and get that person to the counselor quicker. (District C)
School nurses were especially pivotal in student suicide prevention when school counselors or school social workers were out on leave. This inadvertent positioning concerned participants due to their heavy caseload. In one district, a school counselor was out for a family emergency and the school nurse became the “go to” person for assessing a student’s risk. A school nurse from another district, corroborated the possibility of this occurrence and the need for a protocol:
I honestly, in my heart of hearts, I feel like that [risk assessment] is just something [the counselors] feel like they can handle…But I also feel like just in case something happens and they’re not there…like our counselor is out [with] COVID this week. [If] something happens, who’s their next contact? (District B)
It was standard practice for school nurses to refer to school counselors when their assessment indicated a potential safety risk. Subsequently, school counselors and school social workers had the primary role of screening students and making referrals for mental health services. School nurses were comfortable with relinquishing this responsibility as they viewed these clinicians as mental health experts and best suited to take appropriate actions. School nurses in four of the six districts did report situations in which they referred to school-based therapy services. In contrast, school nurses in the other two districts rarely made referrals beyond the school counselor. All districts identified access to mobile crisis services in cases of mental health emergencies. In situations when the school counselor was out on leave, the school nurses often took the lead in these emergencies.
Interdisciplinary Collaboration. While school nurses across all districts had a role in assessment and referral, focus group data indicated variation of practice regarding interdisciplinary collaboration. Two of the six districts (D and E) used a suicide prevention protocol that included school nurses. Because the protocol required two clinicians, school nurses in these districts were more likely to collaborate with school counselors and school social workers in determining a student’s safety risk and making decisions concerning interventions. School counselors and school social workers usually implemented protocols if two of them were available. This practice was particularly common when school nurses were assigned to more than one school. Participants with high school assignments were not likely to be involved in protocols. In high schools, a higher allocation of school counselors (typically three) resulted in a reduced need to collaborate with school nurses.
There were several distinctions between the districts with protocols related to the practice of interdisciplinary collaboration. On occasion, school nurses in District D took the lead implementing the protocol when the school counselor was absent; however, school nurses in District E reported not ever taking the lead. In general, school nurses in District E were less likely to assist with the protocol as part-time school social workers in their schools were available to assist school counselors. In contrast, school nurses in District D regularly assisted with implementing the protocol. One school nurse in particular, frequently served as a co-assessor with the school’s only counselor:
I’m involved in a lot of threat assessments…myself and the counselor. I mean, this is the largest elementary in the district here [and] we only have one counselor. We have a part-time social worker and a part-time psychologist. So there just isn’t anybody else here besides me and her and it does have to be a two-person team. So, I’ve always kind of been pulled into [threat assessments] since the process started. (District D)
In subsequent suicide prevention protocols, some school nurses reported engaging with interdisciplinary collaboration when they attended team meetings where student mental health needs were discussed. There were two districts (A and C) where school nurses did not attend team meetings, while attendance varied within the other districts. The following exemplars from within one district capture this variability:
At my high school, every Thursday, we have [team] meetings. It’s the counselors, the social worker, and graduation coach… I’ve learned a lot about our students. This is the first year I’ve been able to go because [meetings were] on days I wasn’t there. (District F)
[I attended regularly] up until this year. We [have] a new principal, and she just scheduled on a day that I’m not there for some reason. (District F)
Many school nurses were not aware if such meetings existed within their schools. Those that were aware of meetings were often not able to attend because they were scheduled on days they were at another assigned school. For others, they were “not invited.” In one district, school nurses acknowledged that “every school is so different” and “it depends on your principal.”
For some, interdisciplinary collaboration also occurred during re-entry of students after hospitalization for mental health care. School nurses reported that school counselors typically created and managed re-entry plans since these documents primarily focused on mental health care. While a few school nurses reported the occasional involvement with re-entry assessment and planning, normally school nurses were only consulted when there was a need for medication management. One participant recognized the variation in practice:
I think some schools do a much better job than others…I may not know about [re-entry meeting]. I see that [the student has] been out, and I find out [about their hospitalization] through the grapevine. (District D)
While not a standard practice, some school nurses did collaborate with school counselors to determine appropriate referrals for students.
