Perceptions of School Nurses in Addressing Student Mental Health Concerns: An Integrative Review

Abstract

Mental health disorders in school-aged children are on the rise. The need for mental health care is well recognized, and the provision of this care in schools is recommended. An integrative review explored how school nurses view their role in addressing students’ mental health. Fourteen articles were identified, eleven using a qualitative design and three using a quantitative design. Findings suggest that school nurses see their role as trusted members of the school community. They perceive upholding standards of practice as an integral part of their position and recognize competence in mental health care to be highly important. Practice recommendations include providing school nurses with evidence-based training on managing the mental health needs of students, as well as ensuring access to school nurses who can provide mental health supervision in the community.

Keywords

School nurse role school-aged students mental Health integrative Review

Many school-aged children are at risk for mental health concerns. They often experience stressors from an array of situations that they may face in schools, such as bullying and peer pressure, which can negatively impact their mental well-being as well as their academic success (Beckman & Hagquist, 2016; Williams et al., 2017). Toxic stressors or adverse experiences in early childhood can lead to a disruption in healthy development as well as chronic medical and mental health conditions (American Academy of Pediatrics [AAP], 2012). Importantly, a decline in mental health during childhood and adolescence can lead to negative health and well-being outcomes across the lifespan, including a lack of educational success, substance abuse, or violence (Bohnenkamp et al., 2015; Ravenna & Cleaver, 2016). While some youth have a documented mental health diagnosis, such as anxiety, depression, or an eating disorder, others seek treatment for somatic concerns such as headache or abdominal pain that may manifest as the result of an undiagnosed mental health issue or psychosocial concern (Clausson et al., 2015; Muggeo & Ginsburg, 2019).

The school nurses’ familiarity with students and their families, as well as knowledge of social and peer pressures that many students encounter, often make the nurse an invaluable presence for students, especially those at risk of mental health issues (Bohnenkamp et al., 2015; Jönsson et al., 2019; Kim et al., 2015). This familiarity is especially the case due to the evolution of the role of school nurses in the United States (U.S.) since its early twentieth-century inception. In addition to providing communicable disease management for children and communities, as Lina Rogers first did in New York City in 1902, today's school nurse incorporates leadership and standards of practice for coordinated, community-based care (National Association of School Nurses [NASN], 2015). With 74.6% of schools in the United States employing either a full-time or part-time nurse (Willgerodt et al., 2018), school nurses are widely available and maybe the only access to health care for some students. Therefore, school nurses are well-positioned as essential partners within communities, caring for students’ physical and mental health needs (McCabe et al., 2021).

Significance

The need for mental health care for youth is a well-recognized priority. Globally, 10–20% of adolescents (young people 10–19 years old) experience mental health disorders such as anxiety or depression, yet many of these disorders are “underdiagnosed or undertreated,” thus preventing children from achieving their full potential (World Health Organization [WHO], 2019). Using data from the 2016 National Survey of Children's Health, Whitney and Peterson (2019) found that approximately 7.7 million U.S. children (16.5%) of the 46.6 million included in their study had at least one mental health disorder. Unfortunately, almost half of those children did not receive treatment for their disorder (Whitney & Peterson, 2019). In addition, suicide rates among adolescents have risen over the last decade, and suicide is now the second leading cause of death among 10–24-year-olds in the United States (Centers for Disease Control & Prevention [CDC], 2017). The increase in mental health concerns among our nation's youth is alarming, and there does not seem to be an end in sight.

The ongoing COVID-19 pandemic, which closed most U.S. schools and therefore affected in-person learning in the spring of 2020 and much of 2021, may have a lasting effect on students’ mental health. Diagnoses of anxiety or depression in students are likely to increase as a result of COVID-19 due to student isolation or economic hardships (Garmy et al., 2020). Vulnerable populations, such as students who live in households below the federal poverty level, students identified as ethnic and/or racial minorities in the United States, and students living in rural areas were severely impacted by the COVID-19 pandemic, may have limited access to healthcare, and be unduly affected by mental health concerns (Golberstien et al., 2020).

