Collaborating to Support School Reintegration Following Suicide-Related Crises: Voices from the Field

Abstract

Adolescent psychiatric hospitalization for suicide-related crises continue to rise. Although previous reviews have identified frameworks for supporting youth as they return to school settings, there is a need to identify and address barriers to collaboration across hospitals and schools. This qualitative study explored school and hospital professional perspectives to inform a pathway towards partnership for improving practices for school reintegration. As part of a larger project that has been developing guidelines for school reintegration following psychiatric hospitalization for suicide-related crises, the present study explored professional perceptions of: (a) school interactions during hospital stays; and (b) recommendations for adolescents, families, school professionals, and hospital professionals. We conducted in-depth interviews with 19 school professionals and seven hospital professionals and analyzed transcribed interviews using Applied Thematic Analysis. Communication and collaboration emerged as cross-cutting themes across research questions, with additional themes considered across a continuum of care. Findings inform the ways in which professionals can collaborate to support adolescent recovery, spanning universal approaches, implemented in advance of a crisis, to approaches enacted during and following psychiatric care.

Introduction

Rates of child and adolescent emergency department visits for suicide-related crises nearly doubled between 2007 to 2015, increasing from 580,000 to 1.12 million (Burstein et al., 2019). Emergency department visits for suicide attempts among young people also increased during and following the COVID-19 pandemic, with the mean number of visits 50.6% higher in the winter of 2021 compared to 2019 among 12–17 year old girls (Yard et al., 2021). Although a much smaller number of these encounters may lead to hospitalization (between 2.1% to 58.3%; Burstein et al., 2019; Plemmons et al., 2018), hospitalization for mental health concerns often result in heightened emotions (e.g., relief, fear, anxiety, shock) among youth and can disrupt student learning (Haynes et al., 2011; Moses, 2011; Preyde et al., 2018; Salamone-Violi et al., 2015). Moreover, hospital encounters for suicide-related thoughts and behaviors appear to be higher during the academic school year than in summer months (Plemmons et al., 2018).

As rates of adolescent psychiatric hospitalization for suicide-related crises continue to rise (Plemmons et al., 2018; Yard et al., 2021), there is a need to improve practices and procedures that support youth returning to schools following hospitalization (Tougas et al., 2023; Tougas et al., 2019, 2022). Although the stress of suicide-related risk formulation and decisions regarding referrals for hospitalization are well documented (Jobes et al., 2008; Rothes et al., 2014), less research has attended to the specific stressors school professionals may face following an initial referral, while providing ongoing supports and services to students with suicide-related risk. Supporting students following a mental health crisis may bring additional challenges, including the need to consistently communicate with families and community therapists about safety, to adapt safety planning interventions to the school setting, and to address rumors about the student’s hospitalization (Authors, 2022a; Tougas et al., 2023). Moreover, students and families have expressed concerns around managing symptoms while in school, determining what information to share with whom, advocating for mental health supports and interventions, and completing academic work or getting caught up on lessons (Authors, 2022a; Authors, 2023; Preyde et al., 2017, 2018).

Recent reviews have provided overviews of existing programs to support the transition from psychiatric care to school settings (Tougas et al., 2022), as well as expert insight informing a framework for school reintegration (Tougas et al., 2023). Findings identify some of the core components of existing programs (e.g., developing a reintegration plan; Tougas et al., 2022) and a sequential approach for tackling reintegration (e.g., coordinating within and across systems to address needs; Tougas et al., 2023). Nonetheless, reviews have called for further research focused on implications for school reintegration following suicide-related crises specifically. Over the past several years, we have shared findings from a multi-phased study that is developing guidelines for schools and hospitals to use in support of school reintegration following suicide-related crises. Here, we build from our previous work that has described adolescent (Marraccini & Pittleman, 2022) and family (Vanderburg et al., 2023) perspectives and experiences, as well as descriptions of school practices and procedures (Marraccini et al., 2022a), and share hospital and school professional insight on how schools and hospitals can better support adolescents and their families during school reintegration.

School Role in Suicide Prevention

Schools are an ideal setting for suicide prevention (Singer et al., 2019) and, in 22 states, schools are legally required to deliver school-based suicide prevention programs (American Foundation for Suicide Prevention, 2020). Comprehensive suicide prevention programs include upstream approaches that aim to prevent risk prior the onset of symptoms (Ali et al., 2019; Costello et al., 2014), screening and risk assessments leading to referrals (Asarnow & Mehlum, 2019), gatekeeper trainings involving the training of peers and adults to recognize suicide-related risk and refer individuals for treatment (Mo et al., 2018), and interventions supporting youth following a crisis (e.g., safety planning interventions; Singer et al., 2019; Stanley & Brown, 2012). Although the role of specific school professionals in suicide prevention may vary across states, school counselors are among the most common roles to support risk identification and referral (Marraccini et al., 2019).

In practice, identification of risk and referrals for treatment of adolescents with psychiatric concerns often originates in school (Costello et al., 2014). In fact, one study found that approximately 20 percent of all pediatric psychiatric emergency room visits originated as school-based referrals (Soto et. al., 2009). Although adolescents typically return to school settings following emergency services (Savina et al., 2014), less is known about the processes supporting students as they transition back to school following a suicide-related crisis.

School Reintegration Practices and Procedures

Findings from a 2019 survey of school psychologists across the United States indicated that more than 60% of schools followed some type of re-entry procedures, but only 16% were formalized processes (Marraccini et al., 2019). Practitioners described procedures requiring schools to hold a re-entry meeting with returning families, develop a re-entry plan, and communicate with the hospital about student needs and considerations. Since that time, findings from several studies and reviews have provided additional guidance about how best to support students returning to school following psychiatric hospitalization. In their review of 53 scientific and clinical documents, Tougas and colleagues (2023) outlined a 9-step framework for successful re-entry based on expert insights. The steps follow the admissions and discharge process sequentially, promoting practitioners to address school reintegration as soon as possible, and coordinating within and across systems to address both academic and emotional needs throughout the process.

Although transition programs designed specifically to support youth returning to school following psychiatric care are relatively rare, Tougas and colleagues (2022) identified some of their core components in their review of the eight existing transition programs. Core components included having a multidisciplinary team, including a multicomponent intervention, developing a reintegration plan, enacting gradual re-entry transitions, and providing extended support (Tougas et al., 2022). Among the programs included in the review, only two shared an explicit logic model outlining the mechanisms for change, and none focused specifically on the needs and concerns of youth hospitalized for suicide-related crises (rather, they tended to focus on psychiatric concerns more generally). Moreover, across programs, “challenges in communication, collaboration and coordination are at the heart of issues related to school reintegration following psychiatric hospitalization” (Tougas et al., 2022, p. 88).

