The Journal of School Nursing2025, Vol. 41(6) 702–718© The Author(s) 2024Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405241298469journals.sagepub.com/home/jsn
Abstract
Increasing youth behavioral health needs in the United States have underscored the essential role school nurses can play in mitigating them. In response, the District of Columbia Department of Health developed the Behavioral Health Referral Process (BHRP) as a standardized guide, integrating school nurses into multidisciplinary teams and improving students’ access to behavioral health services. To assess the BHRP’s strengths and opportunities while understanding factors that could impact its implementation, key informant interviews were conducted using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework with seven school nurses and school nurse managers working in DC schools. Participants anticipated challenges related to the BHRP, from managing competing priorities to overcoming stigmas. Still, nurses reported the BHRP will enable a more coordinated referral process that promotes student linkage to care. The findings can inform efforts to assess and optimize school behavioral health referral processes as part of larger, comprehensive care systems.
Keywords
care coordination, mental health referrals, multidisciplinary teams, plan implementation, policies/procedures, school behavioral health
Concerns about the mental, emotional, and behavioral health of children and youth have grown in recent years. In the United States, the proportion of high school students who felt sad or hopeless increased from 36.7% in 2019 to 42.3% in 2021, and 22% of respondents seriously considered attempting suicide, up 3.4 percentage points from 2019 (Centers for Disease Control and Prevention (CDC), n.d.). The increase has been attributed, in part, to the stressors and losses associated with the COVID-19 pandemic (Singh et al., 2020). When left untreated, behavioral health conditions negatively affect students’ academic outcomes (Hoover & Bostic, 2021; Wegmann et al., 2017). Schools have long served as a safety net for preventing, identifying, and treating student behavioral health conditions, especially for those who experience barriers to care (Hoover & Bostic, 2021). Coordinated school-based approaches, such as the Whole School, Whole Community, Whole Child (WSCC) model and Comprehensive School Behavioral Health Systems (CSBHSs), call for alignment and integration between multiple school personnel and other stakeholders to facilitate students’ improved health, well-being, and learning (Hoover et al., 2019; Lewallen et al., 2015).
School nurses play a significant role in promoting student behavioral health and addressing acute and chronic behavioral health conditions. School nurses spend approximately 33% of their time addressing student behavioral health concerns, serving as “advocates, facilitators, and counselors of behavioral health services within the school environment and in the community” (Bohnenkamp et al., 2015; McDermott et al., 2018). As accessible and trusted members of the school community, school nurses are often students’ first point of entry into behavioral health services and can help coordinate the ongoing management of students’ conditions (Bohnenkamp et al., 2015; McDermott et al., 2018; Price et al., 2025). Therefore, school nurses are critical partners in the implementation of referral pathways and the execution of school behavioral health plans.
The District of Columbia Department of Health (DC Health) operates and manages the School Health Services Program (SHSP) in participating Washington, DC, public and public charter schools. The SHSP utilizes the WSCC model to provide services to students within a school health suite typically staffed by a Registered Nurse, Licensed Practical Nurse, and/or Health Technician, along with additional patient care tasks supported by unlicensed assistive personnel (School Health Services Program, n.d.). The goal of the SHSP is to improve the health of students, enabling them to thrive in the classroom and beyond by promoting alignment, integration, and collaboration between education and health professionals.
Consistent with national trends, DC has noted concerning increases in youth behavioral health challenges. In 2019, DC youth reported rates of depression symptoms and suicide-related behaviors that were higher than the national average, with DC high schoolers attempting suicide at a rate almost double that of other adolescents across the nation (14.9% vs. 8.9%) (Centers for Disease Control and Prevention, 2019; Office of the State Superintendent of Education, 2019). In response, DC policymakers and agency leaders funded an expansion of school behavioral health resources for students. DC Health later convened stakeholder groups to strategize on processes to integrate school health suite staff into expansion efforts. These stakeholder conversations illuminated that communication and coordination between health suite personnel and school behavioral health teams were limited, leading to inefficiency and duplication of services in the identification and assessment of student behavioral health conditions as well as referrals to community-based behavioral health organizations in lieu of school-based providers.
As a result of these conversations, DC Health, and its partners met for a year to develop the Behavioral Health Referral Process (BHRP) (Appendix A), aiming to promote effective teaming and address students’ health needs by outlining the role of school health suite personnel in behavioral health referrals. Informed by the National Association of School Nurses framework on school nursing practice (National Association of School Nurses, 2017), the BHRP includes a description of the relationships between members of the behavioral health team, the steps required in the referral process, an associated timeline for the required tasks, and an overview of school nurse responsibilities in student healthcare. In the BHRP, a student can self-refer or be referred by a school staff member or caregiver to the school’s behavioral health coordinator or nurse, who then forwards that information to the behavioral health team to assess and determine the best course of action. With early involvement, school nurses can lead collaborative efforts with other providers, including the student’s primary care provider, to communicate medication updates, ensure medication adherence, and update the student’s Individualized Health Plan. At the time of evaluation, the feasibility of BHRP implementation had yet to be assessed.