Prior to the pandemic, efforts to raise mental health care and awareness in U.S. schools were growing over the last decade (National Alliance on Mental Illness [NAMI], 2019). In fact, recent legislation in New York and Virginia requires public schools to incorporate instruction on mental health care to students (Vestal, 2018). In addition, national legislation, including the Mental Health Services for Students Act of 2021 (H.R. 721) is pending in the U.S. Senate. It aims to support “school-based mental health services, including screening, treatment, and outreach programs” (Mental Health Services for Students Act of 2021, 2021–2022). Such policy changes begin to lessen the stigma attached to mental health disorders for students in school and emphasize the need for comprehensive mental health interventions.

School nurses continue to be key in the delivery of school-based mental health services, including problem identification (NASN, 2018). In fact, surveys of U.S. school nurses have found mental health conditions such as depression or anxiety to be common reasons for student visits to the school health office (Krause-Parello & Samms, 2011; & Stephan & Connors, 2013). School nurses can help combat the student mental health epidemic through their expertise in identifying and managing overall physical and mental health concerns. Students, now more than ever, need school nurses to be leaders in the delivery of mental health care in schools. Thus, the purpose of this integrative review is to explore the state of the science surrounding school nurses’ perceptions of their role in addressing students’ mental health needs. Understanding these perceptions may help gain greater knowledge regarding how school nurses function in their roles and as members of the school health team to assist students with mental health concerns. The research question that serves as a guide for this review is: How do school nurses perceive their role in addressing student mental health concerns?

Method

The methodology of Whittemore and Knafl (2005) was used to conduct this integrative review. Using EBSCO as the research platform, the electronic databases CINAHL, MEDLINE Complete, ERIC, APAPsycINFO, and HealthSource: Nursing/Academic Edition was searched on June 22, 2021. The search terms school nurs* AND mental health or mental illness or mental disorder or psychiatric illness AND perceptions or attitudes or opinions or experience or view or reflection or beliefs AND role of school nurse were included as keywords in our search. Following this search strategy, ninety-nine records were identified. Two university librarians also assisted with the search process and confirmed the final terms and search strategy.

To incorporate the most recent view of school nursing, studies from 2005–2021 were considered. In addition, we only considered peer-reviewed studies reported in the English language. Duplicates were removed, and forty-seven records remained. A hand search using Google Scholar and reference lists was also conducted, and it identified four additional titles, resulting in fifty-one titles and abstracts to be reviewed.

Studies that referenced students outside of 5–19 years of age or did not reflect elementary, middle, or high-school students were excluded to amplify the focus on school nurses working with the school-age population. Additionally, studies including school nurses in the United States operating outside of a school setting, such as nurses in a School-Based Health Center, were excluded as most traditional school nurses in the United States work within a school building. This is not the case for many European countries, where school nursing falls under public health nursing services. In the case of a European study, school nurses identified as public health nurses were not excluded if they practiced within a school building or school setting as part of their role.

After title and abstract review of 51 records, 21 of those records were found to not meet the inclusion criteria (i.e., the article referenced nurses working outside of the school-age population or referenced school nurses working outside of a school setting), leaving thirty records for further review. Full appraisal revealed fourteen records that met full inclusion criteria for this review (i.e., the article was in the English language, peer-reviewed, published from 2005–2021, involved school-aged students 5–19 years, and involved school nurses working within the school building). Of the final fourteen, there were eleven qualitative and three quantitative studies. The process for record selection is detailed in Figure A using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis diagram (Moher et al., 2009).

Quality of Included Literature

The quality of included literature was evaluated to maintain the rigor of the review (Whittemore & Knafl, 2005). Critical appraisal of the included literature was conducted using Pearson (2004) checklist for qualitative studies and Bowling's (2009) checklist for quantitative studies. Based on the appraisal, a quality score of high, medium, or low was assigned to each article after review by the primary author. Diverse methodologies are represented in this review, including level I inductive and exploratory qualitative design (Anttila et al., 2020; Garmy et al., 2014; Granrud et al., 2019; Jönsson et al., 2019; Littler, 2019; Pigozi & Bartoli, 2016; Pryjmachuk et al., 2011; Reuterswärd & Hylander, 2016; Rosvall & Nilsson, 2016; Sherwin, 2016; and Skundberg-Kletthagen & Moen, 2017) and level II designs using surveys (Haddad et al., 2010; Moen & Skundberg-Kletthagen, 2018; Muggeo & Ginsburg, 2019). No studies were excluded due to design or reporting quality. A summary table of all included literature outlining the author, purpose, methodology and instrument, quality score, sample, and findings can be found in Table A.

