Prevention of suicidal behavior in schools: Simulation-Based Teaching (SBT)^{* 1}

Abstract

Adolescent suicide has increased in recent years, representing a global concern. Schools provide a conducive environment for identifying emotional distress and implementing actions aimed at promoting mental health and preventing suicidal behavior. Thus, this study aims to develop and validate a simulation-based teaching script for school community professionals on suicide prevention. The method involved developing and validating a simulation-based teaching script, a pedagogical approach designed to build specific skills among education professionals. To develop the script, a review of both national and international scientific literature on suicide prevention in schools was carried out. Experts in simulation and suicide prevention were invited to validate the script, selected through the Lattes Platform and the snowball sampling technique. Data collection was conducted by sending invitations via email with a hyperlink to the Research Electronic Data Capture form. Data were processed and analyzed using the STATA® Statistical Software. Descriptive statistical analysis, the content validity index (CVI), and Gwet’s First-order Agreement Coefficient (AC1) were used. The script achieved acceptability, agreement, and reliability criteria in the expert validation. This study provides a freely available script that can be used for simulation-based teaching, contributing to the ongoing education of school community professionals on mental health promotion and suicide prevention. It is recommended that future studies assess the script’s effects on professionals’ self-confidence.

Keywords:
Suicide prevention; Suicidal behavior; School; Adolescence; Simulation-based teaching

Resumo

O suicídio na adolescência tem aumentado nos últimos anos, o que representa uma preocupação mundial. A escola é um ambiente favorável para a identificação do sofrimento emocional e desenvolvimento de ações de promoção da saúde mental e prevenção do comportamento suicida. Com isso, esse estudo tem como objetivo construir e validar um roteiro para o ensino baseado em simulação para profissionais da comunidade escolar sobre a prevenção do suicídio. O método consiste na construção e validação de um roteiro para o ensino baseado em simulação, que se refere a uma abordagem pedagógica para o desenvolvimento de habilidades específicas para profissionais da educação. Para construção do roteiro, foi realizado levantamento da literatura científica nacional e internacional sobre prevenção do suicídio na escola, e para validação foram convidados experts em simulação e/ou prevenção do suicídio, por meio da busca na Plataforma Lattes e da técnica de Snowball. A coleta foi realizada por meio do envio de convite via e-mail com o hiperlink do formulário de coleta do Research Electronic Data Capture. Os dados foram processados e analisados pelo software estatístico STATA®. Utilizou-se a análise estatística descritiva, o índice de validade de conteúdo (IVC) e o coeficiente de concordância de Gwet First-order Agreement Coefficient (AC1). O roteiro alcançou o critério de aceitabilidade, concordância e confiabilidade na validação por experts. Este estudo disponibiliza, de forma gratuita, um roteiro que pode ser utilizado para o ensino, baseado em simulação, para contribuir com a educação continuada de profissionais da comunidade escolar sobre a promoção da saúde mental e prevenção do comportamento suicida. Recomenda-se que estudos avaliem os efeitos do roteiro sobre a autoconfiança dos profissionais.

Palavras-chave:
Prevenção do suicídio; Comportamento suicida; Escola; Adolescência; Ensino baseado em simulação

Introduction

Suicide is a public health issue that significantly impacts the population. It is estimated that approximately 700,000 people die by suicide each year (WHO, 2022), and suicide is considered the third leading cause of death among individuals aged 15 to 29, a critical period that encompasses adolescence (OPAS/OMS, 2023).

According to the World Health Organization (WHO), adolescence includes the age range of 10 to 19 years old (OPAS/OMS, 2023). In Brazil, the Child and Adolescent Statute (ECA), Law No. 8,069, of July 13, 1990, defines adolescence as the period between 12 and 18 years. However, researchers in the field have already highlighted the need to extend this developmental stage to the range between 10 and 24 years, due to factors involving legal frameworks, social policies, and appropriate service systems for an individual’s development. Despite these differences, this study follows the WHO’s global definition (Brasil, 2002; Sawyer et al., 2018; OPAS/OMS, 2023).

Adolescence is a developmental phase marked by significant transformations in social, psychological, and physiological aspects. Emotion management, sexual identity, problem-solving needs, and social relationships can become stressors, putting adolescents in vulnerable situations if they do not receive proper support and care (OPAS/OMS, 2023).

