Pensar Enfermagem / v.29 n.01 / March 2025

DOI: 10.71861/pensarenf.v29i1.350 /e00350

Review Article

How to cite this article: Coimbra H, Correia R, Alves A, Costa S, Moutinho L, Nunes IR. Nursing

interventions promoting the safety of adolescents at risk of suicidal behavior – an integrative literature review..

Pensar Enf [Internet]. 2025 Mar; 29(1): e00350. Available from:

https://doi.org/10.71861/pensarenf.v29i1.350

Nursing interventions promoting the safety of

adolescents at risk of suicidal behavior – an

integrative literature review

Abstract

Introduction

Adolescence is a stage of human development characterized by changes in multiple

dimensions of life. These changes can act as significant stressors for adolescents, influencing

their mental health. Suicidal behaviors are an escalating concern, posing a threat to

adolescent safety and presenting challenges for nurses across various healthcare settings.

Objective

To identify the available knowledge on nursing interventions that promote safety in

adolescents at risk of suicidal behavior and analyze it through the lens of Betty Neuman’s

Systems Model.

Methods

We conducted an integrative literature review following Whittemore and Knafl’s

framework. The search was carried out in April 2024 in the CINAHL Ultimate and

MEDLINE databases. Both natural and indexed language related to the terms

“adolescent,” “suicide risk,” and “nursing” were used. The review included theoretical and

empirical articles, regardless of methodology, written in English and Portuguese, and

published between 2014 and 2024.

Results

A total of 16 articles met the inclusion criteria. The analysis revealed two main categories

of interventions based on the care context: healthcare services and community. In both

contexts, nurses engage in primary, secondary, and tertiary prevention. Primary prevention

is predominant in community settings, whereas secondary and tertiary prevention are more

prominent in healthcare services. Three key interventions emerged as common across all

contexts: suicide risk assessment, therapeutic relationships with adolescents, and

psychoeducation.

Conclusion

Nurses play a crucial role in promoting the safety of adolescents at risk of suicidal behavior.

Ensuring safety requires interventions that extend across all systems the adolescent is part

of, including family, school, other community settings, and various healthcare services.

Keywords

Adolescent, Suicide, Safety, Nursing care.

Helena Coimbra1

orcid.org/0009-0007-9469-9439

Raquel Correia2

orcid.org/0009-0009-8353-0413

Ana Alves3

orcid.org/0009-0001-3020-6953

Susana Costa4

orcid.org/0009-0008-4131-0212

Lídia Moutinho5

orcid.org/0000-0001-5076-0612

Inês Robalo Nunes6

orcid.org/0000-0003-4718-8285

1 Bachelor. Instituto Português de Oncologia Francisco

Gentil, Lisboa, Portugal

2 Bachelor. Serviço de Internamento de

Pedopsiquiatria, Hospital Dona Estefânia, Unidade

Local de Saúde de São José, Lisboa, Portugal

3 Bachelor. Escola Superior de Enfermagem de Lisboa

(ESEL), Lisboa, Portugal

4 Bachelor. Serviço de Urgência Psiquiátrica, Hospital

de São José, Unidade Local de Saúde de São José,

Lisboa, Portugal

5 PhD. Departamento de Enfermagem de Saúde

Mental e Psiquiátrica, Escola Superior de Enfermagem

de Lisboa (ESEL), Lisboa. Centro de Investigação,

Inovação e Desenvolvimento em Enfermagem

de Lisboa (CIDNUR), Lisboa, Portugal

6 Master. Departamento de Enfermagem de Saúde

Mental e Psiquiátrica, Escola Superior de Enfermagem

de Lisboa (ESEL), Lisboa, Portugal

Corresponding author:

Inês Robalo Nunes

E-mail: inesnunes@esel.pt

Received: 01 Oct 2024

Accepted: 06 Mar 2025

Editor: Paulo Seabra

Nunes, I.

Review Article

Introduction

Adolescence is the stage of human development that

encompasses the transition between childhood and

adulthood. According to the World Health Organization

(WHO)1, adolescents are individuals aged 10 to 19 years.

From the perspective of Betty Neuman’s Systems Model2,

adolescents are considered complex, multidimensional, and

open systems, with a core structure composed of five

interactive variables—physiological, psychological,

sociocultural, developmental, and spiritual—which function

harmoniously in a state of well-being. Adolescence is

marked by significant changes across these dimensions,

which can be framed within three essential developmental

tasks: changes in relationships with parents (through

distancing and the pursuit of autonomy), changes in peer

relationships (through increased closeness and strengthened

bonds), and changes in self-perception and body image3.

Adolescence can be a critical period of heightened

psychological vulnerability. As a system in transition, the

adolescent is exposed to intrapersonal (internal),

interpersonal (immediate relationships such as family,

friends, and school peers), and extrapersonal (external but

indirectly affecting the adolescent, such as the broader

community) stressors, which may compromise well-being.

The adolescent’s response to stressors determines the

system’s stability or instability and, consequently, their

health status. This response depends on the defense lines

compromised by stressors and the system’s resilience.

According to Neuman2, the individual’s core structure is

surrounded by different concentric layers of protection,

which include the normal defense line (corresponding to the

usual level of well-being), the flexible defense line (which

shields against stressors, preventing the system from

reacting), and the resistance lines (activated when a stressor

breaches the normal defense line, posing a potentially fatal

threat due to its proximity to the core). Just as stressors can

affect any of these defense lines, the system’s response and

reconstitution can also occur at any level. If the system’s

response is positive, it tends toward balance, well-being, and

health; if negative, it shifts toward imbalance, leading to

illness and, ultimately, death2.

Suicide has emerged as a growing problem and is currently

the third leading cause of death in adolescence4. In Portugal,

in 2022, the suicide rate among individuals aged 15 to 24

reached its highest level in the past two decades. According

to the National Institute of Statistics (INE)5, the number of

deaths caused by intentional self-inflicted injuries reached

4.9 per 100,000 inhabitants, a significant increase compared

to the 3.2 recorded in the previous year. The WHO6 defines

suicide as the outcome of a deliberate act initiated and

carried out by an individual with full knowledge or

expectation of a fatal result. It is a complex, multifactorial

phenomenon resulting from the interaction of biological,

genetic, psychological, social, cultural, and environmental

factors7,3.

