The Journal of School Nursing2023, Vol. 39(3) 238–247© The Author(s) 2020Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840520979661journals.sagepub.com/home/jsn
This study explored adolescent perspectives on school-based health center (SBHC) services and how services differed from school nurses and community agencies. Six focus groups were conducted with adolescents, 13–19 years old, as part of a larger mixed-methods study. Data were analyzed for themes using content analysis. Adolescents (N = 30) described the accessibility, positive attitude of staff, competence of the nurse practitioner, confidentiality/privacy, and trusted relationships with staff as important aspects of SBHC care. SBHC services allowed adolescents to stay in school, provided confidentiality/privacy, were comfortable and convenient, fostered their independence, and adolescents felt SBHC staff knew them and they did not feel like strangers. SBHCs are adolescent-friendly resources that maximize school time and an important source for contraception, sexually transmitted infection testing, and mental health care. Additionally, SBHC services help support adolescents’ transition from pediatric to adolescent-focused care and foster their growing self-awareness and empowerment related to their engagement in health care services.
Keywords
adolescent, adolescent-friendly care, content analysis, school-based health center, school nurse, focus group, nurse practitioner, trusted relationship, confidentiality, transition, seat time
In the United States, 2,584 school-based health centers (SBHCs) are available to children and adolescents in 48 states and the District of Columbia; more than 80% serve adolescents (Love et al., 2016, 2019). SBHC services typically include physical examinations, immunizations, evaluation and management of acute and chronic illnesses, reproductive health services including pregnancy tests, screening and treatment for sexually transmitted infections (STIs) and HIV, and, in some SBHCs, provision of condoms and contraception, individual and group mental health counseling, substance use/abuse screening, and referrals to needed services (Lofink et al., 2013; Strozer et al., 2010). Health and mental health services are available to all students who attend the school typically through signed parental consent (Gustafson, 2005; Strozer et al., 2010). Teens may access some or all the services available and access is not usually contingent on insurance status or ability to pay for services (Strozer et al., 2010). For many adolescents, especially those who are uninsured, underinsured, or live in limited-resource areas, SBHCs may be their only source of health and mental health care. This model of care provides teens access to services while they are in school, allows ready access to necessary follow-up, and affords teens the opportunity to assume a more independent role in health care services by making their own appointments, communicating with the SBHC staff, and ultimately learning to become an active participant in their health care (Moriarty Daley, 2011; Ginsburg et al., 2002).
SBHCs have been shown to be effective sources of health services by increasing health and mental health care access (Britto et al., 2001; Johnson et al., 2020; Slade, 2002), increasing health knowledge (Culligan, 2002; Kisker & Brown, 1996), decreasing unnecessary emergency room visits (Anderson et al., 2004; Key et al., 2002), and providing successful programs targeted at common sources of morbidity and mortality such as asthma, obesity, teen pregnancy, depression, and STIs (Amin & Sato, 2004; Arenson et al., 2019; Ethier et al., 2011; Guo et al., 2005; Keeton et al., 2012; Lurie et al., 2001; Mansour et al., 2008; McNall et al., 2010; Webber et al., 2003, 2005; Zimmer-Gembeck et al., 2001). Impressive outcomes have also been identified related to the use and continuation of contraception, STI screening, absenteeism, hospitalization from asthma, immunization rates, and the early and continued use of mental health services (Allison et al., 2007; Amin & Sato, 2004; Bersamin et al., 2018; Ethier et al., 2011; Guo et al., 2005; Lurie et al., 2001; Mansour et al., 2008; McNall et al., 2010; Minguez et al., 2015; Munn et al., 2019; Van Cura, 2010; Webber et al., 2003, 2005; Zimmer-Gembeck et al., 2001). Adolescents using SBHCs are more likely to report having a regular clinician, an awareness of confidentiality, an annual check-up, and receiving anticipatory guidance on a variety of health issues including, diet, exercise, alcohol, marijuana, sex, and birth control than those adolescents without an SBHC in their high school (Gibson et al., 2013). However, the services available in SBHCs vary greatly from state to state and even within communities.