Suicidal behavior includes a spectrum of desires, thoughts, or plans to take one’s own life, encompassing suicidal ideation, attempts, and death by suicide (Klonsky; Saffer; Bryan, 2018). Suicide attempts during adolescence require special attention, as this critical developmental phase is marked by risk behaviors that may persist or intensify into adulthood. For every 1,000 adolescents aged 15 to 19 years old, an average of four to five visits to emergency departments are related to suicide attempts. Recently, there has been a noticeable increase in these incidents, underscoring the urgency of addressing this issue with preventive actions that cannot be delayed (Fogaça et al., 2022).

In this context, schools play a crucial role in development, socialization, and health promotion, serving as environments where adolescents’ emotional distress is often both experienced and observed. As such, schools are key spaces for identifying needs, offering support, and planning interventions, particularly for suicide prevention (MacPhee et al., 2021).

Scientific literature shows that schools often lack adequate knowledge and training for suicide prevention, as well as the ability to plan and implement long-term interventions. It is recommended that the entire school community-teachers, administrators, security staff, school agents, other employees, families, and students-be involved, along with local health services and community resources, in implementing these actions (Mo; Ko; Xin, 2018; Torok et al., 2019; Val; Carmen Míguez, 2021; Gijzen et al., 2022).

The development and implementation of these actions require addressing various contexts. Studies emphasize the inclusion of mental health topics in the curriculum, as well as the use of podcasts, newsletters, and student involvement in educational activities-such as posters, videos, seminars-and discussion groups as recommended initiatives for schools (Torok et al., 2019; Val; Carmen Míguez, 2021; Gijzen et al., 2022). In this sense, Simulation-Based Teaching (SBT) has emerged as a pedagogical approach widely used in health training contexts, recognized for its evaluated benefits and potential (Moreira et al., 2022; Nascimento et al., 2022).

The creation and validation of scripts that guide simulated practices have been extensively covered in scientific literature across various health fields, particularly in mental health (Costa et al., 2022; Negri et al., 2019; Pedrollo et al., 2022; Ramos et al., 2023). Additionally, SBT provides participants with experiences that simulate real-life situations in safe learning environments, offering opportunities for both assessment and reflection on the experiences encountered (INACSL..., 2023)⁴.

SBT is a pedagogical approach designed to develop specific skills, primarily used in the health sector; however, it is also gaining traction in education. A recent study on Chemistry education in basic schools found that virtual simulators enhanced learning and made classes more engaging and appealing to students (Martins et al., 2020). These results show that experiential learning models are a promising approach that can be widely replicated in the education sector. This emphasizes the need to develop specific SBT scripts tailored to each skill being developed, with the goal of promoting the planning of long-term (ongoing) and multilevel actions involving all professionals within the educational context. (Altamirano-Droguett, 2019; Moreira et al., 2022; Nascimento et al., 2022; INACSL..., 2023).

When planning an SBT activity, it is crucial to adopt criteria that ensure alignment with best simulation practices. This process starts with developing a structured script, customized to the participants’ learning level and backed by scientific evidence. The script should include: the title, objective, target audience, number of participants and observers, choice of location for the simulated activity, identification of the materials needed to create the scenario, provision of theoretically grounded study materials for prior preparation, duration, pre-briefing plan (which involves preparation and briefing with information on agreements, simulation guidance, and basic instructions for the simulated case), detailed instructions for the facilitator, definition of participants’ expected actions in line with the simulation’s objectives, and finally, the debriefing, which is a critical reflection on the activity performed (INACSL..., 2023).

However, there are no studies in the scientific literature on the use of Simulation-Based Teaching for training education professionals in suicide prevention, reinforcing the relevance and originality of this study.

Therefore, considering the identified needs in the relationship between adolescent suicide prevention and the school environment, this study aims to develop and validate a simulation-based teaching script for school community professionals on suicide prevention.

Method

This is a methodological study (Polit; Beck, 2011), divided into two stages for the development and validation of a SBT script aimed at developing strategies for preventing suicidal behavior in schools.

Development of the SBT script

To develop the script, a review of the scientific literature on suicide prevention in school settings was conducted (Barbosa et al., 2021; Black et al., 2021; Gijzen et al., 2022), along with the use of a script to support the development of SBT. The script is based on international literature on SBT and consists of 13 items: title, general objective, target audience, human, physical, and material resources, prior study materials, duration, pre-briefing (information on agreements and simulation execution), briefing (basic instructions on the simulated case), instructions for the simulated patient, table of expected actions during the simulation, and debriefing structured into three phases (descriptive, analytical, and applicative) according to The Diamond model (Jaye; Thomas; Reedy, 2015). Finally, the script’s storyline was developed and internally evaluated by the responsible research group before being submitted to the expert validation stage.