Findings

The report of findings begins with an overview of the characteristics of the included literature, followed by a synthesis of findings presented as themes, which answers the research question posed in this review: How do school nurses perceive their role in addressing student mental health concerns? Themes were identified after following a strict process of data analysis described in the Whittemore and Knafl’s (2005) methodology. Because data quality was generally good (nine of the included articles had a high-quality rating and five had a medium-quality rating), we did not eliminate or give more weight to some articles than others. Data reduction was aided using color-coding of primary data to assist in focusing and organizing the data and helped to identify patterns and themes.

Study Characteristics

The majority of included studies were conducted in European countries, specifically Norway (n = 3), Sweden (n = 4), Finland (n = 1), and the United Kingdom (U.K.) (n = 5). One study was conducted in the United States. All studies included registered nurses with experience in school nursing, while studies from Europe included public health nurses or nurses from the National Health Service, some with specialized roles as school nurses or additional education specific to public health nursing. Respondent demographics such as age, gender, or years of experience as a school nurse were not reported or only partially reported in five of the fourteen studies (Haddad et al., 2010; Littler, 2019; Muggeo & Ginsburg, 2019; Pigozi & Bartoli, 2016; Sherwin, 2016). All studies reported the perspectives of school nurses working with students with mental health concerns in a generalized context. However, one study was specific to students with anxiety (Muggeo & Ginsburg, 2019) and another to bullying among students (Pigozi & Bartoli, 2016). Four studies examined school nurses’ perceptions of depression among students, with three of those using the Depression Attitude Questionnaire (Haddad et al., 2010; Moen & Skundberg-Kletthagen, 2018; and Skundberg-Kletthagen & Moen, 2017). One study examined school nurses’ experiences after program implementation to prevent depressive symptoms in students (Garmy et al., 2014). Rosvall and Nilsson (2016) examined school nurses’ experience with student mental health concerns related to gender norms. Of the 14 studies reviewed, only three referenced a theoretical framework within the research (Reuterswärd & Hylander, 2016; Rosvall & Nilsson, 2016; and Sherwin, 2016).

Role of School Nurses in Student Mental Health

Three over-arching themes were identified to answer the research question; how do school nurses perceive their role in addressing student mental health? They included the nurses’ perception that in their role, they need to be confident in addressing student mental health, they need to be trusted members of the school community, and they need to uphold the scope and standards of professional nursing practice.

Confident in Addressing Student Mental Health

School nurses perceived the need to be confident to best assist students with mental health issues. While this was discussed in eight of the 14 studies, school nurses reported a need for further mental health training and education to increase confidence and develop communication skills to work with students experiencing mental health concerns (Anttila et al., 2020; Haddad et al., 2010; Jönsson et al., 2019; Littler, 2019; Moen & Skundberg-Kletthagen, 2018; Pigozi & Bartoli, 2016; Pryjmachuk et al., 2011; Skundberg-Kletthagen & Moen, 2017).

Some nurses felt that they lacked training or education in child and adolescent-mental health, which led them to perceive a lack of professional confidence (Jönsson et al., 2019; Moen & Skundberg-Kletthagen, 2018; Skundberg-Kletthagen & Moen, 2017). Some school nurses noted that training in motivational interviewing, identification of cyberbullying, and depression intervention would be helpful to assist students (Pigozi & Bartoli, 2016; Skundberg-Kletthagen & Moen, 2017). Although school nurses had the desire to assist students with mental health problems, Jönsson et al. (2019) found that nurses were worried that they could not effectively care for them. A lack of confidence in “doing” or “saying the right things” (Pryjmachuk et al., 2011, p. 854) was a barrier to fulfilling perceived roles. School nurses reported feeling confident addressing mental health issues that were less likely to involve self-harm or substance abuse (Pryjmachuk et al., 2011).