Little is known about adolescents’ perspectives on the services provided through SBHCs (Moriarty Daley, 2016; Moriarty Daley et al., 2019). The purpose of this study was to address this gap by exploring adolescents’ perspectives on the care they received in SBHCs and how this care compared to the health services of the school nurse and other community health care services by asking:
A multiple-category focus group study was conducted with high school adolescents as part of a larger mixed-methods study (Moriarty Daley, 2016; Krueger & Casey, 2009). This study was approved by the University of Connecticut Institutional Review Board. A purposive sampling strategy was used to recruit adolescents to one of six focus groups. Groups included male or female adolescents from one of three age groups (13–14 years old, 15–17 years old, or 18–19 years old). Each participating high school SBHC (N = 6) was randomly assigned one age-/gender group. Inclusion criteria for participants included adolescents who were 13–19 years old, English speakers, and had completed at least one visit to the SBHC.
The adolescents were recruited by the respective SBHC nurse practitioner (NP; N = 6) and through informational recruitment flyers displayed in the SBHC. Each student provided assent prior to participation, and parental permission was obtained prior to participation for those teens under 18 years old. All participants received a $10 gift card to either Walmart or Target and a bus token or a $5 gas card if school transportation was not available after the group met. Breakfast or lunch foods were provided for participants at each group. All groups were held at the school in a private location.
Each focus group was audio-recorded, and field notes were taken by a research assistant during each group meeting to aid in data analysis. The audio-recordings were transcribed, entered into the software program ATLAS.ti7, and analyzed using content analysis (Krippendorff, 2013). Content analysis is “a research technique for making replicable and valid inferences from texts (or other meaningful matter) to the contexts of their use” (Krippendorff, 2013, p. 382). The data generated from the focus group discussions were read by the researchers to gain a general understanding of the data. The first author led the data analysis and unitized the data from each focus group using recoding units (Krippendorff, 2013). The three researchers discussed and recoded the transcripts for agreement. Each recording unit was then examined across all the transcripts. Items that were similar were clustered into a theme using diagrams called dendrograms (Krippendorff, 2013). An example of a dendrogram from the analysis for the theme trusted relationship is provided in Figure 1.
Thirty adolescents from six different high schools, in five school districts, in a Northeast state participated in this study (Table 1). Three to eight adolescents participated in each focus group. A diverse sample of adolescents from Grades 9 to 12 participated. Demographic characteristics of the group participants are displayed in the table. A thematic analysis of each question follows.
Accessibility of services. Many of the teens reported that they used the SBHC because of the ease of making an appointment for a variety of their needs including physical examinations and immunizations that are requirements for playing sports and school attendance. “It’s easy to go to, you don’t have to schedule an appointment” (female 13–14). “You don’t have to go out of your way. They are just there for you whenever you need it” (female 13–14). “It’s basically a doctor’s office at your school” (male 18–19). In addition, the care they received from the SBHC allowed them to stay in school rather than be sent home. Teens did not need to leave school to go to an appointment at another health care agency. “So, if you have tryouts 1 day and you need to get a physical, you don’t have to leave school. You can go to school—stay inside school and get it done” (female 13–14). The teens liked receiving a “quick physical, right when I need it” (male 15–17) often without an appointment and much sooner than making an appointment elsewhere. Accessibility for more private concerns such as HIV or STI screening or a pregnancy test was emphasized by the participants.
Positive attitude of SBHC staff. Teens liked going to the SBHC because of the positive atmosphere created by the staff. “Their vibe, they give a feeling the way they help you” (female 18–19). The staff was described as “friendly” (male 13–14, 18–19), “always smiling” (female 18–19), “never rude” (female 18–19), “nice” (female 12–13, 18–19), and “cool people” (male 18–19) who were able to leave their personal problems at home. The way they provided care made the teens’ experiences “comfortable” (male 13–14, 18–19 and female 15–17, 18–19).
