Experiences of School Nurses Caring for Newly Arrived Immigrant and Refugee Children

Abstract

Newly arrived immigrant and refugee children are faced with significant physical and mental health issues and often rely on school nurses for care and connection to healthcare. The purpose of this qualitative phenomenological study was to explore urban public school nurses’ experiences caring for newly arrived children. Data were collected through one-time in-depth semistructured interviews with school nurses (n = 20). Three relational themes were identified: (1) Trials and Triumphs: Telling Stories About Newly Arrived Children; (2) Walk a Mile in My Shoes; and, (3) Being a Trusted Health Navigator. The Role of School Nurses in the Context of Trauma emerged as the constitutive pattern. The current study enhances our understanding of the unique role played by school nurses as they address the profound needs of newly arrived children and their families, many of whom have survived trauma and face a number of barriers to accessing care.

Keywords

school nurse immigrant health newly arrived children immigrants refugees

Introduction

In the United States, approximately 132,300 school nurses (SNs) are caring for nearly 77 million school-age children in prekindergarten through grade 12, or about 25% of the total population (United States Census Bureau, 2019; Willgerodt et al., 2018). Additionally, the school population cared for by SNs is rapidly changing with an unprecedented influx of immigrants. Ninety million immigrants and their U.S.-born children account for approximately 28% of the total U.S. population (Batalova et al., 2020). According to the Pew Research Center, immigrants and refugees are regarded as newly arrived (henceforth “newly arrived children”) if their entrance into the United States occurred in the previous 5 years (Radford & Krogstad, 2019).

School nursing is a specialized practice of professional nursing that promotes individual and population health; and advances lifelong well-being and academic achievement for students (American Nurses Association [ANA] & National Association of School Nurses (NASN), 2017). In the context of discrimination and lack of access to formal healthcare and other social services, SNs serve a critical role oftentimes acting as the only source of healthcare for many newly arrived children (Hilfinger Messias et al., 2015). Yet there is limited research on experiences of SNs and how their schools may offer safe harbors and empathetic ports or promote healthy development and deliver services to children in immigrant communities (Capps et al., 2015; McNeely et al., 2017). This may be due in part to some of the feasibility challenges to conducting school-based research related to newly arrived children, such as language barriers and access to undocumented parents who may be hesitant to participate due to justifiable concerns of discovery (Gulb & Zayas, 2017). SNs have comparatively higher access to this population and are bolstered by an established trust with their parents. Given the existing knowledge gap related to the stressors affecting newly arrived children, we targeted SNs and formulated the following research question: What are the lived experiences of SNs in caring for newly arrived immigrant and refugee children in urban public schools in grades K-8? and deemed a qualitative phenomenological study to be the most appropriate study design.

Methods

Study Design

Study procedures were approved by the Office of Human Subject Research Protection at Northeastern University. The study utilized a qualitative approach guided by hermeneutic interpretive phenomenology based on Heideggerian philosophy (Crist & Tanner, 2003; Heidegger, 1962; Ironside, 2006). In phenomenology, qualitative researchers explore the personal meaning, composition, and core of the lived experience of specific phenomena (Edmonds & Kennedy, 2017). Interpretations of lived experiences allows contexts that might otherwise be taken for granted or overlooked to be explored deeply from the perspective of the expert, or those with the lived experience (Husserl & Ideas, 1931; Underhill et al., 2012). Approaching the proposed research question through a phenomenological lens allows insight into the SNs meaning and experience. Therefore, offering an opportunity to identify areas to address and improve in future policy, practice, and research initiatives that will be relevant specifically to SNs caring for children in this context.

Sample and Setting

A purposive sample of SNs was recruited by email and telephone through the Massachusetts Department of Public Health School Health Services and Massachusetts School Nurse Organization listservs from February 2019 through June 2019. Participants were considered eligible if they: (a) were full-time public SNs (including district public charter schools) who work in the Massachusetts cities with a population of at least 80,000 residents; (b) had at least 15% enrollment of English Language Learners in their school/district; (c) were certified through the Massachusetts Department of Elementary and Secondary Education; and (d) in the past year had worked with at least five newly arrived children in a Kindergarten - 8th grade urban school setting. Written and verbal consent were obtained.

Data Collection

The first author conducted all interviews and wrote field notes (i.e., physical expressions, gestures and intonations) of the interview context directly after each encounter (Crist & Tanner, 2003; Underhill et al., 2012). Data were collected through one-time in-depth in-person (n = 16) or telephone (n = 4) interviews framed by a semistructured interview guide (Table 1). Data were collected until redundancy in data, or when common stories were being shared and no new themes emerged.

Table 1

Semistructured Interview Guide.

Interview question	Probes
Tell me about your nursing background	Countries of origin
What has the experience been like for you working with newly arrived immigrant and refugee children?	Strategies that you use when working with these children
Please tell me about how your role as a school nurse has changed over time working with these children	General source of healthcare
What do you see as this group of children’s main healthcare issues and needs?	Gaining trust
How have you worked around language barriers?	Challenges related to learning, socialization, educational testing
With so much discussion in the news about immigration, please tell me about what impact this may be having on your students who are immigrants or refugees?	Connecting these students to healthcare
What have you heard about these children’s family’s experiences with emigration and settling into the community?	Policies/legal issues affecting children/families
What has been your experience connecting these children to healthcare?	Coping with feelings (e.g., sadness, frustration, or other) that are triggered by your work with these children
And, what advice or lessons learned from your caring for immigrant or refugee children could you pass along to other school nurses?
Finally, please tell me what supports you think that you may need for your continued work with these children?

Interpretation Procedures (Data Analysis)

All interviews were audio recorded, de-identified, and transcribed verbatim for analysis in a qualitative analysis software NVivo (NVivo, 2018). Pseudonyms were assigned to the participants to ensure privacy and to protect their confidentiality. Analysis was implemented with a team approach of committee members using a five phase hermeneutic interpretation process as described by Crist and Tanner (2003). In Phase One, hermeneutic interpretation began with examining the first few transcripts to gain an overall understanding and discuss the interpretive process. The early focus resulted in a refined semistructured interview guide in the hope of generating a thicker, richer description of narratives for future interviews. In Phase Two, each interpretive team member (JB, MUB, PB & CL), wrote one-to-three-page summaries of central concerns (i.e., important meanings or themes) and salient excerpts from each early participant’s story. The naming and coding of central concerns was an iterative process that acted as a vehicle for discussion. In Phase Three, team members discussed categories and themes across stories and agreed on a constitutive pattern (i.e., a thread that ties all of the themes together) considered the highest level of analysis (Diekelmann, 1993). A descriptive passage was chosen for the constitutive pattern to establish the essence of the study (Creswell & Poth, 2018; Crist & Tanner, 2003). In Phase Four, the team discussed final interpretations and attended to pending lines of inquiry (Crist & Tanner, 2003). In Phase Five, the manuscript underwent a final review by the entire five-member dissertation committee with emphasis placed on the discussion of the findings, recommendations for school nursing practice and implications for health policy regarding newly arrived children.