Although nurses receive therapeutic communication training pre-licensure, Haddad et al. (2010) noted that almost half (46%) of study respondents reported that they had not received any additional post-registration (post-licensure) training in mental health. Additionally, as they reported on the Depression Attitude Questionnaire (DAQ), 85% of respondents in their study indicated that training sessions for school nurses would be ‘very useful’ to assist in fulfilling their role in caring for student mental health needs (Haddad et al., 2010). However, Moen and Skundberg-Kletthagen (2018) found that nurses who had a degree in mental health nursing in addition to a school nurse specialty did not indicate on the DAQ that more training sessions would be ‘very useful’ as compared to those nurses who did not have a degree in mental health nursing.

Trusted Member of the School Community

School nurses perceive that their ability to be trusted members of the school community is important to their role in assisting youth with mental health concerns (Anttila et al., 2020; Garmy et al., 2014; Jönsson et al., 2019; Muggeo & Ginsburg, 2019; Reuterswärd & Hylander, 2016; Rosvall & Nilsson, 2016; Sherwin, 2016). To be trusted in the school community, one must be available, visible, and consistent with the care provided. The literature notes that when school nurses have a visible presence, it helps students understand the nurses’ role and assists with building a trusting relationship (Jönsson et al., 2019; Pigozi & Bartoli, 2016; Reuterswärd & Hylander, 2016; Sherwin, 2016). Nurses view visibility to students as having an open-door policy, signage regarding school nursing hours, and walking among students during lunch or recess, thereby helping students understand the nurse's role and building trust (Pigozi & Bartoli, 2016; Sherwin, 2016). In Sweden, the nurse's office was described as a “small oasis” where students were comfortable to come and sit with a “safe person” who would listen (Jönsson et al., 2019, p. 206).

Sherwin (2016) found visibility and consistency to be repeated themes in nurses’ shared stories. To increase the visibility of school nurses, Sherwin (2016) reported that some school nurses in the U.K. began wearing traditional nursing uniforms at work. On the other hand, in Norway, Skundberg-Kletthagen and Moen (2017) found that while being visible and available were important, nurses’ responses indicated that they felt that their part-time work hindered their ability to be available. The concepts of trust and school visibility were also identified in studies where collaboration with teachers and administration were discussed (Anttila et al., 2020; Granrud et al., 2019; Skundberg-Kletthagen & Moen, 2017). The aforementioned studies indicated that it was important for interprofessional teams to trust school nurses and include them on teams caring for students with mental health concerns.

Upholding the Scope and Standards of Practice

Finally, upholding the scope and standards of practice was noted as a part of the role of school nurses when assisting students with mental health needs (Reuterswärd & Hylander, 2016; Sherwin, 2016; Skundberg-Kletthagen & Moen, 2017). School nurses function as the primary health care professional on the school campus. They often operate under school system or municipality regulations, sometimes while working at multiple schools (Moen & Skundberg-Kletthagen, 2018). In addition to school system policies and standards, school nurses need to follow standards set forth by governing institutions such as the department of health or department of education as well as their own state nurse practice act.

Practicing within the scope of one's nursing license is a concept well regarded by nurses in all areas of care delivery. School nurses view practicing within their scope as an important part of their role, especially for students with mental health concerns. Confidentiality of students when working in interdisciplinary teams is described in the literature as part of upholding the scope and standards of practice. School nurses describe that they sometimes feel lonely as they “have a lot of information, but I cannot inform the others…” (Reuterswärd & Hylander, 2016, p. 257), and express “we are lonely professionals in school” (Granrud et al., 2019, p. 2905). The theme of upholding the scope and standards of practice can also be applied to the Garmy et al. (2014) study where school nurses delivered a depression prevention cognitive intervention to students. In the study, school nurses struggled with a strict expectation to teach according to the manual, as they felt there were times where they were missing meaningful spontaneous discussion with students (Garmy et al., 2014). The literature demonstrates that school nurses take the responsibility of upholding their code to maintain student confidentiality very seriously, and again, demonstrates the school nurses’ desire for support.

