The Journal of School Nursing2023, Vol. 39(1) 51–71© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211068120journals.sagepub.com/home/jsn
School nurses are crucial to addressing adolescent mental health, yet evidence concerning their evolving role has not been synthesized to understand interventions across levels of practice (i.e., individual, community, systems). We conducted an integrative review of school nurse roles in mental health in the U.S. related to depressive symptoms, anxiety, and stress. Only 18 articles were identified, published from 1970 to 2019, and primarily described school nurses practicing interventions at the individual level, yet it was unclear whether they were always evidence-based. Although mental health concerns have increased over the years, the dearth of rigorous studies made it difficult to determine the impact of school nurse interventions on student mental health outcomes and school nurses continue to feel unprepared and under supported in this area. More research is needed to establish best practices and systems to support school nursing practice in addressing mental health at all levels of practice.
Keywordsmental health, adolescents, integrative reviews, evidence-based practice, school nurse practices
Adolescent mental health issues related to depression, anxiety, and stress are growing concerns across the United States (U.S.). Data from the 2019 Youth Risk Behavior Survey (YRBS) showed an increase in all mental health indicators it measures (i.e., suicidal ideation and attempt, and symptoms of depression) from the previous administration of the survey in 2017. Specifically, in 2019, 36.7% of U.S. high school students felt so sad in the prior two weeks that they stopped doing some of their normal activities, and 18.8% of students had seriously contemplated suicide in the previous year—an increase from 31.5% and 17.2%, respectively in 2017 (CDC, 2018; CDC, 2020). In 2019, approximately 3.8 million adolescents in the U.S. between the ages of 12–17 years (15.7% of this age group) met the DSM-V criteria for depression (National Institute of Mental Health, 2021). Depression and anxiety are of particular concern due to their high prevalence and co-occurrence with other risk-behaviors that are the leading causes of morbidity and mortality during adolescence (Substance Abuse & Mental Health Services Administration, 2021; Centers for Disease Control & Prevention [CDC], 2020). Concerningly there has been a 56% increase in suicide deaths in people aged 10–24 years from 2007 to 2017 (Curtin & Heron, 2019). The COVID-19 pandemic has exacerbated stress and symptoms of mood and anxiety disorders among adolescents and increased the urgency to address their needs (Racine et al., 2020). Schools remain an important venue for engaging adolescents and, as often the only health professional on campus, school nurses are key personnel who interface with students and also have the opportunity to address mental health concerns. Yet, to date, little has been done to synthesize the evidence of school nursing practice related to addressing stress, depression, anxiety, and symptoms of these mental health disorders.
An understanding of the changes in mental health roles of school nurses over time gives insight into how students interface with school nurses with regards to mood disorders, anxiety and stress, whether school nurses have been practicing to their full scope of practice over time, and what lessons have been learned about how to best support them in present time according to the Framework for 21st Century School Nurse Practice (National Association of School Nurses, 2016). The objective of this integrative review is to examine the evolution of the school nurse’s role in mental health interventions practiced in the U.S., what influences these practices, as well as the quality and design of research in this area.
Adolescence is a logical developmental period on which to focus preventive efforts, since over half of mental health conditions begin before 18 years, yet most are not identified until adulthood (Das et al., 2016; Jones, 2013). In addition to the being one of the leading causes of illness and disability, mood disorders such as depression and anxiety are also associated with other risk factors that contribute to long-term effects on individuals and society, including substance use and teen pregnancy (World Health Organization, 2020). Furthermore, high school completion and enrollment in post-secondary schools were significantly lower in those suffering from severe mental disorders (U.S. Government Accountability Office, 2008). Future implications of adolescent mood disorders, such as depression, include increased risk of further mental and physical health issues in early adulthood as well as increased high-risk behaviors (Naicker et al., 2013).
Adolescent mental health issues are often not addressed by primary care providers, assuming youth have access to and utilize primary care. Studies published over the past decade suggest that anywhere from one half to two thirds of youth who need treatment for mental health conditions, particularly depression and emotional distress, do not receive it from their doctor or nurse practitioner (Ozer et al., 2009; Taliaferro et al., 2013; Whitney & Peterson, 2019). Furthermore, upon identifying patients with depressive symptoms, only 40% of providers reported collaborating with mental health specialists (Taliaferro et al., 2013).
