The Role of the School Nurse in Suicide Prevention: Implications for Equitable Care of Vulnerable Youth

For nursing students

Study summary

Youth suicide rates have been rising across the United States, and rural communities are often hit hardest because mental health resources are scarce and spread thin. This study, published in the Journal of School Nursing in 2025 by Deborah Tyndall, Mitzi Pestaner, and Travis Lewis, looks at how school nurses in rural Eastern North Carolina actually practice suicide prevention day to day. School nurses are frequently described as the "gateway" professionals for student mental health, meaning they are often the first adult a struggling student encounters, but the researchers point out that exactly what this gateway role looks like in practice had not been well studied before this project.

To find out, the research team collected data from 35 school nurses working across six school districts. They used a combination of focus groups, where nurses talked together about their experiences, and surveys, which gathered more structured information from each participant. This mixed approach let the researchers hear nurses describe their work in their own words while also capturing patterns that could be compared across districts.

The central finding was that having a suicide prevention protocol that formally includes the school nurse makes a real difference. When a district's written procedures name the nurse as part of the response chain, for example by specifying that the nurse should be notified, involved in risk screening, or looped into follow-up planning, nurses reported feeling more able to actually carry out prevention and response work. Where no such protocol existed, or where the nurse was left out of it, their role became murkier and their ability to act was weaker.

At the same time, the study found real inconsistency. Practices differed not just between different school districts but even within the same district, meaning two nurses working for the same employer could handle a similar situation in very different ways depending on their school, their supervisor, or their own training. The researchers connect this unevenness to three recurring barriers: nurses carrying caseloads too large to allow the kind of individualized attention suicide prevention work requires; a disconnect between how the nurse's role is officially defined and what is actually expected of them day to day; and a lack of specialized training in youth mental health and suicide risk specifically, as opposed to general school health duties.

Why does this matter for equity? The authors argue that when suicide prevention practice varies this much depending on which school or district a student happens to attend, students end up with unequal access to a potentially life-saving safety net. A vulnerable teenager in one school might benefit from a nurse who is trained, protocol-supported, and empowered to intervene, while a similarly at-risk teenager one district over might not have that same safeguard, simply because of where they live. In a rural region already facing broader gaps in mental health services, this kind of variation can widen, rather than close, existing disparities in care.

Although this study is set in the United States, its lessons travel well to Canada. Canadian school health is delivered unevenly too: responsibility usually sits with provincial health authorities and public health units rather than dedicated in-school nurses, so what a student receives can vary by province, region, and even individual school. The same levers the authors identify (clear protocols that name the nurse, manageable caseloads, and targeted mental health training) apply here, and Canadian nurses can look to provincial regulatory scope and RNAO best-practice guidelines to define and defend that role.

For nursing students, this study is a useful reminder that a role described in a job title, "school nurse," does not automatically translate into consistent practice on the ground. Policies, protocols, staffing ratios, and training investment all shape whether a nurse can do the preventive work they are positioned to do. The authors call for school districts, both in North Carolina and nationally, to review their own policies and practices with an eye toward mental health equity, rather than assuming that having a school nurse on staff is, by itself, enough. As you read this study, consider how formal protocols, workload, and training intersect to either enable or limit a nurse's ability to protect the students who need it most.

For educators

Teaching and appraisal notes

This 2025 qualitative study in the Journal of School Nursing (Tyndall, Pestaner, & Lewis; DOI 10.1177/10598405231180618; PMID 37309140) examines school nursing practice around youth suicide prevention in rural Eastern North Carolina, a region the authors frame as reflecting the broader national rise in youth suicide. The authors situate school nurses as a "gateway" profession for student mental health access, then note that the specific contours of the school nurse's suicide-prevention role have been under-examined empirically, which motivates the study's exploratory design.

Data collection combined focus groups and surveys with 35 school nurses across six school districts, a mixed qualitative-leaning design well suited to surfacing both shared themes and cross-site variation in an under-studied practice area. This is a reasonable methodological choice for early-stage inquiry into role enactment, though instructors should note that the abstract does not specify whether districts were purposively or conveniently sampled, nor the exact focus group structure or survey instrument, which limits appraisal of transferability.

The headline finding is that formal, nurse-inclusive suicide protocols appear to functionally enable the nurse's preventive role, suggesting that role clarity and administrative structure, not just individual nurse competence or motivation, shape whether prevention work happens. Set against this, the study documents meaningful variation in practice both between and within districts, which the authors explicitly connect to a mental health equity concern: students' access to a protocol-supported, trained school nurse appears to depend on which school or district they attend rather than on standardized practice expectations.

Three barriers are named as contributors to this variation: elevated caseloads, role disconnect (a gap between the nurse's defined scope and the practical expectations placed on them), and insufficient specialized training in youth mental health and suicide prevention specifically. These map cleanly onto familiar organizational and workforce factors in school health literature, structural workload, role ambiguity, and competency gaps, giving instructors a useful frame for connecting this study to broader school health systems content.

For classroom use, this article works well to teach appraisal of qualitative and mixed-methods workforce research: ask students to distinguish the study's actual findings (protocol inclusion facilitates role enactment; variation exists and correlates with named barriers) from broader equity claims that extend beyond what the data directly demonstrate (that variation causes worse student outcomes is argued, not measured, here). It also pairs well with discussion of policy levers, since the authors' call to action is aimed at district-level protocol review rather than individual nurse remediation.

Limitations for discussion include the single-region, single-state sample (rural Eastern North Carolina, six districts), which constrains generalizability to urban or better-resourced settings; the absence of quantitative outcome data linking protocol inclusion or barriers to actual suicide-prevention effectiveness; and the abstract-level detail available, which does not specify sample demographics, protocol content, or analytic method in depth. Faculty may wish to note that these same authors have subsequently published related work, including a national survey of school nurses and a case study on moral distress in suicide prevention roles, which can be used as companion readings to extend this discussion beyond one region; the same group's 2021 integrative review (Pestaner, Tyndall, & Powell) is the conceptual predecessor that first flagged the role obscurity this study measures. Those findings belong to separate studies and should not be conflated with this article's own results. For Canadian teaching, the equity argument transfers directly: Canada's reliance on provincial health authorities and public health units for school health produces the same between-jurisdiction variation studied here, and provincial regulatory scope alongside RNAO guidance, rather than a US-style national school-nursing association, is where role clarity would be established.