The Journal of School Nursing2023, Vol. 39(6) 517–523© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI:10.1177/10598405211041299journals.sagepub.com/home/jsn
Supporting grieving students is part of a school nurse’s role which can provide meaning or special purpose in their career. This was verified by an online survey completed by 648 school nurse members of the National Association of School Nurses (NASN). A majority of respondents felt personal distress as a result of their work with grieving students which was predicted by a lack of access to work/community resources available and a lower level of educational background of the school nurse. Training to support grieving students and a higher level of educational background of the school nurse, however, appeared to predict a greater level of personal meaning found in school nurses’ support of grieving students. Level of support by school leadership provided to school nurses in their support of grieving students was also found to be related to both the personal distress experienced and the personal meaning derived by school nurses.
Keywordsgrieving, students, training, meaning
By the time they are 18 years old, one in 14 children in the United States has experienced or will experience the death of a parent or sibling (Burns et al., 2020). Disruptions in a grieving child’s ability to learn and function in a school setting are common (Schonfeld & Demaria, 2020; Schonfeld & Quackenbush, 2021). The important role of school nurses in the support of grieving students is clear. School nurses can meet the needs of children by performing early, comprehensive assessments, educating school administration regarding the benefits of bereavement support, initiating appropriate referrals, and directly providing bereavement support (Auman, 2007; NASN, 2020). In addition, school nurses provide student-centered care for individual grieving students or small groups of grieving students who may be first referred to school nurses because of medical complaints.
Basic nursing education covers nursing practice for grieving individuals. However, specialized skill development is primarily accessed through professional development opportunities. Training on grief and bereavement has been recommended to increase personal coping resources (Wenzel et al., 2011) as well as the quality of care provided to patients (Raymond et al., 2017). In addition, training has been found to also promote and develop the self-perceived confidence of school staff to engage with bereaved children (McManus & Paul, 2019) which may result in more children receiving services.
Nonetheless, emotional and contextual factors may influence a nurse’s decision to receive grief training. For example, nurses may fear the emotional impact of their listening to children expressing powerful feelings. Alternatively, they may encounter contextual barriers such as being taxed by large caseloads, which may limit the amount of support that can be provided (Ravenna & Cleaver, 2016), which can contribute to feelings of guilt for not doing more for bereaved children in their school (Dyregrov et al., 2015).
School nurses who offer bereavement support for members of the school community have been encouraged to focus on their own professional self-care needs (Adams, 2014) so that the stress of working with distressed bereaved children and families does not lead to compassion fatigue and burnout as is frequently reported by nurses working with bereavement in healthcare settings (Boyle, 2011). Finding meaning in their work with grieving children may also help school nurses cope with traumatic information they may hear from children (Jönsson et al., 2019). Additional factors which have been found as reducing the distress of healthcare workers who provide bereavement support include the level of support from professional colleagues and supervisors, identification of the benefits of caregiving, and years of professional experience in working with the bereaved (Boerner et al., 2017; Chan et al., 2015; Wenzel et al., 2011).
The present study explored factors associated with the delivery of support to grieving students by school nurses. Specifically, the study examined the potential contributions of school support provided, access to work / community resources, prior bereavement training and demographic factors (years working as a school nurse, educational background, and work setting) on the personal distress experienced and personal meaning derived by school nurses in their support of grieving students.
An online survey was conducted in 2019 by the National Association of School Nurses (NASN) of its membership. A total of 648 NASN members elected to participate in the survey. The study was approved by fourth author’s Institutional Review Board which determined that the survey of NASN members was considered exempt. Potential participants were informed that their name and personal identity would not be asked, no tracking of their internet identity would occur, and their decision to respond would not have an impact on their NASN membership.
