Feature Article
Adolescent Suicide
Prevention in a
School Setting
Use of a Gatekeeper Program
Lisa A. Johnson, DNP, APRN
Mary E. Parsons, PhD, RN
Suicide is a major public health
problem. Nationally, suicide is the
third leading cause of death for
adolescents. The purpose of this quality
improvement project was to initiate
and evaluate a gatekeeper suicide-
prevention program within a local
school system targeting faculty and
staff without a medical or psychology
background who interact regularly
with middle- and high-school students.
Following the implementation of this
program, evaluation of increased
knowledge related to adolescent
suicide prevention was completed.
All participants completed a pretest
and posttest, and results indicate that
the staff members knowledge about
identification of risk factors, behavioral
responses to suicidal students, and
knowledge of community resources
were increased. This project highlights
the need for planned and sustainable
education and training for faculty
and school staff who regularly interact
with adolescents. Additionally, the
importance of continued monitoring,
training, and advocating for suicide
prevention programming is noted.
DOI: 10.1177/1942602X12454459
For reprints and permission queries visit SAGEs Web site, http://www.sagepub.com/journalsPermissions.nav.
2012 The Author(s)
Keywords: suicide prevention;
adolescent suicide; gatekeeper program;
school-based
A
dolescent suicide prevention within
the school setting presents
many challenges and opportunities
for intervention by school nurses.
Many students perceive the school
environment as a safe and stable area
with multiple support systems. It is
within this safe and stable environment
that school nurses and school staff
members have a substantial amount
of interaction with students and
are able to develop meaningful,
significant relationships with them.
These relationships offer a window of
opportunity for staff to identify and
intervene with students who have
significant health issues, including
suicide.
A variety of faculty and staff without a
medical or psychology background come
into contact with suicidal students in
the school setting. These staff members
have regular interactions with students
and many know the students well, and
these relationships enable them to note
or observe changes in student behavior.
These frontline staff members are
natural gatekeepers for mental health
problems in the community and could
serve a vital role in the recognition of
suicidal behaviors, provision of initial
support, and facilitation of access
to the appropriate health services
(Cross, Matthieu, Cerel, & Knox, 2007;
Isaac etal., 2009). Suicide in a school
community is tremendously devastating,
often unexpected, and leaves the school
and surrounding community with
much confusion and many questions.
Most people are uncomfortable with
the topic of death by suicide, and too
often victims are blamed and their
families and friends are left stigmatized
(Quinnett, 2009). As a result, many
people within the school environment
do not communicate openly about
suicide. Thus, an important public health
problem is left shrouded in secrecy,
which limits the potential opportunities
to address and prevent future deaths by
suicide (Centers for Disease Control and
Prevention [CDC], 2011).
Suicide is a major public health problem
and has the potential to be prevented
November 2012 | NASN School Nurse 313
 (National Institute of Mental Health,
2010). In 2009, suicide accounted for
more than 36,000 deaths in the United
States, making it the tenth leading cause
of death for all ages (Kochanek, Xu,
Murphy, Minio, & Kung, 2011). Suicide
is a growing public health concern and
one of the most common causes of
death among adolescents (Whetstone,
Morrissey, & Cummings, 2007). It is
the third leading cause of death for
people ages 15 to 24, surpassed only by
homicide and accidents, and results in
approximately 4,500 lives lost each year
(CDC, 2010). Among young people 15 to
24 years old, for every death by suicide
the rate of suicide attempts is estimated
to be from one hundred to two hundred
(Quinett, 2009). Nationally, in 2009, 13.8%
of high school students reported that they
had seriously contemplated attempting
suicide during the previous year (CDC,
2010).
The U.S. Surgeon General has
introduced a blueprint for addressing
suicide and has called for national
strategies to prevent suicide (U.S. Public
Health Service, 2001). One important
aspect of these strategies includes
addressing the problem of undetected
risk factors as a method to intervene
with and prevent deaths by suicide. The
Surgeon General emphasizes that these
strategies should be used to implement
programs that are best suited for
individual communities.
The problem of suicide cannot
