The Journal of School Nursing2024, Vol. 40(4) 431–439© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405221119518journals.sagepub.com/home/jsn
Abstract
School nurses play a key role in supporting student mental health, and many school nurses report the need for additional mental health education. The Mental Health Training Intervention for Health Providers in Schools (MH-TIPS) is a training and implementation support system for school nurses to enhance their skills in promoting student mental health. The current study evaluated the feasibility of the MH-TIPS online curriculum for school nurses, and its impact on their preparedness and ability to support student mental health. Participants included 1,282 registered nurses and nurse practitioners. Descriptive statistics indicated that MH-TIPS online was feasible, relevant, and accessible for school nurses and helped them support student mental health. School nurses reported significant improvements in their preparedness to conduct brief mental health interventions with students and motivate students to seek help. MH-TIPS online is a promising tool to increase the ability of school nurses to support student mental health.
Keywordsschool nurses, mental health, online education
School nurses promote student health, facilitate optimal development, and advance academic success. They are critical members of the school mental health team promoting positive behavioral health outcomes in students (National Association of School Nurses (NASN), 2017). School nurses are frequently among the first school staff to recognize signs of mental health distress in students, and they spend approximately 33% of their time addressing student mental health (Bobo & Shubert, 2013). School nurses partner with school and community mental health providers, families, and students to advance student and school community mental health and well-being (Bohnenkamp et al., 2015; Hoover et al., 2019).
Despite the critical role school nurses play in school mental health, there is little training and educational supports specifically aimed at improving the mental health competencies of school nurses (Bohnenkamp et al., 2015). Practicing school nurses regularly report a lack of mental health education as a barrier in providing students with adequate care (Pryjmachuk et al., 2011: Ravenna & Cleaver, 2016). A recent study of school nurses in Finland highlights that while many school nurses have basic mental health knowledge and skills, they need more knowledge about mental health interventions, assessment methods, and ways to support culturally diverse students (Markkanen et al., 2021).
School nurses who receive mental health education may be more likely to support students demonstrating mental health concerns and promote student mental health. Given the significant increase in mental health concerns for children and adolescents related to the COVID-19 pandemic, it is especially important to expand the reach of mental health education opportunities for school nurses (American Academy of Pediatrics, 2021; Bryant et al., 2020; Leeb et al., 2020, Loades et al., 2020; Verlenden et al., 2021).
While it has been acknowledged that school nurses are critical members of the school mental health team and need additional education resources to support student mental health, there are limited evidence-based mental health education opportunities specifically for school nurses (Pryjmachuk et al., 2011; Ravenna & Cleaver, 2016). Depending on state regulations, school nurse pre-service education is typically an Associate degree or Bachelors degree (Willgerodt et al., 2018). Accordingly, school nurse pre-service education in mental health varies based on the level of education, and program and state specific requirements. The curriculum requirements for an Associate Degree in Nursing (ADN) vary by state, but most require at least one course in behavioral health (Registered Nursing, 2021). However, most states do not have specific requirements for ADN curriculum to include a separate course focused on youth and adolescent mental health (Registered Nursing, 2021).
Access to additional mental health education courses is limited once school nurses are in practice, and those that exist are often geared towards a specific mental health concern. The Child Anxiety Learning Modules (CALM) is a brief nurse-administered intervention delivered via a one-day in-person training. CALM was specifically developed for school nurses to teach them how to implement empirically supported cognitive behavioral strategies to reduce anxiety and improve academic functioning in elementary school children (Muggeo et al., 2017). Similarly, Allison and colleagues (2014) provided training for school nurses on two validated screening tools, the Patient Health Questionnaire for detecting depression, and the Screen for Child Anxiety Related Emotional Disorders for detecting anxiety. The use of these screening tools helped school nurses improve the identification and referral of students with anxiety and/or depression (Allison et al., 2014). Consistent results were found from the QUEST intervention, an education program that targets school nurses’ competencies to identify depression. School nurses reported improved knowledge and confidence in addressing depression in their students following the program (Haddad et al., 2018). Mental health disorder specific education programs are related to improvements in school nurses’ knowledge and ability to address specific mental health concerns (e.g. anxiety, depression). However, there are limited education opportunities that support school nurses to address the range of mental health problems that they frequently encounter in their students. One such program, designed for all members of the school community, that provides general training for mental health concerns is Mental Health First Aid (Hart, et al., 2016). A published case study highlights how Mental Health First Aid supports school nurses’ mental health assessment and intervention skills (Atkins, 2017).