A majority (93.8%) of the participants possessed either an educational background of an licensed practical nurse (LPN) (3.9%, n = 25), associate (11.8%, n = 76), bachelor (46.7%, n = 301), or master’s degree (31.5%, n=203). Participants reported a wide range of years working as a school nurse (0–4 years = 15.3%, 5–9 years = 19.4%, 10–14 years = 18.1%, 15–19 years = 18.6%, 20–24 years = 16.7%, and 25 + years = 11.9%). Most participants were assigned to primarily suburban school districts (43.8%) with a significant number also working in urban (28.4%) or rural (27.7%) districts. Most worked in public schools (83.0%) with others working in private (7.4%), faith-based (4.1%), charter (3.8%), vocational (0.9%), or boarding schools (0.9%). A wide range of service locations (Pre-School = 16.4%, Elementary (grades K-5, K-6 or K-8) = 34.0%, Middle or Junior High School = 23.5% and High School = 26.2%) were reported. The number of schools covered by a majority of participants (74.3%) was one to two schools with smaller percentages indicating a larger number of schools covered (3–4 schools = 13.0%, 5–6 schools = 4.1%, and 7+ schools = 8.6%).
The survey was posted in NASN’s online “Weekly Digest” which is available for all members. NASN launched the survey in July 2019 and closed participation in September 2019. 17,000 members received the survey link through the weekly digest, however not all members clicked open the survey link. The open rate for the weekly digest averaged 34.4% or approximately 5848 members. Questions on the survey were based on a consensus about relevant questions developed in collaboration with experts from NASN, a subject matter expert from the University of Illinois Chicago School of Nursing, National Center for School Crisis & Bereavement www.schoolcrisiscenter.org and other members of the Coalition to Support Grieving Students www.grievingstudents.org and were based on a review of available literature, personal experience of school nurses, and feedback from school nurses obtained during training on how to support grieving students. The final survey in this research study included a six item Demographic Questionnaire and 25 questions that explored how professional identity and training, support from other school staff and school leadership, a school environment that provided school nurses resources for the support of grieving students, the personal impact of providing such support, and family obligations of the school nurse each influenced the ability and comfort of school nurses to support grieving students. Individual item responses were then analyzed to assess for the factorial structure of the survey.
Given the number of items constructed, we used Exploratory Factor Analysis (EFA) (via principal axis factoring) to create a more parsimonious model. The analysis was conducted using a randomly selected sample of half of the respondents. We then used confirmatory factor analysis on the other half of the sample to cross-validate the model. In addition to chi-square tests (which we expected to be significant given the large sample size), we also examined the Comparative Fit Index (CFI) with values greater than .90 reflecting adequate fitting models (Brown, 2015), and the root mean square error of approximation (RMSEA), with values at or lower than .05 representing “well-fitting” models, and those at 0.08 reflecting reasonable fitting models (Rigdon, 2009). Finally, we analyzed the 90% confidence interval around the RMSEA value to further evaluate model fit.
The exploratory analysis initially yielded six factors, with eigenvalues ranging from 3.89 to 1.08 (the total variance was 58.57%). We then used parallel process to compare these results against a randomly generated correlation matrix in which no factors are assumed (Patil et al., 2010). Five eigenvalues in the obtained correlation matrix were larger than the random eigenvalues, which then led to our running the model again with the five factors and an oblique rotation. This analysis supported the five factors. Ten items were discarded due to poor overall loading and/or elevated cross-loadings. The remaining 13 items underwent a final EFA and all items loaded on their hypothesized factor, which were labeled as School Support, Access to Work/Community Resources, Personal Distress, Training to Support Grieving Students, and Personal Meaning. Collectively, these items accounted for 67.4% of the total variance explained. Table 1 reports each item and their loading on their respective factor, as well as each item’s average interfactor cross-loading.
As expected, the cross-validation (using maximum likelihood estimation in Mplus, version 8.4), yielded a significant chi-square test of model fit χ2 (38) = 203.86, p < .001. However, the CFI (0.92), RMSEA (0.08), and 90% confidence interval around the RMSEA (0.74 and 0.97) all indicated that the model provided a reasonable fit in spite of the low number of indicators for many of the factors. Finally, we then conduced separate one-way analysis of varlances (ANOVAs) (with each factor serving as the dependent variable) to test whether these factors differed with respect to highest professional nursing degree obtained, years of experience as a school nurse, and school setting. Mean scores differences were statistically insignificant (all p values >.05).