The majority of adolescents in the U.S. attend schools (Banspach et al., 2016), and further, a nationally representative sample of adolescents aged 12-to-17 years old found 35% of adolescents received treatment for mental health concerns in a school setting, with the majority being depressive symptoms (Ali et al., 2019; Snyder et al., 2016). Mental health resources provided in school settings are especially important for individuals with decreased access to resources. Students with public insurance, from low-income families, and from ethnic and racial minority groups were also more likely to use school mental health services (Ali et al., 2019).
School nurses are often seen for psychosomatic complaints, and as they are often the only health staff, they have the education and clinical skills to assess and rule out physical ailments that may have underlying mental health causes and etiologies (Ellertsson et al., 2017; Pavletic, 2011). Often considered one of the most trusted staff at school, school nurses are able to identify emotional concerns and also collaborate with school administration and parents to facilitate individualized care appropriate for the student (Lineberry et al., 2018). An American Academy of Pediatrics policy statement (AAP Council on School Health, 2016) highlights the importance of school nurses, their unique position to address individual and population health, their ability to act as a liaison between primary care and students’ environments (family and school), and the need for collaboration between primary care providers and school nurses to identify and address the growing mental health concerns that students face.
Since its inception in 1902, the role of the school nurse has expanded from encompassing the arena of public health and management of chronic illnesses to include surveillance, emergency preparedness, and behavioral and mental health issues (Holmes et al., 2016). Laws expanding the inclusion of students with disabilities in the 1970’s also increased the responsibilities of school nurses as they increased collaboration on teams for Individualized Education Plans (IEP) and engaged in broader community and policy change work (Selekman et al., 2019). Due to reasons such as higher medical acuities of students, more independent and complex management of chronic illnesses, and the increased rate in mental health issues, the illness management and medication administration has also changed significantly from the 1960’s (Mattey, 2019; Maughan et al., 2018). Complex chronic illnesses and issues related to social determinants of health are also more often addressed by school nurses than before, which includes identifying and referring students with mental health issues. A better understanding of the evolution of school nurse mental health practices, specifically in common concerns such as depression and anxiety, as well an examination of the studies conducted in this area, can help to identify gaps between how their role has evolved generally as well as gaps in our knowledge about the impact of school nursing on adolescent mental health.
Kaskoun & McCabe’s (2021) review of school nurses’ perception of addressing mental health highlights how school nurses globally are in an ideal position to address this needed issue. Out of 14 articles published between 2005 and 2021, they were able to identify only one study done in the United States, thus highlighting the need to look back farther in the literature at studies conducted in the U.S. to better understand school nursing practice related to mental health. Similarly, Ravenna and Cleaver’s (2016) scoping review of school nurses and mental health management showed that school nurses see their role as a support to students experiencing mental health issues. Although their review described how school nurses serve as a vital mental health resource in countries across the world, they did not explore how school nurses practiced across individual, community, and systems levels in the unique sociopolitical context of the U.S., specifically. The need to understand the landscape of school nurse mental health practices in the United States is more important than ever, given the magnitude of devastation resulting from our underinvestment in public health and the difficult position schools and school nurses are continually placed in to fill the gaps in our health and social service systems. A clear understanding of the research landscape in the U.S. will help us begin to understand what school nurses actually do to address mental health concerns, specific to emotional and depressive symptoms, anxiety and stress, compare that against evolving student needs and models of practice that have guided the specialty, and identify gaps in our knowledge about how to support school nurses through policies and programs that can practice to their full scope and maximize their impact on student mental health outcomes.