Validation of the SBT script

Participant selection

A minimum participation of 10 experts was determined. The scientific literature on simulation does not establish a minimum number of experts for the validation phase. However, for this study, a minimum of 10 experts was defined. The selection of experts followed the criteria of having a PhD and professional experience in the areas of focus of the simulated script, identified through the Lattes Platform, where 29 eligible experts were initially identified based on the selection criteria. Invitations were sent to all of these experts, of whom six agreed to participate in the study. The remaining 23 were excluded due to lack of response (19), invalid email addresses (3), and one refusal. To reach the minimum number of experts required for the validation of the SBT script (Vinuto, 2014), the snowball sampling technique was used, which involves the referral of new experts by research participants. To avoid research bias, it is important to note that the initial search through the Lattes platform aimed to prevent the initial snowball sources from being linked to the researchers’ personal connections, ensuring the work would be evaluated by individuals with diverse backgrounds and perspectives.

During the snowball phase, 15 experts were invited, of whom four agreed to participate. The remaining 11 were excluded due to lack of response (9) or professional disengagement (2). The selected experts received an invitation to participate in the study via email, which included an explanatory letter about the project and a link to access the SBT script evaluation form on the REDCap platform (Harris et al., 2019). The Informed Consent Form (ICF) was available on the first page of the form, with options to confirm or decline participation. In cases of refusal, a thank-you message was sent. Experts who accepted the ICF were given access to the subsequent pages to evaluate the SBT script. The deadline for completing the evaluation was 15 days, with reminder emails sent weekly after the first contact. Experts who did not complete the evaluation within 30 days were considered to have withdrawn from the study. In summary, 44 invitations were sent (in phases 1 and 2) to reach the minimum of 10 experts participating in the study.

Questionnaires

The experts were invited to complete a characterization questionnaire with questions about gender, age, geographical location, and area of expertise (suicidal behavior and/or clinical simulation). For the evaluation, the previously developed simulation teaching script was used, with items assessed on a three-point Likert scale (adequate, regular, inadequate) and space for suggestions. The three-point Likert scale was chosen because the authors planned from the outset to categorize the Content Validity Index (CVI) calculation into two categories.

Data collection, processing, and analysis

Data collection took place between February and March 2023, with invitations sent via email containing a hyperlink to the data collection form available on Research Electronic Data Capture (REDCap) (Harris et al., 2019). The data were organized and processed in Microsoft Excel 10 and subsequently analyzed using the statistical software STATA®. For the characterization data analysis, descriptive statistics were performed, and for the evaluation of the simulation script, the Content Validity Index (CVI) with an acceptance level of 80% was used (Alexandre; Coluci, 2011). This decision was based on Lynn’s (1986) study, which discusses the importance of the number of experts and suggests that the CVI acceptability criterion should be at least 0.78, especially when the number of experts is relatively small (between five and 10). For evaluating agreement, Gwet’s First-order Agreement Coefficient (AC1) was used, with a confidence interval (CI) of 95%. Gwet’s AC1 coefficient was chosen to assess the level of agreement among the 10 experts due to its robustness in conditions where there is an imbalance in the categories evaluated or a high prevalence of a specific category. According to the established criteria, an agreement value above 0.75 is considered excellent, indicating strong agreement among the experts; values between 0.60 and 0.74 are considered good, reflecting satisfactory agreement; values between 0.40 and 0.59 indicate moderate agreement, suggesting a need for review or re-evaluation; and values below 0.40 are considered poor, pointing to low agreement and, possibly, significant inconsistencies in the experts’ evaluations (Gwet, 2014; McCray, 2013).

Ethical aspects

The research was conducted in accordance with the ethical guidelines and principles outlined in CNS Resolution 510/2016 (Brasil, 2016). The research project was approved by the Research Ethics Committee of the School of Nursing of Ribeirão Preto at the University of São Paulo (CEP EERP/USP) under Opinion number 3.742.077, dated December 3, 2019, CAAE 19918019.8.0000.5393. All participants were included in the study after reading and agreeing to the Informed Consent Form (ICF) prepared by the researchers. During the validation phase, all participants were reminded of the importance of keeping a copy of the document.