There are several programs that provide in-person education for school nurses in mental health. However, practicing school nurses often lack the time and resources necessary for in-person education and could benefit from online professional development (Vought-O’Sullivan et al., 2006). School nurses have access to brief online continuing education for some topics (e.g., anxiety, Adverse Childhood Experiences, emotion management) through the National Association of School Nurses (NASN, n.d.). School nurses also have access to online education in mental health (e.g., Cognitive Behavioral Intervention for Trauma in Schools (Jaycox, 2004) and social emotional learning (CASEL, 2021), but this content is also topic limited and not developed specifically for school nurses. There is a gap in the availability of more extensive, competency based online mental health education specifically designed for school nurses.
COVID-19 has also exacerbated demands on school nurses’ time, and in-person learning restrictions, further highlighting the utility of online mental health education opportunities for school nurses. Additionally, the increased rates of mental health concerns for children and adolescents related to the COVID-19 pandemic increases the need for school nurses to easily access mental health education opportunities and receive education to address student mental health concerns (Loades et al., 2020).
The Mental Health Training Intervention for Health Providers in Schools (MH-TIPS) is an in-service education and implementation support system for school nurses and other school health providers. MH-TIPS aims to increase participant competencies to manage child and adolescent mental health concerns (Bohnenkamp et al., 2018). The MH-TIPS was developed through a data driven process by the National Center for School Mental Health at the University of Maryland School of Medicine in partnership with the National Association of School Nurses and the Center for Mental Health Services in Pediatric Primary Care at the Johns Hopkins Bloomberg School of Public Health (see Bohnenkamp et al., 2018). The MH-TIPS program provides education to aid school health providers in supporting student mental health including: 1) Strategies and Skills to Promote Positive and Supportive Interactions for Student Mental Health Issues; 2) Mental Health Identification and Assessment; 3) Mental Health Referral and Resource Mapping; 4) Mental Health Crisis Response and Safety Assessment; 5) Mental Health Intervention Best Practices for Delivery by School Health Providers and; 6) Psychotropic Medication. The content is organized into three training modules, Foundations for Practice, Skills and Practice I, and Skills and Practice II (see Table 1).
Results from the MH-TIPS development study (Bohnenkamp et al., 2018) indicated both the usefulness and accessibility of an online training format for school nurses. Previous research highlights both the increased reach and feasibility of online education formats for school nurses (Elgie et al., 2010). Given the utility of an online education format, a virtual version of the entire MH-TIPS course is available at https://mdbehavioralhealth.com/training. The MH-TIPS Interactive Online Platform includes: 1) Implementation training videos; 2) School health provider mental health video vignettes; 3) Downloadable resources and tools; 4) Frequently asked questions and; 5) Interviews with experts. The MH-TIPS course also offers free continuing nursing education credits approved by the National Association of School Nurses.
Online education opportunities greatly expand the feasibility and reach of training opportunities for school-based professionals. School nurses report logistical challenges as barriers to attending in-person trainings including cost of in-person trainings, availability of another provider to cover their duties and travel constraints/lack of access in their geographic area (Vought-O’Sullivan et al., 2006). A study of an online education course for school nurses in emergency preparedness demonstrated that the online education format is feasible, more cost effective and expands the reach of the education content (Elgie et al., 2010). There is also a robust literature base for the feasibility and effectiveness of online mental health trainings for other school-based professionals (e.g., Jaycox, 2004; Kognito, 2020). Given the reach, feasibility, and effectiveness of online mental health trainings for other school-based professionals, more research is necessary to understand whether online mental health education opportunities would similarly be feasible and effective for school nurses.
