The Journal of School Nursing2020, Vol. 36(6) 442-450© The Author(s) 2019Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840519846961journals.sagepub.com/home/jsn
Kasey Jordan, PhD, RN1, Lorraine Mion, PhD, RN, FAAN2,
Melanie Lutenbacher, PhD, RN, FAAN3,
Mary Dietrich, PhD, MS3, and Velma Murry, PhD, MS4
School nurses may find increased capacity to respond to student mental health needs by understanding and capitalizing on the innovative work behavior (IWB) of faculty and staff. The purpose of this study was to describe IWB related to student mental health among middle school faculty and staff as well as to determine the influence of selected individual characteristics, school characteristics, and behavioral health indicators on IWB related to student mental health. Multimethods of data collection were used including surveys, interviews, and publicly available school data. Data were described and relationships examined via correlational and multiple linear regression analysis and hierarchical linear modeling. The median IWB score was 41 (range 0–84) for faculty and staff participants. An increase in number of years worked in the K–12 environment was associated with less IWB related to student mental health. School nurses who explore IWB by faculty and staff may find opportunities to collaborate and improve student health outcomes.
school nurse knowledge/perceptions/self-efficacy, innovation, mental health, middle/junior/high school, collaboration/multidisciplinary teams
A key role of the school nurse is to promote health, including mental health, among the student population. Mental health problems among students are prevalent and costly, affecting up to 20% of the nation’s youth (Centers for Disease Control and Prevention, 2013). Mental health problems are associated with a plethora of negative outcomes including suicide, decreased educational attainment, troubled relationships, and increased risk-taking behavior (Centers for Disease Control and Prevention, 2013; Schieve et al., 2011). Highprofile events such as school shootings, bullying, and suicides underscore the urgent need for increased attention to mental health in school environments. Early and appropriate access to treatment may mitigate some of the risks associated with mental health problems (Centers for Disease Control and Prevention, 2015a; World Health Organization, 2003). Furthermore, forward-thinking school health policies such as the Whole School, Whole Community, Whole Child model support the development of schools that promote holistic wellness, including mental wellness, in all students (Centers for Disease Control and Prevention, 2015b). We present findings from a study designed to better understand how middle school faculty and staff push the boundary of their roles to promote student mental health. School nurses can use this information as they exercise leadership in supporting school environments that are responsive to the mental health and wellness needs of students.
Multiple evidenced-based school mental health programs exist, representing crucial progress toward the creation of school environments that promote student mental health (Substance Abuse and Mental Health Services Administration, 2018). Mental health is defined here according to the World Health Organization (2014) definition as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.†Many initiatives, such as the crisis response project Mental Health First Aid (National Council for Behavioral Health, 2018) and the social–emotional learning program Second Step (Committee for Children, 2018), are critically important tools available to school professionals. Still the problem of inadequate mental health promotion and care in schools persists. School nurses are essential leaders for health-related services in their school communities (Maughan et al., 2018; National Assocation of School Nurses, 2013), which includes addressing the unique needs and nuanced context of their particular environment. One strategy that school nurses can use is to build upon effective mental health–related innovative work behavior (IWB) among teachers and staff. This approach is complementary to the implementation of evidenced-based programs already in place and has the benefit of bringing attention to the unique strengths and needs of a particular school environment.
1 Medical University of South Carolina, Charleston, SC, USA
2 Center for Healthy Aging, Self-Management and Complex Care, The Ohio State University, Columbus, OH, USA
3 Vanderbilt University, Nashville, TN, USA
4 Department of Human and Organizational Development, Vanderbilt University, Nashville, TN, USA
Corresponding Author:Kasey Jordan, PhD, RN, College of Nursing, Medical University of South Carolina, Charleston, SC 29425, USA.Email: jordakas@musc.edu
IWB consists of creative activities initiated at the individual level within organizations that result in a change in the work environment (De Jong & Den Hartog, 2010; Janssen, 2000). Employees who engage in IWB apply new ideas to their work environments. IWB is crucial for organizational innovation and, ultimately, organizational survival and effectiveness (Patterson, Gatto-Roissard, & Coan, 2009). Systematic exploration of healthpromoting innovation by employees is, however, minimal in health care. Although IWB has received relatively little attention in health-related contexts, evidence does support organizational-level associations between increased employee IWB and better clinical performance in acute care (Salge & Vera, 2009). IWB has been described in a number of nurse populations including nurse administrators, nurse educators, and the general nurse population (Adams, 1994; Bunpin, 2014; Hebenstreit, 2012; Knol & van Linge, 2009). Similarly, IWB in schools has received minimal attention, but evidence does suggest that IWB in teachers is positively associated with self-perceived job performance (Balkar, 2015).