Research shows that effective protocol implementation and sustainability are associated with improved program outcomes and are dependent on factors such as schools’ openness to implementation, schools’ capacities (i.e., resources and readiness), the creation of manuals, the use of shared decision-making, and the flexibility to modify programs to fit their specific context (Gottfredson & Gottfredson, 2002; Lyon & Bruns, 2019).
Therefore, the current study explores the perspectives of school nurses and school nurse managers on factors affecting the effective implementation of the BHRP in DC public and public charter schools.
Semi-structured interviews with school nurses and school nurse managers were conducted to examine factors associated with the effective execution of the BHRP and evaluate the plan’s potential to achieve sustainable public health impact using constructs from the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework (Holtrop et al., 2021). Harden et al. (2018) recommend researchers utilize the RE-AIM framework prior to an intervention’s implementation to ensure “careful and strategic local planning” (Harden et al., 2018). As the current study was undertaken near the launch of the BHRP, findings were intended to inform the optimization of the process before its complete implementation. RE-AIM outlines five components of effective programming: reach, effectiveness, adoption, implementation, and maintenance.
In general, reach refers to the number or proportion of individuals who receive or would benefit from the intervention; effectiveness is about measuring the potential impact, including negative effects, on outcomes of interest; adoption is defined by the degree to which implementers are willing to deliver the intervention; implementation refers to the delivery of the intervention as intended, as well as necessary adaptations and costs related to its delivery; and maintenance is described as the extent to which the intervention is institutionalized and becomes part of the routine organizational practice (What Is RE-AIM, n.d.). While all RE-AIM constructs are described in the present study, researchers focus on adoption and implementation due to the marked interest in facilitating uptake and execution of the plan and prior suggestions that these two constructs be emphasized when scaling an evidence-based intervention across multiple sites (Harden et al., 2018; Kwan et al., 2019).
Participants were recruited through emails from the DC Health SHSP staff to all school nurses in the program, and recruitment was later expanded to nurse managers who supervise school nurses across multiple sites. Interested participants completed a recruitment form to provide their demographic and contact information to the research team, and they were later scheduled for a 45-minute, one-on-one interview. Recruitment occurred from May to June 2021, and interviews (N = 7) were conducted throughout the recruitment period. Participants were interviewed by a research team member (LH) using a semi-structured interview guide adapted from the Schroeder and Smaldone (2017) study that utilized RE-AIM to examine school nurses’ experiences implementing a school-based obesity intervention. Interviews were conducted via Zoom and video-recorded with participant permission, and transcripts were generated through the platform’s closed captioning feature before being error-checked against the recordings.
The interview transcripts were coded using a deductive approach with an a priori codebook structured around the RE-AIM constructs. Emergent codes were added during the initial coding. Analyses were conducted using Dedoose software Version 9.0.17 (2021). After one researcher (LH) coded three transcripts, a second researcher (RS) proposed codebook revisions that were discussed and incorporated as final. LH coded all transcripts using the final codebook, after which RS reviewed all coding. There was high consensus between coders, and any discrepancies were resolved by open discussion.
The study was determined to be exempt from review by the George Washington University Institutional Review Board and the DC Health Institutional Review Boards. Participants provided written informed consent prior to their participation in the study and oral informed consent prior to the start of their interview. Participants expressed an understanding that their involvement in the study was voluntary.
Seven individuals—six school nurses and one school nurse manager—were interviewed for the study. All participants identified as female, and 57% were African-American. Respondents reported working as a school nurse anywhere from 3 months to over 10 years. Nurses worked in public and public charter schools in five of the District’s eight wards. The majority served students in Kindergarten through grade 5 (n = 5), though nurses serving all grade levels were represented in the sample. Almost all participants (n = 6) reported helping students with behavioral health needs at least “sometimes” in their role.
For this study, reach refers to the representativeness and breadth of students who may benefit from implementing the BHRP. Only two participants felt the guidance would enable school nurses to engage all students equally. The remaining five nurses stated that the plan does not address circumstances impacting select student populations. For instance, nurses mentioned the behavioral needs of students with internalizing behaviors may be more difficult to identify because they may be “quiet” and not show “any red flags.” Nurses noted other students may be missed or overlooked by the process, including students concerned about their confidentiality protections and students belonging to sexual and gender minority groups. Another nurse described challenges related to students without existing diagnoses documented by the school:
When I go through the health certificates, and I see that the student suffers from depression, I usually make sure either the counselor knows … But if it’s not mentioned on a health certificate or the students never take a trip to the school nurse’soffice, I would never know that the student even needs behavioral health information.
Participants also mentioned that cultural barriers related to stigma and diversity may affect the BHRP’s reach. One nurse noted that the topic of behavioral health may be “taboo,” which can lead students to believe that “people will think [they’re] crazy” if they seek services and, thereby, limit their willingness to engage. Another nurse highlighted that a lack of provider diversity may deter students from seeking help, as they are unable to find a provider to whom they can relate:
If you don’t look like me or talk like me, I don’t want to give you my deep, dark secrets … That may be one reason why you may have students not even reaching out ‒ because they can’t relate, and they’re suffering in silence because it’s not a person in mental health that looks like them that they can even actually talk to.