Hospital providers, school professionals, and families have also described barriers to communication during school reintegration more broadly (Henry, 2019; Simon & Savina, 2010; Tisdale, 2014; Vanderburg et al., 2023), coming to relative consensus around the value of improving communication (Blizzard et al., 2016; Clemens et al., 2010; Marraccini et al., 2022a; Tougas et al., 2019). Indeed, communication, collaboration, and coordination across entities is typically dispersed across roles in each institution (Tougas et al., 2019), with some of the barriers to communication potentially related to stigma, lack of trust, and lack of awareness (Vanderburg et al., 2023). Although barriers to communication are relatively well studied, minimal research has attended to the ways in which schools, hospitals, and families can partner in support of school reintegration.

Legal protections that aim to safeguard patient and student privacy, requiring authorization for professionals to communicate about patients and students, can serve as additional barriers to communication. HIPAA (Health Insurance Portability and Accountability Act), enacted in 1996, safeguards the privacy and security of individuals’ health information, including provisions to maintain confidentiality of medical records, to restrict unauthorized access to protected health information (PHI), and to provide individuals certain rights over their PHI (U.S. Department of Health & Human Services). Similarly, FERPA (Family Educational Rights and Privacy Act), enacted in 1974, safeguards the privacy of student educational records for all educational institutions that receive federal funding, granting parents and adult-aged students (18 and older) rights over the confidentiality of student educational information (U.S. Department of Education, 2021). Accordingly, navigating information sharing while supporting students following a mental health crisis necessitates an adherence to these federal privacy laws.

Theories Informing School Reintegration

Ecological systems theory has been used to frame consideration of suicide prevention and intervention approaches across multiple settings (e.g., hospitals, schools, communities). Ecological systems theory considers the adolescent at the center of multiple, intersecting influences on development (Bronfenbrenner, 1979). Cramer and Kapusta (2017) drew on a social-ecological framework to inform a multi-level approach to suicide prevention that integrates contemporary theories addressing risk for suicide, including individual, interpersonal, community, and societal theories. The researchers proposed that this approach could be used to address risk and protective factors of suicide, integrate prevention strategies across levels, implement a multi-level program evaluation approach, ensure theoretical grounding, and address both primary prevention (such as public awareness campaigns) and secondary prevention (such as gate-keeper training programs) (Cramer & Kapusta, 2017).

In schools, an ecological approach to suicide prevention may embed prevention across a multi-tiered systems of support (MTSS), and help inform the selection and delivery of interventions (Ayyash-Abdo, 2002). As Singer and colleagues (2019) outlined, schools can address suicide prevention at multiple levels of MTSS: universal approaches target the entire student body; selected approaches prepare professionals to identify and support youth with risk for suicide; and indicated approaches require professionals to intervene with students at high risk for suicide or following a suicide attempt or death (Singer et al., 2019). The immediate support provided to students as they return to school following a mental health crisis is often considered at the indicated level. Yet, an ecological approach informs how practices that prepare for this crisis support may be embedded across all levels of MTSS, considering not only suicidality, but also positive indicators of mental health and well-being (Suldo & Shaffer, 2008; Marraccini & Pittleman, 2022).

In 2014, Savina and colleagues put forth guidelines for school reintegration that address several ecological factors, including the student’s self-perceptions, their family’s reactions and perceptions, members of their school’s reactions and responses, and the interactions between different entities (Savina et al., 2014). Building on this work and subsequent research, Tougas and colleagues (2019) outlined a bioecological model for school reintegration by integrating research across the youth ontosystem (their own internal influences), microsystem (their school and family), and mesosystems (interactions between schools, families, and hospitals), and considering the ways in which the macrosystem (including issues such as stigma) and exosystem (including consideration of confidentiality, and insurance) may play into this support. Taken together, approaches to school reintegration must consider the systems-level and societal context of the returning student, addressing both risk and resilience as it relates to the student themselves (including their self-perceptions), their immediate environment (e.g., school, home) and the people interacting across their environment (e.g., family, teachers, friends, providers). Moreover, qualitative inquiries indicate the complex interplay between a student’s school experience and a student’s unique risk and protective factors for suicide (Marraccini et al., 2022b), necessitating insight from diverse viewpoints, representing multiple systems and roles.

School Reintegration Guidelines

The present study is part of a larger project that is developing guidelines for school reintegration following psychiatric hospitalization for suicide-related crises. The larger project included three phases of data collection, including: (1) a survey of school professionals (n=133) across one southeastern state; (2) in-depth interviews with adolescents previously hospitalized for suicide-related crises (n=19), parents and care providers (n=19), school professionals (n=19), and hospital professionals (n=7); and (3) iterative development and refinement of guidelines based on one-on-one interviews with adolescents (n=4) and parents/care providers (n=5), and focus group interviews with school and hospital professionals (n=6; note that this analysis is still underway). During the first phase of the project, we aimed to identify existing school-based practices and procedures that could support adolescents returning to school following psychiatric hospitalization for suicide-related crises. Findings from the first phase indicated that rural schools were less likely to have formal school re-integration plans compared to urban and suburban schools; however, more broadly, interventions and modifications available to support youth in their reintegration were relatively consistent across communities (e.g., urban, rural, and suburban; high and low poverty communities; and communities representing different ethnic and racial identities; Marraccini et al., 2022a).

The second aim of the project was to identify adolescent, parent (or care provider), school professional, and hospital professional perceptions of school reintegration following hospitalization for a suicide-related crisis. To date, published findings from the second phase of the study have addressed school professional practices and perspectives on the types of supports and services schools can employ for supporting youth upon their return (Marraccini et al., 2022a); adolescent (Marraccini & Pittleman, 2022) and parents (Vanderburg et al., 2023) perspectives on student school re-entry following hospitalization; and adolescent, care provider, school professional, and hospital professional perceptions of school-related influences of mental health in youth with suicide-related risk (Marraccini et al., 2022b).

Adolescents identified the need for schools to provide emotional, instrumental, informational, and appraisal supports to students returning to school following psychiatric hospitalization (Marraccini & Pittleman, 2022). Parents pointed to the need for hospitals and schools to address disruptions to student learning, as well as difficult peer interactions faced by adolescents returning to school (Vanderburg et al., 2023). Finally, when describing the types of supports and services available to adolescents returning to school following psychiatric hospitalization, school professionals identified the need for hospitals to prioritize school considerations throughout treatment and discharge planning, including the types of modifications and interventions returning students might benefit from (Marraccini et al., 2022a). Across findings, adolescents, parents, and school professionals all identified improved communication between hospitals, schools, and families as critical to improving school reintegration. Therefore, this study focuses on qualitative data collected from school and hospital professional perspectives that had not yet been analyzed, but may shed light on how best school and hospital professionals can partner together, and with families, to overcome barriers to communication and best support adolescent reintegration.