Suicidal behavior is not limited to completed suicide; it

encompasses a spectrum of thoughts (suicidal ideation) and

behaviors (suicide attempts), both of which are known to

potentially precipitate suicide3. It is understood as a gradual

process, beginning with suicidal ideation (thoughts, desire,

or plans for suicide, without necessarily leading to an

attempt), which may or may not progress to a suicide

attempt (a self-inflicted act with the intent to die that does

not result in death)7. Research indicates that each suicide

death is preceded, on average, by more than 20 suicide

attempts.8

According to the International Classification for Nursing

Practice (ICNP)9, suicidal behaviors are a priority focus in

nursing care. The NANDA-International10 classification of

nursing diagnoses includes Risk for Suicidal Behavior

(00298) within the Safety and Protection domain, defining

it as a “susceptibility to self-injurious behaviors associated

with some intent to die.” This diagnosis identifies

adolescents as a high-risk population and is linked to

several risk factors: psychological (low self-esteem,

depressive and anxiety symptoms), situational (access to

lethal means), social (dysfunctional family relationships,

peer pressure, social isolation), and behavioral (difficulty

expressing emotions, reluctance to seek help, and

impulsivity)10,11. In adolescence, most stressors are related

to interpersonal relationships (family and school) and

intrapersonal relationships (the adolescent’s self-

perception)3. From the perspective of Neuman’s Systems

Model, these risk factors can act as potential stressors on

the system.

Risk factors are counterbalanced by a set of protective

factors, referred to as reconstitution factors, which enhance

resilience and well-being. Protective factors against suicide

risk in adolescence may be intrapersonal (including

personal characteristics such as problem-solving ability,

willingness to seek help, sense of self-worth, and

engagement in life projects), interpersonal (such as positive,

supportive relationships with family and peers), or

extrapersonal (such as a positive school environment, easy

access to healthcare services, and effective coordination

with other social and community institutions)7. The

creation, maintenance, or reinforcement of these protective

factors is one of the main strategies for preventing suicide

in adolescence7.

Scientific evidence has supported a set of

recommendations for preventing suicidal behaviors,

including reducing access to lethal means, training primary

healthcare professionals, strengthening the connection

between community health services and mental health

services, developing broad multidisciplinary teams for

suicide prevention, training media professionals, and

increasing literacy to combat stigma surrounding mental

illness and suicidal behaviors.3

Ensuring safety has historically been the guiding principle of

psychiatric care, often justifying the institutionalization of

patients and the use of restrictive or oppressive measures

that were not always humane. However, in contemporary

mental health interventions, the concept of safety

promotion requires a broader perspective centered on the

continuous management of various risks, including suicide

risk12,13. Within the scope of this review, safety promotion

aligns with the principles of the Nursing Interventions

Classification (NIC)14, in which the safety promotion

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Review Article

domain includes nursing interventions aimed at protecting

individuals from harm. This involves both risk management

(interventions designed to reduce and monitor a given risk

over time) and crisis management (interventions that

provide immediate and short-term assistance). The Suicide

Prevention intervention (6340) is classified within this

domain.

Nurses occupy a privileged position in preventing suicidal

behaviors among adolescents and play a fundamental role in

promoting their safety15. Ensuring safety means maintaining

system stability or enabling system reconstitution, ultimately

preventing suicide as a potential outcome of suicidal

behaviors.

This integrative literature review (ILR) aimed to identify the

available knowledge on nursing care interventions that

promote safety in adolescents at risk for suicidal behavior

and analyze it through the theoretical lens of Betty

Neuman’s Systems Model.

Methods

We conducted this literature review following the

methodological framework of Whittemore and Knafl16,

which comprises five stages: problem identification,

literature search, data evaluation, data analysis, and

presentation of conclusions. This framework was selected

because it allows for the development of comprehensive

literature reviews, including theoretical and empirical

sources from different methodologies, ensuring

reproducibility and rigor in assessing the quality of sources

and analysis processes.

Stage 1 – Problem Identification

We conducted an initial exploratory search, leading to the

identification of adolescent suicide as a critical issue and its

contextualization within nursing care. After selecting the

topic, the research question variables were defined:

adolescents as the Population, suicidal behavior risk as the

Concept, and nursing care interventions that promote

safety in any care setting as the Context. We formulated the

research question as follows: What nursing care

interventions promote safety in adolescents at risk of

suicidal behavior?

Stage 2 – Literature Search

We searched the literature in April 2024 using the EBSCO

platform to access two databases: Cumulative Index to

Nursing and Allied Health Literature (CINAHL) Ultimate

and MEDLINE. These databases were selected based on

their robustness and potential scope in identifying relevant

findings for the research question. The search strategy was

developed using CINAHL Subject Headings—

Adolescence, Suicide, and Nursing—and MeSH Terms

(Medical Subject Headings)—Adolescent, Suicide, Nursing

care, and Nursing, combined with natural language for

these terms. Filters were applied directly in the databases to

refine the results by language (Portuguese and English) and

publication period (2014–2024). The decision to include

articles published in the past ten years was based on the

limited number of publications available from the last five

years. The search strategy is detailed in Table 1.

Table 1. Search strategy

Database

CINAHL Ultimate

MEDLINE

Access date

10-04-2024

12-04-2024

strategy

CH adolescence OR

TI/AB (adolescence OR

adolescent OR “teen

ager” OR “teen agers”

OR teenager* OR teen*

youth*)

AND

CH suicide OR TI/AB

(suicide OR suicidal)

AND

CH nursing OR TI/AB

(nurse* OR nursing* OR

“psychiatric nurs*”)

AND

TI/AB (intervention*

OR prevention OR

program* OR strateg*

OR trial)

MH Adolescent OR TI/AB

(Adolescent* OR Adolescence

OR Teen* OR Teenager* OR

Youth*)

AND

MH Suicide OR TI/AB (Suicide*

OR “Suicidal Ideation” OR

“Suicidal ideations” OR “Suicide

prevention” OR “Suicide

Awareness” OR “Suicide

Preventions” OR “Suicide

attempted” OR “Suicide attempt”

OR “Suicide attempts”)

AND

MH (“Nursing care” OR

Nursing) OR TI/AB (“Nursing

care” OR Nursing*)

Filters

Publication date: 2014-2024

Publication language: Portuguese or English

Legend – CH (CINAHL Subject Headings); MH (Medical Subject

Heading); TI – Title; AB – Abstract; * Truncation for expanded word

Inclusion criteria were established as follows: articles

involving or focusing on adolescents, addressing suicide

risk and safety strategies in any setting. The review included

both theoretical and empirical studies, regardless of

research type, as well as literature reviews. Exclusion

criteria were also defined: articles that did not specifically

address nursing interventions, studies on self-harming

behaviors without suicidal ideation, adaptation and

validation studies of instruments, literature review

protocols, experimental study protocols, and opinion

articles. Whenever studies included samples composed of

both adolescents and participants from other age groups,

they were only included if the specific results of the

adolescent population could be analyzed or if adolescents

comprised at least 75% of the sample.