Results

A total of 20 female participants consented to study participation with a median age of 57 years (range 25–71). Participants self-identified as Non-Hispanic. Most of the participants (n = 17) self-identified as White, while the remaining participants self-identified as African American (n = 1), Native American/African European (n = 1), or White/Mixed (n = 1). SNs worked within nine of the eleven cities in Massachusetts that met study eligibility criteria. All of the SNs were registered nurses (RNs) with a bachelor’s degree, 12 had a master’s degree, and two had a doctoral degree (n = 1 PhD; n = 1 DNP). The sample included participants with two to 43 years’ experience practicing as a RN (median 24.5 years); and one to 23 years practicing as a SN (median 13 years). English was the primary language for all 20 participants. Some participants reported speaking Spanish (n = 6), French (n = 1), or sign language (n = 1). Coding yielded a total of sixteen Categories, three main Themes, and one Constitutive Pattern (Table 2).

Table 2

Results: Themes, Categories, and Constitutive Pattern.

		Exemplar quotations
Theme 1	Telling Stories About Newly Arrived Children
	Structural deficits traumatize newly arrived children	“It’s funny because you’re seeing all these kids do well in middle school but as soon as they get to the high school, these MS13 gangs are available…And all the sudden, they belong to something and here’s a way to make money…they’re poor and they have no social support systems. So, what do they do? They turn to ways to make money. And then they’re on the news.” (Sofia)“The city as a whole needs some help pulling up and pulling out…It’s quite palpable. The drugs are in the home. And so, they’re watching their parents make money this way; and, then, [the children] are making money. It’s the vicious cycle that is why they remain in poverty and remain in this situation. It’s just going to continue.” (Sofia)
	Newly arrived children are vulnerable to abuse and exploitation	“Well, [newly arrived children] have access on the internet and nobody has taught them to be aware of the predators. And when someone calls and says, ‘I’ll meet you online’, or ‘meet you in a chatroom’, or ‘meet you when you’re playing a game online’ and they join in the game and they tell you that ‘you’re nice’, and ‘I like you’, and ‘Can I meet you?” (Julia)“Every year we have girls who are new to the country…who have been sexually violated. We have kids who have been trafficked who are right in our school, all from another country. [They are] coming into the U.S. being coopted by the internet, or meeting somebody on the corner, or in a mall.” (Julia)
	Emotional stress of transience and separation	“Pretty much all of [our SLIFE students] come from other countries where they either didn’t go to school; or because of family circumstances and political circumstances had their school interrupted.” (Michelle)
	The burden of living in fear of deportation	“Some undocumented people don’t want to sign up for health insurance, even though they can…they’re suspicious of the government. They don’t want to get detained. They don’t want to get deported. There’s a lot to overcome there in terms of understanding that signing up for healthcare is their right…But that’s tricky.” (Michelle)
	School nurses admire newly arrived children’s resilience	“I think there’s a lot of resilience in the children…when refugee and immigrant families are coming, they’re looking for something better or they’re escaping something traumatic…I think that’s what I’ve experienced is [they are] grateful to be here and appreciate any help and support.” (Elena)
Theme 2	Walk a Mile in My Shoes
	Challenging tasks for school nurses	“The Registration Center does not vet the incoming student; or make parents aware of medical requirements for school…I feel like it’s a walking timebomb because if the kid is new to the country, and in the process, someone gives them six vaccines, they can’t imagine that there’s anything else that needs to be done.” (Julia)“I think sometimes we’re quick [to presume] that the parents are negligent…for example, if we feel like someone is not returning our calls or not signing paperwork… even if it’s written in Spanish. We can get frustrated with them. But I think we have to understand and try to take a walk in their shoes…and don’t assume anything.” (Michelle)
	Caring for newly arrived children in the United States for advanced medical treatment	“When I talk to other people who have a different opinion of immigrants than I do, they’ll [say] ‘they come here for the best care.' My question is always, ‘Where would you go to save your child [and give] them the best quality of life?' These are the people that have made it. I don’t know about the children that haven’t…. So when I look at it from that perspective, there isn’t a human being that I know that wouldn’t do everything they could for their child. They live in some of the most abject poverty under the radar…Even given the minimal amount of support that we [in the U.S.] give to these immigrant children…it’s still significantly more advanced than the best medical care that they can receive in their native countries.” (Kim)
	Lost in translation	“I had a girl the other day who was coming up with a stomachache, or headache, or something pretty much every day. Finally, I said to her, ‘Is it really hard to listen to English all day long?’ She goes, ‘yes.’ I said, ‘That can make you have a stomachache, it could make you feel stressed.’ I said, ‘I understand. It’s hard. It’s really hard’.” (Michelle)
	Newly arrived children with identified psychosocial and behavioral needs	“I would say that a very large number of our kids have pretty significant trauma histories that we learn about by accident…I have never seen one of those kids cry…Even the girl that watched her friend be beheaded, even after she wrote the story and the teacher responded to it, ‘I can’t believe that’s your story. I’m so sorry it happened.’ And she just shrugs and goes about her day. Another girl pulled out a picture of her family that was happening that day…And she said, ‘Oh, it’s my father’s funeral’…But she had no reaction to it. So, I think they become numb. …I think they’ve had so much yuck in their lives that I don’t even think they know what to do with it. They don’t talk about it. And they live in cultures where they might not even be encouraged to talk about it. What’s done is done. Let’s keep on moving.” (Deb)“We try to find out what the family goal is for that child [and] use that as a hook to get them into a therapy-minded process…When she is depressed, she is not able to do her schoolwork…And we talked about receiving an intervention that will improve her academic output. And the family embraced that.” (Kim)
	School nurses coping and responding in the context of trauma	“I cry a lot. I think it’s essential [laughter and welling up with tears]. I feel like crying is healing. I feel like I have to feel the heartbreak. If I don’t feel it, I’ll just get hardened. I’m not somebody who could shove it down in some way. I would go crazy. I have to let it out. I have friends that I talk to and cry with. They are not necessarily nurses. Some are, but they’re usually just people that I feel very close to. They also work with similar populations [tears]. We just have to cry a lot about the injustices of the world and then move on. I don’t feel like I could have stayed in this job if I didn’t have an outlet to do that. I don’t. It’s really difficult.” (Michelle)