Research suggests that, across disciplines, characteristics associated with IWB among employees include motivation, openness to ideas, original problem-solving, and leadership behaviors. Notably, multidisciplinary research has not shown employee innovation to be dependent on individual qualities such as age, education, role, and experience and is thus amenable to organization intervention (Patterson et al., 2009). However, literature describing IWB in public health settings is currently limited, and findings are inconsistent regarding how individual characteristics such as age, education, role, and experience influence IWB in health and educational environments (Baumann, 2011; Hebenstreit, 2012). At the organizational level, Drucker’s (2002) classic work describing settings where innovation is likely to occur includes perceived incongruities between expectations and results as well as process needs. However, research exploring how these characteristics, which may appear as unsatisfactory health risks and outcomes, may influence innovation related to school health is lacking.
Given the critical need for continued improvement in addressing student mental health needs and promotion in schools and the dearth of evidence related to IWB in the school setting, we conducted a study to explore middle school employees’ use of IWB related to student mental health promotion. The specific aims were as follows:
Individual, school, and student population behavioral health indicators were hypothesized to influence the perceived IWB by middle school faculty and staff.
This descriptive study utilized a cross-sectional survey, individual interviews, and publicly available school data to explore IWB related to student mental health promotion. The study was reviewed and approved by the Vanderbilt University Institutional Review Board prior to data collection.
This study took place in the state of Georgia. A convenience sample of local school districts within two regional districts representing rural and suburban areas were invited to participate. Eligibility criteria included identification as a public middle school serving traditional students in Grades 6–8. Schools were excluded from participation if they were not part of the public school system or did not serve Grades 6–8. All eligible public middle schools (N = 47) within consenting school districts were invited to take part in the study. Recruitment strategies included e-mails, phone calls, and inperson visits when requested. A total of 10 schools representing 10 different local school districts ultimately agreed to participate (21% of potential regional middle schools).
Individual characteristics. Individual faculty and staff characteristics were collected through an investigator-developed survey. Variables included age, years in present position, years employed in present middle school, years employed in any middle school, years employed in K–12 education, position in school, and professional training.
School characteristics. Variables at the school-level reflected class size, poverty level, and school size. Variables included student/teacher ratio, the percentage of students eligible for free/reduced lunch, and the size of the student population. The student/teacher ratio and the size of the student population were obtained through a publicly available state-sponsored website (Governor’s Office of Student Achievement, 2018). The percentage of students eligible for free and reduced lunch were obtained through communication with either the guidance counselor or principal.
Behavioral health indicators. Behavioral health indicators aggregated at the school level were collected from publicly available, state-provided indicators. Each year, the state of Georgia administers surveys on various aspects of the school environment from the prior academic year (Governor’s Office of Student Achievement, 2018). The Safe and Substance Free Learning Environment (SSFLE) score, weighted suspension rate, and the College and Career Ready Performance Index (CCRPI) score were chosen to reflect school safety, student behavior, and academic achievement, respectively. The SSFLE score is calculated using measures related to student safety such as violent incidents, drug-related incidents, and incidents of bullying or harassment. The weighted suspension rate provides information about the frequency and severity of suspensions in the school environment. The CCRPI score is calculated using school-level measures of student attendance, academic achievement, achievement gaps, school climate, and other measures reflecting the ability of the school to prepare students for college and career. Higher scores are more desirable for each of these measures, indicating fewer safety and drug incidents, less suspension, and better college and career readiness, respectively. Each of these variables were chosen as an indicator of behavioral health in the student body due to the inclusion of behavioral health incidents in the calculation of each score.