I think it depends on who your counselor is…I’m based here at the high school [and] a lot of times we collaborate [for students] expressing some suicidal ideation. [We] sit down and discuss, ‘Okay, so do we call [Department of Social Services] or do we call mobile crisis? Or what entity do we contact?’ (District B)
Barriers to School Nurse Role in Suicide Prevention. Participants described ambivalent feelings about their level of involvement in suicide prevention. While some school nurses felt it was the role of school counselors and school social workers, others expressed a desire to be more involved. Limited expertise in mental health and left many feeling “not really equipped.” One school nurse elaborated on this feeling:
If you don’t have a background in mental health, then it becomes kind of a scary place to talk to students about suicide. (District C)
Several school nurses described a “disconnect” that hindered collaboration which was perceived to be a result of varied opinions of the school nurse role in mental health. One participant recalled hearing her assistant principal stating to “stay in your lane” suggesting that school nurses didn’t need to be involved with mental health unless they were asked. This disconnect contributed to being “kept out of the loop” regarding student mental health concerns:
I think there’s a disconnect between your counselors and your school nurse…like with the one [school counselor], ‘you’re not a need to know.’ I’m like, ‘but I do need to know.’ And I really think that in her head, I wasn’t a need to know so she didn’t tell me…I think that’s how they’re trained. I don’t think it’s intentional. (District B)
One participant reported only learning of students’ hospitalizations for mental health care when there were coincidental run-ins with the school counselor.
It’s not a must-have that they have to tell us. It just depends how close you are with them, or if you see them in the hallway one day and they’re like, “Oh, hey, by the way,” blah blah blah- (District F)
Caseload was described as another barrier to being kept informed about students. Participants felt like school counselors had learned to manage student mental health needs due to their limited availability:
[School counselors] function so much throughout the week without us. That’s just their norm. They need to, they have to. We’re there one day a week…They’ve learned to function without us, sadly. We don’t like it, but that’s just the way it is. They don’t think to call us or involve us. (District A)
Even in districts with collaborative suicide prevention protocols, school nurses were sometimes kept out of the loop especially if they were assigned more than one school.
I’m involved with threat assessments, but I have two schools. So, a lot of times it’s just the counselor and the social worker. So, they’re doing things that I’m not even aware of…I feel like sometimes I’m out of the loop as far as that goes, so that doesn’t feel comfortable. (District D)
School nurses acknowledged the influence of the pandemic on whether or not school clinicians collaborated with them, recalling how overwhelmed they were with the additional responsibilities related to managing their COVID-19 protocols. Participants felt that others were astute to the caseload of school nurses during this time and consulted with them only when it was necessary. This was particular true in schools where there was more than one school counselor or an available social worker to assist with student concerns.
Twenty (65%) of the 31 participants who completed surveys reported at least one intervention. First, data was analyzed at the individual school nurse level for those reporting interventions (Table 3). For those who made referrals to school counselors or school social workers, referrals were generated by slightly more than half of school nurses. Student concerns prompting a referral included anxiety and stress; suicide ideation with and without threats; drug overdose; and selfinjurious behaviors. School nurses described occurrences of being the first clinician to make contact with students in mental distress. The majority of school nurses estimated a total of twelve or less interventions, whereas SN21 and SN28 reported an estimated total of 44 and 32 interventions, respectively. As denoted by shading in Table 3, more than 80% of the total interventions reported were generated from the two districts with protocols inclusive of the school nurse (Districts D and E).
School nurse interventions were also analyzed at the district level (Table 4). Of the two districts that reported fewer referrals, school nurses had a caseload of five schools (District A) in comparison to one school (District A). Although referrals to school counselors and school social workers were reported from each district, the majority of referrals were generated by the two districts where school nurses were included in protocols. In districts with protocols (Districts D and E), nearly all of the school nurses reported serving as a co-assessor during the school year with an estimated total of 107 co-assessments between the two. In District D, school nurses made less referrals but participated in an estimated 87 interdisciplinary co-assessments. In contrast, District E school nurses made more referrals but participated in less interdisciplinary co-assessments.