An item response analysis found that over 90% (91.4%) of school nurses participating in the survey indicated that supporting grieving students is part of a school nurse’s role and such work gave added meaning or special purpose to their career (91.8%). One school nurse shared that “Grief shows up in my office most often as frequent ‘tummy aches’ and ‘headaches.’ It’s only with time and knowing my students that the real reason for their visit is revealed.” Another school nurse added that “Often times the School Counselor is unavailable and grieving students are sent directly to the School Nurse. I do not feel that other professionals, who also provide support for grieving students, realize that it is often the School Nurse who is the first ‘line of defense’ for all students. School Nurses wear MANY different hats!”
The majority of nurses (62.0%), however, reported that they felt emotionally drained as a result of supporting grieving students with many (37.0%) reporting experiencing trouble sleeping at times because of thoughts or worries about a grieving student. Over 80% (82.8%), however, shared that they engaged in sufficient self-care to sustain their support of grieving students.
Much of the distress reported by school nurse participants may be due to their limited prior bereavement training. Over two-thirds (68.4%) did not believe that their pre-licensure training sufficiently prepared them to meet the needs of grieving students and a similar percent (63.6%) also characterized their training since graduation as insufficient. One school nurse shared that “I am concerned that because a student seems to be doing well, that I may not be sensitive enough to understand how they deal with grief. I don’t really talk with them about their feelings, perhaps to keep up a sense of normalcy.” Nearly all (96.1%) found the content of the Coalition to Support Grieving Students to be a valuable resource (the National Association of School Nurses is a founding member of the Coalition) but a majority of participants reported not being fully familiar with the Coalition to Support Grieving Students (83.8%) with only half (54.7%) indicating they downloaded handouts or other resources and one-third (33%) watching training videos “somewhat or to a great extent” from the Coalition to Support Grieving Students’ website.
There was also a common perception of insufficient support from family, friends and school colleagues with a large amount of school nurses (43.8%) stating that they did not believe family members understood how hard it was to emotionally support grieving students. Perceived support from school administrators was also low, with many school nurses reporting insufficient emotional support (46.4%) and resources including funding, supplies and space (40.5%) to support grieving students.
Table 2 reports the correlations and descriptive statistics of each factor. Training to support grieving students was significantly and positively correlated with deriving a sense of personal meaning as well as with higher levels of school support and access to work/community resources. School support and access to work/community resources were both negatively correlated with distress.
Separate hierarchical regressions were conducted, with three background variables (years working as a school nurse, educational background, and whether the school nurse worked in a rural, urban, or suburban school district) entered at step one, and the factors entered at step 2. The outcomes analyzed were negative personal impact (as measured by Personal Distress) and personal meaning.
The correlation between Personal Distress and key predictors was small (R2 ajd at step 2 was 0.05) but nonetheless significant, F (7,531) = 3.57, p < .001. Educational background was a significant, negative predictor of distress at step 1 (β = −0.10, p < .05), and remained significant at Step 2 (β = −0.09, p < .05) indicating that school nurses with higher levels of educational background or degrees were less likely to report personal distress when supporting grieving students. In addition, (lack of) access to work/community resources was a significant predictor of personal distress (β = −0.19, p < .001) indicating that those who did not have sufficient access to resources in their work to support grieving students were more likely to report personal distress as a result of the support they provided.
The R was small (R2 ajd at step 2 was 0.10) but significant, F (7,531) = 8.53, p < .001. At step 1, education background was a significant, positive predictor of personal meaning (β = 0.17, p < .01) and remained so at the second step (β = 0.16, p < .01) indicting that nurses with higher levels of educational background or degrees were more likely to find personal meaning in their work with grieving students. In addition, training to support grieving students also significantly predicted personal meaning (β = 0.22, p < .01) indicating that those who had more training specific to supporting grieving students were more likely to find more meaning in their support of grieving students.
