How School Nurses Perceive Their Role in Addressing Student Mental Health Concerns

Student mental health is a significant concern for school nurses. National surveys reveal alarming rates of depression, anxiety, behavioral disorders, and suicidality among the nation's secondary school students (Centers for Disease Control and Prevention, 2024). In a 2023 survey by the Centers for Disease Control and Prevention (2024), for example, 40% of high school students reported symptoms of depression, and 10% reported an attempted suicide. Moreover, the National Survey of Children's Health (2022–2023) (Child and Adolescent Health Measurement Initiative, 2023) revealed that 9.2% of 6–11 year-olds and 16.0% of 12–17 year-olds had been diagnosed with anxiety and 1.9% of 6–11 year olds and 8.7% of 12–17 year olds had been diagnosed with depression. Mental health problems in youth are exacerbated by an acute shortage of child and adolescent psychiatrists and therapists in the United States (Health Resources & Services Administration, 2024; Hoffmann et al., 2023).

For many communities, schools are the largest provider of mental health services for youth (American Academy of Pediatrics, 2024), and approximately 93.8% of public schools employ a school nurse at least part time, although this rate varies widely by region (Willgerodt et al., 2024). School nurses are ideally positioned to identify and respond to student mental health symptoms (Taylor-Beirne & Taylor-Beirne, 2022), but research indicates that they may lack the confidence, training, or organizational support to effectively support student mental health (Flodin et al., 2025; Kaskoun & McCabe, 2022).

SBIRT (Screening, Brief Intervention, Referral to Treatment) is a three-pronged evidence-based comprehensive intervention model that has been widely adopted for the prevention, early identification, and early treatment of substance use and has been adapted to address mental health symptoms (Bray et al., 2017). According to the Substance Abuse and Mental Health Services Administration (SAMHSA), the components of SBIRT include screening (i.e., quickly assessing problem severity and identifying appropriate level of treatment), brief intervention (i.e., increasing insight, awareness, and motivation toward behavioral change), and referral to treatment (i.e., identifying persons needing treatment and providing access to specialty care) (SAMHSA, 2024). Whereas some school nurses report providing mental health screenings (Moore et al., 2023; Pestaner et al., 2021), interventions (Bohnenkamp et al., 2015; Hoskote, 2023; Tanner et al., 2020), and/or referrals to treatment (Habib et al., 2024), evidence suggests that few school nurses employ an evidence-based coordinated response to address student mental health needs (Bourgault & Etcher, 2022; Taylor-Beirne & Taylor-Beirne, 2022; Williams et al., 2021). For example, we found only one report of a nurse-led SBIRT intervention to address a student mental health issue in a one-site quality improvement project (Sanders, 2024).

While some training programs have been developed to increase school health provider competence in addressing student mental health concerns (Bohnenkamp et al., 2019), we believe that providing SBIRT training to school nurses could enhance their practice by providing them with the skills to deliver a comprehensive and integrated approach to address the mental health needs of students. However, in order to develop such a training, we need to first better understand what practices school nurses view to be consistent with their role as these views will likely impact their adoption of SBIRT. We also need to determine which of these practices align with the components of SBIRT as this information will help us determine if it is feasible to adapt SBIRT for school nurse practice. The purpose of this study, therefore, is to describe how school nurses perceive their role in addressing student mental health concerns and to determine if these perceptions align with the three components of SBIRT.

Methods

This study used a qualitative descriptive approach as described by Sandelowski (2000). Qualitative description is an approach that provides a straightforward summary of narrative data so as to provide pragmatic findings that can inform policy and practice. The method was deemed appropriate for this study as we sought a clear but low-interpretive summary of participant responses to an open-ended survey question. The study was guided by the School Nursing Practice Framework^TM that emphasizes the role of school nurses in addressing student mental health and the importance of collaboration with mental health teams (National Association of School Nurses, 2024).

Data for this qualitative study were drawn from a parent study of an intervention called Mind-Body Skills Groups (https://cmbm.org/mind-body-resources/skills-group-finder/) that was conducted with school nurses virtually in a Midwest state from October 2024 to December 2024. The parent study was approved by the Indiana University Institutional Review Board (#21030). School nurses responded to recruitment messages shared via the state school nurse affiliate listserv, state annual conference messages, and the state's school nurse consultant monthly newsletter. Those interested in participating in the study visited a research website and completed a pre-screening survey based upon the study's inclusion criteria. Inclusion criteria included (1) being a school nurse practicing in the state in which the study occurred, (2) caring for students in the 4^th grade or higher, (3) no previous experience in a Mind-Body Skills Group, and (4) a willingness to commit to an 8-week intervention that occurred after work hours.