Theme 3	Being a Trusted Health Navigator
	Building bridges between the families and the school	“The community-based health center has family health [services]…dental, vision, social services, primary care, and an ADHD clinic. They offer resources for families and have the language capabilities to communicate…my NP [at our SBHC] gets emails from primary care: ‘Can you check on so-and-so? His blood pressure is high…Can you do the follow-up vaccine for this child?’…Some of our students don’t come through refugee [programs]. We’re able to get those families right into the NP and she can do an initial physical.” (Elena)“I have played [sport] since I was a little girl…And they needed a coach. So I thought, "Why not?" I had 45 kids sign up. And all of them, except for one little girl was new from all different countries. So, they’re like, ‘Wow, the school nurse is our coach.’ So I connected with them on a different level.” (Barbara)
	School nurses work to address structural determinants	They’re hungry and they don’t seem to have food at home. So, we started a food program this year…And it’s in association with the American Red Cross…at the end of the school day we give out bags of food. I think we’re up to about 65 bags last week. (Julia)A lot of them are coming in and they’re going into the shelter system because they’re doubled up. And then, eventually the doubled up doesn’t work and they go into the shelter system…It’s hard for the kids and families. We talk about it. “What kind of shelter are you in right now?” “How is it?” Sometimes they have access to their own bathrooms, sometimes they don’t. That’s why part of what we got for [families] in the shelters is bleach or bleach wipes. (Olivia)
	School nurses provide care in spite of health insurance barriers	“Kids that are here illegally, don’t get mental health services. So, if you don’t have papers…sometimes that’s how we’ll know that [a child] is not here legally…And if we’re taking people in, why would you not have mental health coverages too? That doesn’t make sense. It’s like a strip down [insurance]. But why would you take away mental health?” (Olivia)
	The health office is a “safe zone” for newly arrived children	“In the school setting, it’s a safe zone for them. So, we never talk about it. It’s not a conversation we bring up. It’s not a conversation they bring up…we never talk about what it means to be an immigrant. What are your fears? It’s not a topic. They come to school to learn. It’s a safe place for them, so we don’t touch it. If they volunteer the information. Then that’s fine. But it can never be a direct question. Yeah. I’ve had conversations with families in a roundabout way and they’ve offered me information. But I have to be careful to not directly ask.” (Deb)“If they know [the SN health office] is a safe place, then [the newly arrived families and children] will tell us what else is going on. Sometimes you pick it up right away. There’s the lady who came and couldn’t speak hardly any English [who shared] escaping gang violence. Their little girl came and she had this little satin lovey, But, it’s unusual to see a first grader with a real transitional object like that all the time.” (Olivia)
	One school	“The motto of our school is "One school. Una Escuela "…[My principal] says, "I don’t even consider that there’s some sub-separate, bilingualism…No, we’re one school. Our life skills kids, and our bilingual kids, and our advanced kids, it’s one school." (Diane)
	Culture matters: global school nursing	“So Ramadan, it started on Sunday, and it’s 40 days where they fast from sunrise until sunset. So they can eat at 7:00 p.m. every night. No water during the day. Thankfully it’s been raining for the entire month and it hasn’t been hot. But it poses a challenge for nursing because the kids are outside running at recess. They’re not eating lunch. They are not drinking any fluids and getting headaches. They’re nauseous. So it presents a whole slew of potential problems…Last year, I had kids that were dizzy and fainting. And I’d say, ‘Drink some water.’ And the reply, ‘Nope,’ wouldn’t do it. So it puts me in this weird little pickle because I think, ‘I want you to be okay.’ And yeah, they won’t do it.” (Deb)
Constitutive pattern	The role of school nurse in the context of trauma	“I remember this boy…he was from Honduras. One day he was up in our office for a long time. He started to tell a story of how he got to [my City] from Honduras. It was one of the stories you’d hear about on the news of traveling on foot and in the night. The boy kept being passed off from person to person and hoping to meet up with his mother. It was just an unbelievable story. I think he was seven or eight years old… It just changed everything about the way I saw him [knowing] what he had already been through in his life. I think that’s true for a lot of these children. They’ve experienced family separation. They have experienced trauma, a lot of hardship, and a lot of poverty. And, that’s why they’re here. They’re not just here on a whim.” (Michelle)

Theme One: Trials and Triumphs—Telling Stories About Newly Arrived Children

The SNs illuminated the study phenomenon by sharing human experiences and in-depth perspectives in the context of being with the newly arrived children and their families. SNs described the significant structural deficits encountered by the children and their families along with the risks for exploitation, traumatic stress, and fear of deportation. In recounting their stories, the SNs voiced concerns about the effects on the children’s mental and physical health, shared frustrations with the challenges and barriers to healthcare delivery. The SNs also volunteered admiration for the resilience observed in these vulnerable children. Theme One features the following five Categories.

Structural Deficits Traumatize Newly Arrived Children

The SNs described structural deficits (i.e., lack of food, stable housing, parental supervision, healthcare access) as affecting mental and physical health and educational achievement of newly arrived children. Newly arrived children and their families were also dealing with housing instability (i.e., living in shelters and unsafe housing projects.) Olivia shared that one of the newly arrived children that she cared for “saw somebody get shot when he was getting off the bus.” Stephanie told the story of a 22-year-old immigrant single mother who had fled domestic violence; currently she earns minimum wage and lives in a shelter with her 8-year-old son who requires a one-to-one nurse in school. Stephanie was aware that sending the child to the hospital for medical reasons (e.g., high fever or respiratory crisis) deepens the financial crisis at home, because “for him to go home, [Mom] loses a day’s pay…so, a day’s pay for her is one less step towards getting out of this shelter.” Michelle shared, “There’s a [newly arrived] mom who has escaped domestic violence [with] a couple of kids…she is isolated and has to work all of the time…I just can’t imagine how hard that must be.”

Newly Arrived Children Are Vulnerable to Abuse and Exploitation

Several SNs described situations of predators online, bullying, social media, and sexual exploitation (i.e., sex/human trafficking). Julia explained that newly arrived children “are being caught up” with predators because the culture is so new to them here in the United States. Julia strongly believed that newly arrived children are much more at risk than U.S.- born peers for exploitation, adding: “We don’t have enough support systems in place to help kids and parents to understand the fear and the reality that their children are ‘ready targets’ for sexual predators.” Lisa described the problem of social media, teasing and online bullying in her middle school: “So, this social media stuff now is outrageous. I think it has exposed [newly arrived] kids to a lot of things they’re not ready to be exposed to.”

Ava shared, “[Newly arrived] parents work two and three jobs and the oldest child [may] take care of the younger kids.” Several SNs expressed concern over the predicament faced by parents who needed to work multiple low-paying jobs to make ends meet and thus had to rely on the older children to supervise their younger siblings for extended periods of time.

Emotional Stress of Transience and Separation

The SNs described situations where newly arrived children have experienced transience, separation from families, or both, “which is very traumatic, especially for young kids.” Beth recalled a fourth-grade Asian boy who had not met his parents until he immigrated to the United States at 5 years of age: “He has had issues from day one…behavioral issues, emotional issues…I can see that he is stressed a lot of the time.” Moreover, some newly arrived children are multiple years behind their peers, thus significantly older and placed in Students with Limited or Interrupted Formal Education (SLIFE) classrooms. Deb observed, “So, in this [Newcomer] school…students have either had a three-year gap in education or no formal education. If you conceptualize no formal education, what does that mean as far as healthcare goes?”

The Burden of Living in Fear of Deportation

Most SNs believed that fear of deportation has increased dramatically in the current political climate in which some children are “afraid of having their families ripped apart.” Several SNs described parents who did not want children to go to the school-based health center because of not wanting to be on the radar of needing something from the government, even if the child needed medical care. SNs described the “heightened awareness,” “secretiveness,” and “fear that kids walk around with.” Several SNs who work in a sanctuary city reported that fear of deportation was less problematic due to the limited cooperation with the federal government’s effort to enforce immigration law. Sofia shared, “We’re instructed not to speak to ICE [i.e., U.S. Immigration and Customs Enforcement] and send them to our Central Office or superintendent…We [are directed] to say, ‘I cannot speak to you…speak to the administration.” Sofia believed most newly arrived children and families “are here legally.” Emma voiced, “Our families are protected. ICE cannot come into a school system and have our children deported, so we’re very protective of them.” Ava voiced, “They’re very scared to give some of their information. So, it crosses my mind if they’re undocumented immigrants and, they’re just afraid to give too much.”