Purpose of the Present Study

As schools continue to develop, integrate, and evaluate school reintegration plans, there is a need to address barriers to school and hospital collaboration, and build pathways for partnership in support of student recovery. Although existing research has identified professional perspectives on how best to support youth in their return to school, minimal research has attended to the ways in which professionals serving in multiple roles, across settings, can collaborate throughout the process in support of their recovery. The present study aimed to explore school professional and hospital professional perspectives to inform how best to work together, across school and hospital settings and with families, in support of improved practices for school reintegration following psychiatric hospitalization for suicide-related crises. Specifically, we explored: (1) professional perspectives of school interactions and experiences during psychiatric hospitalization; and (2) professional recommendations for adolescents, families, hospital professionals, and school professionals for navigating school reintegration following psychiatric hospitalization.

Method

As described previously, this qualitative study is part of a larger project that included three phases of data collection. The present study draws from the second phase of the larger project, which included qualitative interviews with adolescents, parents, school professionals, and hospital professionals. Here, we focus specifically on school and hospital professional perspectives of collaboration across hospitals and schools, and school and hospital professional suggestions for the adolescents, parents, school professionals, and hospital professionals experiencing or supporting school reintegration.

Participants

School Professionals

Eligibility criteria for school professional participants included working in a North Carolina high school in a role involving support of youth with suicide-related risk. School professionals were recruited for the first phase of the study in collaboration with school district central staff, in accordance with district policies. Eligible school professionals were sent an email invitation to complete an online survey. Participants indicated their interest in participating in in-depth interviews, with the final sample representative of multiple roles (four school psychologists, four school counselors, four social workers, two nurses, one principal, one special education teacher, and one professional identifying their role as “other”) at 18 different schools. School professional participants identified as female (n=15) and male (n=4); Hispanic/Latinx (n=1) or non-Hispanic (n=17); and Black or African American (n=2), White (n=15), or “other” (n=1).

Hospital Professionals

Eligibility criteria for hospital professional participants included working in an inpatient setting involving adolescents in a psychiatric hospital in one southeastern state. Multiple hospitals in North Carolina were contacted for participant recruitment; however, only one hospital agreed to participate. The hospital in which participants worked is a public hospital serving youth and adults with over 70 total inpatient hospital beds. Anywhere from 10–14 beds are reserved for youth, with a maximum total of up to 20 beds possible for youth stays and an average length of stay between 10–14 days. The hospital serves patients from across the state, with a typical age range of 5–90, though patients younger than 5 years and older than 90 years are also provided inpatient care. The payor mix is available for the entire hospital system (inclusive of the psychiatric hospital) and primarily includes Medicare, Medicaid, and private insurance, ranging from about 20–30% for each. The participating hospital also provides academic instruction and supports to patients through a local hospital school, including hospital teachers. Hospital schools aim to reduce the impact of hospitalization on academic performance and assist with preparation for community school re-entry (Boff et al., 2021).¹

Eligible participants were recruited via email. Although all participants were recruited from one hospital, two participants worked in the hospital school and the other five worked in treatment (as occupational therapists, recreational therapists, or attending physicians). All hospital professional participants identified as female (n=7). Regarding ethnicity and race, participants identified as Hispanic/Latinx (n=1) or non-Hispanic (n=6); and Asian American (n=1), Black or African American (n=1), or White (n=5).

Procedure

Study procedures were approved by the University of North Carolina at Chapel Hill institutional review board (IRB) prior to initiation (IRB# 18–1510). Informed consent was completed in-person or remotely. Participants completed in-depth interviews and a brief set of questionnaires or verbal prompts, depending on role (i.e., adolescent, parent, school professional, or hospital professional). Participants were compensated $20 for completing study procedures.

Instrumentation

Self-report measures

The researchers collected demographic information from all participants. We assessed gender by asking participants the following question: “Which of the following describes your gender?” Response options included male, female, or other. Ethnicity and race were collected separately. For ethnicity, we asked individuals if they were Hispanic or Latinx. For race, response options included American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Pacific Islander, White, or Other. School professionals completed a demographic questionnaire and hospital professionals were asked about demographic information verbally.Although not the focus of the present study, school professionals also completed additional measures (a survey addressing school reintegration; Marraccini et al., 2019; Marraccini et al., 2022c); and the School and Community Mental Health Services Questionnaire and the Authoritative School Climate Survey (Konold & Cornell, 2015)).

In-depth interviews

Two trained, masters or doctoral level researchers (the first and seventh authors) conducted in-depth interviews in-person (n=4) or virtually (n=22). Interviews followed a semi-structured interview guide that targeted four areas: (a) adolescent student experiences in school prior to hospitalization, (b) school-related considerations for adolescents during hospitalization, (c) adolescent school re-entry experiences and processes, and (d) information sharing between hospitals and schools. Interviewers completed debrief summaries following completion of each interview (e.g., documenting any interruptions to the interview, the tone of the interviewee, and the key information discussed). Researchers audio recorded the interviews, then transcribed, cleaned, and redacted them of identifying information.

Data Analysis

We entered final interview transcripts into NVivo or NVivo Pro qualitative data analysis software (depending on the timing of the analysis) (Lumivero, 2020). We used applied thematic analysis (ATA), a systematic and inductive approach to qualitative analysis, to interview transcripts. ATA draws from several theoretical foundations (e.g., basic inductive analysis, grounded theory, and phenomenology; Guest et al., 2011).

Two researchers iteratively developed coding structures, using the interview agenda as a guide, and adapting the structure based on emergent codes across interviews. More specifically, the researchers reviewed at least three transcripts independently, meeting to review emerging codes and themes, revising the structure accordingly. Following this process, the researchers applied codes from the initial coding structure to the remaining transcripts, meeting regularly to come to consensus and revise the coding structure as needed. The researchers then applied the final structure to the remaining and original three transcripts. Note that the overall study included four groups of participants (adolescents, parents, school professionals, and hospital professionals). Therefore, the researchers developed separate coding structures for each group, beginning with adolescents (see Marraccini & Pittleman, 2022) to center their lived experiences in the coding process, and then using the adolescent coding structure to inform the development of subsequent structures (parents, school professionals, and hospital professionals).