Bereavement is a common experience in the life of children so it is likely that school nurses will interact frequently with students who are grieving, whether they present with complaints of emotional distress that they attribute to grief, present with physical complaints due to somatization, or a combination of both (Schonfeld et al., 2016). The recent Coronavirus - 19 (COVID-19) pandemic starkly highlighted the reality of childhood bereavement and the major toll it takes on the physical and social-emotional development of children (D’Antonio, 2011; Hagan et al., 2010; Pham et al., 2018). Over 90% of school nurses participating in this membership survey of the NASN, concluded prior to the pandemic, indicated that supporting grieving students is an important component of the role of a school nurse and something that has the potential to bring added meaning or special purpose to their career. But it also comes at a personal cost to the school nurse in terms of personal distress. The majority of nurses (62.0%) reported that they felt emotionally drained as a result of supporting grieving students; over a third (37.0%) reported experiencing trouble sleeping at times because of thoughts or worries about a grieving student. Identifying protective factors for decreasing this personal distress, while minimizing other barriers to the delivery of effective bereavement support for grieving students, should therefore be an important consideration for the profession, as well as for administrators who oversee services provided to students.
While over 80% reported that they engaged in professional self-care strategies to allow them to provide support to grieving students, the high level of personal distress experienced nonetheless demonstrates that more support is needed. It is therefore disappointing that over 40% of respondents felt that family members did not understand how difficult it was to provide emotional support to grieving students and perhaps even more concerning, the majority reported that they received from school administrators and colleagues insufficient emotional support and were provided insufficient resources including funding, supplies and space for this critical work.
School nurses with higher levels of educational background or degrees as well as specific training in how to support grieving students, were both associated with less personal distress experienced by the school nurse when supporting a grieving student—whether measured through correlations of factors or in regression analyses—and were positively related to the personal meaning that school nurses experience when supporting grieving students. But the current education being provided in nursing preparation programs and through continuing education offerings were felt to be insufficient for approximately two out of three respondents.
The NASN has provided much needed attention to this issue in the education of school nurses. At the 2015 and 2017 annual conferences, NASN featured plenary sessions on the topics of student bereavement and how school nurses can provide support. School nurses welcomed the focus on bereavement support and identified the need for additional training and resources. The Coalition to Support Grieving Students is a unique collaboration of the leading professional organizations representing classroom educators, school administrators and student support personnel (including school nurses, counselors, psychologists and social workers), and other school professionals. In 2015, the Coalition launched a practitioner-oriented website—www.grievingstudents.org—to provide free, practical, accessible information for classroom educators, principals, administrators, and student support personnel. The website houses video training modules featuring expert commentary, school professionals who share their observations and advice, and bereaved children and family members who offer their own perspective on living with loss. Handouts and reference materials oriented for classroom educators, principals/administrators, and student support personnel which mirror the training videos can also be downloaded from the website. Nearly all of the school nurses who participated in this study found the content to be a valuable resource. Further widespread dissemination of the resources of the Coalition to Support Grieving Students and other highquality professional development materials, as well as integrating this training more substantively into nursing degree programs, should help address the perceived insufficient education and training on this topic.
School nurses are encouraged to engage in professional self-care in order to minimize burnout and compassion fatigue. Working with grieving children is well recognized in the healthcare field as an important contributor to personal distress and survey respondents confirmed that this is also an issue in school nursing. But we cannot expect nurses to rely solely on self-care practices; over 80% of respondents indicated that they practiced professional self-care but nonetheless experienced personal distress when caring for grieving students. The limited recognition by those who provide informal support to school nurses, such as family members, and most importantly the limited perceived support provided by school administrators and school colleagues is a critical area in need of attention. It should be noted that 4 school administrator organizations were Founding Members of the Coalition to Support Grieving Students: the School Superintendents Association, American Federation of School Administrators, the National Association of Elementary School Principals and National Association of Secondary School Principals. Both of the major teacher unions were also Founding Members (the American Federation of Teachers and National Education Association). The distress caused by supporting grieving students and the perceived lack of education and training in how to provide this support is not unique to school nurses but also noted in these professions as well. A unique benefit of the Coalition to Support Grieving Students is the inter-professional collaboration—over 100 professional organizations are currently part of this Coalition.
