The Journal of School Nursing2024, Vol. 40(2) 144–154© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211056647journals.sagepub.com/home/jsn
Schools’ health screenings can identify students’ missed health concerns. Data from the 2016 School Health Policies and Practices Study were used to determine the proportion of U.S. school districts with physical and mental health screening policies and the proportion that arrange off-campus mental health services. We also examined differences between districts with and without mental health screening policies regarding having physical health screening policies, patterns of these policies, and off-campus mental health service arrangements. Eleven percent of districts had no policies on any of the four physical health screenings assessed, and 87% lacked policies on mental health screenings, the latter especially concerning considering the impact of COVID-19. Districts with policies on mental health screenings were significantly more likely to have body mass index (p < .01) and oral health (p < .001) screening policies, and to arrange for off-campus case management (p < .001), family counseling (p < .05), group counseling (p < .01), self-help (p < .05) and intake evaluation (p < .05).
Keywordsschool health services, child and adolescent health, student outcomes, chronic diseases, mental and behavioral health, policies, health promotion
Schools are essential venues for health screenings, consistent with a public health framework to enrich all students and families (Brownson et al., 2020; Schaffer et al., 2016). The purpose of these screenings, including vision, hearing, body mass index (BMI), and oral health (subsequently referred to as physical health screenings), and mental health screening, is to identify students with potential impairments that will need follow-up evaluations by health care providers (Rodriguez et al., 2018). Detecting students with impairments that may affect their expression, speech and/or language, and intellectual and/or social development is essential to offer the necessary support and accommodations to ensure that they can reach their greatest potential (Perkins, 2017). Furthermore, although research supports the link between health and academic outcomes (Best et al., 2018; Glewwe et al., 2018; Leroy et al., 2017; Yoder, 2020), screening for health disorders that promote optimal learning is not mandated in every state in the U.S. (Gracy et al., 2018). In addition, in those states where there are mandates, there is wide variation in the types of screenings offered and a lack of standardization of screening criteria and protocols (Gracy et al., 2018; Wahl et al., 2021). With ∼19% of school-aged children not receiving their annual checkup pre-COVID-19 pandemic (Child & Adolescent Health Measurement Initiative, 2019), and an even greater proportion missing their annual checkups and routine childhood immunizations during the pandemic (Mandy et al., 2021; Piché-Renaud et al., 2021), government-mandated screening requirements in schools represent an opportunity to identify children who have untreated or unnoticed health disorders.
In this manuscript, the term mental health disorders is used to signify a wide range of mental, emotional, and behavioral health disorders as defined by the World Health Organization (WHO) (2019) as “…disorders that fall within the International Statistical Classification of Diseases and Related Health Problems (Tenth Revision) that cause a high burden of disease such as depression, bipolar affective disorder, schizophrenia, anxiety disorders, dementia, substance use disorders, intellectual disabilities, and developmental and behavioural disorders with onset usually occurring in childhood and adolescence, including autism” (para. 2). In some instances, we have included the terms emotional and/or behavioral health disorders to be consistent with the language and terms used by the specific organization or journal article referenced.
Because ∼80% of chronic mental health disorders begin in childhood (Goodman-Scott et al., 2019), and because there is ongoing concern regarding suicide rates, self-harm, depression, and school violence among K-12 students (Goodman-Scott et al., 2019), mental health school screenings are arguably at least as essential as physical health school screenings. In schools, mental health screening involves assessing students to reveal whether they may be at risk for a mental health disorder. Screening can be performed using a systematic instrument or process with an entire population (school student body), a group of students (classroom or grade level), or individually (Perron et al., 2021). Research demonstrates that mental health and behavioral health issues impact academic outcomes (Brown et al., 2021; Dalsgaard et al., 2020; Gracy et al., 2017; Marsh & Mathur, 2020). Additionally, unmet mental health needs negatively impact life-long outcomes such as graduation from high school, educational opportunities, employment, and social and financial advancement (Goodman-Scott et al., 2019; Guerra et al., 2019; Larson et al., 2017; Marsh & Mathur, 2020).
