Increasing Referrals to School Counselors by Integrating an Evidence-based Program for Educators Identifying Adolescents at Risk for Suicide in a Rural High School

doi:10.21203/rs.3.rs-2129900/v1

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Increasing Referrals to School Counselors by Integrating an Evidence-based Program for Educators Identifying Adolescents at Risk for Suicide in a Rural High School

https://doi.org/10.21203/rs.3.rs-2129900/v1

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Background: Addressing suicide in America's youth is imperative. Teachers play an essential role in identifying and intervening with adolescents experiencing psychological distress leading to suicide. Unfortunately, teachers and staff lack professional development in addressing the identification of students in psychological distress.

Purpose:This project aimed to increase referrals to school counselors by integrating an evidence-based program for educators identifying adolescents at risk for suicide in a rural high school.

Design Method: This quantitative quality improvement project with a pre-/post-test design was implemented with referrals to the school guidance counselors before and after the program's completion were analyzed.

Conclusion: There was a significant increase in teachers and staff members' confidence in their ability to recognize when a student was exhibiting signs of psychological distress and their ability to talk to a student in psychological distress and help those students connect with the school guidance counselors.

Implications for Nursing: This project showed that implementing an evidence-based professional development program helped build teachers' and staff's skills that support early identification and intervention with students experiencing psychological distress, leading to suicide.

Suicide

adolescents

Kognito

child

program

teacher

prevention

school

school-based

gatekeeper

evidence-based

and strategy

Addressing the high rates of suicide in America's youth is imperative. In 2017, there were an estimated 1.4 million suicide attempts in the United States (America’s Health Rankings, 2020). Suicide is the second leading cause of death in 10-19-year-olds in the United States, with suicide rates nearly tripling from 2007 to 2017 (Curtin & Heron, 2019). Furthermore, according to the Youth Risk Behavior Surveillance Summaries (YRBSS) (2019), 17.2% of high school students seriously considered suicide in the past 12 months, 13.6% of students nationwide had made a plan on how they would attempt suicide, and 7.4% of students attempted suicide. Every year 2,877 people ages 13 to 19 die by suicide, one in six students have seriously considered attempting suicide, and one in 13 high school students have attempted suicide one or more times (Centers for Disease Control and Prevention [CDC], 2018).

According to the Suicide Prevention Resource Center (2019), suicide involves the combination of multiple risk factors such as stressful life circumstances, family history of child maltreatment, history of mental disorders, isolation, physical illness, and unwillingness to seek help because of the stigma attached to mental health and suicidal thought. Most recently, the lockdowns nationwide due to the COVID-19 pandemic have dramatically increased the number of adolescent mental health emergency department (ED) visits. The number of adolescent mental health ED visits increased 69% from March 29-April 25, 2020, compared to the corresponding period in 2019. In addition, the number of adolescent mental health ED visits increased 44% from mid-March-October 2020 compared to the corresponding period in 2019. The number of deaths by suicide among adolescents in 2020 has not been reported at the time of this manuscript’s submission. These risk factors can be the tipping point and trigger suicidal behaviors in adolescents. The economic impact of suicide is immense, with suicide and suicide attempts costing the United States almost 70 billion dollars per lifetime in medical expenses and loss of work income (CDC, 2020; Leeb, Bitsko, Radhakrishnan, Martinez, & Njai, 2020).

Suicide was the 10^th leading cause of death in Alabama, with 823 people lost to suicide in 2018; the rate of suicide in Alabama was 16.8 per 100,000 population. In 2016, the number of deaths by suicide in DeKalb County, Alabama, was 10, all Caucasian race, and seven were males. By 2017, the number had doubled to 20 suicides reported in Dekalb County, all of the Caucasian race, and 18 were males (Alabama Department of Public Health [ADPH], 2016, 2017, 2020). In September 2019, the DeKalb County Sheriff's Office released a statement notifying the community that there had been seven suicide attempts and five completions in 24 hours (DeKalb County Sheriff’s Office, 2019).

Adolescent suicide has dramatically impacted the health of others, the community, and the economy. According to Survivors of Suicide Loss Task Force (2016), an estimated 115 people were exposed to a single suicide, with one in five reporting that the experience had a devastating impact or caused a significant life disruption. Family members may be in shock, grief, guilt, depression, or even complete denial (CDC, 2020). Family members grieving suicide tend to report poorer general health and physical illness, including cardiovascular disease, chronic obstructive pulmonary disease, hypertension, and diabetes, as well as mental health issues such as depression, anxiety, and extreme sadness (Spillane, Matvienko-Sikar, Larkin, Corcoran, & Arensman, 2018). The impact of adolescent suicide may reach people in the community, such as teachers, staff, clergy, and others who support the family, law enforcement workers, and first responders at the scene of a suicide. Teachers and clergy members feel a sense of guilt for not recognizing the warning signs of suicide, and if they were close to the adolescent, they might go through the same depression and grief as the family (Survivors of Suicide Loss Task Force, 2015). First responders and law enforcement are usually the first on the scene of a suicide and may provide emotional and physical support. Over time, this can lead to depression, stress and posttraumatic stress symptoms, suicidal ideation, and substance abuse (Substance Abuse and Mental Health Services Administration [SAMHSA], 2018).