Innovative work behavior related to student mental health. IWB related to student mental health was defined as intentional activities to promote student mental health or well-being initiated by individual employees within a school. This includes creative or new ideas to support the mental health of a student or students that were thought of and implemented by individual faculty and staff in their professional environments. An example of IWB related to student mental health might include, for example, conceptualizing and implementing a new class routine or student activity intended to foster better mental health. IWB was measured through a modified version the 14-item Kleysen and Street (2001) measure of IWB, an established general measure of IWB. Responses to the Kleysen and Street measure gather information regarding “opportunity exploration, generativity, formative investigation, championing, and application†related to the implementation of innovative ideas in the workplace (p. 284). This measure provides information about self-perceived IWB and is best interpreted as a total score ranging from 0 to 84, with a higher score indicating more self-perceived IWB. The original Kleysen and Street measure had been tested on various professionals including educators, with α a coefficient of .945. The original measure was modified for this study to specifically address innovative activities related to student mental health in the middle school environment. Wording in each item was transposed to reflect the middle school environment and specific behaviors related to student mental health promotion. Example questions on the modified scale include items such as “How often do you recognize opportunities to make a positive difference in student mental health in your work, department, school, or with individual students?†and “How often do you pay attention to nonroutine student mental health issues in your work, department, school, or the educational system?†A content validity index score was computed and demonstrated acceptable content validity for the modified scale (Lynn, 1986). The α coefficient for the modified scale in this study was .96. The response set for the modified scale was measured on a Likert-type scale ranging from 1 to 6, with 1 representing never and 6 representing always.
Individual surveys. Surveys, which captured individual characteristics and IWB related to student mental health, were adapted to both digital and hard copy formats. Digital surveys were distributed via REDCap, a secure web-based application designed for data management (REDCap, 2018). Weekly e-mails with a link to the digital survey were sent to all 607 full- and part-time faculty and staff during the 4-week data collection period at each participating school. All school principals were offered the option of an in-person visit by the principal investigator (PI) with hard copies of the survey; only one school elected to utilize that option. A total of 149 usable surveys were obtained for analysis, resulting in a 25% response rate.
Interviews. Guidance counselors were contacted by phone and/or e-mail and invited to participate in one interview with the PI. One consenting counselor in each participating school was interviewed by phone and provided information related to school characteristics such as the number of students on free and reduced lunch, for a total of 10 participating guidance counselors. Qualitative data addressing the ecology of innovative and traditional mental health supports in the school environment were also collected from guidance counselors for later analysis.
Publicly available data. School-level behavioral health indicators (i.e., the SSFLE, weighted suspension score, and the CCPRI score) were obtained from the state website (Governor’s Office of Student Achievement, 2018).
IBM SPSS Statistics (version 24) was used for all data analyses. Nominal and ordinal variables were summarized using frequency distributions. Some of the continuous variables were skewed and thus were summarized using median and interquartile range (IQR). X2 tests of independence and Mann–Whitney tests were used to compare the characteristics of the individuals who did not complete the study measures with those who did complete them and thus were included in the main study analyses. Pearson correlations (univariate) and multiple linear regression (multivariate) were used to examine the associations of individual characteristics with IWB scores. Skewed data distributions were square root transformed for the Pearson correlation and linear regression analyses. A school-level IWB related to student mental health score was generated by averaging faculty/staff survey responses within each school. Spearman’s Ï correlations were used to associate school and mental health climate variables with the school-level IWB scores. Finally, mixed-level (individual and school) linear modeling was used to examine associations to adjust the standard errors for the nested nature of the individual data within the school data. A α level of .05 was used for determining statistical significance.
School. All participating schools were part of public school districts in rural and suburban regions of Georgia. Each participating school was housed in a different local school district. Six of the participating schools held Title 1 designation, indicating that they serve a large number of children from low-income families. All participating middle schools served only students in Grades 6–8.
Individuals. A total of 228 participants provided some data on the survey, but only l49 (65%) provided usable data. Individual participants included administrators, teachers, nurses, certified staff (professionals such as social workers and school psychologists), and non-certified staff (professionals such as para-professionals and clerical staff). Summaries of the characteristics of those retained for analyses and those not retained due to incomplete data are shown in Table 1. No statistically significant differences were observed between those sets of individuals. Within the analysis set (n = 149), the majority were teachers (78%) and the largest training group held a specialist degree (41%). The median number of years spent working in the present middle school for participants with usable surveys was 7 (IQR 3–12).
Participants’ IWB scores ranged from 14 to 84 (IQR 34–52.5, median 41) out of a total possible score of 84. Higher scores indicated more perceived individual IWB related to student mental health.
Participants were given the option to provide free text descriptions of IWB, but too few participants included these responses for qualitative analysis. However, anecdotal examples of IWB were provided by some participants. For example, one participant described changing conditions both in and out of class to foster stronger relationships between educators and students, such as creatively structuring more frequent one-on-one communication during the day. However, another participant suggested that mental health was not a part of their job responsibility or training, and so they did not engage in mental health–promoting activities. Instead, they referred students to guidance counselors as needed.