From the conducted search, we identified 239 articles.

After removing 43 duplicate articles using Rayyan®

software, 196 articles remained. Using the same software,

we conducted a blinded selection process by reading titles

and abstracts. Two researchers independently screened 98

articles, while two others reviewed the remaining. Any

disagreements were resolved through consensus with a

sixth author. At the end of this process, 33 articles were

selected for full-text reading. Following this stage, 16

articles were included in the final sample for review. The

selection process is outlined in a PRISMA (Preferred

Reporting Items for Systematic Reviews and Meta-

Analyses) flow diagram, in Figure 1.

Nunes, I.

Review Article

Figure 1. Selection Process - PRISMA flow diagram

Source: Adapted from The PRISMA 2020 statement: an updated

guideline for reporting systematic reviews.

Stage 3 – Data Evaluation

We extracted data from the 16 articles based on the

variables we defined: year of publication, country, authors,

study objective, population/sample, method (study type),

and results (nursing interventions). To ensure consistency

among all authors, we used a standardized table for data

extraction. Given the diversity of methodologies in the

included studies, we assessed the quality of the articles

using the criteria established by Whittemore and Knafl16.

We applied a two-point scale (1 - Less appropriate and 2 -

Highly appropriate) to classify each article in terms of

Methodological Rigor (MR) and Theoretical Rigor (TR).

Articles were considered highly appropriate in MR when

they presented a clear protocol, including the study sample,

objective, and method. When this structure was not

explicitly outlined, they were rated as less appropriate. For

TR, we classified articles as highly appropriate if they

directly and objectively addressed nursing interventions,

whereas those that discussed interventions only indirectly

were rated as less appropriate.

No articles were excluded based on this evaluation. Two

members of the author group conducted the assessment,

reaching a consensus on each classification.

Stage 4 – Data Analysis

Data analysis involved reduction, visualization,

comparison, and verification. We identified and grouped

articles presenting results that fit into two main

intervention contexts: nursing interventions in the

community and nursing interventions in healthcare

services. Within each of these groups, we categorized the

interventions according to their level of prevention

(primary, secondary, and tertiary) and their dimension

(intrapersonal, interpersonal, and extrapersonal).

We then analyzed the data using Betty Neuman’s

theoretical framework, considering its core concepts. To

enhance this analysis, we cross-referenced findings with

other scientific sources, identifying similarities and

discrepancies both within and across subgroups.

Stage 5 – Presentation of Conclusions

Following Whittemore and Knafl’s16 recommendations,

we prioritized graphical resources to present the

conclusions. As part of this approach, we created a table

categorizing the nursing interventions identified in the

literature, structured according to the selected theoretical

framework.

Since this study is a literature review, it was not submitted

to an ethics review board. However, we ensured that

all primary studies included in the results complied with the

necessary ethical principles and procedures for

research integrity.

Results

The results are systematized in Table 2 and stem from data

extraction from each article, considering the variables we

defined in the data evaluation and analysis stages.

Half of the sample (8) consists of articles published in the

last five years, while the remaining articles were published

between five and ten years ago. Half of the studies were

conducted in the United States (8), while the others were

carried out in Indonesia (2), Thailand (2), Canada (1),

Portugal (1), Sweden (1), and the United Kingdom (1).

Most studies employed qualitative research methods (7),

while only three used quantitative approaches. Additionally,

the review identified two literature reviews—one narrative

review on suicide risk assessment instruments and one

scoping review on the use of the Safety Plan—as well as four

theoretical articles.

All articles were published in nursing journals, with six

specifically appearing in mental health nursing journals.

According to the Scimago Journal Rank17, six articles were

published in Q2 journals, seven in Q3 journals, and two in

Q4 journals.

Among the analyzed articles, seven included adolescent

samples. Other studies focused on the school community

(6), the general community (1), and nurses providing care to

adolescents in school settings and psychiatric services (2).

The theoretical articles broadly centered on adolescents (2)

and adolescents within a youth camp setting (1).

Regarding the risk of suicidal behavior, nearly half of the

articles (7) addressed safety-promoting interventions,

focusing on early identification and suicide risk

stratification. The remaining studies specifically explored

interventions for cases where the risk had already been

identified (8), and one study on interventions applicable

regardless of whether the risk had been previously identified

(1).

The examined articles present a wide range of interventions

implemented within healthcare institutions, particularly in

mental health services, including both inpatient and

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Review Article

outpatient care (7 articles). These interventions target not

only adolescents but also their families, especially parents.

Among the identified interventions are suicide risk

assessment18,19,20,21,22,23, the development of a therapeutic

relationship that fosters insight and new coping

mechanisms19,24,25, the creation of a Safety Plan19,24,26,27, and

discharge planning after hospitalization, ensuring

coordination with parents and schools23,28.

Additionally, several community-based interventions were

identified (9 articles). Many studies emphasized school-

based interventions20,21,22,27,29,30,31, but others highlighted

recreational settings for adolescents32 and the broader

community surrounding the adolescent33.

Some interventions were common across both settings,

including suicide risk assessment18,19,20,21,22,23, mental state

assessment22, emotional support20,21,23,26, cognitive-

behavioral techniques, and increasing literacy among all

stakeholders22,25,26,27,29,33.

This review also identified the need for training healthcare

professionals, especially nurses, as an essential factor for

promoting adolescent safety in the context of suicide risk28

Table 2 – Summary of the obtained results (n = 16)

Year and

Country

Authors

Objective

Population/

Sample

Method

Results

Quality

Assessment

2015

United States

of America

Glodstein

Examine suicide

prevention and

education in

adolescence

within youth

camps. Suggest

suicide prevention

strategies for a

community of

campers.

The article reflects

the perspective of

a mental health

and psychiatric

nurse with

experience in

youth camps.