Teachers, school counselors, and special education teachers are uniquely positioned to recognize behaviors associated with mental health issues in the classroom. Unfortunately, these behaviors are often not recognized by school personnel, who have difficulty understanding the signs that may be observed in adolescents at risk of suicide and depression. They are in constant contact with children, provide a safe environment, and are the best professionals to recognize troubling behaviors in their students. However, many teachers do not believe they have been trained appropriately to identify and intervene with students experiencing psychological distress (Bradley & Kendall, 2019). Training teachers and staff using virtual simulation have proven to help provide professional development in identifying, supporting, and referring at-risk students without the potential for harm (Bradley & Kendall, 2019; Marsh, 2016).

Background

The project was implemented at a rural high school in northeast Alabama. This public school encompasses grades Pre-K through 12 with no feeder schools. The enrollment number was around 1,200 students, with little more than half the number being elementary students. The students' ethnicity was approximately 75% Caucasian, with the remaining American Indian, Hispanic, African American, and Asian groups remaining consistent from year to year. The school was a Title 1 school that received federal funds because of the large concentrations of low-income students, where around 60% of students received free or reduced lunches in the Child Nutrition Program. The school employed 125 teachers and staff members, including three administrators, two librarians, three guidance counselors, instructional resource personnel, and a school resource officer (Plainview High School [PHS], 2020).

Suicide is the 10^th leading cause of death for all ages and the second leading cause of death for youth and young adults, with one person dying every 11 minutes in the United States (CDC, 2020). One million four hundred thousand people attempted suicide in the United States in 2018 (CDC, 2020). Alabama is a rural state with social isolation, poverty, and a lack of mental health services, with few people qualifying for mental health services under Medicaid (Freeman, 2018). The rate of suicide in Alabama in 2018 was 16.8 per 100,000 population, with Alabama showing a pattern of higher rates than the United States national average since 1990. In 2018, 116 youth died by suicide in Alabama, with the rate of suicide being highest among Caucasian and non-Hispanic males (ADPH, 2020).

According to the Alabama 2019 High School YRBSS, 493 ninth-grade students in Alabama had seriously considered attempting suicide in the past 12 months before the survey as well as 591 tenth graders, 509 eleventh graders, and 410 twelfth graders. Of those students, 1,011 were Caucasian, 693 were African American, 148 were Hispanic, 30 were Asian, and 65 were of multiple races. The number of heterosexual students in the Alabama 2019 YRBSS was 1,577, and 542 students considered themselves gay, lesbian, or bisexual. The number of students in grades nine through 12 who attempted suicide in the 2019 survey was 1,685, and all but one of those students had to be treated by a doctor or nurse for injuries due to their attempt (CDC, 2019, 2020).

Teachers play an essential role in identifying students at risk for mental health issues; however, studies have found that teachers may not know how to identify risk factors of suicide or engage youth in a conversation about suicide risk (Marsh, 2016; Robinson-Link et al., 2019). There has been an increased recognition that adolescents are experiencing mental health issues. Despite this, school teachers and staff members have had difficulty identifying those students before a significant incident. Teachers do not feel that they have been adequately trained to identify students with psychological problems or refer at-risk students (Bradley & Kendall, 2019; Marsh, 2016).

Problem Statement

Suicide is the 10^th leading cause of death for all ages and the second leading cause of death for youth and young adults, with one person dying every 11 minutes in the United States. The rate of suicide in Alabama in 2018 was 16.8 per 100,000, with Alabama showing a pattern of higher rates than the United States national average since 1990 (ADPH, 2020; CDC, 2020). Since teachers spend most of the day with their students, they may be the best professionals to recognize and intervene with adolescents at risk for psychological problems; however, teachers and staff do not feel they have been adequately trained to identify or refer at-risk students (Bradley & Kendall, 2019).

Literature to support this problem was collected based upon the following PICOT question: (P) For school teachers and staff in a rural high school (I) does implementing an evidence-based program identifying adolescents at risk for suicide (C) compared to no evidence-based program (O) increase the number of referrals to school guidance counselors (T) in three months?

This project's approach was based on the assumption that implementing a suicide awareness professional development program to help educators and staff identify and intervene early with students experiencing psychological distress would increase referrals to the school guidance counselors.

Organizational Description of Project Site

The problem with suicide in Alabama is that Alabama is a rural state where there is social isolation, poverty, and a lack of mental health services, and few people qualify for mental health services under Medicaid (Freeman, 2018). The project was implemented in a rural area in northeast Alabama that saw a 50% increase in suicides over the past three years and most recently had seven suicide attempts and five completions in 24 hours (Dekalb County Sheriff's Office, 2019). This project will help build skills in teachers and staff members that support early identification and intervention with students experiencing psychological distress, leading to suicide.