Throughout the project, the confidentiality and anonymity of the participants were maintained, along with the principles of human dignity, autonomy, protection, safety, maximizing benefits and minimizing harm, respect for individuals, justice, and beneficence. The author ensured that participants had the right to withdraw from the research at any time, without needing to provide an explanation or justification. None of the questions in the study were mandatory, and participants had the right to skip any questions they did not wish to answer.

The benefits of the research included the development and validation of an SBT script for the prevention of suicidal behavior in schools, presenting an innovative and unique proposal with the potential to strengthen educational practices focused on developing strategies for promoting mental health among adolescents in the school context, provided by students and professionals in the field of education. The training of professionals equipped to work in this area can support and reinforce health promotion efforts, especially in promoting mental health in schools. The principles of human dignity, autonomy, protection, safety, maximizing benefits and minimizing harm, respect for individuals, justice, and beneficence were upheld throughout the study.

Results

Script for SBT on developing strategies for preventing suicidal behavior in schools

The script, titled “Guidance for School Community Professionals on Promoting Mental Health and Preventing Suicidal Behavior in Schools,” aims to guide school community professionals (administrators, teachers, and staff) in promoting mental health and preventing suicide in schools (Chart 01).

Chart 1
Validated script for SBT to guide school community professionals in promoting mental health and preventing suicidal behavior in schools

Pre-briefing (Presentation of instructions):
Presentation of the basic instructions for the simulated case - they may be read, and none of the information should be omitted.
- Present the activity to be developed, instructing participants that they will coordinate a team meeting, during which they will have to welcome, guide, and assist in the initial planning of actions based on the issue presented in the final agenda item.
- Clarify that the participants will not be evaluated: this is a formative simulated experience.
- Discuss agreements regarding emotional and ethical safety with the participants: confidentiality, anonymity, respect, and the importance of participating in the discussion following the simulation.
- Offer post-simulation support, if necessary.
- Explain that the scenario will end either when the task is completed or when the set time limit is reached.
Briefing (Presentation of the case/story):
This will be a simulation of addressing concerns and providing guidance raised by a primary and secondary school teacher. You are education professionals coordinating a team meeting to discuss issues related to the planning of school actions. The final item to be discussed was brought by a teacher regarding the observed change in some students’ behavior after learning about a classmate’s suicide attempt. You should identify the needs related to the concern raised by the teacher and provide initial guidance on action planning.
You will have approximately 20 minutes to conduct this discussion.
The simulation will not be interrupted by external participants and will be concluded by the simulation coordinators either when the task is completed or when the maximum allotted time has passed.
Question for the participants and observers: Do you have any questions about the instructions and preparations presented?
Expected Actions
Items to be considered in evaluating participants’ performance in the scenario, according to the simulation objective(s). For each of the following items, assess whether the action was carried out adequately, using the response options YES or NO.
Items evaluated
Provide welcoming support with empathetic listening:	( ) Yes	( ) No
Explain the concept of suicidal behavior;	( ) Yes	( ) No
Explain that discussing suicide prevention carefully does not encourage suicidal behavior:	( ) Yes	( ) No
Suggest planning long-term (ongoing) interventions rather than one-off actions:	( ) Yes	( ) No
Suggest developing multilevel actions involving different members of the school community (e.g., students, parents, teachers, staff):	( ) Yes	( ) No
Help the principal reconsider the expectation of quick results or complete control of situations:	( ) Yes	( ) No
Present prevention actions recommended by the literature (e.g., Facilitate access to help; Integrate mental health into school activities; Plan continuous actions; Promote activities for the development of socio-emotional skills; Foster social connection; Coordinate intersectorally):	( ) Yes	( ) No
Propose mental health literacy actions (Actions involving the entire school community and families, aimed at promoting knowledge about mental health issues and facilitating recognition, management, and prevention);	( ) Yes	( ) No
Suggest developing socio-emotional skill-building activities with students:	( ) Yes	( ) No
Debriefing based on “The Diamond” model (Jaye, Thomas, & Reedy, 2015)
Descriptive Phase (Highlighting different perspectives on the case)
How did you feel during the process of providing support to Elisa?
Analytical Phase
What positive actions were taken during the support and guidance provided to Elisa? (Directed to the participants and observers of the scenario)
What would you do differently during the support provided to Elisa? (Directed to the participants of the scenario)
How do you evaluate your performance in group work during the support provided to Elisa? (Directed to the participants of the scenario)
Aplicative Phase
What can you take away from this simulated experience about suicide prevention in schools for your professional practice? (Directed to the participants and observers of the scenario)

• Source: Author’s own work, Ribeirão Preto, 2023.