Theoretical Article

The author of the article proposes a model that includes

the following interventions:

- One month before the camp: reviewing all health

assessments and family forms to identify and raise

awareness among responsible adults about adolescents

with mental health issues, those taking psychotropic

medications, and/or those at risk of suicide;

- During orientation: psychoeducation on suicide for

adolescents, parents, and camp staff, including the

screening of a film that tells the story of a suicidal

adolescent to stimulate discussion on the topic;

- Providing information on the camp’s safety policy,

emphasizing that any suicidal statement or gesture

should be taken seriously and require evaluation by

qualified professionals, as well as an overnight stay in the

Emergency Department. Until transported to the

hospital, the adolescent must remain under 1:1

supervision by a nurse.

MR- 1

TR- 1

2 Points

2016

United States

of America

Matel-Anderson

e Bekhet

Explore resilience

in adolescents

who have survived

a suicide attempt

from the

perspective of

mental health

nurses.

Nine mental

health nurses,

aged between 22

and 64 years, with

experience

ranging from 6

months to 30

years. The nurses

were recruited

from two mental

health and

psychiatric

services: one

dedicated to

adolescents aged

13 to 17 years,

and another

serving children

and youth aged 5

to 18 years.

Descriptive

qualitative study.

A 2-hour focus

group was

conducted. Seven

questions were

posed, covering the

themes of suicide

risk factors,

protective factors,

and nursing

interventions.

- Emotional support;

- Encouraging the expression of feelings;

- Early suicide risk assessment in all healthcare settings

(not only in psychiatric services);

- Reducing stigma in schools and the community;

- Discharge preparation (acknowledging the adolescent’s

progress during hospitalization so they can also

recognize their ability at discharge);

- Maintaining contact after discharge;

- Providing crisis helplines in the community.

MR- 2

TR- 2

4 Points

2016

Canada

Patterson

Present and

discuss suicide risk

assessment tools

for the youth

population.

Articles on

various suicide

risk assessment

tools

Narrative literature

review.

The identified assessment tools were:

- Beck Scale for Suicidal Ideation

- Columbia Suicide Severity Rating Scale

- Modified Scale for Suicide Ideation

- Reasons for Living Inventory

- Sad Persons Scale

- Suicidal Behaviours Questionnaire

- Suicide Probability Scale

- Tool for Assessment of Suicide Risk.

There is limited available evidence on screening tools

that accurately identify youth at risk of suicide.

MR- 1

TR- 1

2016

United States

of America

Ramirez

Explore

explanatory

theories of suicide

in vulnerable

groups—children,

Theoretical Article

- Assessing and recognizing adolescent risk and

protective factors;

- Establishing a therapeutic relationship based on trust,

respect, understanding, and responsibility;

MR- 1

TR- 2

3 Points

Nunes, I.

Review Article

adolescents, and

older adults—and

analyze nurses’

responsibilities in

suicide

prevention,

assessment, and

treatment of

individuals at risk.

- Utilizing communication techniques that address the

adolescent with empathy;

- Promoting hope;

- Supporting the recognition of stressful situations that

may trigger suicidal thoughts and encouraging the

sharing of these thoughts;

- Teaching effective coping strategies and new ways to

manage emotions;

- Promoting simple decision-making;

- Providing adolescents and their families with

information on mental illnesses, symptom management,

warning signs, and stigma;

- Supplying a resource list at discharge (24-hour

emergency hotline and crisis response instructions);

- Ensuring monitoring at high-risk moments (admission,

shift changes, unit transfers, discharge, and receiving bad

news).

2017

United States

of America

Morgan

Discuss the

specificities of

suicide risk among

high school

adolescents who

have been

adopted.

High school

adolescents who

were adopted

Theoretical Article

- Assessing suicide risk in schools;

- Evaluating the adolescent’s mental state when suicide

risk is identified;

- Referring adolescents to specialized professionals;

- Implementing suicide prevention programs (e.g., the

SOS Prevention Program);

- Health education on suicide (warning signs) for

parents, teachers, and students.

MR- 1

TR- 2

3 Points

2018

United States

of America

Roberts, Taylor

e Pyle

Explain a

perspective on

suicide as a public

health issue, the

current challenges

faced by students,

and the role of

school nurses in

suicide

prevention.

Describe an

educational

suicide prevention

program to be

implemented as a

community-based

project in a large

suburban public

school district in

Texas.

School

community of a

suburban district

in Texas,

including school

nurses, teachers,

staff, students,

and families

Theoretical Article

- Involving school nurses in open and productive

discussions with parents and families about suicide-

related concerns;

- Raising awareness among the school community about

suicide prevention;

- Assessing suicide warning signs: suicidal ideation, social

withdrawal, expressed suicide plan, acute agitation or

anxiety, and other sudden and significant behavioral

changes;

- Evaluating and developing an individualized

Safety Plan

- Crisis intervention.

MR- 1

TR- 2

3 Points

2018

Thailand

Chaniang,

Fongkaew,

Stone,

Sethabouppha,

Lirtmunlikaporn

e Schepp

Investigate the

perceptions of

adolescents,

teachers, and

parents regarding

the causes and

prevention of

suicide.

Participants were

recruited from a

public school in

Thailand: 40 high

school

adolescents, 4

mothers of

students from the

adolescent group,

and 3 teachers

with experience

working with

students at risk of

suicide.

Descriptive

qualitative study.

The 40 adolescents

were divided into

groups of 10

participants, and a

60-minute interview

was conducted.

Parents and

teachers also

participated in in-

depth interviews of

the same duration.

- Universal strategies: health education on suicide,

suicide awareness, and developing suicide

prevention skills;

- Selective strategies: suicide risk assessment, training

adults (teachers and parents) to understand and support

at-risk adolescents, and promoting peer support;

- Indicated strategies (for youth with identified suicidal

thoughts and behaviors).

MR- 2

TR- 2

4 Points

2018

Thailand

Chaniang,

Fongkaew,

Stone,

Sethabouppha e

Lirtmunlikaporn

Report on the

development and

implementation of

a pilot suicide

prevention

program.

Participants from

a suburban school

in Thailand: 12

adolescents (Core

Working Group -

CWG), 165

school students,

113 parents, and

60 teachers.

Qualitative study.

The main study was

conducted in three

stages: 1- Situation

analysis; 2-

Collaboration with

the CWG for

program

implementation,

adapting it to the

context; 3- Program

evaluation. The

article focuses on

stages 2 and 3.