The purpose of this integrative literature review was to identify the roles of U.S. school nurses in addressing adolescent mental health and factors influencing their practice at the individual, community, and systems levels. We used the Framework for 21st Century School Nurse Practice (National Association of School Nurses, 2016) as the primary framework guiding our review, as it emphasizes five key areas and explains how school nurses practice across levels within these key areas (Figure 1). We also used the concepts of individual, community, and systems level of practice from the Public Health Intervention Wheel, a seminal model for public health nursing practice described by Keller et al. (2004). Examining these three levels of practice (i.e., individual, community, and systems) aligns with the Framework for 21st Century School Nurse Practice concepts, as practices are described to range from the individual level to the systems level, yet the extent to which their mental health practices have not been explicitly examined. Previous research exploring levels of practice, generally, indicated that school nurses primarily practiced at the individual level, 65%, compared to the community, 22%, and systems level, 14%, (Schaffer et al., 2016). By mapping our findings on to both frameworks, we could identify gaps in the evidence-base of school nursing practice and opportunities to empower school nurses to practice at their full scope in order to have the greatest impact.
We aimed to answer the following research questions:
(1) What roles do school nurses play in addressing mental health concerns (depression, anxiety, and stress) among middle and high school populations at the individual, community, and systems levels?
(2) What factors influence mental health practices delivered by the school nurse?
(3) How has the role of the school nurse in mental health evolved over time?
We conducted an integrative literature review (Whittemore & Knafl, 2005), which allows for non-experimental, experimental, theoretical, and empirical literature to be included, in order to thoroughly assess literature related to school nursing practice and adolescent mental health. This method includes literature searches being conducted via databases, with inclusion and exclusion criteria relevant to the research questions identified, followed by article evaluation and analysis. In order to examine whether the role of school nursing in mental health has changed, no date restrictions were placed on the searches.
We searched the following databases based on relevancy to the nursing field, educational setting, and literature pertaining to psychology: PubMed, PsycINFO, ERIC, and CINAHL. Search terms were formulated after consultation with a university librarian, and with two separate Boolean phrase searches used in order to identify mental health practices of school nurses and to identify public health interventions that school nurses engaged in with possible mental health implications. These included:
(1) (“school nurse” OR “school health nurse” or “school nursing”) AND (“mental health” OR “mental illness” OR “mental disorder” OR “anxiety” OR “depression” OR “well-being” OR “distress” OR “stress”) AND (“adolescents” OR “teenagers” OR “young adults” OR “teen” OR “youth” OR “student” OR “adolescence”)
(2) (“public health interventions”) AND (“school nurse” or “school health nurse” or “school nursing”).
Inclusion criteria were: (1) articles about school nurses working in middle and high schools in the U.S., (2) published in peer-reviewed journals, and (3) articles in which school nurses were involved in any capacity when addressing mental health concerns, including symptoms of mood/anxiety disorders and stress, whether they assisted in developing a mental health intervention, or whether they were the target of the study (e.g., observational studies exploring their role, interventions to build their capacity to address mental health). No restrictions were placed on publication year in order to address our research question regarding how the nurse’s role has evolved over time. We also did not put limits on the study design methodology (e.g., quantitative, qualitative, mixed methods), which satisfies the characteristics of an integrative review (Whittemore & Knafl, 2005). Articles were excluded if they were not written or translated into English, sampled college or university students, took place outside the U.S., sampled only elementary students (articles that covered elementary in addition to middle and/or high school, were included), did not address school nurse involvement, took place in an environment other than a school, or addressed solely eating disorders, special needs, or behavioral issues (e.g., attention deficit/hyperactivity disorder) that did not co-occur with mood/anxiety disorders (or symptoms of them) or stress.
The literature search was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta - Analyses process (PRISMA) (Moher et al., 2009). A total of 1799 articles were identified through database retrieval and hand searches, in which we reviewed reference lists of articles in our review to find additional sources. After removing duplicates, leaving a total of 1569 articles, titles were screened for inclusion and exclusion criteria, resulting in 397 articles. Further review of title and abstract, identified 82 articles for which we conducted a full-text evaluation, finally resulting in 18 articles (Figure 2).
In order to address the criticism of integrative reviews’ potential for bias and its lack of rigor (Whittemore & Knafl, 2005), two authors independently appraised each of the articles using the Mixed Methods Appraisal Tool (MMAT), version 2018 (Hong et al., 2018) (Table 1). The MMAT requires satisfying two screener questions which qualify the article as empirical, allowing for further assessment: “Are there clear research questions?” and “Do the collected data allow [the researcher(s)] to address the research questions?” (Hong et al., 2018, p. 2). The MMAT also gives insight into the level of rigor of the research available for informing school nursing practice related to mental health. Gaps in types of research methodologies can be used to guide the development of future mental health evidence-based research, as well as to provide a better understanding of how research is disseminated and shared. Since all articles were included that pertained to school nurse involvement in any capacity, articles varied in target population and the outcomes. Therefore, in addition to scoring the article based on the MMAT scoring criteria, a column was added to Table 1 describing the population of focus in each study. Four articles (qualitative case studies) were not scored using the MMAT, as they did not meet the empirical screeners questions requirement.