Notably, from 2007 to 2017, there was a 56% increase in the suicide rate in youth and young adults aged 10–24 years (Curtin & Heron, 2019). In fact, the suicide rate has almost tripled in the past decade in youth aged 10–14 years (Curtin & Heron, 2019), with the rates for black youth among both boys and girls, aged 5–12 years, twice that of white youth of the same age (Bridge et al., 2018). Many youths may experience stress and anxiety, and the National Academies of Sciences, Engineering, and Medicine (NASEM) estimates that each year, 14%–20% of youth are diagnosed with mental, emotional, or behavioral mental health disorders (NASEM, 2019). Despite this high prevalence, only 45% of youth with a mental health diagnosis receive treatment (Goodman-Scott et al., 2019). In fact, multiple studies report that most children in the U.S. who experience mental health disorders do not have access to the supports they need (Demissie & Brener, 2017; Golberstein et al., 2020; Guerra et al., 2019; Stark et al., 2020).
Previous literature on mental health disorders in children has documented an increase in emotional and behavioral health needs during times of disaster and traumatic events, such as natural disasters and global health concerns (Brown et al., 2021; Golberstein et al., 2020; Stark et al., 2020). In fact, during the early phase of the COVID-19 pandemic (March–April 2020), the Centers for Disease Control and Prevention (CDC) reported that emergency department (ED) visits for youth mental health disorders in 5–11-year-olds and 12–17-year-olds increased 24% and 31%, respectively (Leeb et al., 2020). The authors suggest that the increase in ED visits may be related to a rise in pandemic-related stress coupled with reduced access to routine and crisisrelated youth mental health services. Other mental health disorders, such as substance use disorders, suicide, and depression, are also likely to increase post-pandemic (Hertz & Barrios, 2021; Marques de Miranda et al., 2020). A study on post-traumatic stress disorder (PTSD) by Brown et al. (2021) found unexpected results in a three-year longitudinal study of school children affected by a wildfire in Canada. The authors hypothesized that measures of PTSD (anxiety and depression) would decrease over time. Instead, the measures worsened, suggesting that PTSD effects of the COVID-19 pandemic may be long-lasting and may persist for years.
Therefore, especially in light of the ongoing COVID-19 pandemic, it is vital to examine the prevalence of mental health screening policies in U.S. school districts. School-based mental health screenings are a foundational component of all-inclusive behavioral health well-being and intervention (Martinez et al., 2020). Universal schoolwide screening for mental health disorders is recommended by the National Association of School Psychologists & the National Center for School Mental Health (2015), as well as the National Academies of Sciences, Engineering and Medicine (2019) and the WHO (2020).
While some school districts may perform mental health screenings, the Substance Abuse and Mental Health Services Administration (SAMHSA) (2019) states that schools must approach mental health screening as part of a universal, strategic, and comprehensive plan to address mental and behavioral health needs of all students—a multitiered system of support (MTSS) approach. An MTSS approach includes screening in schools and working with partners in the community to ensure that students have a continuum of support (Marsh & Mathur, 2020). In fact, according to the National Association of State Boards of Education (2019), 22 U.S. states have policies requiring school-based or school-linked mental health promotion and intervention programs. SAMHSA (2019) suggests that schools provide programs that focus on the education of students and staff on mental health wellness and prevention. SAMHSA also suggests that a group of school and community stakeholders be created that meets regularly to support student mental health. Recommended members include parents/guardians, school administrators, school nurses, school social workers and psychologists, school teachers, pediatricians, community mental health professionals, and community agencies for underserved/vulnerable populations.
Because early detection and management of mental health disorders lead to healthier outcomes for students (Bohnenkamp et al., 2015; Guerra et al., 2019; Humphrey & Wigelsworth, 2016), it is essential to examine the resources and supports available off-campus. Support and resources beyond on-campus mental health screenings may be provided through specific systems of care that include community-based (off-campus) services and supports for children and youth with, or at risk for mental health disorders. These systems are organized into coordinated networks that help build meaningful partnerships with families and youth and address children’s cultural and linguistic needs to help them function better at home, school, community, and life (Hodges et al., 2021). Examples of off-campus mental health services may include case management, family counseling, group counseling, and self-help (Cullins et al., 2016; Hodges et al., 2021; Humphrey & Wigelsworth, 2016).
