The Journal of School Nursing2024, Vol. 40(3) 305–315© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405221088957journals.sagepub.com/home/jsn
School nurses have reported stress and worry caring for young people experiencing mental health problems, but why this occurs and how they respond has not been well-explored. In this study researchers generated a substantive theory of the experiences of secondary school nurses who encountered young people with mental health problems using the original method of grounded theory. Thirty-one Western Australian school nurse participants reported that students presented with complex mental and social health needs that were not easily resolved. This was conceptualized as an untenable burden. Participants countered this by engaging in the three-stage process of tactical prioritizing. During an initial period of strategic assimilation into the school and broader community, participants referred students to external service providers. This was frequently inadequate, and participants found themselves grappling with unmet student mental health needs. Participants responded by implementing nursing strategies for optimizing outcomes in the lives of young people, while simultaneously engaging in managing self to support their own well-being.
Keywordsadolescent health, grounded theory, school nursing, youth mental health
Fifty percent of lifetime mental disorders begin by 14 years of age with additional young people experiencing transient mental health problems (van Doorn et al., 2021). Both scenarios have significant potential to derail the developmental trajectory through adolescence, impacting school attainment (von Simson et al., 2021), and damaging the transition to adulthood (Holloway et al., 2018). School nurses work directly with young people in schools and are ideally placed to intervene in emerging or established health concerns. The work of school nurses with young people experiencing mental health problems is therefore critically important.
Several studies have investigated the experiences of secondary school nurses with young people experiencing mental health problems (Dina & Pajalic, 2014; Hilli & Wasshede, 2017; Jönsson et al., 2017; Pryjmachuk et al., 2012; Skundberg-Kletthagen & Moen, 2017). A common finding is that school nurses perceive their work with this cohort to be an important part of their role (Markkanen et al., 2021; Pryjmachuk et al., 2012; Skundberg-Kletthagen & Moen, 2017), but they do not always feel well-equipped clinically or professionally for the work (Jönsson et al., 2017; Markkanen et al., 2021; Moen & Skundberg-Kletthagen, 2018; Skundberg-Kletthagen & Moen, 2017). Several studies have identified that school nurses experience unease caring for this cohort (Jönsson et al., 2017; Markkanen et al., 2021; Pryjmachuk et al., 2012; Skundberg-Kletthagen & Moen, 2017; Thomas, 2017). This has been interpreted mainly as a need for more mental health training and consequently research addressing training has had the most attention in the literature (Abbott et al., 2019; Bohnenkamp et al., 2019; Haddad et al., 2018). Available evidence indicates that mental health training improves school nurses’ confidence and skills to intervene with young people’s mental health problems (Abbott et al., 2019; Haddad et al., 2018). However, it remains unclear if a lack of training is the main factor contributing to the feelings of unease school nurses have identified.
How school nurses themselves respond to these feelings of unease has not been investigated. As largely autonomous providers working in a non-health setting, the nature of school nursing work is that nurses must be self-reliant. This same self-reliance suggests that school nurses will have developed strategies to address and manage the difficulties they encounter caring for young people with mental health problems. These strategies are important for several reasons. In the first instance, chronic feelings of professional anxiety contribute to occupational stress. Unmanaged, this stress can proceed to burnout (Jameson, 2019) and may prompt some nurses to leave school nursing (Sendall et al., 2014). Secondly, school nursing is a unique field of practice and should have speciality-specific competencies that support school nurse sensitive outcome measures (Best et al., 2017). Outcomes measures typically employed in clinical settings such as a reduction in specific symptoms of mental illhealth may not be the most appropriate measures for school nursing practice. Nursing interventions that promote attendance and continued engagement at school – even in the presence of symptoms of mental ill-health – may be a better measure of the unique contribution school nurses make in the lives of young people experiencing mental health problems. This distinction is important if the work of school nurses is to be acknowledged and valued as separate and distinct from other members of the health care team. Nursing work is frequently undervalued (Godsey et al., 2020) and the work of school nurses arguably even more so (Dawe & Sealey, 2019). The perception that school nursing work can be omitted without ill-effect or that it can be undertaken by non-nurses should be challenged. Identifying and measuring the unique contributions school nurses make to the life outcomes of young people is therefore critically important.
The aim of the current study was to develop a substantive theory that explains the experiences of school nurses who encounter young people with mental health problems. Understanding how school nurses respond to the shared common concern they experience in relation to young people experiencing mental health problems provides opportunities to implement assertive and effective nursing supports. This is likely to have significant benefits for nurses and for the young people they provide care to.
The researchers employed the original method of grounded theory (Glaser & Strauss, 1967). Semi-structured interviews were conducted with school nurses who had encountered young people experiencing mental health problems. The nurses’ perception that the young person presented with poor mental health was sufficient. A young person with mental health problems included those with or without a mental health diagnosis. This definition was adopted because young people experiencing mental health problems often first present with non-specific psychological distress or psychosocial disability that has not yet been evaluated by a mental health service (Radez et al., 2021) or is not yet quantifiable as a mental disorder (Cross et al., 2014; Hickie et al., 2013).