A summary of all 18 identified articles with descriptions of sample, study results, alignment with the Framework for 21st Century School Nursing Practice, and whether the practices were conducted at the individual, community, or systems level is provided in Table 2.
A total of 18 articles, from seven different peer-reviewed journals, were included. Seven studies (39%) were intervention studies, six (33%) were quantitative descriptive, four (22%) were qualitative case studies, and one (5%) was a qualitative focus group study. Overall, articles that addressed school nurses and their roles in providing mental health had a variety of study designs. The qualitative studies consisted of six focus groups, with a total of 43 school nurses. Quantitative descriptive studies varied in sample size from 12 to 1,925. The intervention studies either looked at school nurse outcomes regarding mental health practices or consisted of school nurses delivering an intervention in which student mental health outcomes were measured. Three intervention studies looked at the school nurse practice outcomes and ranged from a sample size of 6 to 62, and the other four intervention studies had a sample size of students ranging from 12 to 370. Of the seven journals where we found relevant publications, four were nursing journals and the remaining three non-nursing journals were related to health and psychology in school settings.
According to the articles identified, school nurses practiced primarily at the individual level, with some engagement at the community level. No articles specifically indicated that school nurse mental health interventions were conducted at the systems level, yet one article indicated that potential system level practices could have occurred (Allison et al., 2014).
All 18 articles described school nursing practices in mental health that were appropriately aligned with the Framework for the 21st Century School Nurse. Eleven articles described school nurses simultaneously practicing two principles from the NASN framework specific to their role in addressing mental health, Care Coordination and Community/Public Health (Allison et al., 2014; Anderson et al., 2018; Atkins, 2017; Bohnenkamp et al., 2015; Callan & Howland, 2009; Fox et al., 2005; Kim et al., 2015; Schaffer et al., 2016; Stephan & Connors, 2013; Tkaczyk & Edelson, 2009; Weaver et al., 2019). Within the Care Coordination principle, the components most frequently practiced included direct care, case management, and collaboration (Allison et al., 2014; Anderson et al., 2018; Atkins, 2017; Bohnenkamp et al., 2015; Callan & Howland, 2009; Fox et al., 2005; Kim et al., 2015; Schaffer et al., 2016; Stephan & Connors, 2013; Tkaczyk & Edelson, 2009; Weaver et al., 2019). Community/Public Health principles that were most practiced included referrals, screening, and outreach (Allison et al., 2014; Anderson et al., 2018; Atkins, 2017; Bohnenkamp et al., 2015; Callan & Howland, 2009; DeSocio et al., 2006; Fox et al., 2005; Kim et al., 2015; Schaffer et al., 2016; Stephan & Connors, 2013; Tkaczyk & Edelson, 2009). Referrals were to district providers as well as to external mental health resources, screening tools used by school nurses were primarily for depression and anxiety, and outreach referred to the school nurse providing mental health education within the school setting or in the community.
Six articles described school nurses as solely practicing the key principle of Care Coordination. Findings addressed mental health with students on an individual level only, and the most common components identified were direct care, case management, and collaborative communication (Crosby & Connolly, 1970; Finks, 2012; Hootman et al., 2002; Houck et al., 2002; Muggeo & Ginsburg, 2019; Ramos et al., 2013). In their descriptive cross-sectional study, Crosby and Connolly (1970) described how school nurses provided direct and collaborative care through empathetic listening, physical presence and collaboration with social workers, teachers and other community resources (primary care and family). Houck et al. (2002) showed how a school nurse intervention focusing on improving student skill building and emotional support, reduced direct indicators of suicidal risk.