be adequately understood without
the realization that suicide is
generally associated with other risk
factors including biopsychosocial,
environmental, and sociocultural factors
(American Association of Suicidology,
2008). The French social scientist Emile
Durkheim developed a method of study
that became the foundation for scientific
research about suicide. Durkheim based
his conclusions on commonalities among
people known to have died by suicide
and sociological characteristics among
these population groups (World Health
Organization [WHO], 2010). Comparing
groups with high rates of suicide with
those experiencing low rates of suicide
became the process by which risk and
314 NASN School Nurse | November 2012
Table 1. Risk Factors for Suicide
Biopsychosocial Environmental
Mental disorders, Relational or social loss
particularly mood Easy access to lethal
disorders, schizophrenia, means
anxiety disorders, and Local clusters of suicide
certain personality that have a contagious
disorders influence
Alcohol and other
substance use disorders
Hopelessness
Impulsive and/or
aggressive tendencies
History of trauma or
abuse
Some major physical
illnesses
Previous suicide attempt
Family history of suicide
Source: American Association of Suicidology (2008).
protective factors for suicide have been
identified (WHO, 2010). A risk factor
(Table 1) may be an indicator of an
individual at greater risk of attempting or
completing death by suicide (Waldvogel,
Rueter, & Oberg, 2008).
Additional risk factors for adolescents
include academic difficulties, significant
conflict with the adolescents parent or
caretaker, gay or bisexual orientation,
relational or romantic difficulties, severe
anger or agitation, and a history of
suicidal ideation (Joe, Canetto, & Romer,
2008; Shropshire & Thornton, 2011).
Each additional risk factor makes it more
likely that an adolescent may attempt or
complete death by suicide (Waldvogel
etal., 2008). The understanding and use
of these identified risk factors provides
the basis for identification and referral of
potentially suicidal students.
Adolescent suicide prevention
within the setting of the school
environment may be conceptualized
using a population-focused public
health approach. This framework,
initially used by Florence Nightingale,
incorporates both research and the
Sociocultural
Lack of social support
and sense of isolation
Stigma associated with
help-seeking behavior
Barriers to accessing
health care, especially
mental health and
substance abuse
treatment
Certain cultural and
religious beliefs (for
instance, the belief
that suicide is a noble
resolution of a personal
dilemma)
Exposure to (including
through the media) and
influence of others who
have died by suicide
role of the environment (Polit & Beck,
2008). Nightingale identified factors that
promoted physical and emotional well-
being and used this analysis to effect
changes in nursing care and in public
health. School nurses are in a prime
position to implement population-
focused health care in providing care to
potentially suicidal students.
Suicide Prevention Strategies
The majority of suicide prevention
strategies are aimed at either reducing
risk factors for suicide (Ali, Dwyer, &
Rizzo, 2011; Pea, Matthieu, Zayas,
Masyn, & Caine, 2010; Lubin etal.,
2010; Thompson, Kuruwita, & Foster,
2009) or screening and case finding
potential suicidal people for referral and
treatment (Isaac etal., 2009; Shropshire
& Thornton, 2011). Public awareness and
education programs are a popular and
widely used public health intervention
to reduce death by suicide (Inman,
van Bakergem, LaRosa, & Garr, 2011).
Currently, there are specific education
strategies that are aimed at adolescents
(Inman etal., 2011) and school-based
programs that support positive aspects
of educational interventions (Brown &
Grumet, 2009; Freedenthal, 2010; Inman
et al., 2011; Klimes-Dougan, Yuan, Lee,
& Houri, 2009; Stein et al., 2010; Swartz
et al., 2010; Wyman etal., 2010) but
these programs are not evidence-based
or have not been found to prevent
suicidal behavior. While curriculum-
based programs increased knowledge
related to mental illness and suicide
(Klimes-Dougan etal., 2009; Sawyer
etal., 2010; Walker, Ashby, Hoskins, &
Greene, 2009; Wyman etal., 2010), there
is insufficient evidence that this increase
in knowledge translates to prevention of
death by suicide or results in referrals for
appropriate intervention and care.
The Question Persuade Refer (QPR)
Gatekeeper Program (Quinnett, 2007)
is identified through the Best Practices
Registry (Suicide Prevention Resource
Center, 2011) as a program that is
believed to be effective but has not
undergone rigorous evaluation. One
study evaluated the effectiveness
of implementing the QPR Program
in a school setting and found that