The present study focused on school and hospital professional transcripts addressing two areas of the agenda, each aligning to a research aim: (1) to explore professional perceptions of school interactions and experiences during psychiatric hospitalization, codes related to school, family, and hospital interactions during hospital stay (part of (b) school experiences and considerations during hospitalization) were analyzed; and (2) to explore professional recommendations for adolescents, families, hospital professionals, and school professionals for navigating school reintegration following psychiatric hospitalization, codes related to considerations for adolescents, families, school professionals and hospital professionals during school reintegration (part of (c) school re-entry experiences and processes) were analyzed. A minimum of two trained researchers further reduced these data, in which the researchers identified commonalities within and across codes. The trained researchers met regularly to discuss categories and emergent themes, sharing findings with the primary author. Together, the trained researchers and primary author determined the larger themes related to each research question.

Trustworthiness and Intercoder Agreement

The researchers addressed credibility, transparency, and transferability of findings to optimize trustworthiness. During interviews, we clarified terms used by the interviewees and summarized interviewee statements across key areas of the agenda to be certain we understood the intent of their narrative (i.e., as a form of member checking). All those serving as coders were trained in the development and appropriate application of the study’s coding structure. Specifically, a minimum of two trained coders developed and refined the codebook by first independently coding a single transcript, and then meeting to discuss codes applied and revising the structure for clarity and comprehensiveness. Once the researchers agreed on the structure of the codebook, a minimum of two trained coders applied codes to the final transcripts independently. The coders would then come together to review their independent coding, deliberate as necessary and come to an agreed-upon set of codes for each transcript: these were the final codes used in analyses. Similar to other qualitative studies addressing multiple viewpoints of clinical care (e.g., Gettel et al., 2020; Darling et al., 2021; Hausmann-Stabile et al., 2018; Rattenborg et al., 2019), this approach to intercoder agreement did not involve metrics, but instead involved a review of double-coded text (Guest et al., 2011). As recommended by Guest and colleagues (2011), when we identified disagreements, we discussed the reasons for the discrepancy, came to agreement for a solution, recoded the master coding document, and revised the code definitions (as necessary). If coders could not agree on a given code, another member of the coding team was consulted until agreement could be reached. Throughout this process, we also maintained an “audit trail” that identified changes to the coding structure. Finally, we enhanced transferability of findings through the use of illustrative quotes.

Positionality

This research involved a diverse group of researchers and students. We considered how multiple parts of our identity intersect to afford both privileges and barriers, and their potential for influencing our lens during analysis. Authors identify with diverse racial identities and include university and medical school faculty, postdoctoral fellows, graduate students, post bachelor research assistants, and undergraduate students. Discussions supporting data analysis acknowledged the ways in which power could influence individual interpretation (based on participant-researcher positions) and the decisions made (based on hierarchical institutional power).

Results

We present results separately for each of the two research questions. First, we present an overview of how professionals consider school during hospital treatment, including school-hospital-family interactions and school-related experiences. Next, we share descriptions and themes drawn from recommendations made by professionals for adolescents², their families, and professionals in hospitals and schools.

School Interactions and Experiences During Hospitalization

Both hospital (n=7) and school professionals (n=18) described interactions between hospitals, families, and schools, and the ways in which hospital and school professionals considered schools within the hospital context, revealing two key themes: Facilitating Communication between Hospitals, Schools, and Families; and School-related Influences during Hospitalization.

Facilitating Communication Between Hospitals, Schools, and Families

Nearly all participants (n=18 school professionals; n=7 hospital professionals) provided examples of facilitators to communication between hospitals, schools, and families, which encompassed discussions of direct and indirect conversations between schools and hospitals. Specific categories for facilitating communication between hospitals and schools included the importance of both hospitals and schools identifying a point of contact, the need for hospitals and schools to initiate an authorization for release of information from parents, and cautions about schools and hospitals relying on parents as mediators of communication (but the importance of still engaging with parents). Note that both hospital and school professionals also shared concerns about the many barriers preventing effective communication from occurring during hospitalization (e.g., long delays in receiving work or information from schools) between families and schools, hospitals and schools, and between school personnel.³

Point of Contact

Multiple professionals identified the use of a point of contact (e.g., school counselor, hospital school teacher) to facilitate communication, with many emphasizing a focus on sharing school work with one another during hospitalization. Hospital professionals specifically described their approach to reaching out to both school counselors and teachers, and sometime school administrators, to request schoolwork, with hospital school teachers serving as a “mediator” in determining the appropriate amount of work. Specific academic considerations that professionals described communicating about included coordinating time-limited testing opportunities for patients (e.g., state testing and Advanced Placement exams) and receiving information about student Individualized Education Plans (IEPs) or 504 plans from the school to integrate accommodations into the hospital school day. Although many hospital professionals spoke to the importance of conversing about academic work and concerns, several also described receiving background information from schools to inform treatment planning or consideration of school-related accommodations and services during and following hospital treatment.

Authorization Requests

Hospital and school professionals described the authorization process for requesting parent or guardian permission to communicate with one another about academics and other issues as important. School professionals shared how they “talk directly with the hospital staff the entire time, no matter where they are, which clinic they go to,” when they have an authorization to release information. Nonetheless, depending on the specific hospital and the length of the hospital stay, most school professionals also described instances of receiving little or no communication from the hospital (and the parents).

Cautions Against Relying on Parents as Mediators

Both school and hospital professionals acknowledged parent/guardian-mediated communication, in which parents served as a middleman across settings. The level of parent involvement varied, with one hospital school professional speaking to the complexity of this issue, comparing a family that “had me in the loop constantly” to “a student whose family doesn’t speak any English, doesn’t know how the system works very well” who are “trusting me to do this for them.” In consideration of the benefits and drawbacks of active involvement, the hospital school professional explained:

…the family who was very involved, I’m not sure that in the long-run, it really got them that much, honestly, I think. It made them feel more in control to be able to be in touch with all of us, but I’m not certain that it really ended up benefiting the student that much. I don’t know.

Hospital professionals also described parents as looking to the hospital for support in navigating their child’s return to school, with one hospital school professional sharing a “a real intimidating situation for families” in which a school district required discharge summaries prior to their return. An attending physician expressed concern that minimal communication occurred between parents and schools, “I don’t think school and families talk unless they need to.” Indeed, few school professionals described parents proactively reaching out to them to share information during a student’s hospitalization, explaining that the issue is often swept “under the carpet.” A school social worker explained, it’s [it is] very seldom that a parent would call us and tell us if we were not involved in the process of getting them there.” Still, school professionals described trying to connect with parents during hospitalization, with another school social worker explaining:

If we are aware that they are in the hospital, typically what we’re trying to do is reach out to parents so that we are kept in the loop so that there’s a line of communication where we try to foster this idea that, “Hey, they may be in the hospital right now, but they’re probably coming back to school.”

Importantly, two school professionals shared how their school made gestures in support of the hospitalized student – in one case sending a card from the school to the patient and in another having staff visit the patient in the hospital.