The researcher relied on several search engines, including ERIC, Medline, EBSCO HOST, PubMed, Cochrane, APA PsychINFO, APA PsychArticles, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Academic Search Premier, to gather pertinent evidence-based research data for the literature and full-text search, and peer-reviewed articles. The following keywords proved useful in the search for empirical literature on evidence-based programs identifying adolescents at risk for suicide: suicide, adolescent, child, program, teacher, prevention, school, school-based, gatekeeper, evidence-based, and strategy. The literature review identified two systematic reviews, one quantitative study, one cluster-randomized controlled trial, one longitudinal study, one cross-sectional study, one scoping review, and a literature review.

Suicide Among Youth

Suicide is a leading cause of death among youth, with the sharpest increase in suicide deaths occurring between early adolescence and young adulthood. Research showed key patterns and gaps in knowledge regarding epidemiology, etiology, and treatment (Cha et al., 2018). In 2017, the prevalence rates among youth for suicidal ideations were between 19.8% and 24%, and suicide death accounted for 8.5% of all deaths among adolescents and young adults worldwide (CDC, 2018; Cha et al., 2018). Researchers discovered a wide variation of suicidal thoughts among youths from various countries and sociodemographic populations, and most risk factors stemmed from environmental and psychological influences (Cha et al., 2018).

Research has identified three environmental risk factors for suicidal thoughts and behaviors among youth: childhood maltreatment, bullying, and peer and media influence (Cha et al., 2018). Childhood maltreatment and bullying had the most robust line of evidence; peer and media influence demonstrated mixed evidence of suicide clusters. The different types of childhood mistreatment leading up to suicidal ideation included sexual, physical, and emotional abuse. Suicidal ideations and attempts from bullying included repeated, disturbing behavior, verbal abuse, social exclusion, and cyberbullying through social media. Peer and media influence has been shown to cause suicidal ideations. Studies have validated that having a friend who attempted or died by suicide predicts future suicide attempts in adolescents (Cha et al., 2018; Mars, Heron, Klonsky, Moran, O’Connor, & Tilling, 2019).

Three psychological risk factors of suicidal thoughts and behaviors among youth discussed were effective, cognitive, and social processes (Cha et al., 2018). Evidence supporting negative affected-related processes ranged from worthlessness, hopelessness, and low self-esteem as risk factors for suicidal thoughts and behaviors in youth (Reid-Russell, Miller, Cvencek, Meltzoff, & McLaughlin, 2021). In addition, impulsivity and impulsive aggression are considered prospective risk factors for suicidal ideation and attempts (Cha et al., 2018). Finally, interpersonal connectedness, such as loneliness, was the most common social process assessed as a risk factor for suicidal ideation and attempt. Research suggested that social communication and response processes were critical to maintaining interpersonal relationships (Cha et al., 2018).

Demographic patterns have shown distinguishing characteristics among age, sex, race, and sexual orientation, with adolescent girls more likely to have experienced suicidal ideations and suicide attempts than boys. In contrast, boys were more likely to complete suicide. Older adolescents were more likely to die by suicide than younger adolescents. Indigenous youth had a higher risk of suicide, and lesbians, gay, bisexual, transgender, and questioning (LGBTQ) have shown a higher prevalence of suicidal ideation and attempt compared to heterosexual youth (CDC, 2018; Cha et al., 2018).

Adolescents and School

School is a critical environment where children have first contact with the outside world spending seven to eight hours daily, ten months out of a year. Research suggested that students attending impoverished schools may be confronted with higher levels of violence, drug use, bullying, and crime, with elevated stress levels worsening mental health outcomes (Badr, 2017). In addition, youth at impoverished schools may have lower levels of trust and social connectedness between students, their peers, and teachers, leading to feelings of isolation and a sense of meaninglessness, putting the students at a greater risk of mental health problems such as suicide (Badr, 2017; Fang, 2018).

Badr (2017) aimed to "determine the prevalence of suicidal behaviors and identify psychosocial correlates of suicided behavior" (p. 168). A two-stage cluster sample design was used targeting 2,672 students in Kuwait by employing the Global School-Based Student Health Survey (GSHS) designed by the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC). “Multivariate analysis revealed that girls, smoking, physical violence, feeling lonely, exposure to bullying at school, and having nonempathetic parents were significant correlates of the experience of suicidal behaviors among adolescents" (p. 168). The conclusion was that the prevalence of suicidal behaviors was alarmingly high and suggested that school-based mental health programs were necessary to reduce life-threatening behaviors (Badr, 2017).