This section integrates the results from the focus group and survey data (see Figure 1). Findings indicate that school nurses within these six districts have a supporting role in suicide prevention as the majority of them reported at least one intervention during the school year. Participants employed in districts with protocols inclusive of the school nurse estimated a higher number of interventions, suggesting that inclusivity can facilitate their role in suicide prevention. Limited time due to caseload was reported as a barrier during the focus group sessions; however, survey intervention data suggest caseload may not be the primary barrier for some. In the one district with the lowest caseload (i.e., one school assignment with <500 students), school nurses had less involvement with suicide prevention in comparison to other districts. Nevertheless, caseload appears to be a barrier for many, along with lack of training and expertise. Varied perceptions of how, and if, the school nurse has a role in mental health and suicide prevention seemed to contribute to missed opportunities for interdisciplinary collaboration.
The number of referrals reported for the school year supports the notion that school nurses do have a pivotal role in suicide prevention as they are often the first point of contact for at-risk students. While focus group data indicated that participants from District D were highly involved in suicide prevention, survey data showed fewer referrals from District D than several other districts. This finding may suggest that school nurses in District D refer less often because they activate their risk protocol when student concerns emerge, in lieu of a referral. In regard to role similarity, in all six districts school nurses conduct assessments of self-injurious behavior and medication management during re-entry after hospitalization for mental health care. However, there was variation in the role regarding interdisciplinary collaboration for suicide risk assessment and mental health in addition to participation in interdisciplinary team meetings. Of significance to this study is the variation of school nursing practice noted not only between districts, but within districts. This variation in school nursing practice in Eastern NC has policy implications for equitable care of school-aged children who are at risk for suicide.
A lack of empirical evidence and limitations in research designs have resulted in obscurity of the role of school nurses in suicide prevention (Pestaner et al., 2021). Findings from this study suggest that many of the school nurses have a role in suicide prevention of school-aged children as two-thirds of participants reported interventions of risk assessment and referral. While school counselors and social workers are primarily responsible for assessing student suicidality and follow-up intervention, school nurses contribute to suicide prevention through a supporting role capacity. Of particular interest is the finding related to interventions from districts where school nurses had a role in suicide prevention protocols. Participants in these two districts reported a higher number of interventions, suggesting that protocols inclusive of the school nurse can facilitate their role in suicide prevention. A higher school caseload was reported as a barrier for many of the participants. However, integration of the data suggests that protocols inclusive of school nurses may be more of a differentiating factor in them having a role in suicide prevention, even more so than caseload.
Of significance to this study is the variation of school nursing practice not only found between districts, but within districts. Similar practices existed in all six districts related to the assessment of student self-injurious behaviors and medication management for students re-entering school after hospitalization for mental health care. Yet, variation existed between and within districts regarding their attendance at interdisciplinary team meetings and collaboration with other school clinicians for student mental health concerns. Our findings are similar to recent studies that have also found variations in school nursing practice concerning mental health care of students (Granrud et al., 2019; Hoskote & Johnson, 2020; Markkanen et al., 2021; Vejzovic et al., 2022). Factors including exclusivity in interdisciplinary collaboration (Granrud et al., 2019); availability of full-time school nurses (Hoskote & Johnson, 2020); a lack of clear and structured guidelines (Vejzovic et al., 2022); and time constraints, inadequate education, and limited resources (Markkanen et al., 2021) attributed to practice variation.
While school nurses are commonly regarded as members of a school’s interdisciplinary student services team, along with school counselors, school social workers, and school psychologists (Lewis & Grobe, 2011), findings suggest that minimal collaboration occurs between school nurses and other clinicians with regard to student suicidality. Most often, school nurses in this study referred such concerns to the school counselor, who in turn triaged and referred students as needed to clinical mental health counselors for longterm care. This practice overlooks the experience and perspective of school nurses, who are estimated to spend 33% of their time addressing student mental health concerns (Bohnenkamp et al., 2015). Findings also indicated that even those school districts with a protocol in place for suicide management tended to exclude school nurses from important treatment discussions. School nurses were at times limited to a “need to know” basis and kept out of the loop on the status of students entering the protocol. However, variation in school nurse staffing and the resulting inconsistent presence on campus likely factor into this approach.