Plan effectiveness refers to the perceived impact of the plan’s implementation on behavioral health referrals in schools and, thereby, student behavioral health outcomes. School nurses largely agreed that plan implementation would positively affect school BHRPs and outcomes. All participants endorsed the need for the plan, with most school nurses noting the high level of unmet student behavioral health concerns during the COVID-19 pandemic. School nurses shared that the BHRP could improve existing systems, which they perceived to be insufficient due to inconsistency across schools and poor communication amongst staff. One nurse detailed their experience navigating multiple schools’ processes and the confusion it could cause:
It seems like every school’s SEL [social-emotional learning] team has a different process in place. Some may just want you to send an email if you have a referral, others have a specific Google document or shared document system with specific questions to answer, some just welcome stopping by the office and saying, “Do you have a minute to chat?”
As a result, school nurses named the standardization of BHRPs city-wide as an important anticipated benefit of implementing the BHRP.
In addition, some school nurses expressed frustration about fragmented case management processes that often exclude the school nurse and lead to poor follow-up between school personnel about the students they mutually serve. One nurse highlighted the siloed care in current processes, sharing:
I had this one kid who was a cutter. Would not tell anyone, but a friend came to me and told me … If that other student who’s a friend did not notice, the teacher didn’t. The teacher never came to me. We know that child would not have had some attention. I did get the social worker involved … but I never heard from them again. There was not a consistent follow through. This child never came back to me, so I wasn’t too sure the child was still enrolled, or what happened.’
With the BHRP’s emphasis on multidisciplinary school teaming, however, almost all the school nurses believed that the BHRP would become more coordinated, as one school nurse described:
If you haven’t talked to your 504 [Plan] coordinator, or if you’ve never met your mental health clinician, this plan would definitely make you meet them, know them, know their phone number by heart … It takes a village, and … this plan, it will make us get to know one another.
According to participants, the BHRP’s attention to coordination could effectively connect students and school personnel with appropriate resources, improve student linkage to care, and facilitate consistent communication about the importance and availability of school behavioral health services. One participant explained these potential effects, stating:
It’s not singling them out. It is a service that’s available for all. It’s going to be able to reach more people because that negative stigma that mental health used to have, we’re now normalizing it and saying, “Everybody may be going through something.”
Although participants shared that the plan will likely yield a significant positive impact, five nurses mentioned that the potential effect depends on their knowledge of best practices in behavioral health identification and intervention. The value of training on these strategies for school nurses was highlighted, with one nurse stating:
I worked at a school where … they used a lot of mindfulness language and peaceful strategies to manage their stress and anxiety … If the nurses knew that language and that methodology, then we could also be more supportive when the students visited us.
Apart from the anticipated benefits, some school nurses mentioned that implementation of the more robust referral process may have unintended negative consequences for school nurses, such as an increase in their already full workload.
Adoption was operationalized by factors that could impact the number of school nurses willing to accept the BHRP, such as attitudes toward or concerns about implementation. Table 1 displays the common themes related to adoption that emerged from interviews.
Role Delineation. Role delineation was identified by school nurses as important to the adoption of the BHRP. Most felt that the distribution of tasks across team members as described in the process was equitable and appropriate, with one participant sharing they were “actually pleasantly surprised to see … the team approach” articulated. However, one participant felt that the associated workload may be burdensome, especially when considering their other responsibilities, describing:
It’s one nurse to do so much. It’s very, very difficult to have that amount of time … We have students who have their normal medication. There are breathing issues, diabetic issues, students that have fallen, broken a bone or just fall off the bleacher … Any number of things constantly all day long, so you have to be running down to the gym, or somewhere else, or somebody here with a bloody nose, and it’s just constant.
Acknowledging this conflict, one participant stated that greater flexibility in school nurses’ role, such as not being required to attend every team meeting, would likely facilitate its adoption. Participants also noted that explaining the BHRP’s purpose and the importance of school nurses in its delivery could positively influence adoption, stating, “If you can give them a ‘why’ and show them how they could be impactful, then they’re more apt to [make] a change.”
Buy-In and Prioritization. School nurses highlighted the importance of buy-in from colleagues, supervisors, and schoollevel and city-wide decision-makers. With buy-in at leadership levels, participants stated that there would be more consistent messaging surrounding the process and its adoption. However, two nurses shared that previously failed rollouts of new initiatives have caused a “loss of some trust” among colleagues that could translate to a subsequent lack of support for the BHRP. In addition, participants felt that school personnel may not see the value of the plan amidst a myriad of required protocols, as noted by one participant:
It’s something that would just … come across your desk and go, “Okay, that’s nice”…That’s pretty much how it is with those policies and plans. It’s just another thing that’s been added on to follow. I mean I can’t even really get administration to follow the COVID protocols that are in place right now, and I feel like those are pretty important.