The purpose of this study is to evaluate the impact of the MH-TIPS online course for school nurses. Specific research questions include: 1) How feasible and relevant is the MH-TIPS online course for school nurses? 2) Does the MH-TIPS online course improve in school nurses’ perceived preparedness to address student mental health concerns?) How frequently do participants indicate that they used the skills learned in the MH-TIPS training?) Does the MH-TIPS online course change participant’s perceptions of their ability to support student mental health?
This study was reviewed by the University of Maryland School of Medicine Institutional Review Board and determined that the project (HP-00096510) meets the definition of Not Human Subjects Research (NHSR).
The 3-module, MH-TIPS online course is available for anyone to complete at https://mdbehavioralhealth.com/training with continuing nursing education credits (CNE) available for nurses at no cost. Individuals who registered for the course had the option to complete a registration survey, as well as a survey following completion of each module, and a follow up survey 30 days after completing the entire course. Completion of the survey following each module is required for CNE credit. Although anyone can complete the MH-TIPS online course, the current study includes only registered nurses and nurse practitioners who reported working in schools and who completed the registration survey and completed at least one MH-TIPS module. This study used a descriptive and pre-post study design to assess 1) feasibility and relevance, 2) use of MH-TIPS after completion of the course, and 3) pre-post changes in participant’s preparedness and actions to address student mental health concerns.
After registering for the MH-TIPS online course, participants could begin one of three modules: Foundations for Practice (FP), Skills and Practice I (SPI), or Skills and Practice II (SPII). Though this is the recommended sequence for the training, participants had the option to complete the modules in any order.
Registered nurses and nurse practitioners who registered for MH-TIPS, reported working in schools and completed at least one module were included in the current study. Demographic information for the 1,282 participants is summarized in Table 2. Participants were practicing across the U.S. and in a range of school settings. Participants were majority White or Caucasian (93.7%), non-Hispanic, Latino, or Spanish (94.9%), and female (98.1%). While participants had varying backgrounds and experience, most had earned a bachelor’s degree (63.9%) and been in the field over 11 years (70.5%). Almost half of participants reported seeing between 21 and 50 students (49.6%) during a typical workday in their school setting.
Participants were asked to complete five surveys related to MH-TIPS: 1) The registration survey prior to completing any modules; 2) A post-test survey following each module they completed (3 post-test surveys); and a follow-up survey 30 days after the completion of all three modules. The registration survey includes 25 questions and takes approximately 10 min to complete. The registration survey includes questions about demographic information about participants and their practice and queries their perceived preparedness to address student mental health concerns and their current work supporting student mental health. The post-test survey, administered following each module, includes 25 questions and takes approximately 10 min to complete. The post-test survey includes questions about MH-TIPS feasibility and relevance, perceived preparedness to address student mental health concerns and their current work supporting student mental health. The follow-up survey includes 25 questions and takes approximately 10 min to complete. The follow-up survey includes questions about MH-TIPS feasibility and relevance, perceived preparedness to address student mental health concerns and their current work supporting student mental health.
Feasibility and Relevance. After completing each MH-TIPS module, participants were prompted to complete a post-test survey aimed at assessing opinions of MH-TIPS, including its feasibility and relevance to practice. Participants were asked to rate ten questions to assess MH-TIPS feasibility and relevance (See Table 3). Seven statements (e.g., “Please indicate to what extent you think that the MH-TIPS training is easy to use.” “Please indicate to what extent you think that the MH-TIPS training is based on scenarios relevant to you and your students”) were rated on a 5-point Likert-type scale where 1 = Not at all and 5 = To a very great extent. Two questions asked for participants to rate their level of agreement on a 5-point Likert-type scale where 1 = Strongly Disagree and 5 = Strongly Agree with statements related to the impact of MH-TIPS on their professional growth and practice (e.g. “This educational activity has positively influenced my practice”). The participants were also asked to provide an overall rating for MH-TIPS on a 5-point Likert-type scale where 1 = Poor, and 5 = Excellent. Given variance in the number and sequence of modules completed by the participants, these feasibility and relevance questions were examined using the last posttest survey completed by each participant.