The SBT script was developed for professionals and staff working in school settings, as well as undergraduate students in the field of education. For the development of the SBT activity, the participation of two simulation facilitators (teacher/coordinator), two participants who will engage in the simulated activity (the professionals addressing the issue brought up by Teacher Elisa), one actor (a professional prepared to simulate the person being guided during the activity, representing Teacher Elisa), and observer participants (other participants who will watch the simulated activity) is required. The location for the activity can be a teaching lab, classroom, or a free room that can be adapted to resemble a meeting room. Materials such as tables, chairs, cabinets, and notepads or paper on the table can be used.

The simulated case revolves around addressing a concern raised by Teacher Elisa, a professional at a primary and secondary school, during the final agenda item of a pedagogical meeting. Four weeks earlier, she had noticed changes in students’ behavior following a suicide attempt by one of the students at the school. During the session, participants are expected to discuss possible actions for planning suicide prevention strategies. It is important to note that this is a fictional scenario based on scientific research on real-life situations.

The estimated duration is 70 minutes, distributed as follows: pre-briefing (10 minutes), simulation (20 minutes), and debriefing (40 minutes). For the prior preparation of all participants, two materials are proposed: a) Let’s Talk About Suicidal Behavior in Adolescence and the School Context? (Access: https://inspiracao-leps.com.br/especialistas/vamos-falar-sobre-o-comportamento-suicida-na-adolescencia-e-no-contexto-escolar/), and b) Educational video on suicide prevention in schools. (Access: https://www.youtube.com/watch?v=JCZgugbT4jc) (Silva; Vedana, 2022; Silva et al., 2023).

To enact the case, the actor requires theoretical, attitudinal, and emotional preparation. This preparation should take place in the days leading up to the simulation, following the instructions for the actor’s prior preparation (Chart 02) and the table of expected and analyzed actions during the simulation (Chart 01), so that the actor can align themselves with what is expected in the scenario.

Chart 2
Instructions for the actor’s prior preparation for the SBT activity, focused on suicide prevention in the school context

Topics	Prompts	Examples
It is not an isolated case.	Suicide attempts have occurred among students at the school (which has around 500 students) at least once a year. Situations involving self-harm are more frequent.	“Ah! No one imagined she would do something so serious. It was terrifying!” “The most concerning thing is that at least one suicide attempt happens every year. I also noticed that the number of students cutting themselves has increased.”
Students need to develop socio-emotional skills.	It is noticed that students have difficulty asking for help or talking about their emotions.	“Sometimes we notice that they are not well, but they find it very difficult to express themselves and ask for help.”
Unrealistic expectations about the lecture	She asks her colleagues who are coordinating the meeting to find a professional to give a lecture on suicide and believes that this will solve the problem.	“We need to invite a professional to give a lecture on suicide prevention urgently, or else this behavior will not stop.”
Ambivalence and fear of addressing the topic	At the same time as requesting the lecture, she is afraid to talk about suicide and “encourage further attempts,” and she fears the parents’ reactions if the school chooses to carry out any preventive action.	“I believe the lecture is the best option, but will it not motivate suicide attempts in other students? And how about the parents? I am afraid they will not like the idea.”
Doubts	She wants to know which suicide prevention actions work in schools.	“What suicide prevention actions actually work? What can we propose that is effective?”
School community demands related to literacy	She noticed that the other teachers and staff at the school are eager to help, but they do not know how to act.	“The other day, I was talking to the math teacher and Mrs. Maria from the cafeteria, and they are also worried, but they do not know how to help.”

• Source: Author’s own work, Ribeirão Preto, 2023.

Validation of the SBT script for developing strategies to prevent suicidal behavior in schools

Ten experts participated in the validation of the script, the majority of whom were female (60%), with an average age of 41.10 years (sd=10.12; minimum=30; maximum=66), and 60% residing in the southeastern region. All participants held a PhD (100%) and had professional experience in teaching and scientific research (80%), with an average of 16.80 years of experience (sd=10.50; minimum=6; maximum=42). They had expertise in the area of school-related suicidal behavior (60%) and clinical simulation-based teaching (40%).