Currently, only 41% of school nurses in NC serve just one school, with some assigned to as many as six (Bell, 2019). While NASN (2019) recommends either one nurse per school or one nurse for every 750 students, NC schools vary greatly with ratios ranging from one nurse for 313 students to as large as one nurse for 2,724 students. Regular follow-up and case management of students who have considered or attempted self-harm is critical. Thus, a consistent in-school presence, which among the student services team is typically the school counselor, likely is the justification for the practice of school nurses to refer students of concern to the school counselor. Improved school nurse staffing in schools would allow for increased service to students while fostering opportunities for collaboration across the different student services staff.
During focus groups, school nurses reported they were often the first point of contact for students. These reports were supported by the number of referrals made to in-school services, indicating that school nurses undoubtedly have a pivotal role in school safety. This pivotal positioning may be a result of school nurses routinely being the only healthcare provider in schools (Hoskote et al., 2023) or that students view them as trustworthy because their role is not academic or disciplinary (Nolta, 2014). As such, school nurses are situated to implement mental health interventions (Hoskote et al., 2023). Furthermore, several participants shared experiences of being the ‘go to’ person when the school counselor or school social was absent, reiterating the criticality of school nurses being able to respond to mental health needs of students.
Because of their pivotal role, some participants discussed the need for available screening tools to assess suicide risk. While NASN (2021) supports early identification of student mental health needs through assessment practices, many school settings did not have access to screening tools (Toure et al., 2022). In fact, a 2014 NASN poll revealed a top reason why school nurses do not conduct mental health screening of students is due to a lack of validated tools (Bohnenkamp et al., 2015). This is concerning, as schools are an ideal venue to conduct suicide risk assessments due to the considerable amount of time youth spend in these settings (Nolta, 2014). Screening tools may be particularly helpful to school nurses as they reported situations where students frequent their office with persistent somatic complaints and expressed worry over missing signs of underlying mental health concerns. This worry is justified, as psychosomatic complaints can be an early warning sign of mental health problems or suicide risk (Heinz et al., 2020; Kim et al., 2020).
This study has several limitations that need to be considered when interpreting the findings. Although the sample included school nurses from six school districts, these districts are from one region within one Southeastern state. Thus, findings may not be transferable to other regions of the country. Another possible limitation is that the sample included districts of different sizes which may have moderating factors, such as available resources, which could have affected the role of the school nurse in suicide prevention. In two districts which employed over twenty school nurses, limits in focus group size precluded all of the school nurses from participating. Despite this limitation, we feel perceptions of the school nurse role were representative of the entire district.
Research is underway to examine the two outliers from the survey data more closely. Specifically, SN21 and SN28 reported school nurse interventions that were much higher than other school nurses in the sample and also their counterparts within the same districts. A follow-up study will collect additional data for the purpose of uncovering factors contributing to their higher level of involvement in suicide prevention. Our survey data did not capture the frequency of how often school nurses took the lead in protocols and other safety interventions when school counselors or school social workers were absent. Thus, future studies should include this data element to support the criticality of providing school nurses with specialized training and including them in protocols. Future studies should also include school nurses from a national sample to examine factors that differentiate school nurse involvement in suicide prevention. For example, examination of the potential relationships between school nurse characteristics (e.g., caseload) and/or school district characteristics (e.g., policies inclusive of the school nurse) with suicide prevention interventions is needed.