Preparedness. During the course registration survey and after completing each MH-TIPS module (post-test survey), participants were prompted to assess their feelings of preparedness in addressing student mental health. Participants were asked to rate their feelings of preparedness on eight statements (e.g., “Contact the parent of a student exhibiting signs of psychological distress.” “Use a brief mental health intervention with a student exhibiting signs of psychological distress”)on a 5-point Likert-type scale where 1 = Very Low and 5 = Very High. Given variance in the number and sequence of modules completed by the participants, post-test preparedness outcomes were examined using the final survey completed by each participant.
Use of Skills. Thirty days after completing the final MH-TIPS module, participants were prompted to complete a survey with questions aimed at identifying their use of various elements from the training in their practice. Participants identified how frequently they used six different MH-TIPS elements (e.g., “Mental Health Identification and Assessment”; “Mental Health Referral and Resource Mapping”) on a 5-point Likert-type scale where 1 = Never and 5 = All the Time.
Supporting Student Mental Health. During the course registration survey and after completing each MH-TIPS module (post-test survey), participants recorded their weekly mental health encounters with students. Participants were asked to indicate the number of mental health-related encounters they had with students in the last week (e.g., “In the last week, how many students have you been concerned about due to their psychological distress?”). Given variance in the number and sequence of modules completed by the participants, post-test preparedness outcomes were examined using the last survey completed by each participant and at the 30-day follow-up.
Of the 2,643 registered nurses and nurse practitioners who registered for MH-TIPS, 545 (20.6%) completed only one module, 83 (3.1%) completed two modules, and 654 (24.7%) completed all three modules. Any registered nurses and nurse practitioners who completed any modules and worked in a school setting were included in this study (1,282 (48%)). 1,361 (51%) participants registered and completed some parts of the modules, but did not complete an entire module, and thus were not included in this study. Sixty-three participants completed the follow-up survey 30 days after their last completed MH-TIPS module and thus, the sample for the follow-up survey only includes this subsample of participants.
To examine participant opinions of MH-TIPS, including its feasibility and relevance to practice, means, standard deviations, and percentage of the ten questions were calculated from post-test survey questions). Participants indicated that MH-TIPS was useful (M = 4.33; SD = .72), well-constructed (M = 4.25; SD = .70) and easy to use (M = 4.36; SD = .71). Additionally, participants indicated that the course was likely to help them assist trouble students (M = 4.30; SD = .72) and feasible to implement in their setting (M = 4.20; SD = .78). Overall, 81% of respondents rated MH-TIPS as either Very Good or Excellent. See Table 3 for full results.
Preparedness. A series of repeated measure analyzes of variance (ANOVA) were conducted to assess statistically significant change in participant perceptions of preparedness from pre-test to post-test, with time as a repeated measure and number of completed modules as a between-subjects factor (Table 4). After completing any of the modules (pre-test to post-test- effect of time) nurses reported significantly improved feelings of preparedness, with particularly large effect sizes for increased feelings of preparedness to discuss mental health concerns (η2 = .12) and use a brief mental health intervention (e.g. teaching a student cognitive coping or activity scheduling) with students (η2 = .13). An increased number of modules completed (e.g. one module vs. all three modules), did not significantly increase nurses’ feelings of overall preparedness pre and post-test, except for their feelings of preparedness to motivate a student to seek help (F(1,1179) = 2.35, p = .017, η2 = .005) and conduct a brief mental health intervention (F(1,1152) = 4.83, p = .028, η2 = .004).
Use of Skills. Participants who completed the follow-up survey 30 days after their last completed MH-TIPS module reported on their use of the skills learned related to the five broad categories of MH-TIPS training elements (Common Factor Skills to Promote Positive and Supportive Interactions for Student Mental Health Issues; Mental Health Identification and Assessment; Mental Health Referral and Resource Mapping; Mental Health Crisis Response and Safety Assessment; Common Element Skills for Delivery by School Health Providers; Psychotropic Medication). Results suggested that over half of participants used all the MH-TIPS training elements that they learned at least sometimes in their practice (Table 5). Respondents indicated that they used the Mental Health Identification and Assessment skills they learned in the MH-TIPS training element most often after 30 days, while the Psychotropic Medication skills were used most infrequently.