School-Related Influences During Hospitalization

Several hospital professionals (n=4) shared the ways in which their adolescent patients described thinking about school during their hospital stay (note that this was not a topic addressed with school professionals). As a hospital school professional explained, adolescents commonly expressed concerns for falling behind in school while they are hospitalized:

A lot of times the students, what they’re expressing to me is, “I’m feeling like I’m gonna be so behind,” or “It’s gonna be so hard to catch up with the work.” Even if they’re not behind, most of them will still say that anyway.

Some hospital professionals also described how some of their patients seemed to have anxiety about returning to school, for example, thinking about what they will say to their peers and friends about their absence. A recreational therapist explained:

…I’ve done some role-play on this. It’s like, “What am I gonna tell my friends about where I’ve been?” Sometimes they’re really dreading “What do I say?” and just that whole piece of that if they’re not comfortable or if they don’t want people to know that they’ve been in a psych setting.

A hospital school professional shared how they felt the hospital school needed to increase the rigor of academic work in preparation for their return:

One of the things we’ve tried to do on our end is increase the rigor some and allow for the kids to – not be kids—not use kid gloves all the time. Like have some stressors, have some stressful math work to do because if not, if it’s so easy, then the reports are, “Oh, everything’s great. Everything’s great.” Then they’re discharged earlier, and they’re sent back to a setting that is entirely different.

Hospital professionals explained that adolescents may share specific school-related stressors, such as bullying or other difficult experiences involving adults in their school, to their hospital teacher or other professionals, who may help relay this information to the treatment team or back to the school. Although hospital professionals acknowledged that they sometimes hear particularly troubling stories about school (for example an attending physician described a corroborated story from a patient about the counselors in their school taking bets about who would be hospitalized next), they also explained how they consider that “the truth is always in the middle, right, even if it’s more one way than the other.” As this attending physician put it:

I think, obviously, things like depression and anxiety color the way one sees the world and, then as an adolescent, further. Sometimes, you hear things. You’re like, “That wasn’t supportive, was it?” or “This person really did miss the mark.” Other times, it seems like this adolescent has really misinterpreted what’s happening. That being said, I don’t know the degree to which there’s reporter bias…

Finally, two hospital professionals shared some of positive things adolescents described about school, including looking forward to school activities and their engagement in schoolwork.

Recommendations for Improved School Reintegration Practices

Professionals described existing practices as imperfect, sharing numerous ideas, strategies, and considerations for students, families, and other professionals (hospitals and schools) to better navigate school reintegration (n=19 school professionals and n=7 hospital professionals). In the following sections, we first share themes pertaining to considerations for students and families; and next describe categories and themes pertaining to considerations for hospital and school professionals.

Considerations for Students and Families

A total of eight school and five hospital professionals made recommendations for students and families in navigating hospitalization and their return to school. Recommendations for adolescents reflected one theme: Youth Empowerment; and recommendations for families primarily reflected another theme: Family Collaboration.

Youth Empowerment

When making recommendations to students facing this transition, several school professionals (n=3) and one hospital professional described strategies for empowering youth. A hospital professional suggested how understanding hospitalization processes, such as differences in treatment found in the emergency room compared to on the inpatient unit, would help them when handling a crisis. They further identified the need to ensure that adolescents understand the power they have in determining what can and cannot be shared across settings. A school professional (identifying their role as “other”) encouraged returning students to reach out to trusted adults when feeling overwhelmed (“find your people”), and to be honest about their level of needs: “…don’t think you have to fake it. The less you fake it, the healthier you will be.” A school counselor emphasized the need for students to reach out at appropriate times when checking in (during electives and not core courses, unless in crisis). Finally, a different school counselor emphasized how understanding one’s mental health needs (from specific triggers to diagnosis) can support self-advocacy, with “a level of understanding of their own mental health, of their diagnosis, of what’s going on in their world, and how their systems are either helping them out or not helping them” as a mechanism for empowerment. Although empowerment did not emerge as a theme among recommendations for families, an attending physician endorsed the importance for parents and guardians to understand the hospitalization process and advocate for any needed supports (e.g., IEP or 504 plan) for their returning students.

Family Collaboration

School (n=8) and hospital (n=5) professionals primarily emphasized the significance of families collaborating with both schools and hospitals to support their child’s school reintegration, for example, by increasing monitoring during their recovery. Although school professionals called for families to collaborate with the school to help facilitate information sharing across sites, they also acknowledged the many school-related barriers (e.g., limited professional availability and resources; the school’s role in increasing efforts for community building with families) preventing families from collaborating with schools. Finally, a few hospital professionals emphasized not only the need for families to collaborate with the hospital and school, but also to connect with their children and “do better with listening more.”

Recommendations for Hospital and School Professionals

Both school professionals (n=19) and hospital professionals (n=7) provided recommendations to hospital and school professionals for improving adolescent school reintegration. Recommendations are presented in four sections, according to when they might be implemented: universally, during adolescent hospitalization, when preparing for adolescent discharge, and during adolescent school reintegration.

Universal Considerations

Universal considerations are drawn from discussions focused on improving school and care settings in a way that may better support returning. Here, we outline two themes that emerged from discussions: Establishing a More “Intentional” Approach to Support Mental Health and Building an Understanding of Mental Health in Schools. School and hospital professionals suggested universal considerations for professionals working in schools (n=10 school professionals; n=6 hospital professionals) and for professionals working in hospitals (n=6 school professionals; n=2 hospital professionals).

Establishing a More “Intentional” Approach to Support Mental Health

Seven school professionals and three hospital professionals identified the significance of having more intentionally sensitive, and caring universal school practices or approaches to support student mental health and well-being. Recommendations for improving school-based approaches ranged from systems level changes (e.g., policies that prioritize mental health in schools) to improved resources (e.g., better crisis intervention resources”), to individual approaches (“everything that you do, especially when it comes down to serving children, especially who have been emotionally mentally compromised, it has to be intentional”). Both school and hospital professionals made recommendations to “lesson some of the pressures on teachers,” easing teacher responsibilities and prioritizing teacher support to allow time for student-teacher relationships and prioritization of social and emotional learning. School professionals acknowledged the need to prioritize school professionals’ role in mental health, with both hospital and school professionals identifying the need to prioritize evidence-based interventions (e.g., early interventions and prevention plans) or school-based mental health services. School professionals also emphasized the need for schools to better build and establish relationships with families and communities, prior to crises, in order to facilitate safe and collaborative communication during and following a crisis.

Only a few school (n=2) and hospital (n=2) professionals provided recommendations for improving hospital-based approaches to be more intentional. School professionals emphasized the importance of sensitively caring for patients and their families and ensuring that the hospital provides a safe, therapeutic environment for patient care. Hospital professionals described the importance of applying a team-based approach for preparing for discharge and return to school, and called for increased flexibility in rules and regulations to better support patient needs.