I have been in the health center since 6th grade and they show more care and compassion ...you are sitting there, and they actually make you know friendship and you guys connect. Not just because you guys [SBHC staff] are younger or whatever, but you guys like understand that we are young and know the things we need to know. (female 13–14)
The SBHC environment was viewed as less “serious” (female 15–17) than other places they had received care and the teens appreciated the use of humor encountered in their interactions with the staff. “They joke with you. You can’t do that at a doctor’s office. Everyone is all serious there” (male 18–19).
Competence of the NP. The NP was viewed as someone willing and capable of making teens feel better and “healing” (male 13–14, 18–19) their illnesses or injuries. “It’s [the SBHC] basically a doctor’s office at your school” (male 15–17). The care was provided with the individual patient in mind. “They recommend you go and do things that would be beneficial to you, make sure you feel better” (male 13–14). The teens described the NP as knowledgeable and competent because the NP practiced independently at the SBHC.
I feel like they have to know a little more than like, doctors because they are just by themselves here. So they kind of just kind of have to like, base their own like, opinions on things. So I feel like they are like, more—I don’t know, they have more knowledge (female 15–17).
A part of the competence involved how the NP maintained the environment of the SBHC; “it is clean” (female 18–19 and male 18–19). The teens explained “When you leave ...she [NP] will clean it [exam table] and sanitize the whole area down herself” (female 18–19). They also felt the care provided in the SBHC was the “same thing ...followed the same protocol” (male 15–17) as care elsewhere.
Confidential and private setting. The SBHC was viewed as a confidential and private setting that allowed teens to discuss more personal concerns because they went to their visits alone and scheduled their own appointments. “It’s very private” (female 15–17). “The confidentiality and privacy here is like, good and like, she’ll never leak anything, like, the HIPAA laws won’t be violated or things like that. And like he said, there is always a door that shuts” (male 13–14). They liked that they were able to be seen alone and explained
Other places it is kinda awkward ...when you go there, it’s like—you have to have someone with you. Maybe you don’t want your family members to know, they are just there with you. They [clinician] ask you questions but you might lie to them because the person [family member] is in there. Here, you can just come here without having to have anyone with you. (female 15–17)
Openness of communication. The confidential and private setting facilitated communication between the NP and teens. “The people in the health center seem like cool people-you can open up to them” (male 18–19). The teens felt the NP and SBHC staff “paid attention” (female 18–19) and “wants to hear what we say” (male 13–14).
Well, one time I went [to a hospital] and they didn’t understand what was wrong with my leg and I had fractured it before and I guess when I woke up, it kinda twisted. They didn’t want to give no X-rays; they didn’t want to do nothing. And here, they would try to figure it out. Like how it happened ...which is more better, because you don’t know what’s going on in somebody else’s body, but it’s best to try understanding them. (female 18–19)
The teens found it easy to “open up” (male 15–17) and discuss their concerns especially if they wanted to talk about a private concern. “They listen, and they don’t interrupt you when you are talking, and say ‘no this is what is wrong with you.’ They actually listen and find out everything” (female 18–19). A female teen (15–17) added “[the NP] does a really, like, good job making everyone feel comfortable .... I could talk to her about anything—you know she always knows what to say.” Another participant had a similar experience,
She [NP] makes everything comfortable for you. It’s easier to talk to her ...like, maybe you don’t want to tell your mom about something, you can talk to her or if you don’t want to be like “Mom can you bring me to the doctor because blah, blah blah.” You can just come here [SBHC] and she will talk to you about it and make you feel comfortable about it. (female 15–17)
Trusted relationship. Many of the focus group participants referenced the relationship they had with members of the SBHC staff as an essential aspect of the care they received through the SBHC. These relationships were valued by the teens and made the clinic feel welcoming. The teens expressed that it was very important that they knew who they were going to see at each visit. “You get the same person each time instead of like guessing” (male 18–19) who is going to see you for your visit. The adolescents felt that the SBHC staff “gets to know you very well” (male 13–14), and they are able recognize when something was different or wrong with the teen.