Supporting Student Mental Health. Participants were queried about their weekly mental health encounters with students (e.g. “In the past week, how many students have you: 1) been concerned about due to their psychological distress? 2) approached to discuss your concerns about their psychological distress? 3) referred to additional mental health support services? 4) seen for both physical and mental health concerns?). Number of weekly mental health encounters with students, means and standard deviations were calculated from responses at registration, after the last completed MH-TIPS module, and 30 days after completing the training to examine changes in participants’ weekly mental health encounters with students (Table 6). Responses suggest a decrease in the number of students that participants were concerned about due to their psychological distress after completing the MH-TIPS course, and an increase in the number of students participants approached about a mental health concern. Further, participants reported fewer mental health referrals after completing the MH-TIPS modules.
Findings from the current study illuminate the value, feasibility and positive impact of the online version of the Mental Health Training Intervention for Health Providers in Schools (MH-TIPS) for school nurses. School nurses are increasingly recognized as essential to supporting student mental health (Bohnenkamp et al., 2015; Hoover et al., 2019), yet many feel they need additional mental health education to be able to address student mental health concerns (Ravenna & Cleaver, 2016). While there are some mental health education opportunities for school nurses, those that do exist are primarily offered in-person or target a specific mental health concern, such as depression or anxiety (Haddad et al., 2018; Muggeo et al., 2017). Given the national emergency in children and adolescent mental health, there is additional need for school nurses to be prepared to address a wide range of student mental health concerns (American Academy of Pediatrics, 2021). The findings of this study suggest that MH-TIPS is a feasible and helpful mechanism to increase school nurses’ preparedness to address student mental health concerns.
Of the school nurses in the current study, the vast majority indicated that the online MH-TIPS education course was feasible, relevant, and accessible. Similarly, most reported that the content positively informed their practice and was useful in their professional development. Mental health is the primary reason for approximately 30% of student visits to the school nurse (Stephan & Connors, 2013). It is not surprising that school nurses value education in how to identify and address student mental health concerns.
Many school nurse-student interactions are brief and involve problem identification and brief interventions (Bohnenkamp et al., 2015). Online MH-TIPS participants reported significant improvement in their feelings of preparedness, particularly in identifying student mental health concerns and engaging in brief interventions to address mental health challenges such as anxiety, depression, trauma, and behavioral conduct issues. However, the nurses who completed more MH-TIPS modules felt more prepared to conduct brief interventions and motivate students to seek help. This suggests that receiving more mental health education was related to feeling more prepared to approach students and provide brief interventions, such as teaching a student cognitive coping, activity scheduling or relaxation. In addition to feeling more prepared, the majority of the nurses who provided follow-up data reported they continued to use the mental health skills learned in the MH-TIPS modules in practice. At the 30-day post module follow-up, nurses most often cited that mental health identification and assessment skills were used, while psychotropic medication knowledge and skills were used the least. It is possible that is related to the relatively fewer number of students overall that are on psychotropic medication, or that schools nurses are not typically the prescribers of these medications and support the administration of and education about psychotropic medication. Participating school nurses reported speaking with more students about suspected mental health concerns in their practice following MH-TIPS, but did not report an increase in mental health referrals. It is promising that nurses reported being more likely to address mental health concerns as they arose in their practice after completing MH-TIPS. The lack of an increase in referrals could suggest that following additional mental health education via MH-TIPS, school nurses were more equipped to address some of the student mental health concerns they encountered.
Online education and implementation support offer greater reach and accessibility of education programs (Kognito, 2020). Prior demonstrations of in-person MH-TIPS were similarly successful (Weaver et al., 2019), though arguably more resource intensive, as trainers and learners must travel and be present for all training events. As with other virtual education opportunities, online MH-TIPS allowed learners to access content from their location and to engage with coursework based on their preferred sequence and timeline. Further, learners continue to have access to all education content and implementation support materials following their online education engagement, allowing for them to review and maintain skills as needed or desired.