The Community/Public Health principle was the sole focus for one study, in which a school nurse-led, classroom-based intervention provided mental health education, out-reach and mental health promotion to elementary and middle school students (DeSocio et al., 2006). Although this article primarily focused on the general Community/Public Health practices of school nurses, it also described how community-level education provided by school nurses increased their visibility and increased the students’ comfort level to discuss mental health concerns, thus, inferring that individual level practices increased as a result of the intervention.
The only article describing school nurse mental health practices as having potential for system level change was the intervention study by Allison et al. (2014), in which school nurses performing physical exams for students in 6th and 9th grade also incorporated two mental health screeners within the exam to identify depression and anxiety. The authors suggested that this intervention be adopted by more school districts in Pennsylvania, which would create more system level changes by identifying students with mental health issues at an important transitional period in students’ lives, beginning middle and high school years. Not only does this intervention identify students that score high on the screeners, but they further refer them to a multidisciplinary team that assists each student in support, planning and referral, affecting mental health at the individual, community, and systems levels (Allison et al., 2014).
The factors identified as supporting school nurse mental health interventions were primarily in training resources provided to nurses and the collaboration and support by school administration and staff. The study described by DeSocio et al. (2006) to engage schools in mental health education interventions, designed and taught by school nurses, implied that collaboration between school administrators and teachers was necessary in order for its success. Intervention studies aimed at school nurses taking the time to learn new skills and/or educate students, requires collaboration and support from school administrators, at the very least. They may also require outside training and resources such as screeners and referral sources, as described in the intervention studies described by Hootman et al. (2002) and Houck et al. (2002).
Training and resources provide skills to school nurses that can increase mental health practices. Ramos et al. (2013) described the management of mental health emergencies by school nurses, in which 75% of school nurses rated continuing education in mental health as “very important.” Stephan and Connors (2013) also described school nurse perceptions and competence in mental health practices, in which they reported feeling they had limited mental health training. Bohnenkamp et al. (2015) showed that school nurses attributed the low use of mental health screeners primarily to the lack of screening instruments and mental health screener tools. Furthermore, Muggeo and Ginsburg (2019) reported 96% of school nurses stated they were not using an assessment tool and 94% expressed the desire for training in evidence-based training in anxiety interventions. Similarly, the case studies highlighted the importance of access to resources and training and how they can influence mental health practices. Callan and Howland (2009) described a school nurse using a screening tool for assessment and identification, collaboration with staff, and referral of students when needed. The qualitative case studies by Tkaczyk & Edelson (2009) and Atkins (2017) described how having mental health training and interdisciplinary resources allow for nurses to practice across all levels.
School nurses must understand the pharmacological issues that can arise when students are taking psychotropic medications, since their everyday roles often include medication administration. Finks (2012) described a case in which a school nurse identified that a student was having a rare reaction to an antidepressant, and she was able to get the student medical attention and further assist with medication management and monitoring of behavior and mood. The authors use this case to highlight that school nurses are positioned to notice reactions to psychiatric medications and warning signs.
The overall role of school nurses has changed over the years as have student mental health concerns, leading us to question how mental health practices may have evolved. The results from the articles show that nurses are more frequently addressing student mental health concerns as the frequency of such concerns have increased over the years.
The earliest article to fit the inclusion criteria, describing mental health practices by school nurses was by Crosby and Connolly, published in 1970, which much like recent articles, described the school nurse, working solely at the individual level, to provide direct care, care collaboration and case management. Following this article, the next articles fulfilling inclusion and exclusion criteria were published in 2002 (Hootman et al., 2002; Houck et al., 2002) after a significant gap of more than 30 years, which also addressed practices at the individual level. The first article we found that addressed community level school nurse mental health practices was published in 2005 (Fox et al., 2005). The potential for system level engagement was mentioned in only one article almost a decade later, published in 2014 (Allison et al., 2014). Yet, Davis et al. (2021) demonstrated in their gap analysis, that school nurses are not practicing according to their full scope and standards, which includes individual, community, and systems level engagement.