The Role of Educators

School staff are among the first adults to be confronted with suicidality and nonsuicidal self-injury (NNSI). Previous studies suggested that educators lack knowledge and confidence in dealing with NNSI and suicidal behaviors (Badr, 2017; Bradley & Kendall, 2019; Groschwitz, Munz, Straub, Bohnacker, & Plener, 2017). There was discussion that the frequency of self-injurious behaviors, with 81% to 99% of school staff from the United States, Australia, and Canada reported being in contact with a student presenting with NSSI or suicidality at least once in their careers. As many as 80% of teachers voiced their need for increased knowledge and confidence regarding dealing with these students. Many teachers reported never having received any education regarding NSSI and suicidality, causing worry since teachers are among the first to notice NSSI in a student. Research suggested these “numbers call for school-based interventions which aim to modify attitudes toward students with NSSI and increase confidence and knowledge in school staff” (Groschwitz et al., 2017, p. 189).

Professional development programs and interactive simulations, such as those designed by Kognito, have proven to help teachers and staff identify and intervene with adolescents at risk for suicide. For example, for teachers, school social workers, and school psychologists, 16 two-day professional development programs across different cities in Germany were evaluated on NSSI and suicidality in adolescence. In addition, there were pre-, post-, and six-month follow-up assessments concerning attitudes, confidence in own skills, perceived knowledge, and knowledge of NSSI and suicidality. Two hundred sixty-seven school staff members participated in the professional development programs, where they completed a pre-test before and post-assessment upon completion of the program. Of those participants, 49 completed a 6-month follow-up online assessment. Researchers concluded that a two-day professional development program effectively changed knowledge and confidence in school staff regarding NSSI and suicidality (Groschwitz et al., 2017).

Kognito Interactive designed computer simulations to effectively train teachers and staff personnel in successful identification and referral practices using virtual teachers and students. The teachers and staff members engage in hands-on practice leading conversations with virtual, fully animated, and emotionally responsive students scientifically designed to embody specific personalities, attitudes, and medical/behavioral health conditions (Kognito, 2020). A study by Bradley and Kendall (2019) reported significant improvement in teacher confidence and competence in approaching and referring at-risk students to mental health services. Results from the study suggested that virtual simulations were an effective training tool for educators in identifying and referring at-risk students.

In summary, research showed an increasing number of suicides among adolescents and young adults, and there were crucial patterns and gaps in knowledge regarding epidemiology, etiology, and treatment. Discussions were conducted regarding schools being a stimulating environment where children have the first point of contact with the outside world. It was revealed that smoking, physical violence, loneliness, exposure to bullying at school, and having nonempathetic parents significantly correlate with adolescents experiencing suicidal behaviors (Badr, 2017; Cha et al., 2018). The research identified school staff as the first adults to be confronted with suicidality and NSSI. Studies suggested that educators lacked knowledge and confidence in dealing with NSSI and suicidal behaviors (Badr, 2017). Studies suggested using virtual simulations, such as programs by Kognito, in professional development to help build skills in teachers and staff to identify and intervene early with students experiencing psychological distress, which could lead to suicide (Bradley & Kendall, 2019; Groschwitz et al., 2017). Implementing evidence-based school-based programs to increase school staff and educators' knowledge regarding NSSI and recognizing adolescents at risk for suicide is necessary.

Evidence-Based Practice: Verification of Chosen Option

A literature review demonstrated the need for an evidence-based program to help educators and staff identify and intervene early with students experiencing psychological distress. According to research, evidence-based programs and interactive simulations have proven to help teachers and staff identify and intervene with adolescents at risk for suicide (Groschwitz et al., 2017). Therefore, a rural high school offered an evidence-based quality improvement program to implement best clinical practices for suicide intervention and measure the relationship between a suicide awareness program and referrals. This quality improvement program provided education on the importance of identifying adolescents at risk for suicide and intervening early with students experiencing psychological distress. The effectiveness of the evidence-based program was evaluated by comparing a pre-and post-test survey and the comparison of the number of referrals to the school guidance counselor before and after implementing the program.

The theoretical framework that guided the project was Ida Jean Orlando’s Nursing Process Theory. This theory was developed to focus on the unconscious and conscious mental and emotional forces that determine personality and motivation between the nurse and patient, with the nurse responding to the patient's future needs. Orlando’s nursing theory stressed the reciprocal relationship between patient and nurse and emphasized the importance of nurse-patient interaction. This theory helped educators and school staff members recognize adolescents at risk for suicide (Alligood, 2018; Orlando, 2016).

This project's decision-making was guided by components of Orlando’s Nursing Process theory. It included five interrelated concepts: professional nursing function, patient's presenting behavior, the immediate reaction by the nurse, deliberative nursing process, and improvement. Orlando conceptualized the nurse's unique function as finding and meeting the patient's immediate needs for help, where the patient was the focal point of the nurse’s function (Alligood, 2015).

Orlando’s original work suggested that the nurse and client's verbal and nonverbal interactions helped the nurse understand and plan for a specific situation (Orlando, 1961). The patient’s presenting behavior may not have been reliable for determining the help needed; however, the presenting behavior may have been a plea for help. The nurse-patient situation was a dynamic process where a patient’s behavior stimulated the nurse’s immediate reaction and became the starting point of the assessment (Alligood, 2015).