School Nurses Admire Newly Arrived Children’s Resilience

The SNs expressed admiration for the resilience and strength of newly arrived children in the face of difficult acculturation. Stephanie voiced admiration for the unyielding spirit of the medically fragile children: “the smile, the resilience and happiness…you can’t teach it, you can’t read it, you have to see it and experience it…it is the reason I go to work every day.” Many SNs shared that newly arrived children have peer communities where children speak the same language (e.g., Spanish, Portuguese, Haitian, Chinese, Vietnamese, Arabic) which helps with acculturation. Likewise, SNs identified families who found strength through community supports, especially those living in neighborhoods highly concentrated in their native culture.

As an example of this resilience Elena shared her favorite story about a young girl from the Middle East with a chronic medical condition and needed to be taught a self-care procedure: “When she came into our school, she spoke no English and by the next year, she was fluent. And by the time she was in sixth-grade, she sang at the graduation in her [own] language.”

Theme Two: Walk a Mile in My Shoes

Theme two reflects the SNs’ perspectives of what caring for a newly arrived children population entails on a day-to-day basis. SNs revealed tackling incomplete health records and incomplete immunization records while managing the challenge of newly arrived children and families’ lack of knowledge on the health requirements. Theme Two features the following five Categories.

Challenging Tasks for School Nurses

The SNs concurred that getting follow-up vaccines for newly arrived children is among the most trying aspects of the role. They described school registration centers that vary greatly in vetting processes to secure vital health records and immunizations. According to Deb, “Most of our kids come with no records of any immunizations.” The SNs repeatedly cited the recent Measles outbreak has spurred a call to action in getting children up to date with vaccines. Deb voiced that when children are registered for school, “They’re essentially getting a whole slew of first-round vaccines…I might be the first [healthcare provider] they see…. So, they’re leery of medicine.” The importance of establishing a relationship with a PCP is often lost on newly arrived children and families arriving from completely different healthcare systems where preventative care may not be the cultural norm.

Second, participants noted policies such as national immunization registries that link state to state might help SNs to deliver care to newly arrived children more effectively and efficiently. Julia noted “chasing down” vaccines “is a larger systemic problem…larger than just the local school [and] should be addressed systems wide. And it’s not.” Similarly, SNs agreed that newly arrived families frequently are unable to return phone calls or answer repeated letter requests for health records. The SNs reported newly arrived families leaving sick children at school because they are in the hands of a trusted medical professional and the families often refer to the SN as “doctor.”

SNs described how the SN role has changed over time in response to the changing student demographics. Most SNs voiced an increase in caring for a bilingual population and a heavier caseload. Elena explained, “We’re not seeing nearly the influx of immigrants that we have had in years past…when they were coming in [they came] through two [refugee] agencies.” Lisa spoke of extra children added to the school where she is an SN due to a sister middle school shutting down for renovations. Lisa lamented that the elimination of a bilingual guidance counselor was especially painful. These challenges test the most seasoned of SNs in meeting the goals of the SN practice to care for newly arrived children.

Caring for Newly Arrived Children in the United States for Advanced Medical Treatment

SNs also noted that complex, chronic, and/or advanced medical health problems were reasons for some families to bring their children to the United States: congenital disorders, cerebral palsy, osteogenesis imperfecta and seizures. Newly arrived children with unmet chronic conditions such as diabetes or disabilities further complicate healthcare navigation. Case management, continuing care, and follow-through are high priorities for immigrant families who also require education on serious health conditions and, as Emma noted, may need more education “on what’s next.” Several SNs identified the need to assist newly arrived families with follow-up for critical appointments as well as transportation to and from the specialist (i.e., to make the appointment happen.) Stephanie gave an example of a newly arrived child who had complex care needs and limited insurance. That child was denied formula for G-tube feedings, “the one piece he needs to be healthy.” Stephanie also described locating a wheelchair and a headrest that they adapted using “pool noodles and duct tape.”

Moreover, the SNs described newly arrived children and families who do not understand that dental health is important to overall health and well-being. Linda explained, “Sometimes they smile, and you’re shocked to see all of the metal and silver caps.” Many newly arrived children have never seen a dentist; and thus the SNs consistently referred to the children’s poor oral hygiene and problems such as black or broken teeth, severe oral pain, gum abscesses, halitosis, and general dental neglect. Most newly arrived families were characterized as “poor” and not able to attend to badly needed dental care as it is not prioritized in the hierarchy of survival. Some SNs advocated and defended a family’s decision to come to the United States to seek help by acknowledging the impact of poverty on families and by asking people to consider what they would do if they were in the same position.

Lost in Translation

The SNs described language barriers as the biggest challenge to their role in working with limited English-proficient children and families. With regards to overcoming language barriers, Deb discussed that “even having a translator, things get lost in translation.” Ava emphasized the importance of using an adult interpreter with children as opposed to native-speaking peers “to get to the bottom of the story.” In some cases the SNs relied on bilingual staff in the schools. Beth described an ESL (English as a Second Language) teacher who spoke Chinese. “She’ll drop what she’s doing, I’ll man her class…and she’ll come and make phone calls for me… That’s the biggest help.” Lisa was among several SNs who described using phone applications (such as Google Translate) to translate “very rudimentary things.” However, all SNs concurred that an interpreter is necessary for most, if not all, conversations with parents. Most SNs had access to a three-way phone interpretive services such as Language Line Services or Lionbridge but budgetary expenditures for such helpful mechanisms varied.

Regardless of the source, interpreter services and the quality of translation also varied. School-based health centers (SBHCs) often assist SNs by offering interpreter services on-site. Further, the SNs discussed the communication challenges when dealing with multiple dialects and native indigenous languages. Beth shared, “Certainly, within a year of being here, I see them speaking fluent English. Now, do they understand everything I’m saying, the nuances? Probably not.”

Newly Arrived Children with Identified Psychosocial and Behavioral Needs

The SNs identified newly arrived children with mental health issues such as PTSD, bipolar disorder, ADHD, anxiety, selective mutism, and depression. The SNs told stories that brought up the challenge of educating children with severe trauma histories. Several SNs spoke about newly arrived children who were cutting. Lisa shared a story about a newly arrived child with what she described as “true cutting,” adding “You could tell the cutting had been going on for a very long time in the upper thigh where you wouldn’t see it when she had her clothes on.” Several SNs had also observed some newly arrived children with what to them looked like hyper-startle responses to loud noises such as someone yelling or the sudden noise of books being slammed. Underlying many of the mental health issues is a history of trauma.

The SNs also described somatization that may manifest as a stomachache, headache or unexplained discomfort. The child may cry and be upset out of frustration. SNs noted the demands of acculturation on newly arrived children’s coping, which can then impact their ability to learn and form healthy relationships in school. For some, the stress of not being able to communicate in English can lead to acting out and physical altercations. Navigating mental health issues for newly arrived children is challenging and SNs expressed the need for more treatment options both in and outside of school.