In terms of acceptability and agreement, all items surpassed the minimum acceptance criterion (CVI=0.8) (Table 01). The script achieved good reliability in expert validation agreement (AC1=0.7464, SD=0.06379; CI=0.606-0.887; p=0.0000). Adaptations were made to the title (suggested by expert 2), the pre-briefing time was reduced (suggested by expert 9), and the information that the simulation activity is not evaluative but rather a teaching tool through simulated experience was added to the pre-briefing (suggested by expert 2).

Table 1
Acceptance and agreement of expert validation (n=10) of a simulated script on preventing suicidal behavior in schools

Item	Agreement
	N (%)			CVI
	Yes	Acceptable	No	Total
Title	7 (70)	3 (30)	-	1.0
Objective	7 (70)	2 (20)	1 (10)	0.9
Target population	7 (87.5)	-	1 (12.5)	0.8
Human Resources	9 (90)	1 (10)	-	1.0
Physical Resources	1 (100)	-	-	1.0
Duration	9 (90)	-	1 (10)	0.9
Previous Study	9 (100)	-	-	1.0
Prebriefing	9 (90)	-	1 (10)	1.0
Briefing	6 (75)	2 (25)	-	0.9
Instructions for Actor	9 (100)	-	-	1.0
Expected Actions	8 (88.9)	1 (11.1)	-	1.0
Debriefing	8 (88.9)	1 (11.1)	-	1.0

• Note: Number of participants; CVI=Content Validity Index; SBT=Simulation-Based Learning; S.Beha=Suicidal Behavior; Expected Actions.
• Source: Study data. Ribeirão Preto, 2024.

To assess agreement, the AC1 statistic developed by Gwet (2008) was used. The AC1 statistic has advantages over Kappa in terms of resistance to marginal homogeneity and the prevalence trait (McCray, 2013).

In the context of the experiment, there are two evaluators, referred to as A and B, with the layout shown below in Table 1, in a 2 x 2 format.

Table 2
Distribution table of subjects by evaluator and response category

Rater B	Rater A
	1	2	Total
1	A	B	B1
2	C	D	B2
Total	A1	A2	N

• Source: McCray, 2013.

A1=A+C represents the total number of classifications equal to 1 given by evaluator A; B1=A+B represents the total number of classifications equal to 1 given by evaluator B; and the terms A2=B+D and C+D=B2 represent divergent classifications between evaluators A and B.

Gwet’s AC1 statistic is given by AC1=(p-e(γ))/(1-e(γ))

Where p=((A+D))/N is the overall probability of agreement, and the term e(γ) is given by the equation e(γ)=2P₁ (1-P₁) representing the approximate chance that evaluators A or B will classify into category 1.

$P_1=\left(\left(A_1+B_1\right)/2\right)/N$

The software used for the agreement analyses was the R program (R Core Team, 2023), version 4.3.1, which can be downloaded for free from the website www.r-project.org. A significance level of 5% (α=0.05) was adopted for all analyses.

Discussion

Suicide prevention in schools remains a challenge for institutions and the entire school community (Amaral et al., 2020; Brito et al., 2020; Sganzerla, 2021).

The development of actions and strategies for promoting mental health and preventing suicidal behavior in schools involves complex understandings of both suicide and mental health, as well as propositions aimed at, over time, training education professionals who can recognize needs and act in these contexts. Schools were chosen because they occupy a unique role, not only in education but also in the development of various aspects of young people’s lives (MacPhee et al., 2021).

Moreover, the school environment reflects issues related to society, acting as a social representative concerning social inequities, intersectionality, and cultural and social differences (Macedo, 2023). This relationship can be observed in how schools address mental health, particularly among minority populations, life circumstances, and exposure to various forms of structural violence, as highlighted in the scientific literature (Pereira, 2021; Ferreira, Pinto; Veras, 2018).

Structural violence refers to the deprivation of rights and guarantees that excludes individuals and restricts access to constitutional rights. It can be characterized as a violation by the State, which is an important, but not the only, factor (Lamarão Neto; Teixeira, 2021; Ferreira; Lamarão Neto; Teixeira, 2022). Thus, understanding school dynamics highlights the need for fieldwork focused on preparing education professionals to develop new strategies for promoting mental health and preventing suicide.

Studies emphasize the importance of schools addressing suicide-related topics in a welcoming and evidence-based manner, to increase knowledge, raise awareness, and promote the development of socio-emotional skills (Brann et al., 2021; Barbosa et al., 2021; Kravetz et al., 2021). Actions that involve the entire school community in promoting knowledge about the topic, aimed at recognition, management, and prevention, are referred to as mental health literacy (Brann et al., 2021; Barbosa et al., 2021; Val; Carmen-Míguez, 2021; Gijzen et al., 2022).