They notice [SBHC staff] things about you. They notice if you change your hair ...like you are having a bad day and you are trying not to show [it] ...they notice right off the bat, like, that’s how much they pay attention to us here. (female 18–19)
This relationship “makes you feel like family” (male 18–19) or that you have a “personal doctor” (female 18–19). Another teen referred to the NP as her “health mommy” (female 18–19). The familiarity with the NP helped the teen ask for what they needed.
You don’t feel awkward about saying “I’m getting a physical.” You don’t feel awkward about doing it because one, you would be the only one in the room and two, when you are by yourself and you are bonded with the person you are working with, like who is giving the physical, it feels a lot less stressful. (male 15–17)
Trust grew from the relationship teens had with the NP and other members of the SBHC staff.
It’s a trust you have in a person. You have to build a relationship with somebody in order for you to like, open up to them. So that takes time. But I do feel like that is important because you wouldn’t tell somebody you don’t trust something serious. (female 18–19)
Another teen added,
Especially if something happens to you and you don’t want your mother to know, but you need to talk to somebody, you can talk to them. The more you trust the more you open up. Because you feel like the bond ...how strong it is and how much you know, and you feel you can trust that they won’t sit there and go behind your back. (female 18–19)
The teens expressed that they felt “safe and everything would be safe with her [the NP]” (male 13–14) if a health issue arose. A female teen noticed that it was not just the female students accessing the care of the SBHC “boy students go down there a lot too, to talk to them, which is crazy when you think about it” (female 18–19).
Differences between care provided in SBHC and school nurse
Keep you in school. The most significant difference identified by the teens was that they viewed the SBHC as providing care that allowed them to stay in school rather than being sent home or miss time from school to be evaluated elsewhere.
To go to my ...doctor I would have to miss like a day of school or [go] afterschool, but I have a lot of homework after school. But I could always come here [SBHC] during my lunch period. (female 15–17)
The teens explained that when they were sick, the care they received in the SBHC allowed them to remain in school. “When you are not feeling well, they [SBHC staff] actually try to make you feel better instead of like, making you go home fast” (female 13–14). The teens explained that they understood the NPs goal was to keep you in school and increase their time learning in the classroom.
She’s [the NP] real strict about sending home. You have to be serious sick for her to send you home because if not, she is not sending you home. That is one of her big things. Like, she lets you know too—if you start coming down often, asking her to go home, she lets you know right there and then, “I don’t send kids home unless you are dying or really hurt.” (female 18–19)
The teens recognized the collaborative relationship between the school nurse and SBHC. “If the nurse can’t help, then the school health clinic will help you” (male 18–19). Many of the groups commented that the first interaction they had with the SBHC was a result of the school nurse sending them to the SBHC for care.
The scope of services provided by the school nurse was viewed as more limited than that of the SBHC; however, they recognized that the school nurses’ “focus is different” (male 15–17). “I feel like the school nurse is ...narrow as to what services they provide. But the school-based health clinic, it’s like, more broad” (male 15–17). An example of this was provided by a teen with agreement from others in the group, “Yeah, the nurse can’t really do much. Like the nurse will be like, ‘oh you have a headache, well just go back to class or lie down for a couple of minutes’ and it usually doesn’t help” (male 18–19) or “like sometimes she [the nurse] doesn’t even call your mom herself. She will be like, ‘just text your mother to call me’ .... That’s just so like, not caring” (female 13–14).