Human Resources. School nurses stressed the importance of having sufficient personnel to carry out the BHRP and meet its requirements, as almost all school nurses who mentioned staffing concerns shared that they do not have adequate personnel to implement the process.
Despite limited staff, many school nurses described their relationships with existing personnel as supportive and they felt comfortable asking colleagues for assistance when necessary. One participant stated, “Whenever I’ve had a need or concern, I’ve never felt a need to hesitate. I’ve never said, ‘Maybe I shouldn’t do that.’ It’s always been a very good relationship.” Another school nurse noted that having a supportive team could attenuate challenges around time constraints that may impact BHRP adoption, stating, “We may need the help of the personnel to say, ‘Hey, I do need some extra help right now’…Hopefully, the teams, the principal, can back them up, like …‘We’ll ask for Mr. J. to give the medicine while you work on this.’”
Implementation refers to the ability of school nurses to adhere to all elements of the BHRP with fidelity based on their understanding of the process and confidence in carrying it out and facilitating the necessary collaborations.
Understanding. School nurses’ comprehension of the BHRP, its instructions, and its context were deemed important to implementation fidelity. Nearly all nurses were able to understand the process and described it as “clear,” “simple,” and “straightforward.” However, participants also stated that some elements could be clarified, such as its terminology and vague instructions. For example, some nurses were uncertain about the difference between a 504 Plan, behavioral health plan, and IHP, and others noted the ambiguity of phrases such as “routinely communicate,” with one nurse stating, “Routine … that word can be interpreted in many ways.”
Two nurses felt they lacked enough background information about the process to implement it with fidelity, including understanding why it exists, when it will be used, and how it compares to existing protocols. For example, one nurse described their confusion about the circumstances in which the BHRP would be employed:
How’s the student presenting to me? Is it on an emergency basis, like they want to kill themselves, or they’re actually calling to set up services for mental health services? … Are y’all telling the students, “Oh, hey, do you have a mental health problem? Speak with your school nurse,”… Am I then going through a checklist to say, “What’s your mental health concern?” Or, once you say you’re interested, do I really just contact [the] behavioral support team?
Confidence. Three school nurses stated they felt confident in their ability to carry out the BHRP with fidelity, pointing to their past experiences carrying out similar protocols. On the other hand, some school nurses expressing less confidence indicated they would need additional support from colleagues, with one nurse stating, “I don’t want to be the school nurse who sits here, listens to the problems, [identifies] the problems, and then [is] unable to do something about it.”
Teaming and Collaboration. Most school nurses felt confident in their ability to communicate and collaborate with the various stakeholders identified in the BHRP, including students and their families, teachers, and community health providers. Two participants attributed their confidence to the credibility that the process gives school nurses regarding their value as behavioral health team members. One nurse asserted that individuals will now know “that the school nurse is capable of more than just band aids and ice packs,” with another adding:
It should make things a little easier to approach administration because, this way, instead of me just giving my recommendation, I can actually reference a plan and say, “Well, according to DC Health, this is what we should be doing.” It’s not just me giving a recommendation. It’s me being backed up by DC Health, and I think that means more.
Challenges With Collaboration. Participants identified several challenges around facilitating the necessary collaborations outlined in the BHRP. First, school nurses expressed confidentiality concerns when communicating with stakeholders, with one participant noting, “It’s often difficult to know what you can say and to whom.” Other nurses noted that coordinating schedules for meetings among team members will be difficult. Further, school nurses were apprehensive about other partners’ anticipated lack of interest in collaboration. One nurse explained, “There’s a big disconnect with [the primary care provider] and anybody working in the school,” while two nurses shared that teachers’ willingness to collaborate can be “hit or miss” where some educators may say, “I’m here to teach, you go talk to the nurse or … the guidance counselor about that.”
Communication With Families. A commonly anticipated challenge in implementing the BHRP was addressing families’ lack of receptiveness to students receiving behavioral health treatment, with one school nurse asking, “[If] they hang up the phone, and they don’t want to hear what you have to say, how do you get to that parent?” School nurses also noted families’ concerns about confidentiality, as well as social barriers that make it difficult to ensure their child receives behavioral health care outside of school, such as lack of reliable transportation.
Implementation Resources. To increase their capacity to implement the BHRP with fidelity, school nurses noted additional resources might be helpful, including behavioral health training, orientation to the BHRP, and updated technology to facilitate collaboration. Some nurses suggested involving more school personnel in the BHRP, including nurse managers to serve as case consultants, behavioral health trainees to support nurses in their responsibilities, and principals to ensure adequate communication between students, parents, teachers, nurses, and support personnel.
Maintenance refers to the extent to which the procedures outlined in the BHRP are expected to become part of school nurses’ routine practice, as well as factors that influence sustained implementation. Supporting sustainability, all school nurses reported that the outlined responsibilities in the BHRP align with their nursing goals, particularly given the focus on addressing the whole student as community health nurses. Yet, one participant remained skeptical about the plan’s sustainability due to competing demands:
I’m afraid that it might end up being one of those things where I tuck it away in my folder and forget about it. And then, one day, I remember, “Oh wait, I have that behavioral health plan, let me get it out … With me being a new nurse and being so overwhelmed by everything else … that’s why these things sometimes, especially for me, fall down a little lower because I’m just trying to get done what was due yesterday.