Mental health literacy has been proposed through actions that involve the entire school community and students’ families, aiming to promote knowledge about mental health problems, provide quality information to reduce stigma, facilitate recognition and management, and develop interventions targeting risk factors, with prevention in mind (Pistone et al., 2019; Gijzen et al., 2022).

In this study, approaches to promoting mental health and preventing suicide, including literacy-related issues, were carried out through the development of a script for SBT, which was subsequently validated by experts. SBT is a pedagogical approach that promotes the acquisition of knowledge by simulating a real case and allows the development of specific skills in students or professionals before engaging in real service, safely reducing the possibility of future errors (Yamane et al., 2018; INACSL..., 2023). It is important to note that simulation differs from role-playing in that it aims to develop specific technical skills, rather than focusing on the development of interpersonal and behavioral skills (Nestel; Tierney, 2020).

Simulation is an important approach in training professionals for suicide prevention, providing a safe and controlled environment where they can develop essential skills for identification and intervention. This approach helps reduce anxiety, improve communication, and increase the effectiveness of interventions. In addition to being familiar with useful and relevant resources and strategies for prevention, education professionals need support and dignified conditions to carry out preventive activities (Pedrollo et al., 2022; Pereira et al., 2024).

The decision to use simulation in this context aligns with findings that highlight the potential of simulated practices for professional training in the health field, particularly in mental health (Hutson; Zeno, 2021; Pedrollo et al., 2022; Ramos et al., 2023; INACSL..., 2023).

Although not a recent approach, SBT is still not widely implemented in many spaces, which reinforces the potential of addressing simulation at the intersection of health and education, particularly within the school context.

Thus, the development of an SBT script provides an opportunity for real-life details to be presented through a problem that participants will address and which will be externally analyzed by observers (INACSL..., 2023). In the end, the debriefing phase enhances discussions and reflections, serving as an important conclusion to the simulated practice (Jaye; Thomas; Reedy, 2015; INACSL..., 2023).

It is worth noting that the content and structure of the SBT script were based on a review of the scientific literature on the discussed topics, aspects that were evaluated during the validation stage of this methodological study. When developing an SBT script, it is essential to follow the guidelines on best practices in simulation (INACSL..., 2023).

All items in the SBT script achieved a CVI above 0.80. The evaluation of agreement among experts is essential in validating instruments and guidelines. A practical example is the validation of an item in a cognitive skills questionnaire, where a Content Validity Index (CVI) of 0.80 indicated high agreement among experts, although the disagreement of one expert suggested the need for additional adjustments to ensure the universal applicability of the item. This case illustrates how predominant agreement and divergent opinions are considered to improve the accuracy and effectiveness of the evaluated instruments (Gwet, 2008; McCray, 2013; R Core Team, 2023).

Regarding the changes, some points and relevant suggestions were accepted, including those related to the title, the reduction of pre-briefing time, and the inclusion of information indicating that the simulation activity is not evaluative. The modifications made to the script aimed to enhance its development and were aligned with aspects observed in the literature on the design of simulated practices. In the title, the target audience of the script was specified to ensure alignment with the proposed objective. In the pre-briefing, the time was reduced to ten minutes to promote the feasibility of the activity.

The preparation of the actor is another important aspect of simulation development. It is crucial that the actor has knowledge of the topic to be addressed, the simulated script, and especially the items analyzed in the table of expected actions for participants (INACSL..., 2023). Moreover, the actor is responsible for leading the activity to ensure that the objectives are achieved, guiding participants through pre-established cues, as exemplified in the instructions for the actor’s preparation.

Regarding the items in the expected actions table, they were defined based on the studies that supported the development of the SBT script and aligned with the activity’s objective. It is important to emphasize that simulation can be complemented by other formative strategies, as SBT seeks to foster expected actions in the simulated case and in the daily work of professionals; however, this training and encouragement do not guarantee that these actions will be practiced. Support, supervision, and appropriate working conditions are essential for promoting mental health. It is worth noting that the simulation is formative rather than evaluative; therefore, the “Expected Actions” are intended to guide the actor in leading participants to achieve the script’s objectives. The debriefing phase is when actions are analyzed from the participants’ perspectives, promoting self-reflection and self-awareness. Therefore, there is the possibility of performing all or part of the actions, which serves as a topic for discussion regarding one’s approach in a real situation and provides an indication for continuous improvement (INACSL..., 2023).