The article presents a suicide prevention program that

includes the following interventions:

- Assessing suicide-related knowledge;

- Encouraging experience-sharing and facilitating

discussions;

- Supporting and stimulating the identification of

problem-solving strategies related to suicide prevention;

- Educational intervention for parents on adolescent

development, parenting styles, communication with

adolescents, and expectation management;

- Educational intervention for adolescents, parents, and

teachers using games, role-playing, and videos;

MR- 2

TR- 2

4 Points

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2019

Indonesia

Nasution, Keliat

e Wardani

Determine the

effects of

Cognitive

Behavioral

Therapy (CBT)

and Peer

Leadership (PL)

on suicidal

ideation among

high school

adolescents.

Adolescents

(n=86) from a

secondary school.

They were

randomly divided

into two groups.

Group 1 received

CBT and PL.

Group 2 received

the standard

approach from

mental health

nurses.

Quasi-experimental

quantitative study

with pre- and post-

test evaluation.

- Combining Cognitive Behavioral Therapy (CBT) and

Peer Leadership (PL).

This intervention reduced suicidal ideation, depression,

anxiety, and suicide attempts in depressed adolescents.

MR- 2

Points

TR- 1 point

3 Points

2019

United States

of America

Kim, Walsh,

Pike e

Thompson

Investigate

whether

cyberbullying and

cyberbullying

victimization

increase suicide

risk.

Ninety-three

adolescents (61

male), with an

average age of 15

years.

Longitudinal

quantitative study.

Data from a

bullying prevention

program for high

school students

were used, with a

follow-up period of

2.5 years.

- Facilitating connections between students, teachers,

and other school personnel;

- Providing emotional support

- Assessing suicide risk in both cyberbullying victims and

perpetrators;

- Intervening in bullying-related behaviors and

situations.

MR- 2

TR- 1

3 Points

2019

Indonesia

Wulandari,

Keliat e

Mustikasari

Assess the role of

school

connectedness in

cyberbullying and

suicide risk.

Forty-three

adolescents, aged

15 to 18 years,

recruited from a

secondary school

in Indonesia

Quasi-experimental

quantitative study

with pre- and post-

test evaluation,

without a control

group.

A peer leadership

training intervention

was implemented

through structured

sessions.

Assessments were

conducted before

and after the

intervention (3

weeks later), using

the Beck Scale for

Suicide Ideation.

- Peer leadership training

The intervention reduced suicidal ideation among

adolescents.

MR- 2

TR- 1

3 Points

2020

Portugal

Simões, Santos

e Martinho

Determine the

effect of peer

leadership training

on suicidal

ideation in high

school

adolescents.

Adolescents

(n=33), aged 10

to 19 years, with

suicidal behavior

and a history of

hospitalization in

a child psychiatric

unit

Descriptive

exploratory

qualitative study.

Data were collected

through semi-

structured

interviews and

analyzed using

content analysis.

- Protective factors against recurrent suicidal behavior:

family, friends, and other trusted individuals, as well as

coping strategies learned during hospitalization;

- Key aspects of hospitalization: psychological support,

healthcare professionals, occupational activities,

individual therapeutic interventions, and improvements

in the hospital environment (e.g., extended visitation

hours and greater privacy);

- Post-discharge expectations: maintaining contact with

nurses after hospital discharge.

MR- 2

TR-2

4 Points

2020

Sweden

Omerov,

Kneck,

Karlsson,

Cronqvist e

Bullington

Identify protective

factors against

recurrent suicidal

behaviors in

adolescents,

recognize key

aspects of

hospitalization,

and discuss

expectations for

follow-up nursing

care after hospital

discharge.

Six nurses

recruited from

psychiatric

outpatient

services and

specialists in

suicide prevention

Qualitative study.

Semi-structured

interviews were

conducted.

- Knowledge of warning signs;

- Presence and use of an empathetic approach;

- Establishing a trusting relationship with the adolescent

by actively listening, valuing their concerns, allowing

them to speak without interruption or judgment,

reassuring them they are not alone, and avoiding

minimization of their difficulties;

- Using physical touch and comforting words;

- Forming a partnership with the adolescent as “two

experts,” working together to identify triggers for

suicidal behavior and develop a Safety Plan;

- Creating space for new ways of thinking;

- Supporting problem-solving and assisting in

developing coping strategies;

- Helping adolescents analyze the benefits of choosing

life.

MR- 2

TR- 2

4 Points

2020

United States

of America

Polacek e

Delaney

Understand how

psychiatric

outpatient nurses

perceive their

contribution to

suicide prevention

in young people

Community in the

state of Oregon,

United States

Case Study

The initiative adopted a community participation model

designed to strengthen community capacity and included

strategies such as:

- Increasing knowledge about youth suicide risk;

- Training individuals to become “suicide gatekeepers”;

- Raising public and professional awareness of the

impact of adverse childhood experiences;

- Reducing stigma to encourage help-seeking behaviors.

MR-1

TR- 1

2 Points

Nunes, I.

Review Article

with suicidal

behaviors.

2022

United States

of America

Bradley e Toole

Report and

discuss a local

community

initiative

developed by the

first author (a

nurse) as part of a

national challenge

to reduce

adolescent suicide.

One 15-year-old

adolescent with

self-harming

behaviors and

depression

Case Study

- Using screening tools and inquiries about depression,

suicidal thoughts, and other suicide-related risk factors

in routine consultations (for history-taking and follow-

up);

- Ensuring close interprofessional follow-up;

- Addressing adolescent concerns openly and honestly,

listening attentively, and expressing compassion and

empathy;

- Identifying coping strategies with the adolescent;

- Developing an individualized Safety Plan;

- Educating about the removal of lethal means at home;

- Listing useful resources – nurses should be familiar

with local, regional, and national suicide prevention

resources for adolescents, such as crisis hotlines,

community mental health centers, and community crisis

intervention teams;

- Engaging a multidisciplinary team focused on the

adolescent, including community outreach teams, to

ensure effective care coordination.

MR- 1

TR- 2

3 Points

2022

United

Kingdom

Abbott-Smith,

Ring, Dougall e

Davey

Discuss and

evaluate risk signs,

assessment tools,

and nursing

interventions

regarding suicide

risk in adolescents

with depression.

Articles from

studies involving

children and

youth up to 18

years old with

suicidal ideation

Scoping Literature

Review

Seven key elements should be included in the

adolescent’s Safety Plan:

- Warning signs indicating the onset of a crisis;

- Coping strategies to divert suicidal thoughts;

- Places and people who can help distract from suicidal

thoughts;

- Trusted individuals who can be contacted during a

crisis;

- Mental health professionals and their availability, as

well as emergency contact numbers to use in a crisis;

- Removal of potential suicide means from the

environment;

- Important reasons for living.