Although prior research has examined mental health policies in schools (Demissie & Brener, 2017; Guerra et al., 2019), to our knowledge, no published research has examined school districts’ policies on the provision of physical health screenings when considering whether the districts have policies on mental health screenings. Perhaps school districts that have policies on mental health screenings may be more likely to also have policies on physical health screenings. These school districts may have an established culture of acceptance and inclusion regarding mental health screenings and may be especially committed to simultaneously addressing student behavior and school climate, uncovering students’ potential physical health needs, and referring students to relevant support (Cobb, 2014; Katz et al., 2020; Wong et al., 2019). It is also conceivable that school districts that do not have policies on mental health screenings may be unable to conserve sufficient resources to have policies that offer a range of physical health screenings. In fact, research suggests that schools with insufficient financial resources report that they do not offer social, emotional, and behavioral screening (Dineen et al., 2022; Gracy et al., 2018). In addition, to our knowledge, no published research has examined whether school districts’ policies on mental health screenings are related to the provision of off-campus mental health services.
Thus, the purpose of this study is to determine the extent to which U.S. school districts have policies on screening students for on-site physical health and mental health, and the extent to which they make arrangements with mental health or social service agencies to provide various types of off-campus mental health services. By examining U.S. school districts’ screening policies, we will better understand the extent to which they offer such screenings. In addition, we examine differences between school districts that had policies on on-site mental health screenings with those that did not regard (1) having policies on on-site physical health screenings, (2) patterns or combinations of these physical screening policies, and (3) off-campus mental health service provision. As the school nurse often provides care coordination and directs and/or oversees screening and offcampus arrangements, these issues have special relevance for school nurses.
This study analyzed data from the 2016 School Health Policies and Practices Study (SHPPS) (CDC, 2016). SHPPS 2016 is a cross-sectional survey collected from a nationally representative sample of public school districts that contain elementary, middle, and/or high schools. SHPPS is periodically conducted to assess school health policies and practices at the classroom, school, district, and state levels that correspond to the components of the whole school, whole community, whole child model (ASCD & CDC, 2014). Five questionnaires comprise SHPPS: health education, physical education and physical activity, nutrition services, health services, and healthy and safe school environment (CDC, 2016).
SHPPS 2016 used systematic random sampling based on the October 2015 version of the Market Data Retrieval database, which was stratified according to locale codes developed by the National Center for Education Statistics (NCES; CDC, 2016). A total of 957 public school districts were considered eligible for inclusion. Approximately 77% (n = 740) of eligible school districts completed at least one of the five questionnaires that comprise SHPPS. The publicly available data were considered exempt from review by the Institutional Review Board at Hunter College.
Data from the 2016 SHPPS Health Services questionnaire, the data used for these analyses, were collected from October 2015 through August 2016 at the school district level only. Thus, our unit of analysis is the school district. The health services questionnaire included questions on school health services, counseling, psychological services, and social services supporting student health. Access to the publicly available SHPPS data set and a comprehensive description of the 2016 SHPPS questionnaires, including the health services questionnaire, can be found at https://www.cdc.gov/healthyyouth/data/shpps/index.htm. Web-based questionnaires and paper-and-pencil versions of the questionnaires were available to districts. Each district identified the questionnaire respondent as the individual most knowledgeable about health services within the district. Survey respondents included school stakeholders including lead school nurse, head nurse, school or district nurse, school superintendent, supervisor of health and student services, administrator, director of health services, and administrative support.
We examined and analyzed SHPPS policies associated with five on-site health services screenings and off-campus arrangements to provide specific types of health services or counseling, psychological or social services. We note that SHPPS collected data on such off-site services (rather than both on-site and off-site health services or counseling, psychological or social services). A total of 613 of 957 school districts completed the health services questionnaire with a response rate of 64.1%.
Study outcomes were derived from five questions with “yes” or “no” responses regarding whether or not school districts had on-site policies on screening for hearing, vision, oral health, BMI, and mental health. Study outcomes also involved districts’ “yes” or “no” responses to whether or not they had arrangements to provide each of a number of off-campus health services or counseling, psychological, or social services to students, including (a) case management for students with emotional or behavioral problems; (b) family counseling; (c) group counseling; (d) individual counseling; (e) comprehensive assessment or intake evaluation; (f) peer counseling or mediation; and (g) self-help or support groups.
Analyses were conducted using the complex samples module in IBM SPSS 27 with equal probability sampling without replacement. This allowed the data to be weighted to produce correct confidence intervals, standard errors, valid point estimates, and testing of hypotheses. In addition, it enabled extrapolation of findings to all public school districts in the U.S. (West et al., 2018).