When you miss days of school, then you are behind and then you have to get on track with the other classmates and then a whole bunch of make-up work. And like—it just gets you confused, so you may as well stay at school and try to get help for your illness and just fight through the day. (female 13–14)
They [SBHC NP] won’t just like, send you home ...because sometimes in the day you want to do something, and you don’t want to go home already, you want to get that thing fixed. Like get your treatment, feel better about yourself, make it through the rest of the day. (male 13–14)
The teens explained that they made the decision to go to the school nurse or SBHC based on what their needs were at the time. They were more likely to go to the school nurse if they “needed an excuse” (male 15–17). The SBHC provided them with more options, for example, obtaining medication for a headache that could not be given by the school nurse without a written order. The participants felt because the treatment options were limited that the nurse did not care and were often told “Sorry sweetie there is nothing I can do” (male 13–14). This contrasted with the many options the teens were given by the SBHC NP to assist them in feeling better and remaining in school. The adolescents were aware that the NPs in the SBHCs were able to dispense and prescribe medications for them if needed and the school nurse could only do so with a written order.
More confidential and private even if out of the way. The environment of the SBHC was also seen as being different than the school nurse’s office. “The nurse’s [office] is always crowded” (male 13–14, 15–17) and was described by participants as less confidential and private because of the openness of the space and the multiple students in the office at one time.
That it’s your business only and that she [SBHC NP] respects the fact that no one else should know and it’s something between you and her that she is helping you with. Not like sometimes, like, I will go to the nurse and I will talk about something and I will overhear them talking about lingering topics about other kids that went in there and so on and so forth. Not really keeping it confidential and they don’t care about it either. Like, they are talking about it and the students are walking in and they are listening and everything and they are saying names and so on and so forth. Like, when you go to Miss [SBHC NP], she makes sure that everything you tell her or something that is going on, is not told to anyone. That it’s for your eyes to see and for you guys to know. (male 13–14)
The lack of confidentiality and privacy gave students a “bad vibe” (male 13–14) and made their experience less comfortable. The focus group participants commented that the school nurse’s office was often in a “better” (male 15–17) location than the SBHC because the school nurse’s office was typically more visible, centralized, or accessible to students within the school building. The school nurse’s office was also observed to be larger than the SBHC, however, very open and not private from other students. Teens remarked that the SBHC was likely difficult to find for new students who were not familiar with the school because it was out of the way and poorly marked. A male teen explained,
It’s kind of good if you want to be private about it [going to the SBHC], but if you didn’t know where it was, and you needed to go there, you would have to ask somebody, because you wouldn’t know where it was. (male 18–19)
Differences between SBHC and other community health care services
Comfort. The teens commented that the SBHC felt less “awkward” (female 15–17 and male 15–17). They described the SBHC staff as more “compassionate” (female 13–14, 15–17) and had a “sweeter attitude” (male 13–14 and female 18–19) than their experiences with clinicians in the community. The physical space of the SBHCs was described as “tiny” (male 15–17) by the male focus group participants. “It’s kind of small. It’s really small. When you step in the office, there is nowhere to go” (male 15–17). However, the environment was viewed as pleasant and “comfortable” (male 18–19 and female 15–17). They liked that they knew who was going to be seen next, unlike their experiences in a larger health care agency where they could not determine who would be next as they waited in a crowded and chaotic waiting room. Also, unlike other places, the waiting room in the SBHC was quiet. “Sometimes with your delayed wait, sometimes you will see people—something pleasant, other times, not so much. Some people just don’t control their children ...their kids are all over the place—they give you a migraine” (male 13–14).