Our findings suggest a connection between district protocols inclusive of the school nurse and their role in suicide prevention. The findings should inform school district leadership, and others invested in school nursing practice, to examine their suicide prevention protocols for involvement of the school nurse. If school nurses are not included in such protocols, they should advocate for their involvement and minimize factors contributing to the disconnect expressed by participants in this study. School nurses should also examine the barriers that prevent them from having a role in suicide prevention protocols. In particular, school nurses may find themselves underutilized in high school settings where there are several school clinicians hired to manage student mental health needs. Yet, the school nurse role is equally pivotal in suicide prevention within these settings, as these students may be at higher risk for suicide in comparison to other age groups (NC Department of Health and Human Services, 2023)
School nurses in our study contributed to various practice components aligning with the NASN Framework for 21st Century School Nursing Practice™ (2020). Medical assessment of student self-injurious behaviors, screening at-risk students, and making referrals align with screening/referral/follow-up and direct care components of school nursing practice. Many school nurses also engaged in interdisciplinary collaboration with suicide risk protocols and participation in interdisciplinary team meetings contributing to practice components of collaborative communication, interdisciplinary teams, and case management. As school nurses offer valuable contributions in promoting student mental, behavioral, and social-emotional health, school administrators should refrain from a ‘stay in your lane’ mindset. Instead, administrators should support policies that are inclusive of the school nurse to align with a Whole School, Whole Community, Whole Child (WSCC) holistic approach (CDC, 2023b). As a first step, administrators can ensure school nurses have access to opportunities to collaborate by inviting them to interdisciplinary team meetings where student mental health concerns are discussed. Essential to this step is making sure meetings are scheduled when the school nurse can attend, particularly for those who are assigned to more than one school.
Similar to findings from Moen and Jacobsen (2022), participants reported using intuition, gut feelings, or previous experiences to determine if a referral to in-school services was warranted. Since suicide screening tools facilitate the identification of students at risk and expedite subsequent referral (Allison et al., 2014), the use of formal suicide risk screening tools and protocols would support the ability of the school nurse to enhance student safety (Baur et al., 2023). Suicide risk screening tools are typically brief and simple to administer, while also gathering key information (Patterson, 2016). Training on the use of tools can increase the school nurse’s confidence to manage the mental health needs of students (Hoskote et al., 2023; Kaskoun & McCabe, 2022; Ravenna & Cleaver, 2016). Training should include risk factors and warning signs of mental health and suicide risk (Shattuck et al., 2022) and be ongoing to reflect current trends in youth suicide statistics (CDC, 2023a).
The variation in school nursing practice in Eastern NC has policy implications for equitable care of school-aged children who are at risk for suicide. These variations highlight the need for school districts within the state and across the country to examine their policies and practices for mental health equity. Barriers such as higher caseloads, role disconnect, and lack of specialized training contributed to the variations identified in this study. We found variation in interdisciplinary collaboration as school nurses are often not consulted with by other school clinicians. Yet, school nurses are often the initial access point and offer valuable contributions to the behavioral health and wellness of students (NASN, 2021). We also found that collaboration with school nurses on re-entry plans is generally limited to the medication management component. However, school nurses are uniquely qualified to contribute to many facets of transition planning (NASN, 2019). Although school nurses are regarded as an essential team member (NASN, 2023), attendance to interdisciplinary team meetings varied. Caseloads and accessibility for some school nurses greatly hindered their ability to contribute to suicide prevention efforts. Limited accessibility is contrary to NASN’s (2022) position that all students should have access to school nursing care “to level the playing field with regard to health equity” (para. 7). Our findings of variation in practice are disconcerting, given the vulnerabilities of those students served in this study who live in predominately low-income, rural communities serving underrepresented youth.
Rural communities are often required to maximize limited existing resources in order to meet the needs of its membership. As adolescent suicide rates rise across the country, the number of mental health professionals available to provide treatment in rural communities has not kept pace. Therefore, other available clinicians with access to those in need of care should be engaged in mitigation efforts to address thoughts or acts of self-harm. As such, this study explored the practice of school nurses regarding suicide prevention of school-aged children in rural Eastern NC. The findings demonstrate variation in suicide prevention practice for school nurses both across and within school districts in the region. Variation was the result of nonexistent or inconsistently applied protocols for suicide prevention in conjunction with high caseloads that limit the accessibility of school nurses in the application of any protocol. Clear, consistent school district protocols on suicide prevention and intervention are necessary to reduce variation across schools. Such protocols should thoughtfully employ school nurses in service to suicide prevention efforts within the school. As part of the development of suicide prevention protocols, all school clinicians including school nurses would benefit from the provision of a suicide risk screening tool and the prerequisite training in its utilization. Additionally, increased funding and support is needed for a reduction in school nurse caseloads. Equity of care for rural and marginalized students necessitates a consistent school nurse presence on every school campus, allowing for improved collaboration among school clinicians and staff.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the East Carolina University College of Nursing Seed Grant.