participants gained knowledge related
to suicide prevention (Tompkins, Witt,
& Abraibesh, 2010). In another study
specific to the QPR Program within a
population of a secondary school staff,
QPR was found to be very successful
and participants reported that they were
more prepared to identify potential
suicidal students and reported a greater
understanding of services available to
students (Wyman etal., 2008).
Method
The goal of this quality improvement
project was to implement and evaluate
the QPR Suicide Prevention Program
(Quinnett, 2007) in a suburban
school district in the Midwest with
approximately 3,000 students and 400
staff members. The student population
includes over 50% low-income, single-
parent households and greater than 40%
Hispanic and Black youth.
After training to become a certified
QPR instructor, the school nurse
supervisor provided an overview of
the QPR Program and a plan for staff Data Analysis and Results
development implementation and
A total of 36 staff members
evaluation to the school administration
representing 18% of the middle-
and the school board members.
school and high-school staff were
Next, the nurse supervisor conducted
trained. The method of evaluation of
three 90-minute teaching sessions to
knowledge gained was a 9-question
the school staff within the districts
pretest and posttest. A paired test
middle school and high school. All
(Wilcoxon Signed-Rank Test) was run
high-school and middle-school staff
using the data from the pretest and
members were invited to participate in
posttest. For all questions, results were
the program, including administrators,
significant at .05 (p< .001) (Table
teachers, educational paraprofessionals,
2). All 9 posttest questions showed a
transportation staff, custodial staff, and
significantly higher mean than that of
food service staff. The staff members
the pretest questions, indicating an
were informed of the program through
increase in knowledge about suicide.
e-mail postings and fliers in high-
To determine if use of the QPR
traffic staff areas. Participation in the
intervention had occurred, a monthly
program was voluntary; if the staff
e-mail questionnaire was distributed for
members participated in the program,
a 3-month time period following the
they were allowed to participate during
training. The e-mail included questions
their normal work hours or were
about contact with potentially suicidal
compensated at their normal hourly
students and additional information
wage if the program was outside of their
about preventing suicide. The e-mail
normal work hours.
questionnaire response identified
The in-service consisted of providing
that one staff member implemented
the QPR Gatekeeper Suicide Prevention
the QPR protocol using the question,
Program (Quinnett, 2007) to staff and
persuasion, and referral technique in
providing additional support after
managing a potentially suicidal student.
the teaching in the form of an online
The remaining 35 staff members had not
conference work group via the school
implemented the QPR Program due to
districts informational technology
the belief that they had not encountered
system. The core QPR training content
a student whom they believed was
included basic information about suicide,
suicidal. There were no identified suicide
a review of evidence-based suicide
attempts in these schools during this
warning signs, and information on
timeframe.
how to work with potentially suicidal
students. Following the presentations,
time was allotted for participants to Discussion
role-play potential situations and to ask This quality improvement program
questions. Role-plays included scenarios demonstrated that the QPR Training
pertaining to asking the suicide question, Program increased knowledge related
persuading the suicidal student to accept to adolescent suicide prevention for
help, and making referrals to the school school personnel. Additionally, within
counselor. A QPR take-home booklet a 3-month time period following the
and a youth suicide prevention wallet training, one staff member reported
card was provided to all participants. using the QPR response with a suicidal
The QPR booklet contained the basic student. These results are consistent with
information on suicide prevention, the findings of Tompkins etal. (2010)
a summary of the key points, and and Wyman etal. (2008). With continued
national resource information on interactions between staff and students,
suicide prevention. The youth suicide additional use of the QPR response by
prevention wallet card provided suicide school staff would be anticipated. In
prevention information and local addition, the need for continued periodic
resource information. evaluation would need to be completed
November 2012 | NASN School Nurse 315
 Table 2. Summary of Pretest and Posttest Results