The global pandemic presents additional considerations that speak to the value and timeliness of online mental health education for school nurses. First, we have witnessed an increase in mental health needs among school-age children and adolescents, related multiple stressors and adverse childhood experiences including loss of family members and friends, illness, periods of isolation, academic and social changes and interruptions, fear and uncertainty and economic hardship (Bryant et al., 2020; Loades et al., 2020). Though the long-term effects of the pandemic on student mental health remain unknown, data are already demonstrating increased depressive symptoms, non-suicidal self-injury, suicidal ideation, suicide plans, and suicide attempts in school-age children and adolescents (Leeb et al., 2020; Verlenden et al., 2021; Zhang et al., 2020). Second, COVID-19 forced many to pivot to virtual learning platforms, which has increased the general population’s savvy and comfort with this modality of professional development. Given its potential to optimize reach and accessibility, along with the increase in learners’ comfort and competence with online learning, participation in the online MH-TIPS may be a feasible and useful way for school nurses to access needed mental health education.
Some limitations to the current study are worth noting. The relatively small sample (5% of the original sample) at 30-day follow up reflects significant attrition from the initial study group and may not be representative of the entire sample. It would be important to conduct further investigation to determine whether this study’s findings are generalizable to a broader population of school nurses. It is also unclear whether self-reported preparedness and skill acquisition and use accurately reflect the health providers’ behavior in practice. Observation of school nurses’ mental health competencies and skills before and after training would be an important next step to understand the impact of the online MH-TIPS course. This type of observational investigation could be conducted in the context of pre-service training where school nurse trainees could be observed as part of their practicum experiences and measured on skill improvement or conducted as part of in-service training. The online MH-TIPS program does not prescribe number or sequencing of modules, allowing for self-direction by learners. While advantageous in terms of providing choice and flexibility, we do not yet know whether a certain quantity or sequence of content is optimal for learning and skill development. Finally, school nurses in the current study varied in terms of their school settings and student populations, and therefore it is difficult to determine how their reported impact on practice would generalize to this range of specific school settings (e.g. Is this training more effective for school nurses serving certain geographic areas, school levels, or with specific student population characteristics). Despite these limitations, findings from the current study provide compelling data that online MH-TIPS is feasible, relevant, and impactful on perceived preparedness and skill adoption related to student mental health for school nurses.
The feasibility and positive impact on preparedness of the MH-TIPS online training for school nurses is promising. There is a need to expand the reach of interventions that increase school nurse skills to address student mental health concerns, especially in the context of the national emergency in child and adolescent mental health. The MH-TIPS online course is available at no cost for anyone to complete at https://mdbehavioralhealth.com/training. The learning content was developed specifically for school health providers and there are CNEs available for school nurses at no cost, representing a key resource to support school nurses in expanding their abilities to address student mental health concerns. School systems and other local, regional and national organizations that support school nurses may consider ways to raise awareness about this training resource and increase uptake across the United States.
Special acknowledgment to National Association of School Nurses for collaboration with Nichole Bobo, MSN, RN, Jade Slaffey, MSHCA, BSN, RN, and Donna Mazyck, MS, RN, LCPC, NCSN, CAE, FNASN.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Jill H. Bohnenkamp https://orcid.org/0000-0001-6688-0758
Shannon Nemer McCullough https://orcid.org/0000-0001-9556-0841
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Jill H. Bohnenkamp, PhD is a licensed clinical psychologist and assistant professor and core faculty at the National Center for School for School Mental Health within the Division of Child and Adolescent Psychiatry at the University of Maryland School of Medicine.
Sharon A. Hoover, PhD is a licensed clinical psychologist and professor at the University of Maryland School of Medicine, Division of Child and Adolescent Psychiatry, Co-Director of the National Center for School Mental Health (NCSMH, www.schoolmentalhealth.org), and Director of the Center for Safe Supportive Schools (CS3).
Shannon Nemer McCullough, PhD was a post doctoral fellow at the National Center for School Mental Health and is now a Research Associate at WestEd in the Resilient and Healthy Schools and Communities Division.
1 University of Maryland School of Medicine, Baltimore, MD, United States
Corresponding Author:Jill Haak Bohnenkamp, 737 West Lombard Street, 4th Floor, Baltimore, MD 21201, United States.Email: Jbohnenk@som.umaryland.edu