Parental/Caregiver involvement is a key component of

the Safety Plan. Nurses should ensure:

- Sharing the Safety Plan with parents and encouraging

its use;

- Psychoeducation on warning signs and appropriate

crisis response;

- Supporting parents in building their own support

network and identifying emergency contacts;

- Providing education and encouragement for

supervision and monitoring.

MR- 1

TR- 2

3 Points

Discussion

The diversity of interventions identified in this ILR

underscores the critical role of nurses in preventing suicidal

behaviors and highlights the broad scope of their

involvement across various settings where they provide

care for adolescents.

The findings encompass two primary contexts of

intervention for adolescents at risk of suicide: the

community and healthcare services. We classified articles

discussing adolescents within their social environments

(neighborhood, city, country), family settings, schools, or

other recreational contexts under the category

“Community-Based Interventions.” Meanwhile, the

category “Healthcare Services Interventions” includes all

studies related to healthcare services, ranging from primary

care to specialized mental health services, including

emergency departments, outpatient clinics, and inpatient

units. Although primary healthcare could logically fall into

either category due to its geographic location within

community structures, we opted to classify studies on

primary care within healthcare services. This decision was

based on the idea that this category more specifically

reflects the structured healthcare approach to adolescent

care, such as adolescent health surveillance consultations.

Some studies also explored interventions aimed at bridging

these settings, such as post-discharge support for parents

to enhance adolescent monitoring and emotional

support19,25,26 or strategies to strengthen collaboration with

school-based nurses.27

The analysis of data through the lens of Betty Neuman’s

theoretical framework enabled the identification of nursing

interventions within the three levels of prevention—

primary, secondary, and tertiary. We classified primary

prevention interventions as those that empower

adolescents to manage difficulties and negative emotions,

primarily by strengthening their protective factors. This

approach aims to prevent suicidal behaviors—whether in

the form of ideation or suicide attempts—from emerging

while also promoting recognition of the need to seek help.

Secondary prevention focuses on intervening after a

stressor has triggered a response but before it has breached

all of the client’s defense lines. At this level, interventions

target adolescents already displaying suicidal behaviors and,

consequently, at risk of suicide. These individuals require

early intervention, often including crisis management, to

enhance resilience and support stressor regulation and self-

Pensar Enfermagem / v.29 n.01 / March 2025

DOI: 10.71861/pensarenf.v29i1.350 / e00350

Review Article

management of negative events. Lastly, tertiary prevention

encompasses interventions following a crisis, aiming at

integrating and maintaining new behaviors that ensure

safety and prevent relapse. According to the systems

model2, nursing interventions can simultaneously align with

multiple levels of prevention. The results of this analysis are

presented in Table 3.

Table 3. Analysis of results according to Betty Neuman’s Systems Model

Interventions in Healthcare Services e

Primary Prevention

Secondary Prevention

Tertiary Prevention

Intrapersonal

- Assess suicide risk using assessment

tools18 and suicide risk-related

questions19 across all care settings,

including routine consultations.23

- Establish a therapeutic

relationship with the adolescent by

adopting an approachable stance and

addressing their concerns openly and

honestly.19,24,25

- Identify risk factors (stressors) and

protective factors (reconstitution

factors).25

- Provide education on local mental

health resources and support

hotlines.19

- Assess suicide risk using assessment tools.18

- Identify warning signs.24,25

- Provide emotional support.23

- Establish empathetic communication, listening

attentively.24,25

- Use therapeutic touch.24

- Assist in identifying triggers for suicidal behaviors.25

- Support the development of adaptive coping

strategies.19,24,25

- Provide education on local mental health resources and

support hotlines.19

- Ensure vigilance, with particular attention to high-risk

moments (admission, shift changes, transfers, and

discharge).25

- Develop a Safety Plan.19

- Assess suicide risk using assessment tools.18

- Maintain post-discharge contact.23,28

- Develop a Safety Plan.19,24

Interpersonal

- Encourage parental monitoring of suicidal behaviors

(including restricting access to lethal means.19

- Develop psychoeducational interventions with the family

and the adolescent during hospitalization.28

- Extend family visitation time in healthcare facilities.28

- Implement individualized therapeutic activities.28

- Promote parental involvement in the use of the

Safety Plan.26

- Encourage parental monitoring of suicidal

behaviors (including restricting access to lethal

means).26

- Prepare for discharge.23

- Enhance parents’ mental health literacy

(warning signs and crisis response strategies).25,26

- Provide information on local mental health

resources and support hotlines.19,23,25

- Assist in developing a support network.26

Community Interventions

Primary Prevention

Secondary Prevention

Tertiary Prevention

Intrapersonal

- Assess adolescents’ knowledge of suicide.31

- Promote mental health literacy among adolescents, particularly regarding suicide

and its prevention.22,27,31,33

- Evaluate suicide risk in the school setting.20,21,22

- Assess the adolescent’s clinical history.32

- Provide emotional support.20

- Assist in identifying problem-solving strategies (prevention).21

- Identify warning signs.27

- Conduct a mental status

assessment when suicide risk is

identified.22

Interpersonal

- Promote mental health literacy among parents and teachers, particularly regarding

suicide and its prevention.22,27,31

- Engage parents and teachers in suicide prevention.27

- Develop interventions targeted at parents and teachers to ensure they form an

effective support network for adolescents.31

- Facilitate connection among adolescents, teachers, and other school staff.20

- Intervene in bullying situations. Assess suicide risk for both bullying victims and

perpetrators and provide emotional support in bullying cases.20

- Encourage experience sharing among peer groups, fostering adolescent peer

support.31

- Conduct peer leadership training in classrooms.30

- Implement group interventions

using cognitive-behavioral therapy

and peer leadership to reduce suicidal

ideation.29

- Involve the school nurse in the care

plan and the development of a Safety

Plan.27

- Refer adolescents to specialized

professionals.22

- Involve the school nurse

in the care plan and the

development of a Safety

Plan.27

Extrapersonal

- Reduce stigma associated with suicide in schools and communities.23,33

- Promote help-seeking behaviors.33

- Implement community programs for suicide prevention.22,31

Interventions in Healthcare Services

Nursing interventions implemented within healthcare

services primarily focus on secondary and tertiary

prevention, given that most interactions between

adolescents at risk of suicidal behavior and healthcare

services occur after a stress response has already developed.