School Nurses Coping and Responding in the Context of Trauma

The SNs articulated practical tips or strategies for coping and responding that pervade all resulting themes and are summarized in Table 3. As they shared stories about serving on the frontlines and witnessing the impact of trauma among newly arrived children, some shed tears as they discussed challenging experiences that triggered feelings of helplessness, sadness and frustration. Stephanie voiced that caring for newly arrived children can be “sad, eye-opening and hard.” Most SNs revealed that coping might entail crying and venting to colleagues, family, and friends. Conversely, many SNs also used humor to cope. Physical activities such as going to the gym, swimming, dancing and digging in the garden provided another outlet for their job stress. The SNs’ empathy for immigrant children often circled back to personal protective feelings associated with their own children or grandchildren. Linda described the importance of saving emotional energy for her young daughters at home.

Table 3

Practical Tips.

	Resource links and/or exemplar quotes
Caring for families
Obtain family needed resources	National Center for Homeless Education Set-Aside Funds for children experiencing homelessness Catie’s Closet Clothing store within school The Wish Project Furniture, household goods, clothing and shoes
Offer information on community resources	Young Center for Immigrant Children’s Rights Protects rights of immigrant children who arrive in the U.S. on their own National Immigration Legal Services Directory Immigration legal services- providers by state Preserve and Reunify families Child Welfare Rian Immigration Center Legal, education and wellness
Make personal connections with parents at Open House Night	“That’s the one time that you’ll get parents to come to the school.”
Coordinate your efforts with Primary Care Provider (PCP)	“It was fragmented care…I typed up all the needs for this family and sent a letter to the [PCP] requesting a case manager or visiting nurse referral.”
Caring for children
Vaccinate children in health office under the guidance of a local Health Department	National Association of School Nurses (NASN ) School Located Vaccination (SLV)
Use sports physicals for leverage to access primary care	“For the kids that want to do sports, that makes it very helpful for us to get their physicals and get them in to see a doctor because they can’t play without the physical.”
Help older children be proactive and take responsibility for their own care	“Even though they’re in sixth, seventh and eighth grade, I talk to the student directly about what the situation is around their care and how to go home and talk to their parents about what is needed.”
Create and maintain a SADD chapter	SADD Students Against Destructive Decisions
Provide a quiet space for children when adhering to religious restrictions	“I have several kids that come in my office and just sit there during lunch period to not be around the food or rest.”
Developing your school nurse practice
Conduct home visits to establish trusting relationships	“You get a much bigger idea of what their life is like.”
Initiate contact and establish a therapeutic relationship as soon as possible	“A cheat sheet for what is needed for the health office.”“Who is your trusted English-speaking family member?”
Maintain high level of compassion and sincerity when engaging with children	“I think that for a lot of these kids, coming to school is the happiest part of their day.”"Do you need a hug?"“Just love them and do your best with every kid.”
Create a welcome, safe and private environment for SN child/family interactions	“It is their story to tell.”
Make your interactions with children an opportunity	“Try to turn around the feeling of ‘What does this student want now?’ to ‘What can I do for them?’”
Complete an initial assessment of the child, attentive to their nutritional needs	“Take a walk to the cafeteria to get them cereal and milk and let them sit quietly and eat before entering into the demands of a school day.”
Establish professional support groups among school nurse colleagues	“Our peers are amazing and have profound resources… When someone helps you out, you help someone else out.”
Engage in continuing professional development to maintain cultural awareness	National Association of School Nurses (NASN ) Cultural Health Practice Resources

Theme Three: Being a Trusted Health Navigator

Establishing trust with newly arrived children and their families meant taking the time and seizing upon opportunities to build relationships. SNs assumed the role of a health navigator to bridge gaps in or barriers to services and to coordinate care with the school support team and community partners/healthcare providers. Theme Three features the following six Categories.

Building Bridges Between the Families and the School

Kim described the importance of the SN as the “tri-care provider” in the contexts of school, home and the medical community. The SNs described newly arrived children and families who do not know how to navigate the educational and healthcare systems. Emma voiced, “So it’s our role as school nurses to try to hook them into services.” The SNs recognized the importance of newly arrived families establishing a relationship with a PCP to avoid partial or piecemeal care; and to prevent overuse of Emergency Rooms for episodic illnesses that could be managed in a clinic setting (e.g., minor asthma symptoms, earaches, sore throats). The theme of being a trusted healthcare navigator conjures up the metaphor of building bridges. SNs are a bridge between the school and the School Based Health Centers, especially when both are housed in the same building, and they promote access to: (a) health insurance; (b) immunizations and physical exams; and (c) mental/behavioral health counseling. Some of the SBHCs with which the SNs worked had formal links with government programs for refugees (including unaccompanied minor children.) Overall, SNs described the local community health center as the main source of healthcare for newly arrived children and families.

School Nurses Work to Address Structural Determinants

Several SNs described their work that extends into children’s homes or classrooms as directly mitigating the severe impact of scarce resources on health. These efforts included home visits to conduct first-hand assessments and providing food and supplies to children. The SNs also offered resources to newly arrived children and families ranging from bags of food, toiletries and clothing to arranging cultural support groups at school. One SN offered a weekly peer group for parents that served coffee and celebrated holidays. The SN recounted a new mom who she “pushed” into the support group and asked the other “ladies” to help her out. Such supports help families to acculturate to their new surroundings and reduce isolation.

School Nurses Provide Care in Spite of Health Insurance Barriers

Health insurance is key in accessing healthcare for newly arrived children and families. The SNs concurred that referring to community health centers was the most effective strategy to help families access health insurance or free care. Several SNs could relate to the family’s plight of tackling health insurance and shared personal stories of their own insurance nightmares. It can be a double-edged sword for families if accessing health insurance increases their visibility and vulnerability for discovery (i.e., red flag for deportation.) Deb described a “mindboggling” scenario about a newly arrived refugee child from Africa who needed assistance locating a PCP. The parents sent paperwork from his assigned refugee agency with the word “help” on it. Deb spent three hours trying to locate a PCP for the child, calling eight primary care clinics including the biggest family healthcare center in her city which typically accepts refugee children. “So, we ended up finally finding some [refugee] agency that was willing to take them on…just having someone that can speak to them is the biggest problem.”

The Health Office is a “Safe Zone” for Newly Arrived Children

In the United States there is no consideration of documentation status when it comes to schools which was viewed as instrumental in gaining the trust of newly arrived children and families. The SNs described their health office as a refuge for newly arrived children to take a break from the stress of the day. Newly arrived children who come in regularly for medications or treatments are especially comfortable with the SN and thus may be more apt to freely express their thoughts and fears. Kim offered a story of a (Caribbean) boy who asked, “Does it make me bad because I’m here and I’m not supposed to be?” Kim recalled feeling overwhelmed by the boy’s question and stated that she had to take a moment to regain her composure. The same (Caribbean) child also revealed, “Sometimes my dad yells, because we don’t have enough food in the house. And I’m worried.” Kim responded, “This is a very hard time, but those are adult issues… and we’ll work with your mom and dad to make you safe.” Schools are a safe place where newly arrived families can expect their children to be supported academically and emotionally.