Convenience. All the teens discussed the convenience of having the SBHC in the school. They felt the SBHC was “easy to go to” (female 13–14) because it is located within the school building and allowed students to stay in school rather than need to leave school for an appointment elsewhere. “Don’t need to wait 2 weeks to be seen for a cold, here you can be seen the next period” (female 15–17). Appointments were scheduled during school time and did not interfere with their afterschool commitments like sports or work. The wait both for an appointment and the time spent in the office waiting to be seen were “faster” at the SBHC (female 13–14, 15–17, and 18–19) in comparison to other sources of care. “You don’t have to wait. It’s like right then and there” (female 13–14). “They [SBHC staff] will squeeze you in” (female 15–17). Appointments were available when needed and the teens felt they “can come as many times as they need to” (female 18–19). Teens identified that the SBHC facilitated their ability to comply with school requirements including physicals for school and sports and immunizations. Services were also accessible because they were available without cost to the teen or their family. “They [the SBHC] don’t charge you” (male 13–14).
Mental health counseling, pregnancy tests, and STI testing were all noted to be services that were more accessible through the SBHC in comparison to other health care agencies within the community. Teens commented that these were also services that they may forego if they had to go somewhere else because of concerns about confidentiality and privacy. STI/HIV testing could be done quickly and the “results are given right away” (male 15–17) at the SBHC. The teens felt that it was harder to trust mental health counselors outside of school because “there are no repercussions” (male 18–19) if counselor shared their confidential conversation with other clinicians or their parents. The teens elaborated, that if confidential information was shared by a counselor at school, the counselor would face negative consequences if they chose to divulge their confidential information.
Crisis intervention was a service that was identified as valued and unique to the SBHC. This was used for many assorted reasons from “having a really bad day” (male 13–14 and female 18–19) to helping a teen cope with the loss of a family member and stated
I wouldn’t go to my real doctor about it ...it would be really comfortable coming here. I think she would understand me, like she knows me and a little bit about me. So, she would be like, “oh, but why did this happen?” Like, she already knows. She would have like a background. (female 15–17)
The teens described a team approach to the mental health and crisis intervention services and the clinicians are “all on the same page” (female 13–14) and able to help them at any time.
Not a stranger. The teens appreciated that the SBHC staff “don’t treat you like a medical record” (male 13–14) or view their role as “just a job” (male 13–14 and 15–17). In contrast to their experiences with SBHC, the teens described that they often were unable to see the same provider at community agencies. “Sometimes you get a new physician ...and it’s just like alright ‘I don’t know who you are, and you don’t know who I am.’ They kinda treat you like a medical record, nothing more, nothing less” (male 13–14).
I feel like a lot of people go to my doctor ...he sees a lot of people ...every day. But here—she [the NP] still sees like a lot of people like every day, but like, she remembers who I am ...she will remember my face. Like, my doctor—I only go to him like, once every—whenever I have to, so he really doesn’t remember me .... I’m kinda like a stranger to him. Here I don’t feel like a stranger. (female 15–17)
As a result, the teens preferred to go to the SBHC for care. “I would rather go here [SBHC] than my actual doctor” (female 15–16).
SBHC fosters independence for teens. In comparison to other community health care services, teens explained that they can make and attend appointments independently and “don’t have to wait to for your parents to take you” (male 13–14). They remarked on how the staff listened to them instead of their parents, they were able to “fill out the forms” (male 13–14) were able to “answer questions yourself” (male 13–14), and most importantly “don’t have to lie [to the clinician] because your parent is in the room with you” (female 15–17). Another teen added
You don’t have to—like lie to your parents about going to—[or] like, scheduling an appointment for something else because you were too embarrassed by it ...you can go inside the school and do it instead of going to a hospital or clinic. (male 15–17)
The adolescents in this study articulated the important role of SBHCs to their health and its impact on their education. They endorsed SBHCs as providing adolescent-friendly health and mental health care that is confidential, accessible, affordable, appropriate, and equitable as described by the World Health Organization (WHO) as key components of services for adolescents (McIntyre, 2002; WHO, 2012). An important goal for school-based health services is to assist adolescents to be healthy and fully participate in school. The adolescents in this study described the important function of the SBHC as a source of care to help them stay healthy, feel better, and remain engaged in school rather than sent home or remain in school nurse’s office. The teens identified how important it was to be in class and not miss seat time because they would have difficulty understanding material and getting caught up.