According to Teixeira34, adolescents most frequently seek

emergency services due to acute situations, including

behavioral changes, intentional overdoses, and suicide

attempts. Healthcare-based interventions mainly target

intrapersonal dimensions (centered on the adolescent) and

interpersonal dimensions (focused primarily on

relationships with parents). Notably, we did not identify any

extrapersonal-level interventions, underscoring the need

Nunes, I.

Review Article

for healthcare services to expand their outreach into

broader community-based settings.

At the primary prevention level, we identified only

intrapersonal interventions, which focused on enhancing

adolescents’ awareness of available resources, early

identification of risk and protective factors, and suicide risk

assessment, including during routine adolescent health

check-ups. The National Suicide Prevention Plan (PNPS)7

underscores the significance of these interventions,

reinforcing the essential role of nurses in promoting

adolescents’ overall health. This involves minimizing their

exposure to potential stressors and strengthening their

protective factors.

From the perspective of Betty Neuman’s theoretical

framework, health is understood as a dynamic equilibrium

continuously shaped by the complex interaction of

psychological, physiological, developmental, spiritual, and

sociocultural variables.2 Within primary healthcare settings,

nurses play a pivotal role in fostering adolescents’ overall

well-being by strengthening protective factors by

promoting healthy lifestyles, expanding their knowledge

about developmental challenges (such as risky sexual

behaviors or substance use), and encouraging the

development of positive social and family relationships.35

Secondary prevention plays a prominent role in healthcare

services, with most data derived from mental health

services, both outpatient and inpatient. Within the

intrapersonal dimension, the findings highlight the

importance of interventions focused on suicide risk

assessment and the identification of suicidal behaviors.

These also include establishing a therapeutic relationship

between the nurse and the adolescent, empowering them

to recognize and manage triggers while developing effective

coping mechanisms. The NIC14 also underscores the need

to engage adolescents in their own therapeutic plan and

provide education on coping strategies.

Building a trusting nurse-adolescent relationship requires

nurses to acknowledge and validate the adolescent’s

emotions and feelings. Regular interactions create

opportunities for the adolescent to express their emotions,

fostering a sense of care and openness. Addressing the

topic of suicide openly and without judgment allows the

adolescent to articulate their current feelings and provides

a space for sharing knowledge, meanings, and fears and

evaluating the severity of warning signs and symptoms

associated with suicidal behaviors, including suicidal

ideation, planning, and past attempts.14

The findings on secondary prevention further emphasize

the importance of collaboratively developing a Safety Plan.

This plan serves as a written resource, often structured as a

checklist, co-created by the adolescent and the healthcare

professional. It outlines a set of coping strategies and

resources the adolescent can utilize in crisis situations.36

Regarding tertiary prevention, the identified interventions

targeted the period following contact with healthcare

services, particularly after discharge from inpatient care,

focusing on promoting the adolescent’s rehabilitation and

reintegration into society. Within the intrapersonal

dimension, interventions included maintaining contact with

the adolescent after discharge to ensure regular suicide risk

assessment and continuous monitoring of the Safety Plan.

In the interpersonal dimension, interventions primarily

centered on parents, emphasizing mental health literacy

promotion, parental involvement, encouragement of

adolescent supervision, and the establishment of a secure

support network. The NIC14 also incorporates suicide

prevention interventions that highlight the necessity of

parental involvement in discharge planning, including

education on the illness, pharmacological treatment, and

available community resources.

As cross-cutting interventions across all levels of

prevention, we identified the establishment of a therapeutic

relationship through empathetic communication and

emotional support, education on local mental health

resources and helplines, and continuous suicide risk

assessment. According to NIC14, suicide risk should be

assessed regularly and continuously, considering the

presence of a plan and the availability of means to carry it

out. It is also crucial to observe changes in mood or

behavior that may indicate an increased risk of suicide.

Additionally, we identified two interventions as bridging

secondary and tertiary prevention: developing and

monitoring a Safety Plan and promoting mental health

literacy among adolescents and their parents.

NIC14 primarily includes suicide prevention interventions

aimed at inpatient settings. Although we did not find

several of these activities in the articles included in this

review, it is important to mention them despite this IRL’s

lack of empirical support. Some examples include

interventions related to pharmacological treatment

(administration, supervision of medication intake, and

monitoring of side effects and therapeutic responses) and

environmental safety measures, such as restricting access to

windows, implementing physical and area restrictions, and

ensuring frequent monitoring. In terms of safety, NIC14

also highlights the importance of restricting access to

potentially lethal objects, such as sharp instruments and

cords. While Bradley and Toole19 mentioned this

intervention in the study included in this review, it was

solely directed at the family setting. However, this measure

is equally essential for ensuring adolescent safety within

healthcare services.

Community Interventions

Unlike the findings regarding interventions in healthcare

settings, nursing interventions developed in the community

primarily fall within the scope of primary prevention. This

is because many identified interventions are implemented

directly with adolescents—in schools, among peer groups,

with families, and with teachers—before stressors affect

the system or to minimize their exposure to potential

stressors. Primary prevention not only focuses on

promoting health by enhancing resilience-building skills

and resources but also on the timely prevention of illness

among individuals with specific vulnerabilities37, such as

those who perpetrate or experience bullying in school

environments.20

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Review Article

At the primary prevention level, interventions were

identified across all three dimensions. In the intrapersonal

dimension, interventions included suicide risk

assessment20,21,22, adolescent medical history evaluation32,

and assessment of their knowledge about suicide.31

Additional interventions aimed at strengthening

adolescents’ capacities by promoting health literacy and

teaching problem-solving strategies to prevent suicidal

behavior.21,22,27,31,33 The interpersonal dimension

encompassed interventions targeting not only parents but

also teachers, school staff, and peer groups, engaging them

in the adolescent’s protective process through literacy

promotion, relationship facilitation, and experience

sharing.20,22,27,30,31

These interventions align with the guidelines set forth in

the Portuguese National Suicide Prevention Plan7, which

emphasizes the need for a support network across the

various environments surrounding adolescents as a means

of ensuring their safety. Unlike the interventions identified

in healthcare services, community-based interventions also

addressed the extrapersonal environment, calling for a

broader nursing role in suicide prevention. This includes

developing community programs22,31, reducing societal

stigma23,33, and encouraging help-seeking behaviors.33

These approaches also align with PNPS7

recommendations, which advocate for raising public

awareness about suicide and suicidal behaviors.

Additionally, the Nursing Interventions Classification

(NIC)14 includes implementing community programs

within the “Suicide Prevention” intervention framework.