Question Description M SD p Value

Pre-1 Asking someone about suicide is appropriate. 3.25 0.77 <.001

Post-1 4.50 0.74 <.001

Pre-2 Rate your knowledge about suicide prevention facts. 2.50 0.70 <.001
Post-2 3.83 0.70 <.001

Pre-3 Rate your knowledge of warnings signs of suicide. 2.75 0.77 <.001
Post-3 3.81 0.71 <.001

Pre-4 Rate your knowledge of how to ask someone about suicide. 2.28 0.78 <.001
Post-4 3.67 0.76 <.001

Pre-5 Rate your knowledge of how to persuade someone to get help. 2.58 0.77 <.001
Post-5 3.69 0.75 <.001

Pre-6 Rate your knowledge of how to get help for someone. 2.75 0.81 <.001
Post-6 3.83 0.74 <.001

Pre-7 Rate your knowledge about information of local resources for help with suicide. 2.31 0.89 <.001
Post-7 3.39 0.93 <.001

Pre-8 Rate your level of understanding about suicide and suicide prevention. 2.61 0.84 <.001
Post-8 3.72 0.70 <.001

Pre-9 Rate your knowledge of or experience with development and use of safety 2.25 0.84 <.001
Post-9 plans. 3.22 0.90 <.001

to determine if staff retained knowledge
related to adolescent suicide prevention.
Because most school personnel do
not receive training regarding mental
health issues (Walter, Gouze, & Lim,
2006) or identifying and responding to
students with these issues, including
suicide should be a training priority for
school district staff. School nurses are in
a prime position to articulate this need
and coordinate this training for their
school communities. Continued training
may be a challenge for local school
districts to sustain; however, the benefit
of intervening and responding cannot
be understated and every front-line staff
member should know how to intervene
with this potentially lifesaving response.
Additionally, staff members need to be
supported by school boards and policy
makers. This support would include the
time to participate in suicide prevention
training. School nurses should work to
develop relationships with school district
administrators and school board members
to be in a position to advocate for suicide
prevention programming. Finally, more
research needs to be done on prevention
strategies for adolescent suicide and the
role that school staff members could
take in identifying and referring at-risk
studentsand ultimately preventing
suicide.
References
Ali, M. M., Dwyer, D. S., & Rizzo, J. A. (2011).
The social contagion effect of suicidal behavior
in adolescents: Does it really exist? Journal of
Mental Health Policy and Economics, 14(1),
3-12.
American Association of Suicidology. (2008).
Recognizing and responding to suicide risk;
Essential skills for clinicians. Washington, DC:
American Association of Suicidology.
Brown, M. M., & Grumet, J. (2009). School-based
suicide prevention with African American
youth in an urban setting. Professional
Psychology: Research and Practice, 40(2),
111-117.
Centers for Disease Control and Prevention.
(2010). Youth risk behavior surveillance
United States 2009. Morbidity and Mortality
Weekly Report, 59(SS5), 1-142.
Centers for Disease Control and Prevention.
(2011). Injury center: Suicide prevention.
Retrieved March 26, 2011, from http://www
.cdc.gov/ncipc/dvp/suicide/youthsuicide.htm
Cross, W., Matthieu, M. M., Cerel, J., &
Knox, K. L. (2007). Proximate outcomes of
gatekeeper training for suicide prevention in
the workplace. Suicide and Life-Threatening
Behavior, 37, 659-670.
Freedenthal, S. (2010). Adolescent help-seeking
and the Yellow Ribbon Suicide Prevention
Program: An evaluation. Suicide and Life-
Threatening Behavior, 40, 628-639.
Inman, D. D., van Bakergem, K. M., LaRosa,
A. C., & Garr, D. R. (2011). Evidence-based
health promotion programs for schools and
communities. American Journal of Preventive
Medicine, 40, 207-219.