Descriptive statistics determined the proportion of districts providing various types of on-site screenings and offcampus health services or counseling, psychological, or social services to students. On-site screening patterns were also created according to responses (“yes” or “no”) to the screening questions on physical health. For example, a pattern where the district answered “yes” to having a policy to provide hearing, vision, oral health, and BMI screenings was coded as “1,1,1,1.” A pattern where the district answered “yes” to having a policy on hearing, vision, and oral health but “no” to BMI screening was coded “1,1,1,2.” Sixteen patterns were created.
Chi-square analyses were used to determine the statistical relationships between policies on mental health screening and other on-site screening policies and patterns. They were also used to determine the statistical relationships between on-site mental health screening policies and arrangements to provide various off-campus health services or counseling, psychological, or social services to students. Statistical significance was determined by a p-value of ≤.05.
A total of 495 U.S. school districts responded to whether or not they had a policy on district schools’ screening students for physical health and mental health, and whether or not they had made arrangements with mental health or social service agencies to provide various types of off-campus mental health services (i.e., case management, counseling, assessment, and self-help). The 495 districts constitute the study sample, with results extrapolated to the population of school districts in the U.S. The majority of districts had policies to screen on-site for hearing and vision, 25.8% had policies on on-site oral health screening, 29.6% on on-site BMI screening, and 12.8% on on-site mental health screening. See Figure 1.
We then examined if there were differences in school districts with and without policies on on-site mental health screening regarding having policies on the four types of on-site physical health screening. The majority of U.S. school districts, both those with and without on-site mental health policies, had policies on on-site vision and hearing screening, and there were no statistically significant differences according to whether they had policies on on-site mental health screening. However, districts with policies on on-site mental health screening were significantly more likely than districts without policies on mental health screening to have policies on on-site screening for oral health and BMI. See Figure 2.
Next, we examined if there were differences in the patterns of on-site physical health screening policies depending on whether or not the district had a policy on on-site mental health screening. These differences were highly significant (p < .001). As can be seen in the last column of Table 1, all but 14% of the districts had policies on on-site hearing and vision screening, with or without policies on on-site oral health and on-site BMI screening. Of these 14% of districts, 11% had no policies on on-site hearing, vision, oral health, and BMI screenings, and the remaining 3% had various other on-site policies that did not include vision and hearing screening.
As can be seen in Table 1, 33.6% of the districts with an on-site policy on mental health screening had on-site policies on hearing, vision, oral health, and BMI screening, and 31.8% only had policies on on-site hearing and vision screenings. Most of the remaining districts with on-site mental health screening policies had policies on on-site hearing and vision screenings and either on-site oral health or on-site BMI screenings, but not both.
Almost half (46.2%) of the districts that did not have a policy on on-site mental health screenings had policies only on on-site hearing and vision screenings. In all, 10.3% of these districts had policies on on-site hearing, vision, oral health, and BMI screening, and 28.4% had policies on on-site hearing and vision screenings and either on-site oral health or on-site BMI screenings, but not both. In all, 11.7% of these districts had no policies on on-site hearing, vision, oral health, and BMI screenings and the remaining 3.4% had various other patterns of on-site policies.
Regarding provisions for off-campus mental health services, 29.7% arranged for individual counseling, 27.7% arranged for case management, and 24.5% arranged for intake evaluation. In addition, 20.6% arranged for group counseling, 20.2% arranged for family counseling, 18.9% arranged for self-help, and 16.5% for peer counseling.
Compared with districts that did not have a policy of an on-site mental health screening, about twice the proportion of districts having such a policy had statistically significant differences concerning arrangements to provide off-campus case management (p <. 001), family counseling (p < .05), group counseling (p < .01), and self-help (p < .05). In addition, a significantly greater proportion of districts with a policy on on-site mental health screening had arrangements to provide intake evaluation than districts without a policy on on-site mental health screening (p < .05). See Figure 3.