The domains in this study were generated by a statistical analysis of common factors distilled from questions supplied by content experts, a review of available literature and personal experience of school nurses. The exploratory factor analysis that was conducted of the original survey questions generated categories that will be useful in designing this new survey namely: school support, access to work/community resources, personal distress, training to support grieving students, and personal meaning. Findings of this exploratory study are primarily limited by the total number of participants and the manner in which the web-based convenience sample was obtained. Future research in this area should utilize a random sampling of NASN members and multiple collection methods (e.g., paper mailing, NASN website-based, emails directed to members) to increase the response rate and obtain a more representative sample.
One particularly hopeful observation from this study was that school nurses, recognizing the importance of supporting grieving students and the critical role they can and should play in this area, persevere in providing this service despite multiple barriers. And when they do so, it brings personal meaning to their career. This personal meaning derived from delivering compassionate care can contribute significantly to a decrease in burnout. Providing compassionate care to grieving children in school settings, which are often under-resourced for social-emotional support of this nature, can be challenging, but it lies at the foundation of the nursing profession. We owe it to the school nurses, and the children they serve, to minimize these barriers and to better prepare and support school nurses in this role.
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.
Thomas Demaria, PhD https://orcid.org/0000-0002-7984-2344
Adams, J. (2014). Death and bereavement: A whole-school approach. Community Practitioner, 87(8), 35–36. PMID: 25226706.
Auman, M. J. (2007). Bereavement support for children. The Journal of School Nursing, 23(1), 34–39. https://doi.org/10.1177/10598405070230010601
Boerner, K., Gleason, H., & Jopp, D. S. (2017). Burnout after patient death: Challenges for direct care workers. Journal of Pain and Symptom Management, 54(3), 317–325. https://doi.org/10.1016/j.jpainsymman.2017.06.006
Boyle, D. A. (2011). Countering compassion fatigue: A requisite nursing agenda. The Online Journal of Issues in Nursing, 16(1), 2. https://doi.org/10.3912/OJIN.Vol16No01Man02.
Brown, T. A. (2015). Confirmatory factor analysis for applied research (2nd ed.). The Guilford Press.
Burns, M., Griese, B., King, S., & Talmi, A. (2020). Childhood bereavement: Understanding prevalence and related adversity in the United States. American Journal of Orthopsychiatry, 90(4), 391–405. https://doi.org/10.1037/ort0000442
Chan, W. C., Tin, A. F., & Wong, K. L. (2015). Coping with existential and emotional challenges: Development and validation of the self-competence in death work scale. Journal of Pain and Symptom Management, 50(1), 99–107. https://doi.org/10.1016/j.jpainsymman.2015.02.012
D’Antonio, J. (2011). Grief and loss of a caregiver in children: A developmental perspective. Journal of Psychosocial Nursing and Mental Health Services, 49(10), 17–20. https://doi.org/10.3928/02793695-20110802-03
Dyregrov, K., Endsjø, M., Idsøe, T., & Dyregrov, A. (2015). Suggestions for the ideal follow-up for bereaved students as seen by school personnel. Emotional and Behavioural Difficulties, 20(3), 289–301. https://doi.org/10.1080/13632752.2014.955676
Hagan, M. J., Luecken, L. J., Sandler, I. N., & Tein, J. Y. (2010). Prospective effects of post-bereavement negative events on cortisol activity in parentally bereaved youth. Developmental Psychobiology, 52(4), 394–400. https://doi.org/10.1002/dev.20433