The school nurse and clinicians in the SBHC have complementary roles in any school; however, these roles are often confused by parents, community members, and even school staff and students (National Association of School Nurses [NASN], 2015). The school nurse is responsible for the general health of all students in the school and assists those with additional health care needs through individualized education plans and communication with parents, teachers, and other members of the school staff (NASN, 2015). The SBHC clinicians provide individualized primary health and mental health services to students as needed. The school nurse is an important source of referral for the SBHC. Many of the teens in this study explained their initial encounters with the SBHC were a result of collaboration between the school nurse and SBHC. Surprisingly, most of the teens were aware of the different roles of these two services and articulated when and how they would access one or the other.
The teens described the importance of a trusted relationship for accessing and continuing health care services in the SBHC (McIntyre, 2002; WHO, 2012). The variety of available services allowed the SBHC staff to respond to the everchanging needs of adolescents accessing services. This patient–provider relationship was fostered by the private and confidential services; the atmosphere of the clinic created by the NPs, medical assistants, and mental health providers; and the accessibility of services at school. SBHCs also support the initial transition from pediatric to adolescent-focused care and the necessary and progressive steps toward adolescents assuming a primary role in their health care by late adolescence through fostering their independence in seeking services (Lestishock et al., 2018, Moriarty Daley et al., 2019; White & Cooley, 2018). SBHCs also remove many of the barriers that may cause adolescents to forego or delay access to more sensitive, needed services including contraception, STI/HIV testing, pregnancy tests, and mental health services that may be more difficult to access in the community because of concerns about confidentiality, billing, transportation, and appointment times.
The Whole School, Whole Community, Whole Child (WSCC) model calls for “greater alignment, integration, and collaboration between health and education to improve each child’s cognitive, social and emotional development” (Carter et al., 2014, p. 7). The results of this study support the essential tie between health and education from the adolescent perspective. Health services, social and emotional climate, behavioral health, health education, safe environment, and nutrition are elements of the WSCC model and are addressed in SBHC services. The teens described many factors that have the potential to interfere with their ability to remain active participants in their learning experience at school. The services provided through the SBHC assisted them to be both physically and mentally healthier, remain active, engaged participants in their academics and sports, and feel connected to their school. Additionally, these adolescents are learning essential self-care skills and how to be active, independent participants in their health in a supportive environment where they can practice these skills.
School nurses are an essential aspect of keeping adolescents healthy and in school (NASN, 2001, 2015). The collaboration between the school nurse and SBHC staff provides a more holistic approach to meeting the everchanging needs of the school community. As explained by the students in this study, the roles of the school nurse and SBHC staff are different yet complementary and can be powerful, with appropriate communication and collaboration, in enhancing both wellness and learning in schools. Referrals from the school nurse to the SBHC, or in schools without SBHC, to community providers, can help to remove significant barriers to timely care for adolescents especially for reproductive health and mental health concerns.
Privacy and confidentiality and building relationships with health professionals are essential elements of care for adolescents (Moriarty Daley et al., 2019). Efforts to improve confidentiality and privacy in school nurses’ offices are important to adolescents. For example, talking to students in a more private space about their reasons for coming to the office, using curtains to separate spaces, and even calling parents from a private location can go a long way to help adolescents feel more comfortable and engage in care. Building trusted relationships and “being known” by those providing care was viewed as important for the teens in this study and needs to be prioritized by all health care providers (Moriarty Daley et al., 2019).
School nurses can advocate for expanding the scope of their specialty practice and including additional standing medication orders for more common concerns (e.g., headaches, dysmenorrhea) that would allow for treatment and the return to class. Assisting with efforts to encourage students to have signed consents for the SBHC “in case” they need to be seen would enhance SBHC access for students. Additionally, providing a warm handoff to SBHC staff is also a key strategy to help adolescents access needed services through the SBHC. Most SBHC incorporate mental health services into their care and extend the services available through the school or even the community. School nurses and teachers are critical referral sources for adolescents. The teens in this study identified crisis management services and counseling as important aspects of care they received in the SBHC. School nurses can provide a critical linkage for students in need of mental health services and the SBHC.