Deborah E. Tyndall https://orcid.org/0000-0001-9030-2464
Allison, V. L., Nativio, D. G., Mitchell, A. M., Ren, D., & Yuhasz, J. (2014). Identifying symptoms of depression and anxiety in students in the school setting. The Journal of School Nursing, 30(3), 165–172. https://doi.org/10.1177/1059840513500076
Baur, A., Carpenter, D. M., Driscoll, K., Fromewick, J. C., Belden, C. M., & Thomas, K. C. (2023). Implementing facilitative leadership to develop a school nurse research agenda in western North Carolina. Journal of School Health, 93(2), 158–161. https://doi.org/10.1111/josh.13250
Bell, L (2019, January 18). Governor’s Leandro commission looks at North Carolina’s school support personnel. Education NC. https://www.ednc.org/governors-leandro-commission-looks-at-north-carolinas-school-support-personnel/
Bohnenkamp, J. H., Stephan, S. H., & Bobo, N. (2015). Supporting student mental health: The role of the school nurse in coordinated school mental health care. Psychology in the Schools, 52(7), 714–727. https://doi.org/10.1002/pits.21851
Centers for Disease Control and Prevention [CDC]. (2023a). Leading causes of death and injury. https://www.cdc.gov/injury/wisqars/LeadingCauses.html
Centers for Disease Control and Prevention [CDC]. (2023b). Whole school, whole community, whole child (WSCC). U.S. Department of Health & Human Services. https://www.cdc.gov/healthyschools/wscc/index.htm
Cowell, J. M. (2019). Fragmented school mental health services: Directions for research. The Journal of School Nursing, 35(2), 87. https://doi.org/10.1177/1059840519831777
Elo, S., & Kyngäs, H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62(1), 107–115. https://doi.org/10.1111/j.1365-2648.2007.04569.x
Golberstein, E., Wen, H., & Miller, B. F. (2020). Coronavirus disease 2019 (COVID-19) and mental health for children and adolescents. JAMA Pediatrics, 174(9), 819–820. https://doi.org/10.1001/jamapediatrics.2020.1456
Goldman-Mellor, S., Allen, K., & Kaplan, M. S. (2018). Rural/urban disparities in adolescent nonfatal suicidal ideation and suicide attempt: A population-based study. Suicide and Life-Threatening Behavior, 48(6), 709–719. https://doi.org/10.1111/sltb.12390
Granrud, M. D., Anderzèn-Carlsson, A., Bisholt, B., & Steffenak, A. K. M. (2019). Public health nurses’ perceptions of interprofessional collaboration related to adolescents’ mental health problems in secondary schools: A phenomenographic study. Journal of Clinical Nursing, 28(15–16), 2899–2910. https://doi.org/10.1111/jocn.14881
Heinz, A., Catunda, C., Duin, C. V., & Willems, H. (2020). Suicide prevention: Using the number of health complaints as an indirect alternative for screening suicidal adolescents. Journal of Affective Disorders, 260, 61–66. https://doi.org/10.1016/j.jad.2019.08.025
Hoskote, A. R., Croce, E., & Johnson, K. E. (2023). The evolution of the role of U.S. School nurses in adolescent mental health at the individual, community, and systems level: An integrative review. The Journal of School Nursing, 39(1), 51–71. https://doi.org/10.1177/10598405211068120
Hoskote, A. R., & Johnson, K. E. (2020). The role of school nurses in addressing student mental health in Texas alternative high schools. Journal of Adolescent Health, 66(2), S94–S95. https://doi.org/10.1016/j.jadohealth.2019.11.189
Kaskoun, J., & McCabe, E. (2022). Perceptions of school nurses in addressing student mental health concerns: An integrative review. The Journal of School Nursing, 38(1), 35–47. https://doi.org/10.1177/10598405211046223
Katz, C., Bolton, S. L., Katz, L. Y., Isaak, C., Tilston-Jones, T., & Sareen, J., & Swampy Cree Suicide Prevention Team. (2013). A systematic review of school-based suicide prevention programs. Depression and Anxiety, 30(10), 1030–1045. https://doi.org/10.1002/da.22114