One nurse noted that efforts to help manage responsibilities may still fall flat, sharing, “I’ve got a reminder in my calendar and, somehow, I still missed this week’s weekly report.”
The current study used the RE-AIM framework to describe school nurses’ perspectives on a BHRP in DC schools, as well as school nurses’ recommendations to maximize its implementation in the face of increasing behavioral health needs among youth. Previous literature utilizing RE-AIM, including those with school-based programs, has centered around evaluations of physical activity, nutrition, and obesity interventions after implementation already occurred (Dunton et al., 2014; Gaglio et al., 2013; Larsen et al., 2017; Nielsen et al., 2018). Thus, this is one of the first studies to apply the framework as a prospective planning tool in school behavioral health, particularly focusing on school nurses’ role in implementation.
As eventual promoters and implementers of school behavioral health interventions, school nurses have perspectives essential to understanding the true barriers and facilitators relevant to the actualization of these interventions. School nurses, including those in this study, consider mental health services within their scope of practice and describe enthusiasm in addressing student behavioral health concerns (Bohnenkamp et al., 2015; Price et al., 2025). One national survey of school nurses found that referring students to mental health professionals was the secondmost often reported mental health practice among nurses, preceded by communicating with parents/guardians about student mental health concerns (Bohnenkamp et al., 2015). Therefore, the current study’s focus on school nurses’ attitudes is consistent with both their professional priorities and the crucial role they play in student behavioral health promotion.
Despite the BHRP’s alignment with their goals, school nurses in the study worried about the limited time they have to dedicate to the required tasks, echoing findings from other school nurse-led interventions and school behavioral health programs (Ravenna & Cleaver, 2016). Participants noted that the addition of tasks from the BHRP may lead to overburdened nurses and subsequent neglect of other important responsibilities, though they provided recommendations that may alleviate these challenges and contribute to long-term sustainability that have not yet been mentioned in the literature (Bohnenkamp et al., 2015), including cultivating supportive staff relationships, building flexibility into the school nurses’ role, setting reminders for tasks, and consistently emphasizing the process’ importance.
Overall, school nurses in the study felt that the school health services program would benefit from the BHRP, particularly due to its potential to create a more standardized, coordinated approach to behavioral health management across schools. Participants appreciated that the increased coordination would be facilitated by the process’ emphasis on interdisciplinary teaming. However, they expressed concern about their ability to engage all stakeholders due to difficulties that have been documented in previous studies: coordinating schedules, navigating confidentiality policies, and effectively communicating with families (Bohnenkamp et al., 2023; Garbacz et al., 2023; Splett et al., 2017). It is essential that school nurses feel supported in their communications with all individuals involved in students’ care, including teachers, community providers, family members, and students, in order to aid with implementation and see the improvement in student behavioral health outcomes that is associated with effective team communication (Vaughn et al., 2017). DC Health has begun these efforts by publishing a memorandum to share standard communication procedures and hosting internal and external meetings with stakeholders to facilitate BHRP adoption, buy-in, and collaboration amongst partners.
Regarding communication with students, participants in the study anticipated gaps in the BHRP’s ability to reach all students equally in its implementation, particularly expressing concern for overlooking students with internalizing behaviors, confidentiality concerns, and stigmatized outlooks on behavioral health. Each of these populations has been documented to have decreased engagement with behavioral health services (Flink et al., 2014; Gulliver et al., 2010; Kladis et al., 2020), so special attention should be given to ensuring non-stigmatizing, clear behavioral health messaging in schools when outlining available services and confidentiality protections.
To address participants’ concerns about communication and engagement across stakeholders, school health officials can provide school nurses with behavioral health education and orientation to the referral process. In other studies, school nurses have observed a deficiency in available resources and training needed to support the execution of their behavioral health duties. Limited training and resources have been associated with lower confidence and less effectiveness in addressing behavioral health concerns (Bohnenkamp et al., 2015; Ravenna & Cleaver, 2016). Participants in this study similarly hoped for additional training to help them identify students who need care, provide preliminary behavioral health interventions, and increase their confidence in implementing the process. The training could include supplemental materials such as screening tools, decision guides, and definitions of terms, all of which may be presented in list and/or visual format to assist with recall of text information (Jansen, 2014). Behavioral health training has been shown to significantly increase nurses’ confidence and competence in addressing behavioral health issues, illustrating the importance of education for optimal program effects (Ravenna & Cleaver, 2016).
School nurses interviewed for this study provided both direct recommendations to optimize the implementation of the BHRP and general insights to inform efforts to involve school nurses in behavioral health processes on a broader scale. Based on the interviews and existing literature, three overarching recommendations to advance the implementation of a school BHRP have been prioritized: (a) consistently emphasize the process’s purpose and its operation; (b) maintain an infrastructure for information exchange to facilitate communication; (c) provide staff with behavioral health and process-specific training.
