Implementing school nursing strategies to reduce LGBTQ adolescent suicide: a randomized cluster trial study protocol

In 2012, the United States (U.S.) Surgeon General identified lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) youth as at heightened risk for suicide [1]. Risk factors include depression, substance use, inadequate social support, and not feeling safe at school [1–7]. Large population-based studies over the past 15 years have found that lesbian, gay, and bisexual (LGB) youth are at two to four times increased risk for suicidal ideation and attempts when compared to their cisgender, heterosexual peers [1–3, 5, 8–16]. Within LGB populations, suicidality disproportionately affects racial and ethnic minorities, including American Indian and Hispanic people [1, 17, 18]. In numerous surveys and qualitative studies, transgender youth report elevated risk for suicide, depression, and substance use [19–24].

In general, LGBTQ youth report high levels of rejection, harassment, victimization, violence, and sexual abuse that can contribute to mental health problems and suicide behaviors [3, 9, 13, 18, 25]. These behaviors relate to “minority stress,” i.e., chronic stress from stigmatization, prejudice, and discrimination [26]. National school climate surveys have found that LGBTQ youth are often exposed to minority stress in schools [25, 27]. Youth describe being victimized because of their known, or perceived, sexual orientation or gender identity [8–11, 13, 19, 27]. LGBTQ youth are also more likely to experience high school victimization when they disclose their orientation, self-identify as a sexual minority, recognize same-sex feelings at a younger age, or demonstrate gender-atypical behavior [14, 28].

LGBTQ youth with greater school connectedness and safety report lower suicidal ideation and attempts [29]. Gay-Straight Alliances (GSAs)—peer-to-peer support groups—protect against suicide and depression for LGBTQ students [25, 30–34]. School policies are also pivotal to the mental health of LGBTQ youth. LGBTQ students at schools with anti-harassment policies may feel safer and are less likely to be harassed [35]. Those at schools with supportive staff, anti-bullying policies, and GSA clubs are less likely to be victimized, skip school because of safety concerns, or attempt suicide compared with those in other schools [32]. LGBTQ youth may be at lower risk for attempting suicide if they attend school in districts with anti-bullying policies covering sexual orientation and gender identity [36]. LGBTQ students in settings with more protective school climates report fewer suicidal thoughts than those in places with less protective climates [37].

A supportive, safe school environment is key to a comprehensive public health strategy to prevent youth suicide [38]. As a protective factor against suicidal ideation and attempts, school connectedness is second in importance only to family connectedness [39]. The Centers for Disease Control and Prevention (CDC) endorses six EB strategies for schools to meet the needs of LGBTQ youth (see Table 1) [40]. However, the 2012 School Health Profiles Report based on data from 44 states found that only 5.5 % of secondary schools implement all six [40].

Several factors within an organization can impact the success of implementation efforts. For example, organizational culture and climate influence staff willingness to engage in new practices [41], as do job tenure and level of professional development [42]. Leadership is also important [43]. Implementation leaders require capacity to be successful change agents and local champions, and their ability to motivate and interact effectively shapes staff attitudes toward adopting an EB strategy [44]. Personal innovativeness or ability to adapt or change can also impact attitudes toward new ways of working in a team or organization [45]. Provider attitudes toward adopting EB practices are also associated with actual utilization [46].

Schools are vital but largely untapped venues for intervention research on LGBTQ youth [2]. However, efforts to address the unmet mental health needs of youth in general and LGBTQ students specifically may not reach their full potential due to implementation challenges in school settings. The proposed intervention model, “RLAS” (Implementing School Nursing Strategies to Reduce LGBTQ Adolescent Suicide), builds on the Exploration, Preparation, Implementation, and Sustainment (EPIS) conceptual framework and the Dynamic Adaptation Process (DAP) to implement EB strategies in U.S. high schools [47, 48].

The EPIS framework segments implementation into four phases: exploration (considering new approaches to carry out EB strategies); preparation (planning to apply EB strategies); implementation (ongoing planning, training, coaching, and use of EB strategies); and sustainment (maintaining EB strategies over time) [47]. Per Fig. 1, the model emphasizes three levels of influence: system (or school), provider (or school nurse), and client (LGBTQ student). The model also attends to factors pertinent to both the “inner context” (e.g., schools, school nurses) and the larger “outer context” (e.g., policies, funding, resources) of EB strategy implementation and sustainment.

The DAP is an implementation strategy guided by the EPIS framework that provides direction for activities to undertake during each EPIS phase and a continuously iterative data-informed approach to support EB strategy implementation [48]. The DAP has four key components: initial assessment; stakeholder engagement and training; problem solving; and outcomes feedback to address challenges. Another core feature of the DAP is the development of an Implementation Resource Team (IRT), a collaboration comprised of multiple stakeholders to assist with implementation, interpret data, and address adaptation as an explicit part of the implementation process.