One School

The SNs often described the importance of school unity and feeling connected to the school team. Many SNs recognized the need for the principal’s support in their practice caring for newly arrived children, particularly with regards to interpreters and backing for requests for state-mandated vaccines. Kim voiced appreciation that her principal includes her in “common planning time” when she meets with the Student Support Team and invited community partners to discuss the needs of children, most of whom are English Language Learners. The fact that one SN received space for her parent mentor group signified that the school administrator was empathetic to her work. Olivia recounted lessons learned from her work with a young boy from [the Middle East] who presented with a “mangled arm” that he tried to hide under a sweatshirt. The child had been made fun of in the past. “So, we went to the classroom [and I said] this is what makes him special and I know you guys will be good to him.” This approach appeared to work as the boy went on to wear short sleeves. Olivia explained: “I think if something’s going on, it’s better to talk to the kids and explain it. Don’t let them figure it out.” Her approach was intended to tap into her school’s community spirit and the protection of its members.

Culture Matters: Global School Nursing

The SNs told stories of cultural sensitivity and accommodating cultural practices and differences, describing “small” and “undernourished” newly arrived children struggling to adapt to eating American food. The SNs touched on the pride of newly arrived families and discussed honoring boundaries even when they knew the child could benefit from help (e.g., not offering clothing or food to families who are not receptive to handouts.) Two SNs detailed their first encounters with the Asian healing practice of “cupping” (i.e., circular pronounced bruises) remnants of which the SNs mistook as possible signs of abuse until they were educated by colleagues about the custom. Other SNs voiced unease over Ramadan fasting and detailed challenges with tired and hungry children. Stephanie told a frenzied story of a new [African] child who was “pulling out yellow pills” which her parents had given her to take during the school day: “The girl was screaming and trying to run away...We had to find somebody that could speak to the family to explain to them [school policy]…And the parents were lovely. ‘We are so sorry. It won’t happen again’.”

Constitutive Pattern: The Role of School Nurse in the Context of Trauma

The constitutive pattern that emerged across all interviews was the SN’s role in the context of trauma and challenges to caregiving. SNs told rich and often raw stories about caring for newly arrived children with trauma from acculturation or histories of trauma pre-, post-, or during migration. The SNs encounters with newly arrived children and their families, many of whom had experienced and/or were continuing to experience trauma, had a profound effect on the way they perceived their role as a trusted health navigators. They illustrated the importance of empathy and compassion in providing culturally sensitive and holistic nursing care. See Table 2 for the exemplar quote that captures the meaning of the role of the SN in the context of trauma.

Discussion

This phenomenological study explored the lived experiences of 20 SNs caring for newly arrived children in urban public schools, grades K-8. The SNs experiences reflected the inherent complexity of caring for newly arrived children and their families. The SNs shared stories about working with these linguistically and culturally diverse children, many of whom presented with health issues that threatened their physical, emotional and social well-being. The SNs voiced concern about the gaps in health and mental health service utilization among newly arrived children, who may be the most underserved segment of the U.S. population (Hacker et al., 2015; Toppelberg et al., 2013). Study findings enhance our understanding of the SN’s role in the context of trauma and challenges to caregiving. The Community/Public Health component of the Framework for 21st Century School Nursing Practice promotes population-based care, access to care, health equity and health education (ANA & NASN, 2017).

The SNs identified the credible fear of undocumentedness (i.e., lack of birth certificate or citizenship) creates a barrier to accessing healthcare in general and mental healthcare in particular, underscoring the critical need for education on health and guidance for access to services (Hilfinger Messias et al., 2015; McGuire, 2014). McGuire (2014) has suggested that the social construction of undocumentedness may be regarded as a kind of violence toward the immigrant because of the marginalization, trauma and suffering it creates. SNs offer a safe haven for the provision of services to newly arrived children, and by extension, they may have the opportunities to help immigrant parents and immigrant communities overall (Capps et al., 2015).

The SNs shared stories about the impact (stress, sorrow) that fear of deportation has on newly arrived children and their families, suggesting that the fear of deportation has increased dramatically under the current political climate. The intensified fear of deportation affected SNs decision making around when/how to contact parents in order to avoid disturbing them at work or calling attention to their employers. Our findings indicate that parents’ legal vulnerability to detention or deportation are indeed associated with stigma, fears of separation, anxiety, depression and social isolation (Ataiants et al., 2018; Dreby, 2012; Toppelberg et al., 2013; Zayas & Heffron, 2016). Understanding parents’ fear of detention and deportation has important implications for promoting health and well-being of newly arrived children and families.

The SNs provided narrative accounts of structural deficits (i.e., lack of food, stable housing, parental supervision, healthcare access.) Indeed, newly arrived children undergo a profound disruption in essential experiences of security and structure that are critical for healthy development (Seery et al., 2015). Promising practices point to directives/policies at the Federal and State levels that can address structural deficits and poverty among newly arrived children. For example, SNs can connect newly arrived families to programs such as “WIC” (i.e., special supplemental nutrition programs for women, infants and children). Further, SNs can advocate that WIC be expanded to newly arrived children over 5 years old to improve nutrition, screening and referrals to health, welfare and social services (United States Department of Agriculture, 2019).

SNs also observed that newly arrived children under their care, who had come to join their parents in the United States, may suffer psychological damage caused by years of separation (Nazario, 2014). The mental health toll was most evident within stories of SNs working with SLIFE children (Students with Limited or Interrupted Formal Education). As an advocate, the SN plays a vital role in the assessment of the physical and emotional needs of SLIFE children; and in assuring that appropriate referrals and follow-through are carried out with regards to immunizations, dental and physical/mental healthcare. Further, SNs validated their role in the protective circle of security that supports children who are separated from detained or deported parents; children who present with loss of appetite, stomachaches, headaches, poor sleep, nightmares, crying, clingy behavior, anger, fear, anxiety, and withdrawal (Chaudry et al., 2010; Dreby, 2012; Park & Katsiaficas, 2019).

SNs expressed admiration for the resilience and strength of newly arrived children in the face of the challenges to acculturation. Witnessing the resilience and strengths of newly arrived children and families spawned hope and appeared to be a critical factor for SNs continuing to care for this unique population who have endured difficult circumstances. In response to stressors triggered by their work with newly arrived children, the SNs identified coping strategies such as venting, crying, praying and exercise. A recent qualitative study of Swedish SNs described experiences working with unaccompanied refugee children and adolescents (Musliu et al., 2019). The authors highlighted the importance of SNs’ self-awareness to promote self-care. SNs also expressed a need for personal and professional development in trauma focused care for children and adolescents who had been exposed to chronic trauma and adversity (Musliu et al., 2019).

SNs play an essential role in health promotion and chronic disease management for newly arrived children (ANA & NASN, 2017; Council on School Health, 2016; Maughan et al., 2018). This study underscores the critical role of SNs as trusted health navigators and the importance of forming partnerships and alliances with families and community providers to promote newly arrived children’s health and safety, which in turn impacts their educational achievement. Narratives of the SNs succinctly echo the sentiment of the American Academy of Pediatrics that no child should live in fear and that what newly arrived children deserve the most is to be healthy and safe (Stein, 2017).

Study Limitations

Despite the strengths of this study, there are also some limitations. This study used a small purposive sample of SNs recruited from urban public schools in Massachusetts, thus limiting transferability to SNs working in other states and school settings. Furthermore, in comparison to many other states, Massachusetts is considered to offer more generous health services and benefits to newly arrived children (Capps et al., 2015).