Discussion

While there may be variations in how the school nurse's role is delivered around the globe, school nurses everywhere are in an ideal position to positively impact the physical and mental health of young people in schools. This literature review suggests that nurses in Europe and the United States perceive feeling trusted and available as important elements of their role. In this regard, school nurses especially perceive the need to be trusted by students and view their ability to form trusting relationships with them as facilitating their role. Previous research found that school nurses view their role as a trusted member of the school as unique due to the confidentiality they offer, as well as not being connected to other educational duties such as grading or discipline (Spratt et al., 2010). Conversely, Bartlett (2015) reported that students are unsure of confidentiality practices by school nurses and viewed concern for their discretion as a barrier for accessing care. Findings from this review did not link confidentiality and trust. However, confidentiality was described as part of the nurse's role to uphold the scope and standards of practice. While trust and confidentiality are recognized as important to their role in student mental health, school nurses may need to educate students on confidentiality practices in the school health office to ensure that students are not avoiding treatment or referral.

School nurses also identified the importance of trust when seeking collaborative relationships with other school personnel. This collaboration, including with teachers and administrators, was found to help facilitate the school nurse's role. Teachers were found to be an important part of the supportive network. Granrud et al. (2019) found that school nurses perceived teachers to be in control of getting included in collaborative teams, while Spratt et al. (2017) reported collaboration with teachers to be “dependent on the teacher's knowledge of interest in the students’ mental health” (p. 5048).

Confidence in the care delivered was found to be an important part of the school nurse's role. School nurses need to feel comfortable assessing mental health concerns, suggesting that they may benefit from additional training in students’ mental health. There appears to be a relationship between confidence in school nurses’ role regarding offering student mental health support and a limitation concerning insufficient education and training related to students’ mental health needs. Moen and Skundberg-Kletthagen (2018) specifically examined differences between school nurses who had previous education in mental health compared to those who did not. They found that nurses who had a degree in mental health nursing did not indicate that more training sessions would be ‘very useful’ as compared to those nurses who did not have a degree in mental health nursing. Haddad et al. (2010) found that “prior mental health education, a more senior role, and specialist practitioner status were all linked to improved confidence in working with depressed young people” (p. 2476).

Although school nurses express concern within their role regarding a lack of confidence related to caring for student mental health needs, they report a desire to learn and grow professionally. The sense of worry described by Jönsson et al. (2019) and Pryjmachuk et al. (2011) recognizes that school nurses may not trust their knowledge or they may feel that they lack the emotional competence to manage students who are struggling or having an acute mental health need. In fact, a need for additional training or education in youth mental health assessment and care is well documented (Arnold & Baker, 2018; Bartlett, 2015; Ravenna & Cleaver, 2016). It remains critical to implement professional development programs that provide school nurses with evidence-based training on assessing and managing students with mental health needs, as well as programs that school nurses can deliver to students to prevent mental health problems.

This review does have limitations. With a large amount of research being qualitative, the sample size in many of the studies is small, thereby requiring further explorations regarding role perception and outcomes. Additionally, many of the studies lacked detail regarding the sample, including complete demographics, limiting generalizability. Also limiting generalizability to nurses practicing in U.S. schools is that only one study from this review was conducted in the United States. Excluding gray literature as part of the review is also a limitation in the search methodology, as some newly published literature may not have been included.

Implications for School Nursing Practice

This review indicates that school nurses currently play an important role in student mental health and that addressing mental health is a priority for them. School nurses establish a presence as trusted adults who provide knowledgeable, comprehensive care with a profound impact on youth struggling with mental health concerns (NASN, 2018). The findings from this review emphasize the need to support school nurses as collaborative members of the care team, consisting of administrators, teachers, social workers, and school psychologists. Supplying school nurses with opportunities for knowledge enhancement will assist in advancing their professional competence. Further research on the implementation and efficacy of training programs and continuing education courses for school nurses on youth mental health topics is critical to support school nurses and allow them to better care for students who need mental health support. Ensuring that full-time nurses are positioned in all schools to maintain a healthy school environment provides a consistent, available presence essential to supporting the school nurse role, as well as supporting the students in their care.

Educational experience and background are significant in how confident school nurses feel in their mental health skills. State and local agencies and school districts in the United States must adopt consistent policies on school nurses’ education and experience, allowing for a school nurse workforce that is better prepared to assist students with mental health needs. With the number of mental health providers declining (Bishop et al., 2016), especially in rural and other underserved areas, school nurses have the opportunity to supply a much-needed service to the school community through identification, referral, management, and care coordination of students with mental health needs.