Adolescent symptoms of depression, anxiety, and stress are on the rise, and even more so due to the COVID-19 pandemic (Fegert et al., 2020) which has altered access to supports provided by the school system. This places students at greater risk than ever of falling through the cracks of an already fragmented mental health care system yet also provides opportunities to reimagine mental health promotion and treatment in schools, including the critical role of school nurses. Schools, districts, and communities must collaborate with each other to develop evidence-based policies and practices that address student mental health needs across the spectrum of prevention (i.e., primary, secondary, tertiary). School nurses are vital along this spectrum of prevention, given their knowledge and access to students, families, and community stakeholders as well as their trusted status (Maughan & Jameson, 2020).
The unmet need and negative trajectories for mental health issues among adolescents, particularly those from under-resourced and marginalized communities, is an area of particular concern and opportunity for school nurses to make an impact (Golberstein et al., 2020). Our review adds an important and novel perspective to understanding school nursing practice in the U.S. by using the NASN Framework to organize our results. This approach helped to identify gaps between actual practice and ideal practice across individual, community, and systems levels, related to student mental health related to symptoms of mood/anxiety and stress. Additional research using the NASN Framework can help to determine gaps between actual practice and ideal practice, specifically in mental health. This will provide more insight to better understand the facilitators and barriers of mental health practices to increase their efficacy in addressing mental health and their contributions at the community and systems level.
Relative to the potential of school nurses to impact student mental health and the number of young lives they encounter each day across the U.S., the extant literature describing their roles and impact on student mental health over the past several decades is relatively scant or does not directly address school nurse roles. The articles reviewed in this study spanned from the 1970s to the 2010s, yet there were only 18 related to school nurses and mental health practices related to symptoms of mood/anxiety disorder and stress, with a significant 30-year gap between 1970 and 2002. Although articles related to mental health services in schools were published in the period between 1970 and 2002, they did not satisfy the inclusion criteria for this review. Most of them pertained to demonstrating the effectiveness of the interdisciplinary school-based health clinics (SBHC), which were introduced in the 1970s in response to public health demand (Keeton et al., 2012), which may have contributed to the lack of research of mental health specific to school nurses during this time period.
The lack of relevant articles in this review is similar to findings in the review by Pestaner et al. (2021) and Kaskoun and McCabe (2021), which both revealed a lack of empirical research in school nurses’ roles in suicide interventions and in addressing mental health. The articles in our review had varied study designs and quality, also exhibiting the lack of rigor in this research area. For example, most studies reviewed had small samples and were not generalizable due to the lack of random sampling. Further research using more rigorous descriptive (e.g., population-based random sampling) and intervention designs (e.g., group randomized trials) can bring to light what interventions are being provided, what the nurses’ role is in them, and what impact they are having on adolescent mental health.
The dearth of empirical data highlighting the roles and impact of school nurses on student mental health in the U.S. has implications related to establishing and supporting best practices and policies within our federalist system that decentralizes many decisions related to education and health. Funding for school nurse positions, appropriate nurse-to-student staffing ratios, and reimbursement models, for example, can influence school nurses’ ability to practice to their full scope on behalf of their students.
Results from our review highlight the need for an increase in quality research in the U.S. that describes the role of school nurses in addressing student mental health and the impact on student mental health outcomes. Such evidence is needed to identify gaps more clearly between actual practice and ideal practice (as outlined by the NASN Framework) so that school nurses can be adequately supported to work with students, families, communities, and systems to improve adolescent mental health. Researchers should consider staffing models—including whether the school nurse is the only health provider in the school or has a team of collaborators (e.g., mental health counselors, social workers), cost-benefit analyses that show the value of school nursing, and how school nurses influence student-level academic and mental health outcomes.
Our results suggest that the majority of mental health interventions delivered by school nurses were at the individual level—primarily in Care Coordination. This is consistent with previous literature assessing real-world scope of practice of school nurses by Davis et al. (2021), who found that school nurses primarily engaged in Care Coordination activities. Yet, they also found the largest scope of practice gaps to be in Quality Improvement and Community/Public Health principles, which is inconsistent with our findings. Our findings showed that school nurses commonly engaged in Community/Public Health principles with mental health practices. These practices align with the model of integrated behavioral health, as they include interdisciplinary collaboration among school personnel as well as community and primary care providers, which has been adopted in schools through various behavioral services (Power et al., 2019). Therefore, evaluating school nursing using the 21st Century Framework can help identify areas where school nursing is aligned with integrated behavioral health through the lens of a school nurse-centric framework.