The nurse's immediate reaction may differ for each situation due to the nurse's thoughts or feelings and evoke perceptions that the nurse uses to assess the patient's behavior. The nurse might display a unique reaction because of past experiences and knowledge combined with an understanding of the current situation. The nurse must be aware of his or her perceptions, not assuming they are correct until a thorough assessment of the patient and situation has been completed (Alligood, 2015).

Orlando discussed the importance of involving the patient in decisions to ensure a deliberative process of inquiring was utilized to prevent automatic responses, causing the patient's care to be ineffective, even if it was the correct action to take (Orlando, 1961). The resolution component of Orlando's framework focused on whether the patient’s verbal and nonverbal behavior had changed, with the nurse reevaluating the process until there was an improvement (Alligood, 2015).

According to Orlando (1961), persons became patients who required nursing care when they had needs for help that could not be met independently. Patients experience distress or feelings of helplessness as a result of unmet needs. Orlando's theory visually represents nursing faculty members' experiences supporting psychologically distressed students. Orlando's Nursing Process Theory guided the project of integrating an evidence-based program for educators identifying adolescents at risk for suicide in a rural high school. The theory focused on the importance of a thorough assessment of the student’s immediate needs, an equal relationship between the student and educator, treating the student as a whole, and successfully assisting the student in returning to his or her optimal state of well-being (Alligood, 2015; Orlando, 1961).

Goals, Objectives, And Expected Outcomes

School educators and staff members are in constant contact with students and are well-positioned to observe students’ behavior and act when they suspect self-harm (Suicide Prevention Resource Center, 2019). This project aimed to increase referrals to school counselors by integrating an evidence-based program for educators identifying adolescents at risk for suicide in a rural high school.

The objectives of this project were to (a) increase 75 percent of educators and staff member's knowledge of the warning signs for suicide and how to connect students in crisis with assistance and care; (b) integrate school-based suicide prevention into the values, culture, leadership, and work of the local school system to support suicide prevention activities; (c) encourage school-based settings to implement a suicide awareness program and provide yearly education that promotes wellness and prevents suicide and related behaviors, and (d) instruct educators and staff members at a rural high school on how to intervene to reduce suicidal thoughts and behaviors in adolescents with suicide risk. The project's primary objectives were to implement a suicide awareness program in a local school system, educate teachers and staff on identifying adolescents at risk for suicide, and refer those students to the school counselor, increasing the number of adolescent students referred to the counselor.

Project Design

The methodology chosen for this project was based on the assumption that implementing a suicide awareness professional development program to help educators and staff identify and intervene early with students experiencing psychological distress would increase referrals to school guidance counselors. Therefore, this evidence-based quality improvement project's primary purpose was to implement the best clinical practices for suicide intervention in a rural high school and measure the relationship between a suicide awareness program and referrals.

Participants voluntarily enrolled in the virtual professional development by Kognito. Kognito was the evidence-based program that was used for the professional development project. Kognito offered participants a virtual environment where they engaged in role-play conversations with emotionally responsive virtual humans. Through practice and personalized feedback, participants learned and assessed their competency to lead similar real-life conversations (Kognito, 2020). Once enrolled, the participant completed the two-hour program over four weeks. A pre-test and post-test designed by Kognito were collected on every participant. In addition, the number of referrals to school guidance counselors was recorded before and after implementing the program.

Project Site And Population

The project occurred in a rural high school that served students in a small city in the southeastern United States. According to the Census Bureau's Zip Code Tabulation Areas (ZCTFAs), the community had a population of approximately 21,000 people, including the dense rural area within a 10-mile radius of the city. The median household income in 2018 was $35,449, and approximately 25.5% of the population were considered persons in poverty. The city had three manufacturing facilities and several other business enterprises, including two utility cooperatives, a city library, two large public venues in the area, and was 10 miles from a local community college (RainsvilleAlabama.com, 2019; United States Census Bureau, 2020). In addition, the city was home to a youth center that offered various services for children and adolescents, including but not limited to psychiatric and psychological evaluations, diagnosis, forensic evaluations, medication management, substance assessments, and counseling (SAM Foundation, 2020).

Participants in the program were teachers and staff members of the rural high school. The school was comprised of 1,239 students enrolled from pre-kindergarten to 12^th grade and 125 staff members, including 46 kindergarten through sixth grade, 33 teachers, seventh through 12^th-grade teachers, three administrators, three counselors, two librarians, instructional resources personnel, and support workers. The teachers ranged in age from 24 to 65 years of age. According to the National Center for Education Statistics [NCES] (2020), the student-to-teacher ratio was 17:1. The percentage of student enrollment by ethnicity was approximately 75% Caucasian, with the remaining groups being American Indian, Hispanic, African American, and Asian descent. This school received Title 1 funding, with around 60% of the population receiving free or reduced lunches in the Child Nutrition Program (Plainview High School, 2020).