Consistently Emphasize Process Purpose and Operation. All members involved in the implementation of the referral process—from public health officials to school staff ‒ are strongly encouraged to recognize and communicate the process’s purpose, as well as their commitment to the success of a more coordinated referral system. Understanding why the process exists, when it will be used, and how it aligns with existing protocols is integral to its effective implementation and increasing implementer buy-in.
Maintain Infrastructure for Information Exchange to Facilitate Communication. Multidisciplinary teaming and communication with personnel in and out of the school system, including teachers, families, administrators, and community providers, is essential to the coordinated referral process. One way information sharing among stakeholders can be facilitated is through a health information exchange (HIE), while emphasizing comprehensive health documentation and an understanding of the confidentiality protections guaranteed by the system. HIEs facilitate team members’ ability to coordinate students’ physical and behavioral health care and lead to better patient outcomes, including improved medication reconciliation, increased immunization and health record completeness, and a reduction in care disparities (Menachemi et al., 2018).
Provide Behavioral Health and Process-Specific Training. Increasing implementers’ behavioral health knowledge, including how to screen for behavioral health concerns, communicate with families and other stakeholders about behavioral health, and facilitate behavioral health interventions such as mindfulness practices, will likely enhance their ability to implement referral processes more effectively for students in need. In addition to behavioral health training, an orientation to the process would be helpful, including instances around its use, relevant community resources, a decision tree outlining the steps, and a definition of terms. Table 2 provides a list of recommendations for implementing BHRPs for school nurses, school administrators, and public health leaders.
A main limitation of the study is the small sample size, which may be partially attributed to the COVID-19 pandemic. School nurses indicated that their efforts were focused on Coronavirus-related tasks. Hence, an increase in time-sensitive demands likely hindered the involvement of moreschool nurses in the study and contributed to the low response rate. Due to the limited sample, it is unlikely that the study achieved saturation, and therefore, additional considerations for effective implementation of the BHRP may exist. In addition, response bias may limit the generalizability of study findings, as those who participated may have a strong interest in school behavioral health. Despite these limitations, the study analyzed seven in-depth interviews with on-the-ground implementers, offering important insights into how to strengthen school BHRPs.
School nurses play a vital role in promoting youth behavioral health, a critical role given the increased prevalence of mental health concerns across the nation. The city-level BHRP in this study aims to address these concerns by centering school nurses within a multidisciplinary team working to improve students’ behavioral health in a coordinated care system. Findings from the present study demonstrate the potential of the BHRP in achieving such goals, as participating school nurses believe the new process will increase students’ linkage to behavioral health support despite some implementation challenges. Future research should assess BHRP implementation and impact from the perspective of additional stakeholders, including school administration, community mental health providers, and students and their families, to build a more holistic view of the process feasibility. In addition, future studies may explore whether unique approaches to behavioral health referrals are needed based on different school and school nurse characteristics, such as grade levels served, neighborhood, and years of nursing experience. After the implementation of the BHRP, researchers may evaluate the process and its impacts on youth school behavioral health outcomes.
Leila Habib: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Writing – original draft; Writing – review & editing.
Rachel Sadlon: Conceptualization; Formal analysis; Methodology; Supervision; Writing – review & editing.
Tiffany Wise: Conceptualization; Methodology; Project administration; Supervision; Writing – review & editing.
Kafui Doe: Conceptualization; Methodology; Project administration; Supervision; Writing – review & editing.
Lori Garibay: Conceptualization; Project administration; Supervision; Writing – review & editing.
Olga Acosta Price: Conceptualization; Methodology; Supervision; Writing – review & editing.
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.