Building an Understanding of Mental Health in Schools

Both school (n=5) and hospital (n=5) professionals identified the need for ongoing trainings and psychoeducation addressing mental health to be provided to school faculty, staff, and students; however, no professionals suggested that hospital professionals may need psychoeducation regarding school practices and procedures. Hospital professionals endorsed the need for school professionals to learn about specific issues that returning students face, such as attention difficulties, anxiety, self-regulation, and school-related stressors. Three hospital professionals specifically shared the importance of school understanding of legal and ethical boundaries related to information sharing: that it is the family’s choice per HIPAA and FERPA to share information, that schools cannot refuse re-entry, and that hospitals cannot provide documentation about suicide-related risk and safety to clear students for return to school. Finally, an occupational therapist described how school professionals may have misperceptions of what hospitalization can do for patients, who may think that hospitalization will “fix them” – emphasizing the need for them to continue to consider how to adjust the environment and their expectations, and support and care for returning students during their recovery.

During Hospitalization

School and hospital professional discussions relating to considerations during hospitalization revealed one primary theme: Proactive School-Hospital-Family Collaboration and Communication. Participants identified collaboration as a priority for both school (n=9 school professionals; n=7 hospital professionals) and hospital (n=8 school professionals; n=7 hospital professionals) professionals, including improved communication and information sharing across schools and hospitals to better support patient needs. As described previously, hospital and school professionals identified the need for a point of contact at both the school and the hospital to help facilitate information sharing between families, hospitals, and schools, and support the continuum of care of returning students. An occupational therapist suggested that inclusive language and resource sharing could help improve communication across entities, and a few school professionals emphasized the need for hospital professionals to communicate more proactively and openly with them.

Hospital professionals expressed the need for school professionals to share the social, emotional, and educational context of students to inform hospital treatment, and suggested that school professionals proactively request to speak with hospital professionals. Likewise, both hospital and school professionals endorsed the need for hospital professionals to attend to school context, as well as other pertinent background information schools could provide about patients, during treatment, with one suggesting hospitals use a checklist that includes “school” on it. Moreover, professionals in both roles spoke about the need to communicate about academics, allowing hospitals to support their patients in completing schoolwork during hospitalization (if appropriate). Two hospital professionals emphasized expectations for workload, academic intensity level, and support for work during hospitalization as important. Hospital professionals further identified the need for hospital staff to collaborate around standardized testing expectations and deadlines while students are absent and in the hospital. When meeting with families, several school and hospital professionals shared the importance of explaining the implications of information sharing across entities, such as how information would be kept confidential and who will have access to information (e.g., that it will not be shared with colleges during the application process), as well as the potential benefits (including that schools are ideally situated to provide increased monitoring regarding safety concerns).²

Preparation for Discharge

Hospital (n=3) and school (n=5) professional recommendations for hospital professionals when preparing patients for discharge addressed one theme: Planning for School Context. For example, a few hospital professionals described how role-playing potential experiences reflecting a patient’s return to school could benefit patients as they approached discharge. Several hospital and school professionals identified specific information that could be shared with the school to support the student’s return, including an overview of goals set during hospitalization and specific skills learned, a crisis plan to help schools support and monitor recovery, and psychoeducation tools for helping students in distress. Moreover, school professionals called for hospitals to share an overview of hospitalization experiences and treatment approaches with schools, and both professionals identified the need for additional supports and resources to be provided to students and families following hospitalization.

Following Hospitalization

School (n=10) and hospital (n=6) professional recommendations for school professionals in improving school re-entry revealed one theme: Procedural Supports.

Participants provided specific recommendations for re-entry meetings and planning, calling for schools to hold re-entry meetings as soon as possible. They also identified the need for schools to consider both accommodations and supports, including re-evaluating or considering IEP or 504 Plans. School and hospital professionals shared the importance of schools determining the pace of return to school, with varying opinions on the best approach for typical returning students. School professionals recommended academic, social, and emotional supports, such as teacher feedback about prioritizing missed content, advisory programs, continuous homerooms, adolescent advisors/advocates, identifying a support person for the returning student, and regularly occurring check-ins; however, school and hospital professionals also acknowledged the many constraints preventing schools from flexibly applying accommodations and supports, as well as barriers to enacting re-entry plans (e.g., limited staff time, resources, and family support or buy-in). A hospital occupational therapist emphasized how the rigidity of both schools and hospitals can get in the way of schools and hospitals implementing needed supports and services, which can leave students feeling “powerlessness and hopelessness”:

It’s reinforcing: “Nobody cares. Nothing’s ever gonna change. This is never gonna get better. I’m not gonna get any better no matter where I go. I was at the hospital and it was terrible. Now, I’m in school and it’s terrible. I’m at home and it’s terrible.”

Discussion

This study shares findings from a multi-phase project that aimed to synthesize multiple perspectives to inform improved practices in support of student school reintegration following psychiatric hospitalization for suicide-related crises. Previously reported findings from the project identified adolescent and parent perspectives of school reintegration, revealing the need for emotional, instrumental, informational, and appraisal supports during a student’s return to school (Marraccini & Pittleman, 2022) and improved communication and collaboration between hospitals, schools, and families stressors (Marraccini et al., 2022a; Vanderburg et al., 2023). Although results from the present study reinforce findings from our previous work, they also provide new insight into school and professional perspectives for improving school reintegration and the ways in which professionals can partner to support collaboration and communication. Results from the present study also suggest substantial overlap between school and hospital professional perspectives – pointing to shared ideas for partnering to improve practices within the student’s microsystem and across their mesosystem.

In the following sections, we further discuss findings related to school and hospital professional perceptions of school-hospital-family interactions during psychiatric hospitalization and their recommendations for professionals, families, and returning students. Across research questions, communication and collaboration emerged as key, cross-cutting themes. Therefore, framed within the literature at large (Preyde et al., 2017, 2018; Savina et al., 2014; Tougas et al., 2023; Tougas et al., 2019) and the findings from our larger body of work (Marraccini & Pittleman, 2022; Marraccini et al., 2022a, 2022b), our discussion aims to inform the ways hospitals and schools can come together to best support returning students and their families.

Preparation for School Re-Entry

Consistent with an ecological approach to suicide prevention, recommendations for how school and care settings can best prepare for a smooth re-entry to school for adolescents following psychiatric hospitalization are situated across multiple levels of MTSS. For example, recommendations call for universal prevention practices such as cultivating a positive psychosocial climate in schools, which may benefit all patients and students. Recommendations, however, also identify the need for preparation that directly addresses the immediate support provided to students returning to school on an indicated level, such as helping school professionals better understand the hospital context for students hospitalized for suicide-related thoughts and behaviors.