The NASN (2016) twenty-first century school nursing framework principles of “care coordination” and ‘leadership’ can and should be applied to understanding school nurses’ perceptions of their role in student mental health. School nurses incorporate care coordination principles when caring for students’ mental health needs, including motivational interviewing (Skundberg-Kletthagen & Moen, 2017). Additionally, school nurses practice care coordination as collaborative partners with the school health team. School nurses employ ‘leadership’ to positively impact health services, including mental health offered in schools and districts. This may include education for all faculty and staff and support life-long learning (Skundberg-Kletthagen & Moen, 2017). The nurse's ability to establish trust with students, discussed by Sherwin (2016), and Skundberg-Kletthagen and Moen (2017), creates an environment of professionalism and safety, two important values also supported by the NASN Framework.

Directions for Future Research

This study demonstrates a global view of school nurses’ perspectives on student mental health care. While multiple studies used qualitative methodology to explore school nurses’ role in student mental health care, most have been conducted in Europe. These studies have limited transferability to U.S. school nurses due to differences in the trajectory to school nursing practice and variations in clinical practice. For example, Sweden practices a more traditional school nursing model, similar to the United States, while Norwegian school nurses are part of the public health service. School nurses in Finland conduct annual health screenings at school, including a depression screening for eighth-grade students, which are regulated by law and national guidelines (Anttila et al., 2020). These differences reveal a ripe opportunity for a contemporary qualitative study of U.S. school nurses. This research methodology will allow investigators to uncover U.S. school nurses’ opinions, experiences, and identify trends as well as consider hypotheses for follow-up research, including intervention and longitudinal work. Qualitative research on school nurses’ role perception in the United States, as well as an examination of relationships between school nurses’ perceptions and student perceptions of what facilitates a trusting relationship, is beneficial and necessary as it will help to understand better how school nurses can positively impact youth mental health. Additional qualitative and quantitative research, including longitudinal studies, on the effectiveness of educational programs on school nurses’ perceived self-confidence, would add to the quality of the data.

The literature recognizes the increasing number of students who seek care from school nurses for mental health needs. Because of growing mental health issues that students confront, understanding what facilitates or hinders school nurses from addressing mental health needs is important to uncover and address. While some barriers and facilitators were revealed in the literature reviewed, additional research on this topic would help set or change school nurses’ policies and practices in the United States and beyond.

The impact of COVID-19 on student mental health and its impact on school nurses’ roles has only begun to scratch the surface. This global pandemic will have far-reaching implications on the health and well-being of students and school communities. While gaining an understanding of U.S. school nurses’ role in students’ mental health, we also encourage research on the effects of school closures, social distancing, and remote learning on the mental health of diverse student populations. Future research designs should include a longitudinal approach to improve current health services and prepare for future pandemics. School health service researchers need not only rely on primary data collection in the school setting, as the COVID-19 pandemic has taught researchers that they can access secondary data sets collected in the school setting. This data analysis will allow researchers to continue interpreting school data and improving school health services, including mental health services. As school nurses are the new front-line workers of this pandemic, giving a voice to school nurses’ work will be critical to understanding the specialized role they play in ensuring that students remain healthy, safe, and ready to learn.

Footnotes

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 Senator Patricia K. McGee Faculty Nursing Scholarship through the New York State Higher Education Services Corporation

ORCID iDs

Jeannine Kaskoun

Ellen McCabe

Author Biographies

Jeannine Kaskoun, MS, RN, CNE, is an Instructor of Nursing at Siena College, Baldwin Nursing Program in Loudonville, NY as well as Ph.D. student at The Graduate Center City University of New York, New York, N.Y. She also practices as a substitute school nurse.

Ellen McCabe, PhD, RN, PNP-BC, is an Assistant Professor at Hunter College, Hunter College School of Nursing. She is also on faculty at the Graduate Center City University of New York and The Roosevelt House Public Policy Institute of Hunter College. Dr. McCabe also practices as a school nurse in New York City.

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