Leila Habib https://orcid.org/0000-0002-1468-8614
Olga Acosta Price https://orcid.org/0000-0002-2748-6528
Bohnenkamp, J. H., Patel, C., Connors, E., Orenstein, S., Ereshefsky, S., Lever, N., & Hoover, S. (2023). Evaluating strategies to promote effective, multidisciplinary team collaboration in school mental health. Journal of Applied School Psychology, 39(2), 130–150. https://doi.org/10.1080/15377903.2022.2077875
Bohnenkamp, J. H., Stephan, S. H., & Bobo, N. (2015). Supporting student mental health: The role of the school nurse in coordinated school mental health care. Psychology in the Schools, 52(7), 714–727. https://doi.org/10.1002/pits.21851
Centers for Disease Control and Prevention. (2019). District of Columbia 2019 results. High School YRBS. https://nccd.cdc.gov/Youthonline/App/Results.aspx?LID=DCB
Centers for Disease Control and Prevention (CDC). (n.d). 1991-2021 high school youth risk behavior survey data. U.S. Centers for Disease Control and Prevention. http://nccd.cdc.gov/youthonline/
DC Health. (n.d.). School Health Services Program. DC Health. https://dchealth.dc.gov/service/school-health-services-program
Dunton, G. F., Liao, Y., Grana, R., Lagloire, R., Riggs, N., Chou, C.-P., & Robertson, T. (2014). State-wide dissemination of a school-based nutrition education programme: A RE-AIM (reach, efficacy, adoption, implementation, maintenance) analysis. Public Health Nutrition, 17(2), 422–430. https://doi.org/10.1017/S1368980012005186
Flink, I. J. E., Beirens, T. M. J., Butte, D., & Raat, H. (2014). Help-seeking behaviour for internalizing problems: Perceptions of adolescent girls from different ethnic backgrounds. Ethnicity & Health, 19(2), 160–177. https://doi.org/10.1080/13557858.2013.801402
Gaglio, B., Shoup, J. A., & Glasgow, R. E. (2013). The RE-AIM framework: A systematic review of use over time. American Journal of Public Health, 103(6), e38–e46. https://doi.org/10.2105/AJPH.2013.301299
Garbacz, S. A., Minch, D. R., Lawlor, K. L., & Flack, C. (2023). Advancing research to improve family–school collaboration in school mental health. In S. W. Evans, J. S. Owens, C. P. Bradshaw, & M. D. Weist (Eds.), Handbook of school mental health: Innovations in science and practice (pp. 153–167). Springer International Publishing. Https://doi.org/10.1007/978-3-031-20006-9_11
Gottfredson, D. C., & Gottfredson, G. D. (2002). Quality of schoolbased prevention programs: Results from a national survey. Journal of Research in Crime and Delinquency, 39(1), 3–35. https://doi.org/10.1177/002242780203900101
Gulliver, A., Griffiths, K. M., & Christensen, H. (2010). Perceived barriers and facilitators to mental health help-seeking in young people: A systematic review. BMC Psychiatry, 10(1), 113. https://doi.org/10.1186/1471-244X-10-113
Harden, S. M., Smith, M. L., Ory, M. G., Smith-Ray, R. L., Estabrooks, P. A., & Glasgow, R. E. (2018). RE-AIM in clinical, community, and corporate settings: Perspectives, strategies, and recommendations to enhance public health impact. Frontiers in Public Health, 6, 71. https://doi.org/10.3389/fpubh.2018.00071
Holtrop, J. S., Estabrooks, P. A., Gaglio, B., Harden, S. M., Kessler, R. S., King, D. K., Kwan, B. M., Ory, M. G., Rabin, B. A., Shelton, R. C., & Glasgow, R. E. (2021). Understanding and applying the RE-AIM framework: Clarifications and resources. Journal of Clinical and Translational Science, 5(1), e126. https://doi.org/10.1017/cts.2021.789
Hoover, S., & Bostic, J. (2021). Schools as a vital component of the child and adolescent mental health system. Psychiatric Services, 72(1), 37–48. https://doi.org/10.1176/appi.ps.201900575
Hoover, S., Lever, N., Sachdev, N., Barvo, N., Schlitt, J., Acosta Price, O., Sheriff, L., & Cashman, J. (2019). Advancing comprehensive school mental health: Guidance from the field. National Center for School Mental Health, University of Maryland School of Medicine.
Jansen, F. (2014). How bulleted lists and enumerations in formatted paragraphs affect recall and evaluation of functional text. Information Design Journal (IDJ), 21(2), 146–162. https://doi.org/10.1075/idj.21.2.06jan
Kladis, K., Hawken, L. S., O’Neill, R. E., Fischer, A. J., Fuoco, K. S., O’Keeffe, B. V., & Kiuhara, S. A. (2020). Effects of check-in check-out on engagement of students demonstrating internalizing behaviors in an elementary school setting. Behavioral Disorders, 48(2), 83–96. https://doi.org/10.1177/0198742920972107
Kwan, B. M., McGinnes, H. L., Ory, M. G., Estabrooks, P. A., Waxmonsky, J. A., & Glasgow, R. E. (2019). RE-AIM in the real world: Use of the RE-AIM framework for program planning and evaluation in clinical and community settings. Frontiers in Public Health, 7, 345. https://doi.org/10.3389/fpubh.2019.00345
Larsen, A. L., Liao, Y., Alberts, J., Huh, J., Robertson, T., & Dunton, G. F. (2017). RE-AIM analysis of a school-based nutrition education intervention in kindergarteners. Journal of School Health, 87(1), 36–46. https://doi.org/10.1111/josh.12466
Lewallen, T. C., Hunt, H., Potts-Datema, W., Zaza, S., & Giles, W. (2015). The whole school, whole community, whole child model: A new approach for improving educational attainment and healthy development for students. Journal of School Health, 85(11), 729–739. https://doi.org/10.1111/josh.12310
Lyon, A. R., & Bruns, E. J. (2019). From evidence to impact: Joining our best school mental health practices with our best implementation strategies. School Mental Health, 11(1), 106– 114. https://doi.org/10.1007/s12310-018-09306-w
McDermott, E., Bohnenkamp, J. H., Freedland, M., Baker, D., & Palmer, K. (2018). The school nurse’s role in behavioral/mental health of students: Position statement. NASN School Nurse, 34(1), 62–64.