Jönsson, J., Maltestam, M., Tops, A. B., & Garmy, P. (2019). School nurses’ experiences working with students with mental health problems: A qualitative study. The Journal of School Nursing, 35(3), 203–209. https://doi.org/10.1177/1059840517744019
McManus, E., & Paul, S. (2019). Addressing the bereavement needs of children in school: An evaluation of bereavement training for school communities. Improving Schools, 22(1), 72–85. https://doi.org/10.1177/1365480219825540
National Association of School Nurses (2020). Framework for 21st century school nursing practice™: Clarifications and updated definitions. NASN School Nurse, 35(4), 225–233. https://doi.org/10.1177/1942602X20928372
Patil, V. H., McPherson, M. Q., & Friesner, D. (2010). The use of exploratory factor analysis in public health: A note on parallel analysis as a factor retention criterion. American Journal of Health Promotion, 24(3), 178–181. https://doi.org/10.4278/ajhp.08033131
Pham, S., Porta, G., Biernesser, C., Walker Payne, M., Iyengar, S., Melhem, N., & Brent, D. A. (2018). The burden of bereavement: Early-onset depression and impairment in youths bereaved by sudden parental death in a 7-year prospective study. American Journal of Psychiatry, 175(9), 887–896. https://doi.org/10.1176/appi.ajp.2018.17070792. Erratum in: American Journal of Psychiatry, 2019;176(9):764. https://doi.org/10.1176/appi.ajp.2018.17070792
Ravenna, J., & Cleaver, K. (2016). School nurses’ experiences of managing young people with mental health problems: A scoping review. The Journal of School Nursing, 32(1), 58–70. https://doi.org/10.1177/1059840515620281
Raymond, A., Lee, S. F., & Bloomer, M. J. (2017). Understanding the bereavement care roles of nurses within acute care: A systematic review. Journal of Clinical Nursing, 26(13–14), 1787–1800. https://doi.org/10.1111/jocn.13503
Rigdon, E. E. (2009). CFI Versus RMSEA: A comparison of two fit indexes for structural equation modeling. Structural Equation Modeling: A Multidisciplinary Journal, 3(4), 369–379. https://doi.org/10.1080/10705519609540052
Schonfeld, D., & Quackenbush, M. (2021). The grieving student: A guide for schools (2nd ed.). Paul H Brookes.
Schonfeld, D. J., & Demaria, T. (2016). Committee on psychosocial aspects of child and family health, and disaster preparedness advisory council: Supporting the grieving child and family. Pediatrics, 138(3), e20162147. https://doi.org/10.1542/peds.2016-2147
Schonfeld, D. J., & Demaria, T. (2020). Supporting grieving students. In E. Rossen (Ed.), Supporting and educating traumatized students: A guide for school-based professionals (2 ed.).
Schonfeld, D. J., & Demaria, T. (2016). Committee on Psychosocial Aspects of Child and Family Health, Disaster Preparedness Advisory Council. Supporting the grieving child and family. Pediatrics, 138(3), e20162147. https://doi.org/10.1542/peds.2016-2147
Wenzel, J., Shaha, M., Klimmek, R., & Krumm, S. (2011). Working through grief and loss: Oncology nurses’ perspectives on professional bereavement. Oncology Nursing Forum, 38(4), E272–E282. https://doi.org/10.1188/11.ONF.E272-E282
1 National Center for School Crisis & Bereavement, Los Angeles, CA, USA
2 Terrace Metrics, National Center for School Crisis & Bereavement, Cincinnati, OH, USA
3 National Association of School Nurses, Los Angeles, CA, USA
4 National Center for School Crisis & Bereavement, Children’s Hospital Los Angeles, Los Angeles, CA, USA
Corresponding Author:David Schonfeld, MD, FAAP, National Center for School Crisis & Bereavement, Mailstop #53, 4650 Sunset Blvd., Los Angeles, CA, USA.Email: schonfel@usc.edu