The participants completed a baseline online REDCap survey after completing an e-consent process via REDCap and a follow-up survey upon completion of the intervention. The intervention included an 8-week, facilitator-guided, small group educational program in which school nurses shared self-reflections with fellow school nurses and learned meditation, guided imagery, autogenic training and feedback, breath work, movement, and self-expression through journaling and drawing. Outcomes will be reported in a forthcoming publication.

The baseline survey included demographic, mental health, physical health, health behavior, and professional well-being questionnaires. In anticipation of our intent to develop mental health-focused SBIRT training for school nurses, we included a single open-ended question at the end of the survey: “What role do school nurses play in addressing student mental health?” These responses were entered in a text box on the survey.

The participant responses to the open-ended question were analyzed for the study reported here using content analysis and magnitude coding (Miles et al., 2019). The research team entered the open-text responses in the first column of a Microsoft Excel spreadsheet. The subsequent columns were labeled with terms reflecting the three SBIRT components (i.e., screening, brief intervention, referral for treatment). An “other” column was added for responses not aligned with any of the components. The first author assigned each response to one or more of the columns based on the SAMHSA definitions presented previously. The second author reviewed the assignment designations made by the first author and noted any discrepancies. Discrepancies were easily resolved through discussion and review of data. Using a similar process, the responses in each column were categorized to allow description of the participants’ perceptions of school nurse roles in addressing mental health needs organized according to the three components of SBIRT.

Results

Of the 38 participants who responded to the open-ended question, 19 (50%) offered a response that aligned with at least one component of SBIRT. Eight responses aligned with screening, eight with brief intervention, and seven with referral for treatment. One response aligned with all three components. Thirty participants identified activities that did not align specifically with one or more SBIRT components but reflected an overarching approach to address student mental health needs. Some participants provided examples of how they themselves had engaged in activities to support the mental health of their students. Some participants strongly affirmed the important role of school nurses in addressing student mental health concerns. These results are summarized in Table 1 and described below.

OPEN IN VIEWER

Table 1.

School Nurse Perceptions About Activities Related to Student Mental Health That are Within Their Role as Aligned With SBIRT Components.

School nurse activities aligned with SBIRT component(s)	Number of school nurses who viewed activity as part of their role	Exemplar Quote
Screening Mental health screenings Mental health assessments Identifying mental health concerns	8	“[School nurses] are sometimes the first to assess a need in the student.”  “We also see mental health manifest as physical symptoms.” “School nurses are often first to identify emotional needs in their students and are responsible for ensuring the right people are aware of specific needs.”
Brief Intervention Teaching/supporting use of coping strategies Having therapeutic conversations Providing education related to mental health Assisting students in managing somatic symptoms Helping students articulate their mental health needs	8	“Helping students navigate their own mental health issues and helping to find resources for them.” “[School nurses provide] assistance in dealing with current incident and offering suggestions for help.” “[School nurses play] a major role in helping students express their problems or situations. We are some of the first people they might come to when having mental health problems.”
Referral to Treatment School counselors School social workers Mental health professionals external to the school Other “right people” to meet the students’ mental health needs	7	“Referring the students when appropriate, advocating for them” “We assist in listening to concerns and getting students connected to the right person to address their mental health.” “Depends on availability. Often they start with me then see the counselor or social worker as needed.”
All Three SBIRT Components	1	“We can be a listener and screener to send onto the counselors in the school. Give the students ways to cope when they come to the clinic.”
Other Being a first contact for students Providing students resources Listening to students Offering students support Advocating for students Building a trusting relationship with students Working with students’ families	30	“[School nurses] are a touch point for school aged kids to come to if they are experiencing any issues and feel like they can talk to the school nurse.” “School nurses address mental health every day. They are often the first contact for the student and can help support and provide resources to the student and family.” “We can advocate between school and parents, especially if they do not know.” “They can be a great resource and bridge between a school counselor and home.”

Note: SBIRT: Screening, Brief Intervention, and Referral to Treatment.

Discussion

The participants indicated school nurses have a critical role to play in addressing student mental health. Some of the activities they identified clearly aligned with a component of SBIRT, whereas other activities were more generally related to forming a trusting and supportive relationship with students.