Participation in the project implementation was voluntary. The administration agreed to give teachers and staff who participated in the program professional development hours. In addition, a letter was sent out via email to each potential participant explaining the importance of recognizing students at risk for suicide and referring them to the guidance counselor for additional resources. This letter served as an advertisement for the project and allowed teachers and staff to check their availability with their work schedules. This letter was sent by work email to all participants approximately one month before implementing the program. During the week of implementation, an email was sent to all faculty and staff with instructions, in the form of a flyer, showing the steps to register for their Kognito account. The registration process entailed creating a new account with the individuals’ first and last name, email address, password, and enrollment key.

Stakeholders in this project were teachers and staff members of the rural high school consisting of the high school principal, elementary school principal, one assistant principal, one school nurse, three guidance counselors, 46 kindergartens through sixth-grade teachers, 33 seventh through 12^th-grade teachers, and 19 support staff personnel. Each stakeholder acted in a participatory role by participating in the mental health professional development program. Other stakeholders were students, the community, House Majority Leader Nathaniel Ledbetter, and Senator Steve Livingston, who provided funding for the Kognito licenses.

Setting Facilitators And Barriers

The project required operating systems/dates for the teacher and staff members to complete the Kognito simulation. The school provided the computers. Another resource needed was time for teachers and staff to complete the program at the school. The high school principal allowed teachers and staff four weeks to complete the program from November 9^th through December 9^th. Funding was needed to purchase the Kognito licenses for teachers and staff and was awarded by House Majority Leader Ledbetter and Senator Steve Livingston. The project's facilitators included the primary author and the high school principal. The high school principal agreed to provide 2 hours of professional development time to each teacher and staff member who completed the evidence-based program.

Constraints and barriers to implementing the project included a limited timeframe, teacher and staff workload, the ability to use the technology, budget, and teachers for project implementation. School closed early for Winter Break due to COVID-19. This early dismissal was a barrier because teachers and staff not being on campus to complete the program. Upon return, the high school principal allowed an additional two-week time frame for teachers and staff to complete the Kognito program during regular work hours. Teachers and staff may not have been willing to participate due to a heavy workload or limited free time. The Kognito license was $32 per person. This cost would have been a barrier without the granted funding.

Implementation Plan/procedures

The participants' initial contact was a letter drafted by the author and the high school principal sent by email to encourage participation in the project and inform the teachers and staff on the importance of early identification and intervention with students experiencing psychological distress that could lead to suicide. In addition, the letter notified teachers and staff that they would earn professional development hours upon completion. This letter was sent one month before the project was implemented. The school administration provided the email address of teachers and staff members to the author. An attachment was sent in an email that had directions on how to create a Kognito account, and the email included the product key to begin the simulation. There was a pre-test and post-test embedded in the simulation. It took the participants approximately one hour to complete the Kognito virtual simulation.

Participants included 39 teachers and staff members from the rural high school. Twenty-six participants completed the "At Risk for Elementary School Educators" simulation, and 13 participants completed the "At Risk for High School Educators” simulation.

Measurement Instruments

A variation of the Gatekeeper Behavior Scale (GBS) was used as a pre-survey and post-survey to measure project outcomes. A follow-up survey was sent out two months after the completion of the project. The number of referrals before the project was compared to the number three months after completing the project.

The GBS has high internal consistency using the 3-factor model based on the sub-scales of preparedness, likelihood, and self-efficacy (Timmons-Mitchell, Albright, McMillan, Shockley & Cho 2019). The effectiveness of training between pre-survey and post-survey scores was assessed on (a) participant preparedness to assist a student in psychological distress, (b) likelihood of engaging in helping behaviors, and (c) self-efficacy to engage in such behaviors. The pre-/post-test evaluated preparedness by viewing the average scores of two separate items; self-efficacy was evaluated by viewing the average scores of six separate items; likelihood was evaluated by viewing the average score of three different items (Timmons-Mitchell et al., 2019).

Two months following the implementation of the project, anonymous surveys were sent to all participants. Surveys included self-reflection questions regarding teachers' and staff's perceptions of improvements in their ability to recognize adolescents in psychological distress and refer those students to guidance counselors. The survey was created and distributed by Kognito through a SurveyMonkey™ link to the participants’ work email.

Data Collection Procedures

The first step of implementation was to collect data from a pre-and post-survey. A pre-survey and post-survey were embedded into the program for teachers and staff to complete in the Kognito simulation. A follow-up survey was sent to teachers and staff two months after implementing the project through their work email. The data from the follow-up survey was collected through the utilization of SurveyMonkey™. The data from the pre-survey, post-survey, and follow-up survey was uploaded in de-identified format by Kognito and was exported to a Comma-Separated Values (CSV) file and stored on a jump drive in a secure, locked location. The school guidance counselors provided the number of referrals in a de-identified format from teachers and staff starting August 10, 2020, through March 2021.