Kim, H., Ryu, J. M., & Kim, H. (2020). Characteristics and trends of suicide attempt or non-suicidal self-injury in children and adolescents visiting emergency departments. Journal of Korean Medical Science, 35(33), e276–e276. https://doi.org/10.3346/jkms.2020.35.e276
Lewis, T. E., & Grobe, W. (2011). Student services and educational leadership: The effect of student services staffing ratios on student achievement and dropout prevention in public schools. Southern Regional Council on Educational Administration 2011 Yearbook, 13–21. https://67a1ad19-c320-4f16-bd55-6e2b121299a9.filesusr.com/ugd/40dc8e_71b0c4d9ff664cd8af3b8ff1b2db30a8.pdf
Markkanen, P., Anttila, M., & Välimäki, M. (2021). Supporting student’s mental health: A cross-sectional survey for school nurses. Children, 8(2), 129. https://doi.org/10.3390/children8020129
Miller, D. N., Eckert, T. L., & Mazza, J. J. (2009). Suicide prevention programs in the schools: A review and public health perspective. School Psychology Review, 38(2), 168–188. https://doi.org/10.1080/02796015.2009.12087830
Moen, Ø. L., & Jacobsen, I. C. R. (2022). School nurses’ experiences in dealing with adolescents having mental health problems [PDF]. SAGE Open Nursing, 8,(January-December 2022), 1–9. https://doi.org/10.1177/23779608221124411
Morse, J. M. (2017). Essentials of qualitatively-driven mixed-method designs. Routledge.
National Association of School Nurses. (2019). Transition planning for students with healthcare need [Position Statement]. https://www.nasn.org/nasn-resources/professional-practice-documents/position-statements/ps-transition
National Association of School Nurses. (2020). Framework for 21st century school nursing practice: Clarifications and updated definitions. NASN School Nurse, 35(4), 225–233. https://doi.org/10.1177/1942602X20928372
National Association of School Nurses. (2021). The behavioral health and wellness of student [Position Statement]. https://www.nasn.org/nasn-resources/professional-practice-documents/position-statements/ps-behavioral-health
National Association of School Nurses. (2022). Student access to school nursing services [Position Statement]. https://www.nasn.org/nasn-resources/professional-practice-documents/positionstatements/ps-access-to-services
National Association of School Nurses. (2023). IDEIA and section 504 teams—The school nurse as an essential team member [Position Statement]. https://www.nasn.org/nasn-resources/professional-practice-documents/position-statements/ps-ideia
Nolta, K. (2014). A school-based suicide risk assessment strategy. NASN School Nurse, 29(6), 295–298. https://doi.org/10.1177/1942602X14547276
North Carolina Child Fatality Task Force. (2023). Annual report to the Governor and General Assembly. https://webservices.ncleg.gov/ViewDocSiteFile/75628
North Carolina Department of Health and Human Services [NCDHHS], North Carolina Division of Public Health, Injury Epidemiology and Surveillance Unit, North Carolina Violent Death, Reporting System. (2022). Suicide among school aged youth in North Carolina ages 10-28, 2020. https://injuryfreenc.dph.ncdhhs.gov/DataSurveillance/SIIED/School-Aged-Youth-Suicide.pdf
North Carolina Department of Public Instruction. (2023). North Carolina school report cards. https://ncreports.ondemand.sas.com/src/
North Carolina Rural Health Leadership Alliance. (2021). 2021 North Carolina rural health snapshot. https://foundationhli.org/wp-content/uploads/North-Carolina-Rural-Snapshot-Report-FINAL-WEB.pdf