Davis et al. (2021) also described school nurses being frequently engaged in the Leadership principle, yet this was not identified in our review articles. This discrepancy may indicate that there are factors that influence mental health practices that differ from overall practices of school nurses. Given the evolving role of school nurses and increases in student mental health concerns, mental health interventions and engagement may not be supported as much in policy as other areas of school nursing focused on physical health. Asthma management and obesity prevention, in comparison, have state and district policies supporting the nurse to take action and collaborate with staff and parents (Hollenbach & Cloutier, 2014; Quelly, 2014). Additionally, there may be more resources to address mental health in schools (e.g., school counselors, social workers) than there are physical health needs which typically fall more under the umbrella of school nursing. However, we are comparing our findings to a limited body of literature, and much remains empirically unstudied regarding the role of school nurses in addressing symptoms of mood/anxiety disorders and stress in the U.S. Nonetheless, it is concerning that there is not more in the literature regarding school nurses engaged in leadership and other areas of the NASN Framework, for it could indicate that school nurses are not operating at their full scope of practice. Future research is needed to further understand these differences.
Our findings also indicated how mental health training influences school nurse practices, not only in their assessments of students, but also in interventions used and whether they practice at the individual, community, or systems level. Specifically, lack of continuing education in mental health was raised as a potential limiting factor to the mental health practices of school nurses in more than one article in our review. Further assessment is needed to understand the specific types of continuing education nurses would be interested in related to mental health and how their interests map on to the NASN Framework, different levels of practice, and other important documents guiding nursing practice. For example, given that school nurses’ work has been documented predominantly at the individual level, they may express more interest in continuing education opportunities focused on this level of practice such as medication management. While leaders should certainly be responsive to these wishes, they should also consider opportunities that are more upstream and may be given less consideration given time and staffing constraints on school nursing practice. For example, the recently released Future of Nursing 2020–2030 (National Academies of Sciences, Engineering, & Medicine, 2021) report emphasizes the need for nurses to engage in upstream advocacy to address social determinants of health. Such advocacy is certainly warranted in the school environment to address inequities and risk factors related to mental health, yet it remains unclear whether such opportunities for learning advocacy skills are widely available for school nurses or applied specifically to factors that influence mental health. Additionally, school nurses may be well-positioned to undertake certain community-level interventions in schools beyond developing and evaluating programs (e.g., build coalitions to address mental health), but little is known about continuing education in these areas, either. In order to propel school nursing to its full scope of practice in addressing the adolescent mental health crisis in the U.S., answer the call to action by the new Future of Nursing Report, and realize the full scope of practice outlined by the NASN Framework, we must expand continuing education beyond individual-level mental health interventions, but also include skills and strategies for how school nurses can be more involved in community and systems level practice. School nurses primarily spend their time practicing at the individual level, and much less time on community and systems level interventions, which may be due to lack of opportunities in this area as well as lack of knowledge (Schaffer et al., 2016). A deeper understanding of what is needed in mental health continuing education will also better support school nurses to improve health outcomes. Further research is also needed to understand how consistent understaffing of school nursing services relative to existing recommendations (AAP Council on School Health, 2016; Maughan et al., 2016; Willgerodt et al., 2018) impacts the school nurses’ ability to practice across all levels.
Every effort was taken to include terms that encompass all the research questions in this review, including consultation with a librarian, yet some articles may have been missed. Additionally, dissertations and unpublished manuscripts were not included in this review, which may have missed any current research being done in this area.
Limiting articles to those about schools in the U.S. only, may have also missed models of practice from other countries experiencing similar adolescent mental health concerns (e.g., England; Turner and Mackay, 2015). Although studies of school nursing mental health practices have been conducted in other countries, their policy landscape differs substantially in how it supports school-based mental health (e.g., children and young people’s mental health services [CYPMHS]; National Health Services [NHS], 2019). This makes it difficult to compare the evolution of the school nurses’ role in the U.S., given that many of their laws and policies are standardized at the national level due to their NHS which influences health care practices, even at the school nurse level. This contrasts with the U.S., where school nurse funding and practices are governed by state and local policies. Therefore, it was necessary to focus on U.S. studies in order to identify gaps in research and practice within the U.S. context which includes unique staffing, funding models, and policies for school nurses and education as well as unique factors influencing student mental health (e.g., impacts of racism, wealth gap, gun violence).