To our knowledge, this is the first study to systematically examine the extent to which U.S. school districts have policies on on-site physical health screenings and on-site mental health screenings, and the extent to which they partner with mental health or social service agencies to provide various types of off-campus mental health services. Consistent with previous research (Nottingham Chaplin et al., 2020; Wahl et al., 2021; Yong et al., 2020), the current study results indicate that the majority of U.S. school districts have policies on hearing and vision screenings (87.5% and 87.4%, respectively). Results also indicate that 29.6% have BMI screening policies and 25.8% have oral health screening policies. Previous research demonstrates that approximately two out of every five schools in the U.S. conduct schoolbased BMI screening (Sliwa et al., 2019). In addition, 14 states and the District of Columbia have dental screening laws, but the provisions vary by state. These variations include whether or not the screening is performed prior to school entry and whether the screening is mandatory or voluntary (Children’s Dental Health Project, 2019).
Our results also indicate that only 12.8% of school districts have policies on mental health screenings. Such a small proportion having such policies strongly suggests that there is an unmet need for mental health services. In fact, this study found that only 29.7% of U.S. school districts arranged for off-campus individual counseling and 27.7% arranged for case management, 24.5% for intake evaluations, 20.6% for group counseling, 20.2% for family counseling, 18.9% for self-help, and 16.5% for peer counseling. Prior research from the NCES demonstrates that in the 2017–2018 school year, 51% of U.S. public schools reported that they provided mental health assessment services to evaluate students for mental health conditions (NCES, 2020). Perhaps the differences in proportions between this NCES study and the current one can be attributed to the unit of analysis of collected data and questionnaire wording. The NCES used school data and examined the provision of mental health assessments, whereas the current study, using SHPPS 2016, collected district policy data and asked about policies regarding mental health screening. Regarding off-campus treatment services, NCES found that <10% of U.S. public school districts offered them outside of the school setting (NCES, 2020), a proportion considerably less than current findings.
Our results also indicate that a greater proportion of districts with mental health screening policies than those lacking such policies were significantly more likely to have policies on oral health and BMI screenings but not vision and hearing screenings. This result was as we anticipated, as we expected that school districts with mental health screening policies might be more likely to also have physical health screening policies. We hypothesized that these school districts might have established screening resources, and therefore have the financial support, adequate staffing, and supportive school culture to also “spend” on physical health screenings, including vision and hearing. It is not surprising that most districts that did not offer mental health screenings would have policies on hearing and vision screenings, as school districts have been offering hearing and visions screenings for some time (Allensworth et al., 1997; Appelboom, 1985). For these districts, perhaps having policies on hearing and vision screenings has been a part of the school culture and/or state mandates, and therefore offering the screenings may be included in the annual budget.
We found statistically significant differences when examining the patterns of policies on physical health screenings according to whether or not the school district had a policy on mental health screening. About the same proportion of U.S. school districts with a policy on mental health screening had policies on vision, hearing, BMI, and oral health screening as they did on only vision and hearing screening. By contrast, districts without a policy on mental health screening were greater than four times more likely to have a policy on only vision and hearing screenings as on all four physical health screenings. The proportional similarity for districts with mental health screening policies may capture a cultural shift toward more districts providing all four of the physical health screenings that we considered compared to traditional vision and hearing screenings only. The proportional discrepancy for districts with no policy on mental health screening may be due to existing barriers surrounding school health services, including a lack of supportive culture, structure, and resources. Additionally, Shelton and Owens (2021) report that among urban, suburban, and rural school districts, there are geographic differences in mental health services provision. Specifically, in rural areas, inadequate access to mental health professionals, inadequate funding, and payment policies limits mental health efforts. Of particular concern and cause for further research are the 11.7% of U.S. school districts with no policy on on-site mental health screenings also having no policies on on-site physical health screenings.
We also found that a greater proportion of districts with mental health screening policies compared with the proportion of those lacking such policies were significantly more likely to have arrangements for off-campus case management, family counseling, group counseling, intake evaluation, and self-help. We were unable to locate peer-reviewed literature or other data sources on school district arrangements for off-campus mental health services that support or refute this finding. However, in a recent systematic review, Arora et al. (2019) report that multi-tiered supports in mental and behavioral health emanating in schools can form a significant foundation through early identification and referral of students to programs on-campus and with arrangements for off-campus services. Given lessons learned from the COVID-19 pandemic, the use of telehealth services may also offer an opportunity for school districts to reconsider previous limitations and barriers to the provision of both on-campus and off-campus mental health services (Goddard et al., 2021; Sanchez et al., 2019).