Future research should focus on the perspectives of school nurses on school-based health services. In addition, some research has demonstrated the positive impact of SBHCs on school participation by increasing “seat time” (Van Cura, 2010). Research examining the implementation of the WSCC model and how it influences SBHC services is needed. Further, research should examine the role of SBHCs related to engagement in wellness care throughout adolescence, health literacy, and the outcomes related to the successful transition into adult health care services for those adolescents who have participated in SBHC services. A cost analysis and cost-benefit ratio examining multiple factors of nurse costs, seat time, graduation rates, and future education can be done to determine the efficacy of care provided through SBHCs.
A convenience sample of adolescents who had a least one visit at the SBHC was recruited and enrolled into this focus group study. A strength of this study was that all the teens who participated had experience with the school nurse(s), SBHC, and other community health care services, which allowed them to compare and contrast their experiences. This study is limited to the perspectives of adolescents in one northeastern state; the results may have been different if adolescents from different areas of the country were included in the study.
This study provides the adolescent perspective on the significant role SBHCs have in assisting adolescents to participate more fully in school. The confidentiality and the trusted relationship established with the SBHC staff allowed and encouraged adolescents to assume a more primary and engaged role in their health care experience and access to health care services that met their needs. The adolescents in this study describe the critical role between health and education and how the SBHC supported their ability to stay in school. The complementary roles of the school nurse and SBHC services facilitated access to timely health and mental health services for adolescents.
The first author gratefully acknowledges Sigma Theta Tau Mu Chapter, Mu Chapter, and Connecticut Nurses’ Foundation Dr. Sheila Packard Memorial Scholarship for funding this research and Cheryl T. Beck, DNSc, CNM, FAAN, Thomas J. Van Hoof, MD, EdD, and Arthur Engler, PhD, RNC, APRN, for their support of this research. Thank you to the adolescents who participated in this study and shared their experiences and insights into school-based health care.
Alison Moriarty Daley contributed to conception, design, acquisition, analysis, or interpretation; drafted the manuscript; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. E. Carol Polifroni and Lois S. Sadler contributed to conception, design, acquisition, analysis, or interpretation; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
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 and/or authorship of this article: This work is funded by Connecticut Nurses’ Foundation, Dr. Sheila Packard Memorial Scholarship and Sigma Theta Tau Mu Chapter, Mu Chapter.
Alison Moriarty Daley, PhD, APRN, PPCNP-BC, FAAN https://orcid.org/0000-0002-2455-429X
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Alison Moriarty Daley, PhD, APRN, PPCNP-BC, FAAN, is an associate professor in Master’s Program at Yale University School of Nursing, Orange, CT and is a pediatric nurse practitioner at Yale–New Haven Children’s Hospital, New Haven, CT.
E. Carol Polifroni, RN, EdD, CNE, NEA-BC, ANEF, is a professor of nursing and director, Office of Clinical Placement Coordination at University of Connecticut, Storrs, CT.
Lois S. Sadler, PhD, RN, FAAN, is a professor at Yale University School of Nursing, Orange, CT and Yale Child Study Center, New Haven, CT.
1 Yale University School of Nursing, Orange, CT, USA
2 Yale–Haven Children’s Hospital, New Haven, CT, USA
3 University of Connecticut, Storrs, CT, USA
4 Yale Child Study Center, New Haven, CT, USA
Corresponding Author:Alison Moriarty Daley, PhD, APRN, PPCNP-BC, FAAN, Yale University School of Nursing, PO Box 27399, West Haven, CT 06516, USA.Email: alison.moriartydaley@yale.edu