Results from the univariate and multivariate associations of faculty/staff characteristics with IWB related to student mental health can be found in Table 2. Only surveys with fully completed IWB responses were included in those analyses (n = 144). A statistically significant inverse univariate association of number of years in K–12 education with IWB related to student mental health was observed (β = −.22, p = .009). In addition, compared to teachers, non-certified staff and other personnel had a statistically significantly higher IWB related to student mental health values (β = .26, p = .002). Finally, compared to those with a bachelor’s degree, those with less education also had statistically significantly higher IWB related to student mental health scores (β = .22, p = .015; see Table 2).
A multivariate model containing the individual faculty and staff characteristics demonstrated a statistically significant association with IWB related to student mental health scores (R = .34, p = .045) and accounted for 12% of the variance in those scores (adjusted R2 = .06). After controlling for the associations among the variables, only the inverse association of years spent working in K–12 education with the IWB related to student mental health scores remained statistically significant (β = −.30, p = .029, see Table 2). This finding indicated that more time spent in the K–12 environment was associated with less perceived IWB related to student mental health.
Results from univariate associations of school-level variables with the school-level IWB values can be found in Table 3. An inverse association was found between the percentage of students on free/reduced lunch and weighted suspension rate (rs = −.68, p = .030), and a positive association was found between the percentage of students on free/reduced lunch and the Safe and Substance Free School score (rs = .64, p = .046). There were no statistically significant univariate associations of the student mental health or mental health climate variables with the school-level IWB values (see Table 3).
Findings from a mixed-level linear model analysis that accounted for the nesting of the individuals within the school data are shown in Table 4. The overall model was statistically significant (Wald X2 = 31.53, p = .008). After controlling for all of the other individual- and school-level variables, only the individual-level inverse association of the number of years in K–12 education with IWB related to student mental health remained (standardize coefficient = −.29, p = .017).
Findings from this study describe self-perceived IWB related to student mental health by faculty and staff in the middle school environment and potential characteristics that may influence the presence of these behaviors. The IWB scores in this study indicate that most faculty and staff perceive themselves to engage in creative activities to improve student mental health. Further study is needed to better describe what types of innovations are occurring and how perceptions of innovativeness and willingness to engage in innovations may be influenced by training and the perceived professional role and function of faculty and staff.
Faculty and staff reported engaging in innovation related to student mental health regularly in their middle schools. While the amount of self-perceived IWB ranged from minimal to highly innovative, the majority of faculty and staff reported moderate amounts of IWB related to student mental health. This finding suggests that faculty and staff may be consistently observing and responding to the mental health needs of students in ways that are not clearly prescribed in their job expectations. The presence of IWB related to student mental health in middle schools may be positive in regard to the capacity of schools to respond to the unique and varied mental health needs of their student body, though the nature and effectiveness of these innovations are presently unclear.
Notably, this study did not find many of the hypothesized relationships, indicating that IWB related to student mental health was likely to occur by individuals diverse in terms of age, educational preparation, and practice settings. While some relationships were present in the univariate model, such as more IWB among staff who were non-certified and those with less education, these did not persist after controlling for other variables. These results add to the health literature, which has been inconclusive in terms of the correlation of age with general IWB (Baumann, 2011; Hebenstreit, 2012). A key finding of this study is that participants who had been employed in the K–12 environment longer were less likely to report engaging in innovative behavior related to student mental health. It is unclear why this might be observed. It is possible that more experienced staff define their role differently, have determined that IWB related to student mental health is either ineffective or unwanted, or do not perceive the same activities to be innovative. It is also possible that the middle school environment was not conducive to fostering staff innovation or that highly innovative individuals did not persist in the K–12 environment. This finding necessitates further work to confirm and better understand how faculty and staff behave when responding to student mental health needs, and particularly how faculty and staff burnout may influence student mental health.
Other incidental findings include relationships between students on free/reduced lunch and weighted suspension rate and between free/reduced lunch and the SSFLE score. More students on free/reduced lunch were associated with an increase in the frequency and severity of suspensions. This indicates that schools may be responding to students who exhibit negative behaviors related to the stress of chronic poverty by educating them in an isolated setting, such as in a suspension room, or by removing then from the school environment entirely. Schools with more students on free/reduced lunch were also more likely to have better SSFLE scores. It is possible that this is related to a decreased presence of students experiencing poverty due to suspension. Further research should be done to confirm and clarify these relationships, particularly in light of the risk for negative adult outcomes related to suspension (Wolf & Kupchik, 2017).