As often the only healthcare provider in a school setting, nurses have great potential to provide a variety of mental health interventions at all levels, such as intervening with individual students experiencing mental health concerns, collaborating with school and community partners in developing programs to address unmet needs, and advocating for policies to address the social determinants of health that place adolescents at increasing risk for mental health problems.
Yet, there are many factors influencing school nurses’ abilities to practice to their full scope, including their licensure, work experience and environment, and workload (Davis et al., 2021). Davis et al. (2021) explain that school nurses are affected by constraints of district and state policies, and therefore scope of practice must be addressed at the local and national levels. In light of recommendations from the Future of Nursing 2020–2030 report, reimbursement models and staffing ratios must also be critically examined and adjusted to meet the needs of students.
Additionally, as public health nurses, school nurses have the potential to create system-level change, and in order to do so, they must be present in leadership spaces and prepared to contribute their expertise to such discussions. An editorial by Denehy (2006) appropriately explains the multiple roles of school nurses that go beyond band aids and pain management including more complex physical and mental health issues and explained “it is about being a leader and an advocate for those who cannot speak for themselves and becoming involved in policy making that affects the entire school community” (Denehy, 2006, p. 192).
It is clear, that school nurses have been addressing mental health issues throughout the years. Yet, the dearth in evidence-based literature and rigorous studies in this topic hinder our ability to determine whether they are indeed practicing to their full scope, and as well as to unleash the full potential of the NASN’s Framework for 21st Century School Nursing Practice to guide school nursing practice related to growing mental health concerns. It is apparent that more rigorous research is needed to inform practice and to provide the necessary support for school nurses in this area to address adolescent mental health. School nurses work at the front line, and it is imperative that they be empowered to practice in a way that they can be most efficient and effective.
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: This work was supported by the Robert Wood Johnson Foundation (grant number 75271) and National Institutes of Health (grant number T32NR019035).
Ashwini R. Hoskote https://orcid.org/0000-0003-4806-4778
Emily Croce https://orcid.org/0000-0002-6213-1335
Karen E. Johnson https://orcid.org/0000-0002-3935-9067
Supplemental material for this article is available online.
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Ashwini R. Hoskote, MPH, RN, is a PhD candidate in the School of Nursing at The University of Texas at Austin. Her research is focused on school nursing and adolescent mental health.
Emily A. Croce, MSN, APRN, CPNP-PC, is a PhD candidate in the School of Nursing at The University of Texas at Austin and a long-time pediatric nurse practitioner specializing in dermatology at Dell Children’s Medical Group, Austin, TX. Her interests include racial and ethnic health disparities in children, atopic dermatitis (eczema) and related diseases, and access to healthcare.
Karen E. Johnson, PhD, RN, FSAHM, FAAN is an Associate Professor in the School of Nursing at The University of Texas at Austin. Her expertise is in public health nursing, school nursing, adolescent health, social determinants of health, and health inequities. Since joining the faculty in 2012, her research has focused primarily on inequities in health-risk behaviors among marginalized populations of youth through the use of epidemiological surveys such as the Youth Risk Behavior Survey, School Health Profiles, and Minnesota Student Survey; and understanding factors across the social ecological model that influence the role of the school nurse in addressing health risk behaviors, mental health, and social determinants of health among adolescents in a variety of settings. She has taught public health nursing at the undergraduate and graduate levels for over a decade and has served in various roles on a national level to advance teaching and research in public health nursing.
1 Robert Wood Johnson Foundation Future of Nursing Scholar, University of Texas at Austin School of Nursing
2 The University of Texas at Austin School of Nursing; Dell Children’s Medical Group, Austin, TX
3 University of Texas at Austin School Nursing
Corresponding Author:Ashwini Hoskote, Robert Wood Johnson Foundation Future of Nursing Scholar, University of Texas at Austin School of Nursing, 1710 Red River St., Austin, Texas, United States.Email: ahoskote@utexas.edu