The study was conducted in Western Australia where secondary school nurses provide care to school-attending young people aged between 11 and 19 years. They are referred to in this paper as young people. Thirty-one school nurse participants were recruited, 21 from metropolitan Perth (the capital city), and the remaining 10 from rural and regional areas of the state. The sample size was determined by the achievement of data saturation. Glaser and Strauss (1967, p. 61) defined saturation as meaning that ‘no additional data are being found whereby the sociologist can develop properties of the category’. All participants were government funded secondary school nurses meeting the inclusion criteria (see Figure 1). Participants were recruited via an email distributed by the relevant health service nursing director in 2017. Interested school nurses contacted the researchers directly. All participants received an information sheet and provided written consent to participate. Most school nurse participants were female and the duration of employment as a secondary school nurse ranged from six months to 16 years. Ethical approval for the study was obtained from the Child and Adolescent Health Service in Western Australia (RGS00056), and Curtin University (HRE2017-0280).
The aim of grounded theory is to develop a substantive theory that explains the participants’ shared common concern or basic social psychological problem (Glaser & Strauss, 1967). Data collection and data analysis were undertaken concurrently, closely adhering to the methods described by Glaser & Strauss (1967). Data in this study included semi-structured interviews, demographic data, memos, and field notes. Interviews took place by phone or face-to-face in a setting of the participant’s choosing, were digitally recorded and transcribed verbatim. A question guide was used as a prompt (see Figure 2).
Data analysis was undertaken using the constant comparative method of analysis central to the grounded theory method (Glaser & Strauss, 1967). Interview transcripts were examined line by line using NVIVO (QSR International, 2016) to identify common codes, processes, or concepts. Initial codes were compared and contrasted for similarities and differences. Subsequently codes were modified, discarded, or subsumed under broader code categories to capture the meaning in the data and to identify the basic social psychological problem. Memos captured researcher insights to aid data analysis, while the field notes captured researcher observations not otherwise recorded in the interview transcripts.
Once the basic social psychological problem was identified theoretical coding reassembled the deconstructed data into a substantive theory using inductive analysis. This process makes explicit the complex links and connections in the coded data (Glaser & Strauss, 1967). The behaviour participants engage in to overcome the basic social psychological problem was identified and is referred to as the basic social psychological process. Throughout theory development theoretical sampling was employed. This sampling strategy was guided by the developing theory and sought out participants with extended or different experiences to ensure that data collected was rich and expansive (Conlon et al., 2020). Theoretical sampling continued until categories were well developed with no new information or insights emerging. Consistent with the original method of grounded theory (Glaser & Strauss, 1967), the existing published literature formed part of the data analysis process but was considered only after the substantive theory was developed.
Trustworthiness and credibility of the data were maintained by adhering closely to the grounded theory method. The research team comprised one former school nurse (the primary author) and two mental health nurses. The primary author employed bracketing to mitigate the risk that the personal lens of having been a school nurse would influence the study. Data collection and analysis were verified using investigator triangulation, conducted monthly via in-person meetings. Extensive written memos provided an audit trail. Thick descriptions of the phenomenon are provided to aid readers in determining the transferability of the findings (Polit & Beck, 2018).
In this study, secondary school nurses who encountered young people with mental health problems experienced the basic social psychological problem of untenable burden. Participants overcame this problem by employing the basic social psychological process of tactical prioritizing. Figure 3 presents a conceptual model representing untenable burden and tactical prioritizing.
Participants perceived their work with young people experiencing mental health problems to be very important, but reported that providing care had a sustained personal and professional impact on them. This problem was conceptualized as an untenable burden. There were four categories that contributed to the basic social psychological problem of untenable burden: wicked problems, persistent intensity, autonomy and isolation and a heavy toll.
Wicked problems. The term ‘wicked problems’ was first used by Rittel and Webber (1973) to describe complex problems with multiple causes that do not have easy or ‘correct’ solutions. Participants reported that young people often presented with wicked problems that went well beyond the school walls, affected multiple systems in the young person’s life, and were frequently ongoing and difficult to resolve:
I had this girl self-harming … her family issues weren’t [being dealt with]. The father had left her to go to [redacted location], left her in his house, with the older brother who [used] drugs. He didn’t provide money for her … She came in one day with [self-harm] cuts … we tried to link her up with [government financial support], [and the] Department for Child Protection and Family Support because she was an older [student]. She just wanted to finish Year 12, but she didn’t have any [home] support. (P2)
Wicked problems ranged from acute but transient issues to complex and continuing challenges: ‘[Presenting issues] can range from anxiety, suicidal [ideation], self-injury, bereavement, relationship breakdown, peer conflict, family issues at home, drug and alcohol dependant parents, exam stress, sexual health issues … just anything and everything … walks through the door’ (P30). Participants reported that young people experiencing wicked problems were frequent attenders to the school health centre and often presented in crisis, conceptualized as persistent intensity.