School nurses, as the holistic health experts in school environments, are in a key position to support faculty and staff efforts to improve student mental health. The median IWB score of 41 indicates that innovation is regularly taking place to meet student mental health needs, and it is important for school nurses to communicate with faculty to become aware of what creative activities are being implemented. Activities that are consistent with current evidence and best practices can be encouraged and supported. School nurses with skills in measurement and translational science may be able to partner with faculty and staff to measure, disseminate, and ultimately scale up effective innovations. Creative activities that are not consistent with evidence or best practice may require intervention to ensure that creativity is encouraged but applied in ways that are safe and effective. School administration must also support the nurse’s role in fostering safe and effective school health innovation through formalized access to power in the school environment. Examples of such structures could include nurse participation in leadership meetings and providing adequate nursing staff to allow nurses to engage in their full scope of practice. Ultimately, nurses can collaborate with faculty and staff, utilizing effective communication, education, and leadership skills, to better address student mental health needs.
The results of this study highlight several areas requiring future work. Importantly, school nurses and educational leaders need to better understand what creative activities faculty and staff are engaging in and how they can influence student mental health. The finding that the more years faculty and staff work in K–12 education the less they report IWB is an important area to focus in the future. Understanding how service time in general and specifically in K–12 education intersects with school faculty and staff professional development over time may be a critical piece to understanding how IWB, particularly as related to student mental health, might be fostered throughout the tenure of a faculty or staff member.
This study serves as a foundational piece to exploring school health–related IWB. Important practical lessons were learned and study limitations should be noted. The study sample was relatively small with a limited number of participating school sites (21% of potential middle school sites). This may limit the generalizability of results. Further strategies to engage school participation should be explored, particularly related to district-level approvals and principal support. The survey was designed to be brief, but 79 potential respondents (35%) opened the survey and did not complete it. In addition, an open comment section was provided to gather exemplars from respondents but very few participants provided any comments. Additional strategies such as conducting focused discussions or interviews with a subsample of participants may yield more detailed data. Incentives to engage school faculty and staff participation should be explored. The response rate and the convenience sampling method may have biased results in a way that it was not possible to detect through statistical analysis, thus introducing a threat to internal validity. A relatively small number of variables were included in this initial assessment of IWB related to middle school student mental health, and it is possible that relevant variables were not examined. Finally, this study relied on a self-perceived measure of IWB related to student mental health. While the tool used was validated, it is still possible that selfperception did not fully reflect the reality of innovative behavior in the school environment. Further work with different types of IWB measures will provide more clarity about the presence and persistence of innovative behavior related to student mental health.
School nurses take on the enormous responsibility of serving as the holistic health experts in our educational system. Fostering effective collaboration around grassroots mental health–promoting innovations has the potential to promote positive, holistic student outcomes. Data from this study indicate that diverse school employees are regularly finding innovative ways to meet student mental health needs, though more experienced employees perceive themselves to innovate less than those with fewer years of experience. Further research to further clarify the nature and context of these innovations may help school nurses exercise leadership in school mental health care and promotion.
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or Vanderbilt University.
All authors contributed to the conception of the manuscript, data analysis, and interpretation; were involved in revising the manuscript as well as gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Kasey Jordan drafted the article.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institute of Health under Award Number UL1 TR002243 as well as the Vanderbilt College of Nursing PhD fund.
Kasey Jordan, PhD, RN https://orcid.org/0000-0002-8437-1823
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Kasey Jordan, PhD, RN, is an instructor at the Medical University of South Carolina, Charleston, SC, USA.
Lorraine Mion, PhD, RN, FAAN, is a professor and the director at the Center for Healthy Aging, Self-Management and Complex Care, The Ohio State University, Columbus, OH, USA.
Melanie Lutenbacher, PhD, RN, FAAN, is an associate professor of nursing and medicine (General Pediatrics) at Vanderbilt University, Nashville, TN, USA.
Mary Dietrich, PhD, MS, is a professor of Nursing (Statistics & Measurements), Biostatistics, and Psychiatry & Behavioral Sciences at Vanderbilt University, Nashville, TN, USA.
Velma Murry, PhD, MS, is a professor, specialty in poverty and intervention, and Betts Chair at the Department of Human and Organizational Development at Vanderbilt University, Nashville, TN, USA.