Menachemi, N., Rahurkar, S., Harle, C. A., & Vest, J. R. (2018). The benefits of health information exchange: An updated systematic review. Journal of the American Medical Informatics Association, 25(9), 1259–1265. https://doi.org/10.1093/jamia/ocy035
National Association of School Nurses. (2017). The role of the 21st-century school nurse (position statement). NASN School Nurse, 32(1), 56–58. https://doi.org/10.1177/1942602X16680171
Nielsen, J. V., Skovgaard, T., Bredahl, T. V. G., Bugge, A., Wedderkopp, N., & Klakk, H. (2018). Using the RE-AIM framework to evaluate a school-based municipal programme tripling time spent on PE. Evaluation and Program Planning, 70, 1–11. https://doi.org/10.1016/j.evalprogplan.2018.05.005
Office of the State Superintendent of Education. (2019). District of Columbia Youth Risk Behavior Survey 2019. Government of the District of Columbia. https://osse.dc.gov/sites/default/files/dc/sites/osse/publication/attachments/2019%20DC%20YRBS%20Report.pdf
Price, O. A., Saunders, B., Gibbons, J., Sadlon, R., Garibay, L., Doe, K., Nelson, F., Wise, T., & Isaac, E. (2025). School nurses’ perceived role and capacity to support school behavioral health programs in DC public and public charter schools. The Journal of School Nursing, 41(6), 689–701. https://doi.org/10.1177/10598405241266237
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
Schroeder, K., & Smaldone, A. (2017). What barriers and facilitators do school nurses experience when implementing an obesity intervention. The Journal of School Nursing, 33(6), 456–466.
Singh, S., Roy, D., Sinha, K., Parveen, S., Sharma, G., & Joshi, G. (2020). Impact of COVID-19 and lockdown on mental health of children and adolescents: A narrative review with recommendations. Psychiatry Research, 293, 113429. https://doi.org/10.1016/j.psychres.2020.113429
Splett, J. W., Perales, K., Halliday-Boykins, C. A., Gilchrest, C. E., Gibson, N., & Weist, M. D. (2017). Best practices for teaming and collaboration in the interconnected systems framework. Journal of Applied School Psychology, 33(4), 347–368. https://doi.org/10.1080/15377903.2017.1328625
Vaughn, W. M., Bunde, P. K., Remick-Erickson, K., Rebeck, S., & Denny, D. (2017). Forging multidisciplinary collaboration to improve mental/behavioral health. NASN School Nurse, 32(5), 298–301. https://doi.org/10.1177/1942602X16689664
Wegmann, K. M., Powers, J. D., Swick, D. C., & Watkins, C. S. (2017). Supporting academic achievement through school-based mental health services: A multisite evaluation of Reading outcomes across one academic year. School Social Work Journal, 41(2), 1–22.
What is RE-AIM. (n.d.). RE-AIM. https://www.re-aim.org/about/what-is-re-aim/
Leila Habib, MPH was formerly a practicum student at the DC Department of Health Family Health Bureau and is now a medical student at the Johns Hopkins University School of Medicine. She obtained her Masters in Public Health in Community-Oriented Primary Care from the Milken Institute School of Public Health at the George Washington University. Her research stems from her background in community health and storytelling.
Rachel Sadlon, MPH, was associate director of the Center for Health and Health Care in Schools at the George Washington University with expertise in school mental health. She is currently the Director of the Healthy Schools & Wellness Programs in the Office of the State Superintendent of Education in DC.
Tiffany Wise, MPH, was the Special Projects Coordinator in the Child, Adolescent, and School Health Division and is now serving as the Maternal, Infant, Early Childhood Home Visiting (MIECHV) Program Coordinator in the DC Department of Health Family Health Bureau. Her expertise and work stem from her background in maternal and child health.
Kafui Doe, EdD, MPH, CHES, PMP, CPH was formerly the Chief of the Child, Adolescent and School Health Division and is currently the Family Health Bureau Chief and the District of Columbia’s Title V Maternal and Child Health Services State Director at DC Department of Health. Her expertise includes but are not limited to community health, school health, strategic planning, and change management.
Lori Garibay, MPH, MA, was Program Manager for Data Quality Assurance and Improvement, Child, and is currently Division Chief, Child, Adolescent, and School Health Division, Family Health Bureau in the DC Department of Health. Her expertise is in school health, data analytics, and public health program evaluation.
Olga Acosta Price, has a PhD in clinical psychology. She is an associate professor in the Milken Institute School of Public Health and Director of the Center for Health and Health Care in Schools at the George Washington University with research expertise in school mental health, school-family-community partnerships, and social influencers of health and education.
1 Department of Prevention and Community Health, The George Washington University Milken Institute School of Public Health, Baltimore, MD, USA
2 Prevention and Community Health, The George Washington University, Washington, DC, USA
3 Family Health Bureau, District of Columbia Department of Health, Washington DC, USA
Corresponding Author: Leila Habib, The George Washington University Milken Institute School of Public Health, Baltimore, MD 21205-1832, USA. Email: leilashabib@gmail.com