Although the participants in this study reflect national demographics (gender and race/ethnicity) for SNs, they lacked diversity in that they were all female, Non-Hispanic, and predominantly White. Walter (2017) argues the voice of White privilege (i.e., “unearned privilege”) in nursing is the result of unequitable social systems that award dominance to some groups and subordination to others. The majority of the SN workforce identifies as female (98%) and White (87%) (Willgerodt et al., 2018). We acknowledge our study presents narratives (i.e., results) based on individual participant’s bias and stereotypes inevitably brought to the table.

Implications and Recommendations for School Nursing Practice and Research

An essential component to ensuring a well-prepared SN workforce is education, whether that be in the form of their professional development (i.e., continuing education) or advancing their degrees. A well-educated SN workforce is better prepared to lead care navigation with community partners and to advocate for and connect newly arrived children and families to needed services and resources. Nursing’s workforce in general and school nursing in particular could greatly benefit from attracting a more racially/ethnically diverse workforce, one that more closely represents the diversity of the populations they serve.

It is imperative for interdisciplinary efforts to critically examine current school health policies and procedures and to work collaboratively to make improvements as needed. For example, assistance with language barriers is vital to working with newly arrived children and families. SNs need access to cultural brokers, interpreters, high quality three-way phone interpretive services, translated documents and language classes. Additional school policy-related actions on behalf of newly arrived children and their families include: (1) National Immunization Registries; (2) Entitlement to comprehensive health insurance including mental and behavioral healthcare; (3) Support for and addition of more SBHCs in communities with growing numbers of newly arrived children and families; and (4) Fostering professional development for all school personnel on trauma informed care and cultural humility. For example, SNs need federally funded state-level immunization information systems to link immunization data across states to decrease reliance on medical record abstraction or parental report (Fuller et al., 2017). Further, SNs would benefit from support groups to talk about their own “trials and triumphs” regarding this unique population.

The following are suggested research priorities for supporting the SN role when caring for newly arrived immigrant and refugee children: (1) exploring barriers and facilitators to accessing and engaging in routine pediatric healthcare; (2) investigating child health outcomes related to care coordination and continuity tailored to the needs of newly arrived children; (3) studying the impact of access to comprehensive health insurance on newly arrived children’s physical and mental health outcomes; (4) examining best practices in schools for promoting holistic health and cultural humility to support healthy development; and (5) exploring the impact of incorporating trauma informed care into school health. Acquiring new knowledge through research can increase our understanding about how to tailor school-based, health-related interventions for newly arrived children and enhance their educational achievement.

Conclusion

SNs are accountable health professionals working with vulnerable newly immigrated children and play a pivotal role in engaging families and helping to manage the children’s healthcare needs and are uniquely positioned to provide needed care. Many of these families are living in abject poverty, with the credible fear of deportation. Laws and policies related to immigration affect newly arrived children’s physical health, mental health, and psychosocial well-being. Therefore, it is incumbent on all school personnel to consider what may be at stake if newly arrived children do not receive effective health services and interventions to promote well-being and academic achievement. Healthcare and education for all children is a moral imperative.

Footnotes

Acknowledgment

The authors offer sincere thanks to Dr. Allan Osborne for his expert consultation and generous time supporting this manuscript’s publication.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Theta-at-Large and the Gamma Epsilon Chapters of Sigma Theta Tau and the Massachusetts School Nurse Organization.

ORCID iDs

Jacqueline A. Brady

Pamela J. Burke

Author Biographies

Jacqueline A. Brady is currently working as a school nurse for Boston Public Schools. She has worked as a full-time school nurse in Boston and Quincy, Massachusetts, for over 20 years. Jackie graduated with her PhD in Nursing at Northeastern University in May of 2020. Jackie presented the results of her data study, Experiences of School Nurses Caring for Newly Arrived Immigrant and Refugee Children, at the Northeastern University School Health Summer Academy in August 2020. Jackie’s manuscript, Evaluation of a Tool to Measure the Demands of Immigration, is in press with the Journal of Nursing Measurement.

Meghan L. Underhill-Blazey is an assistant professor at the University of Rochester School of Nursing; nurse practitioner at the Wilmot Cancer Institute; and Nurse Scientist at Dana-Farber Cancer Institute. Her program of research focuses on patient-centered hereditary cancer care and she has over a decade of research methods expertise.

Pamela J. Burke is faculty for the Boston Children’s Hospital LEAH Fellowship Program (Leadership Education in Adolescent Health) in the Division of Adolescent & Young Adult Medicine and co-investigator on two federally funded studies. She was previously PhD program director and clinical professor in the School of Nursing at Northeastern University. Pam is currently an affiliate professor in Nursing at Northeastern University and a lecturer in Pediatrics, Part Time at Harvard Medical School. She is also a member of the Motivational Interviewing Network of Trainers.

Christina S. Lee is an associate professor at the Boston University School of Social Work and the Research Core director at Boston University’s Center for Innovation in Social Work and Health. Her area of research focuses on structural determinants of mental health among immigrants, stigma and mental health outcomes, understanding the mechanisms of change in behavioral treatments for substance use, and optimizing addiction treatments to minimize health inequities related to the use of substances among immigrant and diverse populations.

Elizabeth P. Howard is an associate professor at the Connell School of Nursing and an associate fellow in interRAI, a collaborative network of researchers, representing 35 countries, who share a commitment to improve the quality of life for vulnerable populations. She holds an appointment as Adjunct Scientist with the Hinda and Arthur Marcus Institute for Aging Research, a Harvard Medical School affiliate within Hebrew SeniorLife. Dr. Howard maintains and enhances her skills as an adult nurse practitioner clinician through her advanced clinical practice at Harvard Vanguard Medical Associates.

Lisa V. Duffy is an assistant professor at Northeastern University and a fellow in the Betty Irene Moore Fellowship for Nurse Leaders and Innovators at UC Davis School of Nursing. Dr. Duffy teaches numerous research courses at both the baccalaureate and doctoral level. Dr. Duffy’s research focuses on the use of technology in the management of pediatric chronic neurological conditions. Dr. Duffy currently conducts her program of research at Boston Children’s Hospital where she holds an associate research position in the Department of Neurology.

References

American Nurses Association (ANA) & National Association of School Nurses (NASN) . (2017). School nursing: Scope and Standards of Practice (3rd ed). ANA & NASN.

Ataiants

Cohen

Riley

A. H.

Tellez Lieberman

Reidy

M. C.

Chilton

. (2018). Unaccompanied children at the United States border, a human rights crisis that can be addressed with policy change. Journal of Immigrant and Minority Health, 20(4), 1000–1010.doi:10.1007/s10903-017-0577-5

28391501

Batalova

Blizzard

Bolter

. (2020). Frequently requested statistics on immigrants and immigration in the United States. https://www.migrationpolicy.org/article/frequently-requested-statistics-immigrants-and-immigration-united-states

Capps

Koball

Campetella

Perreira

Hooker

Perdoza

J. M

. (2015). Implications of immigration enforcement activities for the well-being of children in immigrant families. https://www.migrationpolicy.org/research/implications-immigration-enforcement-activities-well-being-children-immigrant-families

Chaudry

Capps

Pedroza

J. M.

Casteñeda

R. M.

Santros

Scott

M. M

. (2010). Facing our future: children in the aftermath of immigration enforcement. https://www.urban.org/sites/default/files/publication/28331/412020-Facing-Our-Future.PDF

Council on School Health (2016). Role of the school nurse in providing school health services. Pediatrics, 137(6), 1–8.doi:10.1542/peds.2016-0852

27217476

Creswell

J. W.

Poth

C. N

. (2018). Qualitative inquiry and research design: Choosing among five approaches (4th ed). Sage.