At the secondary prevention level, we identified

interventions in both the intrapersonal and interpersonal

dimensions, particularly among peer groups. Findings

highlight the need for nurses to engage at the intrapersonal

level by identifying warning signs and assessing the mental

health status of adolescents already identified as at risk for

suicide.22,27 In the interpersonal dimension, results suggest

the implementation of group interventions for adolescents

experiencing depressive symptoms and suicidal ideation.

These interventions incorporate cognitive-behavioral

therapy techniques and peer leadership approaches29, as

well as referrals to specialized professionals.22

Such strategies play a crucial role in preventing suicidal

behaviors in schools by promoting early recognition and

timely intervention.

Considering that more than 20% of adolescents exhibit

depressive symptoms11 and that most spend a significant

portion of their day in school settings, the involvement of

school health nurses is essential in supporting these

adolescents.38 Findings highlight the critical role of these

nurses in developing a Safety Plan27 and providing follow-

up and monitoring, particularly when an adolescent returns

to school after a crisis.27

Although not directly aligned with the specific objectives of

this review, the results also indicate a pressing need for

greater investment in nurse training. Several studies

emphasize the necessity for health professionals,

particularly nurses, to improve their practice by undergoing

specialized training on suicidal behaviors.28 According to

DGS7, nurses working with adolescents in primary

healthcare settings still exhibit limited competencies in

addressing and intervening in mental health and

suicide-related issues. This gap likely stems from

insufficient knowledge on how to approach suicide-related

discussions, fear of incompetence in managing such cases,

and a lack of awareness of available resources,

infrastructure, and the mental health referral system.7

Additionally, reducing stigma among healthcare teams

unfamiliar with mental health and psychiatric care remains

a critical step. Addressing this barrier will help ensure that

healthcare professionals are open to learning and engaging

with this area of intervention.39

Finally, the findings highlight the need for nursing

interventions to be developed within a multidisciplinary

framework, as this is a key strategy for effectively

addressing suicide risk in adolescents.19

In summary, nurses play a crucial role across multiple

settings, enabling interventions at the primary, secondary,

and tertiary levels of suicide prevention. Their expertise in

identifying stressors that may affect adolescent well-being

and health allows them to intervene to restore the

adolescent’s system, either by preventing exposure to

stressors or by fostering resilience to those already present.

Ensuring adolescent safety requires an early,

multidisciplinary intervention primarily focused on

strengthening the normal and flexible lines of defense. This

approach must encompass intrapersonal, interpersonal,

and extrapersonal environments, engaging the adolescent,

their family, peers, teachers, healthcare professionals, and

society as a whole.

Conclusion

This literature review successfully addressed the defined

objectives by identifying a significant body of theoretical and

empirical studies that reflect the available nursing

knowledge on interventions that promote the safety of

adolescents at risk of suicidal behavior. Additionally,

it allowed for analyzing this knowledge through a nursing-

specific theoretical framework.

Integrating nursing theoretical perspectives into research

enhances the recognition of the breadth and depth of

current disciplinary knowledge in a given field. In this

regard, integrative literature reviews serve as a valuable

research method for generating or testing theories,

contributing to the consolidation and expansion of nursing

knowledge40,41. Using a systemic theoretical framework,

such as Betty Neuman’s model, provided a comprehensive

understanding of nursing interventions for adolescents at

risk of suicide. By conceptualizing adolescents as open

systems constantly interacting with other systems and being

influenced by dynamic forces that may act as stressors or

protective factors affecting mental health, this theory

underscores that nursing interventions aimed at ensuring

safety in suicide risk must focus not only on reducing risk

factors but also on strengthening the adolescent’s protective

factors and support network. Neuman’s perspective thus

facilitated the systematization of nursing interventions

across all levels of prevention and in all contexts relevant to

Nunes, I.

Review Article

adolescents, including their homes, neighborhoods, schools,

and healthcare services.

We concluded that the existing body of nursing knowledge

is extensive but still presents some gaps. Based on the

findings of this review, further research on this topic is

recommended, particularly through quantitative and

mixed-method studies that focus on determining the

effectiveness of nursing interventions in reducing the risk of

suicidal behavior among adolescents. The results also

highlight the need to improve the accuracy of suicide risk

assessment tools.

Additionally, the findings emphasize the importance of

investing in the training of healthcare professionals. All

nurses, regardless of their care setting, should have access to

education and training for suicide risk assessment and crisis

intervention. The evidence suggests that suicide risk should

be proactively discussed with adolescents, for example,

during routine health surveillance visits, rather than being

addressed solely within specialized mental health services.

Moreover, using validated assessment tools could contribute

to early risk identification.

Several studies point to the need for implementing both

global and local community-based suicide prevention

initiatives. Nurses should actively engage in these initiatives

and contribute to adolescent safety across all aspects of their

lives. This involvement can be achieved by promoting

mental health literacy in general and suicide awareness in

particular. The evidence on school-based interventions

further supports the need to strengthen the role of nurses

in schools.

Study limitations

We acknowledge certain limitations in this integrative

literature review. First, we searched only two databases,

which may have led to the omission of relevant evidence

not included in this review. However, we consider that the

16 retrieved articles provided access to a substantial body

of results.

Additionally, the quality of the identified articles represents

another limitation. Although we assessed their

methodological rigor, no articles were excluded based on

this evaluation.

Finally, despite the breadth of studies identified, most were

theoretical articles, literature reviews, or qualitative

research. The scarcity of quantitative studies, particularly

experimental or quasi-experimental designs, prevented us

from analyzing the effectiveness of the identified nursing

interventions.

Authorship

Coimbra H: Conception and design of the study; Data

collection; Data analysis and interpretation; Writing the

manuscript;

Correia R: Conception and design of the study; Data

collection; Data analysis and interpretation; Writing the

manuscript;

Alves A: Conception and design of the study; Data

collection; Data analysis and interpretation; Writing the

manuscript;

Costa S: Conception and design of the study; Data

collection; Data analysis and interpretation; Writing the

manuscript;

Moutinho L: Data analysis and interpretation; Approval of

the final version of the manuscript and taking responsibility

for it;

Nunes IR: Conception and design of the study; Data

collection; Data analysis and interpretation; Writing the

manuscript; Approval of the final version of the manuscript

and taking responsibility for it.

Conflicts of interest and Funding

No conflicts of interest have been declared by the authors.

Sources of support / Financing

The study was not funded.

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