While we do not have a clear explanation for why mental health screening proportions are so low, our results indicate that school-based mental health screening needs attention. No matter the rationale, it is important to highlight that of those school districts that provided mental health screening, there was an association with providing more physical health screenings and off-campus mental health services. This may suggest that if other districts begin to offer mental health screenings, they may offer other kinds of screenings and partner to provide off-campus mental health services. These screenings and services are important to children’s health and well-being, especially in view of the physical and mental health issues that have arisen because of COVID-19 (Mandy et al., 2021; Piché-Renaud et al., 2021; University of Washington SMHA, 2021).
There is a need for research to delve deeper into the reasons districts have policies on mental health screenings. This information can help inform policymakers and may result in the implementation of such policies. We must become a society that promotes wellness for all, and there should be deep concern over the lack of U.S. school districts’ mental health screening policies. Overall, this scarcity regarding mental health screening policies is concerning as it suggests a lack of commitment to optimizing children’s academic success. Presently there is no federal mandate for comprehensive physical and mental health screening policies throughout the U.S., with policies varying by school districts (McCance-Katz & Lynch, 2019; National Academy for State Health Policy, 2021). In addition, many school-aged children are not currently receiving their annual checkups that may include assessing mental wellness. Recent research has noted that the gaps in health screening for children are not following best practice guidelines as delineated by the American Academy of Pediatrics (Gracy et al., 2018). Schools represent an optimal place to fill these gaps and identify unmet health needs and the school nurse is key to identifying these needs. The next steps in school healthcentered policy include the active pursuit to develop standardized, evidence-based school health screening policy requirements and the implementation of such policies. These should especially take into consideration the COVID-19 pandemic and the impact that it has had on school-aged youths’ mental health.
Limitations in the current study include the use of crosssectional data, preventing an examination of causal relationships. A second limitation is that SHPPS 2016 primarily asks policy and practice questions, which is its intention but leaves questions unanswered about implementation. Further research should aim to learn more about implementing school health service policies. Additional information and follow-up are also needed regarding on-site mental health services. Overall, this study encourages further exploration and discovery about health services with a strong emphasis on the role of schools, school districts, and stakeholders, including school nurses, in mental health care and follow-up.
By examining U.S. school districts’ health screening policies, we are better able to understand the extent to which U.S. school districts offer such screenings, as well as the patterns or combinations of offered health screenings. As a nation, we need to focus on the role of schools and school districts in facilitating screening and the role of the federal government in offering more significant protection to vulnerable students who may have unmet physical, mental, and behavioral health needs. Large numbers of school-age children are projected to have some level of mental health disorders due to COVID-19 (Marques de Miranda et al., 2020). Researchers report that untreated mental health disorders can cause life-long disability or suicide in students (Bridge et al., 2018; Curtin & Heron, 2019). Implementing schoolbased wellness and prevention strategies, often led by school nurses, can promote educational outcomes, improve mental and physical well-being for students, their families and communities, and contribute to decreasing financial burdens to society (Belfield et al., 2015; Corcoran et al., 2018). School nurses can also examine local school district policies and advocate for changes that align with evidencebased research and current mental health best practices. As researchers, policymakers, and education stakeholders who want to improve the health of the U.S. population, we have a socially just expectation to address this gap in holistic healthcare by overcoming financial and other barriers, while recognizing that schools are a safety net for all children.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The authors received no financial support for the research, authorship, and/or publication of this article.
Ellen M. McCabe https://orcid.org/0000-0003-2901-1670
Beth E. Jameson https://orcid.org/0000-0003-0225-3741
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Ellen M. McCabe, PhD, RN, PNP-BC is at Hunter Bellevue School of Nursing, Hunter College.
Beth E. Jameson, PhD, RN, CNL is at Seton Hall University College of Nursing.
Shiela M. Strauss, PhD is at Hunter Bellevue School of Nursing, Hunter College.
1 Hunter Bellevue School of Nursing, Hunter College, New York, NY, USA
2 Seton Hall University College of Nursing, Nutley, NJ, USA
3 New York University, Rory Meyers College of Nursing, New York, NY, USA
Corresponding Author:Ellen M. McCabe, PhD, RN, PNP-BC, Hunter-Bellevue School of Nursing, 425 East 25th Street, New York, NY 10010, USA.Email: em3766@hunter.cuny.edu.