Crist

J. D.

Tanner

C. A

. (2003). Interpretation/analysis methods in hermeneutic interpretive phenomenology. Nursing Research, 52(3), 202–205.doi:10.1097/00006199-200305000-00011

12792262

Diekelmann

N. L

. (1993). Behavioral pedagogy: A Heideggerian hermeneutical analysis of the lived experiences of students and teachers in baccalaureate nursing education. The Journal of nursing education, 32(6), 245–254.8394888

10.

Dreby

. (2012). The burden of Deportation on children in Mexican immigrant families. Journal of Marriage and Family, 74(4), 829–845.doi:10.1111/j.1741-3737.2012.00989.x

11.

Edmonds

W. A.

Kennedy

T. D

. (2017). An applied guide to research designs: Quantitative, qualitative and mixed methods (2nd ed). Sage Publications, Inc.

12.

Fuller

J. E.

Walter

E. B.

Dole

O'Hara

Herring

A. H.

Durkin

M. S.

Specker

Wey

. (2017). State-level immunization information systems: Potential for childhood immunization data linkages. Maternal and Child Health Journal, 21(1), 29–35.doi:10.1007/s10995-016-2090-1

27443650

13.

Gulb

L. E.

Zayas

. (2017). Exploring the effects of U.S. immigration enforcement on the well-being of citizen children in Mexican immigrant families. The Russell Sage Foundation Journal of Social Sciences, 3(4), 53–69.

14.

Hacker

Anies

Folb

B. L.

Zallman

. (2015). Barriers to health care for undocumented immigrants: A literature review. Risk Management and Healthcare Policy, 8, 175–183.doi:10.2147/RMHP.S70173

26586971

15.

Heidegger

. (1962). Being and time (J. Macquarrie & E. Robinson, Trans.). Harper & Row. (Original work published 1926).

16.

Hilfinger Messias

D. K.

McEwen

M. M.

Clark

. (2015). The impact and implications of undocumented immigration on individual and collective health in the United States. Nursing Outlook, 63(1), 86–94.doi:10.1016/j.outlook.2014.11.004

25645486

17.

Husserl

Ideas

. (1931). General introduction to pure phenomenology (W.R. Boyce, trans.). Gibson. (Original work published 1931).

18.

Ironside

P. M

. (2006). Using narrative pedagogy: Learning and practising interpretive thinking. Journal of Advanced Nursing, 55(4), 478–486.doi:10.1111/j.1365-2648.2006.03938.x

16866843

19.

Maughan

E. D.

Cowell

Engelke

M. K.

McCarthy

A. M.

Bergren

M. D.

Murphy

M. K.

Barry

Krause-Parello

C. A.

Luthy

K. B.

Kintner

E. K.

Vessey

J. A

. (2018). The vital role of school nurses in ensuring the health of our nation's youth. Nursing Outlook, 66(1), 94–96.doi:10.1016/j.outlook.2017.11.002

29331445

20.

McGuire

. (2014). Borders, centers, and margins: Critical landscapes for migrant health. Advances in Nursing Science, 37(3), 197–212.doi:10.1097/ANS.0000000000000030

24759252

21.

McNeely

C. A.

Morland

Doty

S. B.

Meschke

L. L.

Awad

Husain

Nashwan

. (2017). How schools can promote healthy development for newly arrived immigrant and refugee adolescents: Research priorities. Journal of School Health, 87(2), 121–132.doi:10.1111/josh.12477

28076923

22.

Musliu

Vasic

Clausson

E. K.

Garmy

. (2019). School nurses’ experiences working with unaccompanied refugee children and adolescents: A qualitative study. SAGE Open Nursing, 5, 237796081984371.doi:10.1177/2377960819843713

33415234

23.

Nazario

. (2014). Enrique’s Journey: The story of a boy’s dangerous odyssey to reunite with his mother. Random House Trade Paperbacks.

24.

NVivo [Computer Software] . (2018). Unlock insights in your data with powerful analysis. http://www.qsrinternational.com/nvivo/nvivo-products

25.

Park

Katsiaficas

. (2019). Mitigating the effects of trauma among young children of immigrants and refugees: the role of early childhood programs. https://www.migrationpolicy.org/research/mitigating- effects-trauma-young-children-immigrants-refugees

26.

Radford

Krogstad

J. M

. (2019). Recently arrived U.S. immigrants, growing in number, differ from long-term residents. https://www.pewresearch.org/fact-tank/2019/06/03/recently-arrived-u-s-immigrants- growing-in-number-differ-from-long-term-residents/

27.

Seery

Boswell

Lara

. (2015). Caring for refugee children. Pediatrics in Review, 36(8), 323–340.doi:10.1542/pir.36-8-323

26232463

28.

Stein

. (2017). American Academy of pediatrics (Aap) statement on protecting immigrant children. https://www.healthychildren.org/English/news/Pages/AAP- Statement-on-Protecting-Immigrant-Children.aspx

29.

Toppelberg

C. O.

Hollinshead

M. O.

Collins

B. A.

Nieto-Castañon

. (2013). Cross-sectional study of unmet mental health need in 5- to 7-year old Latino children in the United States: Do teachers and parents make a difference in service utilization? School Mental Health, 5(2), 59–69.doi:10.1007/s12310-012-9089-6

23667398

30.

Underhill

M. L.

Lally

R. M.

Kiviniemi

M. T.

Murekeyisoni

Dickerson

S. S

. (2012). Living my family’s story: Identifying the lived experience in healthy women at risk for hereditary breast cancer. Cancer Nursing, 35(6), 493–504.doi:10.1097/NCC.0b013e31824530fa

22544165

31.

United States Census Bureau . (2019). Census bureau reports nearly 77 million students enrolled in U.S. schools. https://www.census.gov/newsroom/press- releases/2019/school- enrollment.html

32.

United States Department of Agriculture . (2019). WIC eligibility requirements. https://www.fns.usda.gov/wic/wic-eligibility-requirements

33.

Walter

R. R

. (2017). Emancipatory nursing praxis: A theory of social justice in nursing. Advances in Nursing Science, 40(3), 225–243.doi:10.1097/ANS.0000000000000157

34.

Willgerodt

M. A.

Brock

D. M.

Maughan

E. D

. (2018). Public school nursing practice in the United States. The Journal of School Nursing, 34(3), 232–244.doi:10.1177/1059840517752456

35.

Zayas

L. H.

Heffron

L. C

. (2016). Disrupting young lives: How deportation and detention affect U.S.-born children of immigrants. https://www.apa.org/pi/families/resources/newsletter/2016/11/detention-deportation.aspx