Studies indicate that reducing the stigma surrounding suicide is directly related to increased knowledge of the subject and highlight the importance of schools developing actions focused on risk factors, publicizing help channels, forming a welcoming committee for student support, utilizing technologies (greater accessibility and better cost-effectiveness), and collaborating with health services and community resources (Pistone et al., 2019; Brann et al., 2021; Breet et al., 2021). Based on this information, the expected actions from participants were defined in the form of items to evaluate performance in scene development, which can serve as guidelines for discussion during the debriefing.

Additionally, it is worth noting that the SBT script presented in this study is an approach that can be integrated into a broader plan aimed at promoting mental health in schools, with long-term monitoring and periodic evaluations (Walsh; McMahon; Herring, 2022; Gijzen et al., 2022).

Another key point relates to the results of Gwet’s agreement coefficient, which indicated a result considered good based on the utilized parameter (AC1=0.7464, SD=0.06379; CI=0.606-0.887; p=0.0000) (McCray, 2013). The tests conducted during the validation corroborate the foundation of the proposed script, with statistical support for content validity and agreement analysis among participating experts. Studies that have validated scenarios also emphasize the importance of this phase and propose similar tests to those developed in the present proposal (Costa et al., 2022; Negri et al., 2019; Pedrollo et al., 2022; Ramos et al., 2023).

Finally, it is emphasized that the feasibility of simulated practice depends on the structured development of the script, especially when considering preparation and simulation development issues. It is crucial that the simulation coordinators, along with the entire team involved in the practice, adopt careful and cautious approaches in developing the activity (INACSL..., 2023). For experiences that foster the construction of knowledge, skills, and attitudes among participants, best simulation practices must be upheld, as well as a focus on achieving the objectives and results proposed in the script. Additionally, it is essential to provide appropriate theoretical content to participants, prepare facilitators (preferably with experience in the topic and simulation), and avoid excessive exposure and evaluation of those involved.

It is also important to emphasize that, given the sensitive nature of the subject, facilitators must be willing to offer support to participants throughout the simulated activity; ensure that participation is not mandatory; allow participants the freedom to leave the room if they feel unwell; and offer support when necessary. Furthermore, facilitators should maintain safe communication regarding suicide, following ethical recommendations that prevent imitative behaviors and/or enhance prevention (INACSL..., 2023).

The main limitation of this study is the small sample size, consisting of only ten experts. Increasing the number of specialists could contribute to the validation of future works, enhancing the robustness and quality of validated studies. This research used two recruitment methods: the snowball method and the Lattes platform, which limited the inclusion of international professionals. Therefore, it is recommended that future similar studies diversify and expand the number of specialists involved. The small sample size may compromise the generalizability of the results and introduce selection bias, as it may not adequately represent the diversity of opinions within the target group. Furthermore, it may affect the accuracy of agreement indices, such as the Content Validity Index (CVI) and Gwet’s agreement coefficient, resulting in variations and less consistency in evaluations. Future studies should consider increasing the sample size and adopting more rigorous sampling methods to enhance the representativeness and validity of the results.

Final considerations

This study presented the development and validation of a SBT script aimed at guiding school community professionals in promoting mental health and preventing suicidal behavior in schools. The proposed SBT script was based on national and international scientific studies that evaluated suicide prevention strategies implemented in schools over the past five years, and it received positive feedback from experts during the validation phase. Therefore, this study provides a fully validated simulation script, available free of charge, which can be used as a teaching tool and integrated into the planning of a set of actions aimed at preventing suicidal behavior in schools. It is recommended that future studies assess the script’s effects on professionals’ self-confidence.

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• *
  English version by Agência Latino-Americana de Traduções. The authors take full responsibility for the translation of the text, including titles of books/articles and the quotations originally published in Portuguese.

• 1- Data availability:
  The complete dataset supporting the findings of this study is available within the article itself.

• 4
  International Nursing Association of Clinical Simulation and Learning (2023)

• Editor:
  Prof. PhD Viviane Potenza Guimarães Pinheiro Fonseca.

Data availability

The complete dataset supporting the findings of this study is available within the article itself.

Publication Dates

• Publication in this collection
  31 Jan 2025
• Date of issue
  2025

History

• Received
  07 July 2023
• Reviewed
  06 Aug 2024
• Accepted
  23 Sept 2024
• Corrected
  20 Feb 2025