Data Analysis

The formative evaluation consisted of administering a pre-test survey embedded into the Kognito program that established a baseline level of preparedness to assist a student in psychological distress, the likelihood of engaging in helping behaviors, and the teachers' or staff members' self-efficacy to engage in such behaviors. The post-survey assessed any increase in preparedness, the likelihood of helping behaviors, and self-efficacy to engage in such behaviors. Pre- and post-test surveys were compared to evaluate the program's overall evaluation effectiveness.

The data are primarily descriptive. For example, in the pre-test, both elementary and high school teachers were asked about their preparedness to recognize students in distress and talk about them. Both groups reported being moderately prepared, and there was no statistical difference between the elementary and high school teachers.

Six items were asked in both the pre-and post-surveys related to teachers recognizing and helping students in psychological distress. In addition, the elementary survey included an additional item about talking to parents. Because the responses to the pre-and post-surveys were not matched, an unpaired t-test was used to determine whether the training seemed effective in helping teachers recognize and respond appropriately.

Twenty-six teachers and staff members completed the "At Risk for Elementary School Educators," and 13 completed the "At Risk for High School Educators." High school teachers and staff members indicated they felt significantly more confident in their ability to recognize when students exhibited psychological distress after completing the training (see Appendices F and G).

Comparing the responses before and after training indicated that high school teachers' ratings on three of the items were significantly higher after training: "I feel confident in my ability to recognize when a student is exhibiting signs of psychological distress" (t(22) = 2.1994, p = .038), “I feel confident in my ability to talk to a student in psychological distress to motivate them to connect with mental health support services” (t(22) = 2.7391, p = .012), and “I feel confident that I can help a suicidal student seek help” (t(22) = 2.3820, p = .026).

Among the elementary teachers, results were similar to the above three statements. Elementary teachers agreed more after the training with the statements regarding ability to recognize students in distress (t(43) = 4.8946, p < .001), talk to such students (t(43) = 3.8479, p = .004), and help suicidal students (t(43) = 4.4401, p < .001). The change in a fourth item shared among the two groups showed a significant increase among the elementary teachers after the training: “I think that a student who is receiving mental health treatment is showing a sign of personal strength” (t(43) = 2.4792, p = .017). A fifth item that was not on the high school survey also showed a statistically significant increase after the training: “I feel confident in my ability to help parents be informed about mental health support services available to a child who is exhibiting signs of psychological distress" (t(43) = 3.3542, p = .001).

On both surveys, two items asked teachers to rate their preparedness to recognize students in psychological distress and to talk to such students to connect them with mental health support services. After the training, high school teachers reported being more prepared to recognize students in psychological distress, and the increase was significant (t(22) = 2.0866, p = .048). This was also true of the elementary teachers (t(43) = 2.8250, p = .007). Both groups reported being more prepared to talk to distressed students after training, but the result was only significant for elementary teachers (t(43) = 4.1048, p = .002).

The elementary survey included two additional items on how prepared they felt to talk to and help parents be informed about mental health support services. After the training, elementary teachers reported feeling much more prepared to talk to parents whose child is exhibiting signs of distress (t(43) = 3.7340, p = .005). They also reported being more prepared to help parents be informed about available mental health services (t(43) = 2.8507, p = .006).

The number of referrals to school guidance counselors before implementing the quality improvement project was 39 referrals in ninth through twelfth grade, 33 referrals in fifth through eighth grade, and 22 referrals in kindergarten through fourth grade. After implementing the quality improvement project, the number of referrals to the school guidance counselors was 54 referrals in ninth through twelfth grade, 46 referrals in fifth through eighth grade, and 31 referrals in kindergarten through fourth grade. This was a 39% increase in referrals to school guidance counselors after implementing the quality improvement project.

The quantitative quality improvement project was effective in helping educators and staff identify and intervene early with students experiencing psychological distress by increasing referrals to school guidance counselors. Overall, participants felt the program was effective in helping them recognize students in psychological distress and respond appropriately. Given the high rate of suicide in adolescents, this program is an essential tool for preparing teachers and staff members to recognize and intervene early with students at risk for suicide. Participants indicated they felt more confident talking to students in psychological distress to motivate them to connect with mental health support services. They also felt more confident that they could assist a suicidal student in seeking help.

Results were similar among participants who completed the “At Risk for Elementary School Educators" training. They had a significant increase after training regarding their confidence and ability to recognize students in distress, talk to such students, and help suicidal students seek help. These participants showed a significant increase in their belief that a student receiving mental health treatment shows a sign of personal strength. They also showed a statistically significant increase in their confidence and ability to help parents be informed of mental health support services available to a child exhibiting psychological distress. The elementary participants reported feeling much more prepared to talk to parents whose child is exhibiting signs of distress and to help parents be informed of available mental health services.