Regarding universal approaches, findings suggest the need to address the school microsystem. Specifically, improving school professional attitudes and understanding of suicidality and treatment of suicide-related risk (e.g., providing regularly occurring professional development trainings related to mental health) may help set the stage for ongoing support of youth following a crisis. One example of a program with demonstrated effects for improving mental health literacy in schools (as well as other settings), is Mental Health First Aid (Morgan et al., 2018). Although a recent review identifies a lack of rigorous research addressing the efficacy of Mental Health First Aid for improving recipient (e.g., student) behaviors, emphasizing the need for additional research in this area (Forthal et al., 2022), trainings that address mental health identification and knowledge may better prepare students, staff, and students to meet the needs of youth after risk identification.

Because participants also prioritized the need for schools to learn more about the hospitalization process, additional training components may address typical treatment and outcomes associated with psychiatric care. Indeed, previous research has identified professionals’ familiarity with other care positions and systems as a facilitator in care integration for youth (Nooteboom et al., 2021). Although practitioners working in different disciplines may have limited time to jointly explore best practices across settings, the shift in preparing health care professionals towards prioritizing interprofessional education (IPE) appears to be a promising approach for setting a foundation for future cross-discipline knowledge and collaboration (van Diggele et al., 2020). Unfortunately, psychologists report having limited involvement in IPE programs (Robiner et al., 2021), and even fewer IPE programs may include school professionals or educators (Kiger et al., 2021). Given that youth mental health care spans across school, outpatient, and inpatient settings (Duong et al., 2021), training programs focused on child and adolescent mental health in school (e.g., school counseling, school psychology, school social work, school nursing) and medical settings could consider IPE programs addressing school-hospital context.

Participants also emphasized how schools can cultivate a positive psychosocial climate and prioritize family and community partnerships. Certainly all schools aspire to build meaningful partnerships with their families and communities; nonetheless, the previously hospitalized adolescents (Marraccini & Pittleman, 2022) and parents (Vanderburg et al., 2023) in our larger project have also voiced the need to prioritize the psychosocial climate of schools. Considering the protective effects of school connectedness for youth at risk for suicide (King et al., 2019; Marraccini et al., 2022c), such practices appear especially important in the context of youth returning to school following a suicide-related crisis. Interventions that have demonstrated effects for improving school connectedness typically require system-wide change, with a literature review reporting several interventions (Battistich et al., 2004; Hawkins et al., 2001) to demonstrate positive effects on school connectedness (Chapman et al., 2013). Yet, school-community partnerships, including school-based health and wrap-around services, may also play a promising role in fostering a sense of school connectedness (Grover et al., 2021). Thus, as hospital and school professionals consider ways to partner in support of youth mental health, universal approaches may involve care coordination in advance of crises.

School and hospital professionals also described how hospitals may better integrate caring and intentional approaches to mental health care in the hospital setting. Indeed, despite their potential for harmful effects, practices such as restraints and seclusion are typical within residential and inpatient settings (Bryson et al., 2017). In response to these issues, and increased attention to the prevalence and impact of trauma among children and adolescents, scholars have called for trauma-informed practices to be embedded in psychiatric (Bryson et al., 2017) and school (Thomas et al., 2019) settings. Based on the definition provided by Substance Abuse and Mental Health Services Administration (2014), trauma-informed practice “realizes the widespread impact of and understand potential paths for recovery”; “recognizes the signs and symptoms of trauma”; and “responds by integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization” (Huang et al., 2014; p. 9). Although to date, there have been no rigorous studies evaluating the effects of trauma informed practices in schools (Maynard et al., 2019), trauma informed practices in psychiatric settings can lead to reductions in seclusion, restraint practices, and patient and staff injury rates (Bryson et al., 2017). Accordingly, trauma-informed approaches may help build a foundation for caring environments sensitive to the needs of recovering youth, considered “essential to the context of care” (Substance Abuse and Mental Health Services Administration, 2014; p. 9).

During Hospitalization

As described by Tougas and colleagues (2023), school reintegration should be considered as soon as possible during hospitalization. In the present study, communication between schools, families, and hospitals (i.e., the student’s mesosystem) emerged as a critical component for considering school context during hospitalization, aligning to findings from several other studies addressing school reintegration (Clemens et al., 2010; Simon & Savina, 2010; Tisdale, 2014; Vanderburg et al., 2023). School professionals voiced the need for schools and hospitals to ensure communication pathways between entities are possible (still adhering to HIPAA and FERPA), noting the potential for improved treatment when schools and hospitals communicate about patient background, strengths, and needs. Hospitals can provide explanations of relevant privacy law and necessary authorizations early on during parent contact (e.g., intake or referral) to facilitate communication between hospitals and schools.

Although many school and hospital professionals noted that parents may be less likely to communicate with schools during this time, perhaps, in part because “they’re overwhelmed, having a child hospitalized” (indeed, the stressors faced by families during their child’s hospitalization are among one of many possible barriers to communication; Vanderburg et al., 2023), many also identified parents as a common middleman to communication. These findings reinforce the need to ensure schools are building these partnerships with families in advance of crises, and also intimate the need for hospitals to discuss the benefits and cautions of sharing information with parents during hospitalization. When schools are in contact with families, they may also consider offering gestures of supports to hospitalized adolescents to show their concern and stay connected during their stay.

Academic supports emerged as another key area to communicate about during hospitalization (Tougas et al., 2023). Participants described how they can communicate with one another about specific academic content and assignments for patients to complete during hospitalization, and to collaborate in determining the appropriate pace of their return (gradual or immediate re-entry). They also shared some of the ways in which the hospital can honor a student’s specific learning needs (including IEPs) when determining the right workload for each student and ways in which the hospital can honor a student’s specific learning needs (including IEPs). Indeed, professionals identified the potential for students to fall behind in school, or the possibility of missing a test that cannot be made up, as a prominent stressor for some, aligning with previous studies focused on student concerns (Preyde et al., 2018; Marraccini & Pittleman). Thus, when making recommendations to schools regarding how best to handle missed work, hospital professionals may encourage school professionals to outline differences between course content and assignments that can and cannot be exempt (e.g. general education courses versus advanced placement courses adhering to the college board requirements).