316 NASN School Nurse | November 2012

Isaac, M., Elias, B., Katz, L. Y., Belik, S.,
Deane, F. P., Enns, M. W., & Sareen, J.
(2009). Gatekeeper training as a preventative
intervention for suicide: A systematic review.
The Canadian Journal of Psychiatry, 54,
260-268.
Joe, S., Canetto, S., & Romer, D. (2008).
Advancing prevention research on the role of
culture in suicide prevention. Suicide and Life-
Threatening Behavior, 38, 354-362.
Klimes-Dougan, B., Yuan, C., Lee, S., & Houri,
A. K. (2009). Suicide prevention with
adolescents: Considering potential benefits
and untoward effects of public service
announcements. Crisis: The Journal of Crisis
Intervention and Suicide Prevention, 30, 128-135.
Kochanek, K. D., Xu, J. Q., Murphy, S. L.,
Minio, A. M., & Kung, H. C. (2011). Deaths:
Preliminary data for 2009 [National Vital
Statistics Reports]. Hyattsville, MD: National
Center for Health Statistics.
Lubin, G., Werbeloff, N., Halperin, D.,
Shmushkevitch, M., Weiser, M., & Knobler,
H. Y. (2010). Decrease in suicide rates after a
change of policy reducing access to firearms
in adolescents: A naturalistic epidemiological
study. Suicide and Life-Threatening Behavior,
40, 421-424.
National Institute of Mental Health. (2010).
Suicide in the U.S.: Statistics and prevention
[Publication No. 06-4594]. Retrieved April 10,
2011, from http://www.nimh.nih.gov/health/
publications/suicide-in-the-us-statistics-and-
prevention/index.shtml
Pea, J. B., Matthieu, M. M., Zayas, L. H., Masyn,
K. E., & Caine, E. D. (2010). Co-occurring
risk behaviors among White, Black, and
Hispanic US high school adolescents with
suicide attempts requiring medical attention,
1999-2007: Implications for future prevention
initiatives. Social Psychiatry and Psychiatric
Epidemiology, 45(3), 114-124.
Polit, D. F., & Beck, C. T. (2008). Nursing
research: Generating and assessing evidence
for nursing practice. Philadelphia, PA:
Lippincott Williams & Wilkins.
Quinnett, P. (2007). QPR: Certified QPR
gatekeeper instructors training manual.
Spokane, WA: QPR Institute.
Quinnett, P. (2009). Counseling suicidal people: A
therapy of hope. Spokane, WA: P. Quinnett.
Sawyer, M. G., Harchak, T. F., Spence, S. H.,
Bond, L., Graetz, B., Kay, D., etal. (2010).
School-based prevention of depression: A
2-year follow-up of a randomized controlled
trial of the beyond blue schools research
initiative. Journal of Adolescent Health, 47,
297-304.
Shropshire, A., & Thornton, K. (2011).
Prevention measures for adolescent suicide: An
evidence-based review. American Journal for
Nurse Practitioners, 15(5), 30-36.
Stein, B. D., Kataoka, S. H., Hamilton, A. B.,
Schultz, D., Ryan, G., Vona, P., etal. (2010).
School personnel perspectives on their schools
implementation of a school-based suicide
prevention program. Journal of Behavioral
Health Services & Research, 37, 338-349.
Suicide Prevention Resource Center Evidence
Based Practices. (2011). Best practices registry.
Retrieved September 2, 2011, from http://
www2.sprc.org/bpr/index
Swartz, K. L., Kastelic, E. A., Hess, S. G., Cox,
T. S., Gonzales, L. C., Mink, S. P., etal. (2010).
The effectiveness of a school-based adolescent
depression education program. Health
Education & Behavior, 37, 11-22.
Thompson, M., Kuruwita, C., & Foster, E. (2009).
Transitions in suicide risk in a nationally
representative sample of adolescents. Journal
of Adolescent Health, 44, 458-463.
Tompkins, T., Witt, J., & Abraibesh, N. (2010).
Does a gatekeeper suicide prevention program
work in a school setting? Evaluating training
outcome and moderators of effectiveness.
Suicide and Life-Threatening Behavior, 40,
506-515.
U.S. Public Health Service. (2001). National
strategy for suicide prevention: Goals and
objectives for action. Rockville, MD: U.S.
Department of Health and Human Services.
Retrieved May 15, 2011, from http://www
.surgeongeneral.gov/library/calltoaction/
recommendations.htm
Waldvogel, J. L., Rueter, M., & Oberg, C. N.
(2008). Adolescent suicide: Risk factors
and prevention strategies. Current Problems
in Pediatric Adolescent Health Care, 38,
110-125.
Walker, R. L., Ashby, J., Hoskins, O. D., &
Greene, F. N. (2009). Peer-support suicide
prevention in a non-metropolitan U.S.
community. Adolescence, 44(174), 335-346.
Walter, H. J., Gouze, K., & Lim, K. G. (2006).
Teachers beliefs about mental health needs in
inner city elementary schools. Journal of the
American Academy of Child and Adolescent
Psychiatry, 45(1), 61-68.
Whetstone, L. M., Morrissey, S. L., & Cummings,
D. M. (2007). Children at risk: The association
between perceived weight status and suicidal
thoughts and attempts in middle school youth.
Journal of School Health, 77(2), 59-66.
World Health Organization. (2010). Mental
health: Strengthening our response. Retrieved
from http://www.who.int/mediacentere/
factsheets/fs220/en/
Wyman, P. A., Brown, C., Inman, J., Cross, W.,
Schmeelk-Cone, K., Guo, J., etal. (2008).
Randomized trial of a gatekeeper program for
suicide prevention: 1-year impact on secondary
school staff. Journal of Consulting and Clinical
Psychology, 76(1), 104-115.
Wyman, P. A., Brown, C., LoMurray, M.,
Schmeelk-Cone, K., Petrova, M., Yu, Q., etal.
(2010). An outcome evaluation of the Sources
of Strength suicide prevention program
delivered by adolescent peer leaders in high
schools. American Journal of Public Health,
100, 1653-1661.
Lisa A. Johnson, DNP, APRN
Nurse Supervisor, Ralston Public
Schools
Ralston, NE
Lisa is the school nurse supervisor
for Ralston Public Schools in
Ralston, Nebraska. She recently
graduated from Creighton
University with her Doctorate of
Nursing Practice and is currently
an adjunct professor in the school
of nursing at Creighton University
in Omaha, Nebraska.
Mary E. Parsons, PhD, RN
Associate Professor, Creighton
University
Omaha, NE
Mary is an associate professor in
the School of Nursing at Creighton
University in Omaha, Nebraska.
November 2012 | NASN School Nurse 317