Our finding that school nurses view screening for mental health concerns to be part of their role has not been well documented in prior research. Research suggests that school nurses commonly screen for physical health concerns, such as vision, hearing, dental, immunization status, blood pressure, body mass index, or concussion (Goulding et al., 2024; Ilgaz, 2022; Nickum et al., 2023), but it is unclear how often they screen for mental health concerns. A nationwide survey revealed 87.5% of school districts have policies regarding on-site screening for student hearing concerns and 87.4% for vision concerns but only 12.8% for mental health concerns (McCabe et al., 2024). Among the small portion of school districts that provide screening for mental health concerns, it is unknown if school nurses conduct any screenings.

Our participants used the terms screening, assessment, or identification somewhat interchangeably, yet the terms have distinct meanings in the school mental health arena. A mental health screening is the formalized use of a standard set of questions to help school nurses and other health care providers check for signs or symptoms of a mental disorder (National Library of Medicine, 2022), whereas a mental health assessment is a part of the nursing process and consists of a general overview of student characteristics, demeanor, and health and academic data (Perron et al., 2021). Both mental health screenings and nursing assessment of student mental health can be used to identify students at risk for or exhibiting symptoms of mental disorders (Lytle et al., 2024; Perron et al., 2021). The distinct meanings of these terms have practical implications for nursing practice. For example, some states prohibit mental health screening of students without written consent from parents (von Zastrow, 2022) but it is within the scope of school nursing practice to assess the mental health status of all students, including those who have been diagnosed with a mental health condition or are exhibiting sub-clinical mental health symptoms. Furthermore, a nationwide analysis of schools revealed 49% of schools conduct mental health assessments (National Center for Education Statistics, 2022), which is a much greater proportion than schools who have policies regarding mental health screenings (McCabe et al., 2024). Developing school nurse practices related to the first component of SBIRT, therefore, may require differentiating activities related to screening for, assessing, or identifying mental health concerns.

While school nurses in our study identified several brief interventions they felt were within their scope of practice, previous studies suggest many school nurses are not clear regarding whether they can or should provide mental health interventions (Bohnenkamp et al., 2019). However, research has revealed that school nurses often do provide mental health interventions. An integrative review of school nurse mental health interventions revealed that most interventions were group-based, lasted at least 30 to 60 min, and involved a series of multiple sessions (Tanner et al., 2020). Barriers to school nurses providing mental health interventions include lack of time, limited resources, and lack of space (Bohnenkamp et al., 2019). In a study of an online mental health training for school nurses, school nurses expressed feeling prepared to deliver brief interventions, such as teaching a student cognitive coping or activity scheduling, after receiving the training (Bohnenkamp et al., 2024).

Our finding that some school nurses view mental health referrals as part of their role is inconsistent with findings of a study by Bohnenkamp et al. (2024). They reported that an intervention called Mental Health Training Intervention for Health Providers in Schools (MH-TIPS) increased rates of screening and delivery of brief interventions by school nurses but not rates of mental health referrals. Referrals may depend on the availability of mental health providers and may be curtailed by the widespread provider shortage. School nurses may need a referral list that is constantly updated in light of the provider shortage. Additionally, school nurses may be empowered to provide appropriate levels of mental health support with formalized training thereby decreasing the need to refer some students to additional mental health support.

Because many of our participants saw at least one of the three SBIRT components within their scope of practice and engaged in a number of relationship-building activities that provide a foundation for SBIRT, we believe that school nurses would be receptive to implementing SBIRT in the context of their everyday practice by integrating the intervention into routine or episodic student visits to their office. However, because our results and those of prior studies reveal that school nurses are not providing mental health care that is coordinated, systematic, and evidence based (Hoskote et al., 2023), we recognize that school nurses would need formalized training and organizational support in order to implement SBIRT.

Our findings should be understood in terms of the primary study limitation. The data were drawn from an intervention study and analysis was restricted by the dataset that included open-text responses to a single question on a survey designed for another purpose. This approach did not allow us to obtain rich narratives or ask follow-up or clarifying questions to understand the nuances of school nurses’ views on providing mental health care for students. Future studies should include designs that allow for in-depth exploration of school nurses’ views as well as objective assessments of their actual day-to-day practices in addressing student mental health.

Conclusion

Results indicate that school nurses consider SBIRT activities within their realm of practice, but they do not provide a comprehensive three-pronged approach. The development of an SBIRT intervention tailored for school nurses is thus indicated. Our team will collaborate with school, SBIRT, and implementation experts to develop and test such an intervention.