Participants from "At Risk for High School Educators" and "At Risk for Elementary School Educators” reported being more prepared to recognize students in psychological distress and talking to students in distress after completing the program. The number of referrals before the program's implementation was compared to the number three months after completing the program, determining an increase in referrals after completion.

Limitations

Future research with a larger sample size from other school districts is recommended to determine if the results are related directly to the small school size and rural area. It is also recommended to repeat the study when most teachers and staff are on campus to participate. Due to the COVID-19 pandemic, some disruptions caused the school to close for long periods.

Practice Recommendations

This project demonstrated that implementing an evidence-based professional development program helped build teachers' and staff's skills that support early identification and intervention with students experiencing psychological distress, leading to suicide. Teachers spend most of the day with their students. As a result, they may be the best professionals to recognize and intervene with adolescents at risk for psychological problems that could lead to suicide (Bradley & Kendall, 2019). Teachers and staff members must recognize adolescents at risk for suicide and intervene early. They should feel confident in their ability to recognize at-risk students and not be fearful or reluctant to discuss their concerns with those students and their parents. The project effectively helped teachers and staff members feel more prepared and confident in their ability to recognize students in distress, talk to such students, and help suicidal students seek help by connecting those students with school guidance counselors.

Cost-Benefit Analysis/Budget

The budgetary needs for the project were the cost of licenses. Each license was $32.00. There were a total of 125 licenses needed for the teachers and staff. Funding was awarded by House Majority Leader Ledbetter and Senator Livingstone in the amount of $4,000. This funding went toward purchasing mental health virtual simulation programs from Kognito. Sixty-two licenses were purchased for the elementary school teachers and staff, and 63 licenses were purchased for the high school teachers and staff. There were no other budgetary needs for implementing the project as all resources and supplies were obtained through in-house items already purchased by the school district. The author provided data collection and analysis.

Timeline

The project proposal was submitted for evaluation on September 11, 2020. Upon successful completion, the proposal was sent to the Institutional Review Board (IRB) for approval by September 25, 2020.

The letter to encourage participation in the project was sent out the third week in September 2020, and the project was completed by the end of January 2021. The dates of completion for each aspect of the project were:

Kognito licenses were purchased on September 11, 2020.
A letter of encouragement to participate was sent via email by September 20^th, 2020.
On November 9, 2020, the registration and product key instructions were available to teachers and staff through work email. In addition, the pre-survey and post-survey were embedded into the Kognito program.
The two-month follow-up surveys were sent through work email beginning February 21, 2021, and completed by March 15, 2021.

In conclusion, addressing suicide in America’s youth is imperative because suicide is a leading cause of death among youth, with the sharpest increase in the number of suicide deaths occurring between early adolescence and young adulthood. Suicide was the 10th leading cause of death in Alabama in 2019, and the rate of suicide in Alabama was 16.8 per 100,000 (ADPH, 2020; Cha et al., 2018). Teachers play an essential role in identifying students at risk for mental health issues; however, studies have found that teachers may not know how to identify the risk factors of suicide or how to engage youth in a conversation about suicide risk (Marsh, 2016; Robinson-Link et al., 2019).

Professional development programs and interactive simulations, such as those designed by Kognito, have proven to help teachers and staff to identify and intervene with adolescents at risk for suicide by engaging in hands-on practice leading conversations with virtual, fully animated, and emotionally responsive students that are scientifically designed to embody specific personalities, attitudes, and medical/behavioral health conditions (Kognito, 2020).

This project showed that implementing an evidence-based professional development program helped build teachers' and staff's skills that support early identification and intervention with students experiencing psychological distress, leading to suicide.

Participants were voluntarily enrolled in virtual professional development by Kognito. Once enrolled, the participant completed the two-hour program over four weeks. A pre-test and post-test designed by Kognito were collected on every participant. The number of referrals before the program's implementation was compared to the number three months after completing the program, demonstrating an increase in referrals after completion.

The approval of the Jacksonville State University Institutional Review Board (IRB) was obtained before initiating the project. Participation in the project was entirely voluntary, and participants could have withdrawn at any time without penalty. The high school principal provided a letter of approval to implement the program in the school system. An information session was conducted, and those interested in participation received an informed consent document describing the project. The project was completely voluntary and confidential. Participants had the opportunity to ask questions prior to signing the informed consent. Once all questions were answered, informed consent documents were signed.

There was a potential risk of inconvenience for participants because the project was completed during work hours. The principal agreed to allow teachers and staff a four-week window at school that was less demanding on faculty and staff. There was a potential risk for professional development bringing up memories or experiences, thus creating an emotional risk. If this risk had occurred, the participant would have been referred to a counselor. Any identifiable data collected for registration was on a separate secure server not available to the researcher. All data were de-identified when used for analysis and could not be linked to individual users. The de-identified data was exported into a CVS file and was password protected. The author was the only one with access to the CVS file.

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Increasing Referrals to School Counselors by Integrating an Evidence-based Program for Educators Identifying Adolescents at Risk for Suicide in a Rural High School

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Introduction

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