Patterson, S. (2016). Suicide risk screening tools and the youth population. Journal of Child and Adolescent Psychiatric Nursing, 29(3), 118–126. https://doi.org/10.1111/jcap.12148
Pestaner, M. C., Tyndall, D. E., & Powell, S. B. (2021). The role of the school nurse in suicide interventions: An integrative review. The Journal of School Nursing, 37(1), 41–50. https://doi.org/10.1177/1059840519889679
Price, J. H., & Khubchandani, J. (2019). The changing characteristics of African-American adolescent suicides, 2001-2017. Journal of Community Health, 44(4), 756–763. https://doi.org/10.1007/s10900-019-00678-x
Probst, J., Zahnd, W., & Breneman, C. (2019). Declines in pediatric mortality fall short for rural US children. Health Affairs, 38(12), 2069–2076. https://doi.org/10.1377/hithaff.2019.00892
Ravenna, J., & Cleaver, K. (2016). School nurses’ experiences of managing young people with mental health problems: A scoping review. The Journal of School Nursing, 32(1), 58–70. https://doi.org/10.1177/1059840515620281
Robinson, J., Cox, G., Malone, A., Williamson, M., Baldwin, G., Fletcher, K., & O’Brien, M. (2013). A systematic review of school-based interventions aimed at preventing, treating, and responding to suicide-related behavior in young people. Crisis, 34(3), 164–182. https://doi.org/10.1027/0227-5910/a000168
Rural Health Information Hub. (2022). Rural Data Explorer. https://www.ruralhealthinfo.org/data-explorer?id=209&state=NC
Saldaña, J. (2015). The coding manual for qualitative researchers (3rd ed.). Sage.
Sandelowski, M. (2001). Real qualitative researchers do not count: The use of numbers in qualitative research. Research in Nursing & Health, 24(3), 230–240. https://doi.org/10.1002/nur.1025
Shattuck, D., Sebastian, R., Zamarin, K., Acosta, S., & Ramos, M. M. (2022). School nurse management of behavioral health, violence, and trauma-related emergencies: Findings from a statewide survey. The Journal of School Nursing, 40(5), 536–546. https://doi.org/10.1177/10598405221120437
Stone, D. M., Mack, K. A., & Qualters, J. (2023). Notes from the Field: Recent changes in suicide rates, by race and ethnicity and age group—United States, 2021 (Morbidity and Mortality Weekly Report 72, 6). Center for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/72/wr/mm7206a4.htm
Toure, D. M., Kumar, G., Walker, C., Turman, J. E., & Su, D. (2022). Barriers to pediatric mental healthcare access: Qualitative insights from caregivers. Journal of Social Service Research, 48(4), 485–495. https://doi.org/10.1080/01488376.2022.2088949
United States Census Bureau. (2022). Quick facts: United States. https://www.census.gov/quickfacts/US
United States Census Bureau. (2023). Nation’s urban and rural populations shift following 2020 census [Press Release]. https://www.census.gov/newsroom/press-releases/2022/urban-rural-populations.html
Vejzovic, V., Carlson, L., Löfgren, L., & Bramhagen, A. (2022). Early identification of mental illness in primary school pupils by school nurses: A qualitative study [PDF]. SAGE Open Nursing, 8, (January-December 2022). https://doi.org/10.1177/23779608221081452
Deborah E. Tyndall, PhD, RN, CNE is an associate professor in the College of Nursing, East Carolina University.
Mitzi Pestaner, PhD, RN, JD, LLM is an assistant professor in the College of Nursing, East Carolina University.
Travis Lewis, EdD, MSA, MEd is an assistant professor in the College of Education, East Carolina University.
1 College of Nursing, East Carolina University, Greenville, NC, USA
2 College of Education, East Carolina University, Greenville, NC, USA
Corresponding Author:Deborah E. Tyndall, College of Nursing, East Carolina University, 4165-N Health Sciences Building, Greenville, NC 27858, USA.Email: tyndalld@ecu.edu