Participants also explained how collaborating with their patients and families can help to empower them during their care. By providing a clear overview of the hospitalization process, families and patients may better advocate for themselves. Professionals can remind families and patients of their power during hospitalization – in determining what information is shared with whom – while also brainstorming the benefits and cautions of information sharing across entities. Such calls align to theoretical foundations of psychological empowerment, which recognize empowerment to include critical awareness (a patient’s recognition of how power structures impact care), perceived control (a patient’s sense of self-efficacy), and citizen participation (value and appreciation for the role a patient plays in their decision making and involvement) (Agner & Braun, 2018)

When preparing patients for discharge, participants described how hospital professionals can help prepare returning students to face upcoming social stressors. For example, hospital school professionals or other therapists can role-play ways of handling expected stressors (e.g., practicing what they will say to peers about their absences, or sharing information with school professionals about the safety plan they developed). Indeed, findings from previous studies have identified the need to provide hospitalized youth practice opportunities for responding to expected re-entry stressors during hospitalization, for example, by practicing responses during stressful social interactions (Preyde et al., 2017; Tougas et al., 2022).

With these recommendations in mind, schools should also be prepared to collaborate with returning students on safety planning interventions. O’Neill and colleagues (2021) outline the ways in which school professionals can partner with families to engage in trauma-informed safety planning interventions to mitigate and monitor risk (O’Neill et al., 2021). Schools might also consider implementing the recently developed suicide risk monitoring tool, which allows school mental health professionals (e.g., school counselors, school psychologists) to track changes in key areas of risk for youth already identified with suicide-related concerns (Erbacher & Singer, 2018). Note, however, that research evaluating the effects of Erbacher and Singer’s suicide risk monitoring tool is needed (Erbacher & Singer, 2018).

Following Hospitalization

Findings from the present study reinforced consensus on the need to hold a re-entry meeting and develop a re-entry meeting for supporting youth following hospitalization (Authors, 2019; Authors, 2022b; Savina et al., 2014; Tougas et al., 2019). Although the present study did not explore the specific professional roles to include in these meetings, previous research suggests that individuals may vary according to each student’s and school’s context, with consensus that there needs to be an established leader (or re-entry coordinator) who facilitates a multidisciplinary team with mental health expertise (e.g., school counselors and school psychologists) with student and family involvement (Authors, 2019; Authors, 2022b; Tougas et al., 2023). The recommended content and format to re-entry planning matched recommendations made by others (e.g., summary of needs, modalities of student’s return, academic and social-emotional interventions, roles, responsibilities and timeline, and follow-up mechanisms; Tougas et al., 2023), with the acknowledgement that such accommodations and supports are not always simple to provide in the context of strict school structures and limited resources and support. Recognition of these constraints by hospital professionals is encouraging, but should not prevent hospitals from providing tentative recommendations for supporting student mental health upon return. Indeed, in our previous analyses of available modifications and interventions to support returning students, comparable modifications (e.g., gradual re-entry, pass to leave class) and interventions (e.g., individual counseling, check-in/check-out) appeared available across school districts representative of rural and urban communities and communities with varying levels of poverty (Authors, 2022b).

Finally, participants emphasized how recognizing the power held by students and families for decision making (e.g., identifying trusted peers and adults) can empower them during a student’s return to school. A required foundation for empowering returning students, however, is addressing the ways systems transact with empowerment processes (Agner & Braun, 2018). In schools, this requires a positive school psychosocial climate, which values student and family collaboration, and encourages teachers, staff, and students to connect meaningfully with one another. Indeed, one of the participants in the present study emphasized the need for schools to cultivate environments conducive to empowerment, careful to avoid placing the burden on families. Thus, to empower returning students and families, schools must ensure the previously described universal practices and procedures fostering school-family-community partnerships are in place.

Limitations and Future Directions

The findings of the present study should be considered within the context of several limitations. Participants were recruited from one state in the southeast, thus findings may not generalize to other areas. Moreover, hospital professionals were recruited from the same hospital, and their views may reflect the specific facilitators and barriers associated with its setting. For example, the hospital in which participants worked provides patient access to a hospital school, with dedicated staff for providing instruction and coordination with schools.

Another limitation is the study’s focus on school and hospital personnel perspectives, as opposed to the patients themselves. Indeed, most research addressing school reintegration following a mental health crisis has prioritized provider perspectives, with a need for more research centering adolescent and family voices. Therefore, the present findings should be interpreted within the context of the larger study’s findings addressing adolescent and parent perspectives, as well as other research centering patient voices.

A related limitation pertains to the attitudes and views that participants may have held towards different professional roles, which may have influenced their view of the problem and ideas for solutions. For example, although participants described the need for psychoeducation for school personnel and the need for schools to better understand hospital practices, few suggested that hospital professionals should learn more about education and school systems. It is likely that professionals from both institutions would benefit from improved understanding, especially considering that previous research has identified that a lack of appreciation for other professionals can serve as barriers to interprofessional collaboration (Nooteboom et al., 2021).

Finally, although the authors of this work considered the ways in which our own privilege and power could influence interpretation of data, there is a potential for both participant biases, and our own biases, to have shaped data and interpretation. As students and professionals in an academic institution, our views are typically framed by a value system that is shaped by our peers, underscoring the need to consider how knowledge is situated in our social context (Agner & Braun, 2018).

Conclusion

As rates of adolescent hospitalization for suicide-related crises have risen over the past decade, it has become increasingly important to improve practices for supporting students as they return to school following psychiatric hospitalization. Existing guidelines for supporting youth following psychiatric hospitalization highlight the need for improved communication, with ample research identifying barriers in school-hospital communication during the process. Findings from the present study shed light on the ways in which hospitals, schools, and families can take an ecological approach towards partnerships in support of youth before, during, and following a suicide-related crisis. To facilitate improved communication across a student’s mesosystem, hospitals and schools can have an established point of contact, ideally with expertise that spans both settings (e.g., a school professional with expertise in mental health and a hospital professional with insight into school settings). Hospitals can initiate authorization to share information with schools early in the process, and both hospitals and schools should engage in proactive communication with one another.

Implications for improving school reintegration span beyond the need to develop and enact re-entry plans, but require schools to engage in universal practices that cultivate a school microsystem supportive of student mental health. In particular, it is important for schools to cultivate an understanding of the legal and ethical boundaries related to information sharing, avoiding policies that require families to provide documentation from medical providers clearing students to return (as minimal suicide-risk is not something that can be guaranteed). During hospitalization, hospital professionals can help prepare patients for their return to school by considering their school-related stressors during treatment and when making recommendations to school, and also by reinforcing some of the positive aspects of school their patients may be looking forward to returning to. Hospital professionals can also prepare patients for school reintegration by helping them practice what to say about their hospitalization to their peers and teachers. As students return to schools following a hospitalization, schools can support their recovery by providing academic, social, and emotional supports, resulting in “a better, kinder, gentler” school experience for returning students.

Impact Statement:

Increased rates of hospitalization for suicide-related crises necessitate improved collaboration between hospitals and schools in support of adolescent recovery. The present study shares insights and recommendations from school and hospital professionals to inform school reintegration practices and procedures in support of school and hospital partnerships.