School-Based Suicide Prevention Efforts: The Impact of School Nurse Exclusivity on Moral Distress

For nursing students

Study summary

School nurses are often the first health professional to notice a child or teen who is struggling with thoughts of suicide. They see students every day, they know the building, and they are usually the ones families and teachers turn to when something feels wrong. This study, published in The Journal of School Nursing by Deborah E. Tyndall, Mitzi Pestaner, and Travis Lewis, asked a focused question: what personal, behavioral, and environmental factors shape how school nurses actually carry out their role in youth suicide prevention and intervention?

The researchers used a multiple-case study design, a qualitative method that looks closely at a small number of real-world examples to understand a phenomenon in depth rather than to produce numbers that apply broadly. They used purposive sampling, meaning they deliberately chose participants who could offer especially rich insight, and recruited two school nurses identified as unique cases. Data came from three sources: interviews with the nurses, surveys, and relevant documents (such as school policies or protocols). Combining sources this way is called triangulation, and it lets researchers cross-check what people say against what is written down and what patterns emerge across cases. The team then conducted a cross-case analysis, comparing the two nurses' experiences side by side to find shared patterns and important differences.

The study draws on Social Cognitive Theory, a framework developed by psychologist Albert Bandura that explains behavior as the product of three things constantly interacting: personal factors (a nurse's own knowledge, confidence, and values), behavior (what the nurse actually does day to day), and environment (the school's culture, policies, and relationships). This lens helped the researchers see suicide prevention not as something one nurse simply decides to do well or poorly, but as something shaped by the system around her.

The central finding was that school-level exclusive practices, meaning patterns where the nurse is left out of communication and collaboration with teachers, counselors, and administrators, strongly limited how far a nurse's suicide-prevention role could reach. When a nurse was not looped into conversations about a struggling student, or when school teams did not routinely bring her into safety planning, her ability to identify risk early and follow through on referrals was reduced. The study also found that these environmental barriers created real ethical dilemmas for the nurses. They could see students at risk but felt blocked from acting on that concern in the way their training told them they should, and this gap between what they believed they should do and what the system let them do contributed to moral distress, a recognized problem in nursing where a clinician knows the right action but faces obstacles to taking it.

The authors argue that these findings matter beyond the two nurses studied. Because suicide risk and access to mental health support are not distributed evenly across student populations, a school system that inconsistently includes its nurse in prevention efforts may be widening rather than closing gaps in mental health equity. The paper calls for schools to use data more deliberately to demonstrate the pivotal role school nurses already play, and to build more inclusive, responsive suicide-prevention structures rather than leaving nurses' involvement to chance or to individual relationships within a building.

For nursing students, this study is a useful case for thinking about how organizational culture, not just individual skill, shapes clinical practice. It is also a clear, real-world illustration of moral distress: a concept that can otherwise feel abstract in a classroom setting. Because this is a qualitative study of two cases, its findings describe patterns worth paying attention to rather than results you should assume apply to every school nurse or every district. Read it as an invitation to ask how communication structures in your own future workplace will either support or undermine your ability to act on what you notice.

For educators

Teaching and appraisal notes

This qualitative multiple-case study by Tyndall, Pestaner, and Lewis, published in The Journal of School Nursing (Vol. 41, No. 6, pp. 731-740, 2025; DOI 10.1177/10598405241267210), examines the personal, behavioral, and environmental factors shaping the school nurse's role in youth suicide prevention and intervention. The study is grounded in Social Cognitive Theory, using Bandura's model of reciprocal interaction between personal, behavioral, and environmental determinants as an analytic frame for understanding why school nurses' involvement in suicide-prevention work varies across settings.

Methodologically, the researchers used purposive sampling to recruit two school nurses identified as unique cases, then triangulated data across interviews, surveys, and documents to conduct a cross-case analysis. This design is appropriate for generating rich, context-specific understanding of a phenomenon that is difficult to capture through survey research alone, and the multi-source data collection strengthens the credibility of within-case findings even though the sample is small.

The central finding is that school-level exclusive practices, particularly a lack of communication and collaboration between the nurse and other school personnel, significantly constrain the role and reach of the school nurse in suicide prevention. Where nurses were not systematically included in school teams' communication about at-risk students, their capacity to identify risk, coordinate referral, and follow up was diminished regardless of their individual competence or motivation. The study further identifies that the ethical dilemmas produced by these environmental barriers, seeing a need to act but being structurally excluded from acting, are directly implicated in moral distress among the nurses studied. This links an established nursing ethics construct to a concrete organizational mechanism (exclusion from communication and collaboration structures) rather than treating moral distress as a generic occupational hazard.

For discussion in class, this article works well alongside the same author team's related work, including a national survey study on the school nurse role in youth suicide prevention and an integrative review of school nurse suicide interventions, allowing instructors to contrast qualitative case findings with survey-based and review-level evidence on the same topic. It is also a strong prompt for connecting Social Cognitive Theory to practice settings beyond individual health behavior change, showing its use as an organizational and role-analysis framework.

Instructors should flag the study's methodological boundaries directly: a two-case qualitative design cannot establish prevalence or generalize findings to school nurses broadly, and the purposive sampling strategy, while appropriate for the research question, means the cases were selected for their informativeness rather than representativeness. The abstract does not report participant demographics, school type, geographic setting, or the specific interview/survey instruments used, and no effect sizes or quantitative measures of moral distress are reported since none were intended. Students should be encouraged to treat this as hypothesis-generating, well-suited to informing further mixed-methods or larger-sample qualitative work, rather than as a basis for practice standards on its own. The authors' explicit call to use data to demonstrate school nurses' value and build more inclusive prevention structures is a useful anchor for discussing how nursing research can translate into policy and organizational change within schools.