Persistent intensity. The category of persistent intensity had two aspects: the high volume of young people presenting to the school health centre and the high stakes nature of presentations which frequently included risk for self-harm or suicide. Many participants reported that they had daily contact with young people experiencing mental health problems. Emotional distress was common: ‘sometimes … they’re just tearful and they’ll disclose all sorts of things’ (P16). Many participants reported that young people actively sought them out: ‘a lot of students … feeling a bit overwhelmed or panicky or anxious or not safe … will automatically come to my room’ (P4). Intervening with students experiencing a high stakes crisis was a commonly reported task which required that all other demands be temporarily set aside:
He had written a [suicide] note … he was going to run out in front of a bus in front of the school and kill himself … we held on to each of his arms … I used every single skill and tactic that I could … rather than dragging him back physically … to preserve his dignity but also to protect the other children … he was really distressed, he was crying, he was sobbing, he was dribbling. (P21)
Persistent intensity was also incurred in the assertive monitoring of young people with known mental health and wellbeing concerns:
I could probably name 10 or 11 students at the moment that I would check in on nearly every week. Especially Monday. Monday is difficult because things may have happened on the weekend. Tuesday is difficult for the ones that also use cannabis, because they tend to fall in a heap on Tuesday mornings [due to cannabis withdrawal after weekend use]. (P29)
A key source of persistent intensity for participants was that the high stakes risks with which young people presented could be of an unpredictable and fluctuating nature: ‘With teenagers, the risk assessments are at that very moment. Five minutes later those risk assessments could be [irrelevant] and totally different because they might have a break-up with a partner or [argument with a] best friend’ (P17). The high stakes aspect of persistent intensity was not limited to what happened at school: ‘the sort of young boys that [go unnoticed], and then suddenly write a suicide note in the middle of the night … they always worry me a bit’ (P28). Nor did engagement with a specialist mental health service prevent an exacerbation of known risks at school: ‘[the student said] “I feel terrible, I feel unsafe, I feel like I’m going to go and harm myself.”’ (P18). Participants reported that wicked problems and persistent intensity defined the clinical workload, but the work was further complicated by the level of autonomy and isolation inherent in the school nurse role.
Autonomy and isolation. Participants worked as autonomous clinicians, usually as the only nurse in the school, concurrently reflecting high levels of autonomy and isolation. Participants perceived this could be overwhelming especially when they first commenced their school nursing career: ‘I was left in there [the school health centre]. I had the [outgoing] nurse with me for a week [to orientate me] and then she was gone. I [thought] [whispers] “oh my God”’ (P1). Given that the specifics of wicked problems were variable and unpredictable, participants reported that they frequently had no prior experience of a given clinical scenario: ‘At the beginning I’ve definitely had a few come through and I thought “I don’t think I know what to say to you. You’ve come to me with this problem, and I don’t know what advice to give you”’ (P3). As a consequence of this unfamiliarity, participants reported a high degree of clinical uncertainty, which was particularly acute early in their school nursing career: ‘Should I have said this? Should I have done that? Should I have reported it to …? I do that, a lot’ (P12). More experienced participants were not invulnerable to feeling clinically uncertain but had developed a tolerance for it: ‘I don’t know that I’m getting it right … [but] I feel like I am’ (P8). The isolation participants experienced was exacerbated by the finding that every school is different. Some participants worked in supported education settings for young people with cognitive or physical disabilities, government boarding schools, specialist colleges and intensive English language centres catering for young people entering Australia as refugees. In addition, Western Australia is approximately 2.65 million square kilometres in size. Characteristics such as geographic location and socioeconomic factors were all highlighted as contributing to every school is different.
Experienced participants had adjusted to working autonomously, but a specific set of circumstances continued to exacerbate feelings of isolation. This occurred when mental health treatment for young people could not be sourced, leaving participants to feel that they had been left holding the baby. This phrase explains circumstances where the school nurse might be the only health professional providing any level of mental health support for a young person:
He wrote a suicide note. He’s a 12 year old Aboriginal boy. … [he] lives with mum and a couple of other siblings, [and an] older sister … [The boy] attended Child and Adolescent Mental Health Services with his Year 10 sister … but mum wouldn’t engage so they discharged him … into the care of the school psychologist …. who equally discharged him because she couldn’t get mum to sign consent [for psychology input]. This little boy was then [no-one else’s professional responsibility]. (P28)
It was not unexpected that the chronic nature of the stresses participants experienced had a significant impact on their emotional well-being. This was conceptualized as a heavy toll.
A heavy toll. A heavy toll was expressed directly and in emotions such as tearfulness: ‘I’ve been dealing with some really heavy, heavy cases. It’s taking a toll on me’ (P15). Participants commented on the emotional impact of caring for young people experiencing very difficult circumstances: ‘What I’m exposed to at the secondary school is as traumatic, if not more so [than working in the hospital], because we’re dealing with … children who are … in very difficult situations. In a hospital environment it’s quite controlled, quite contained’ (P31). An especially painful contribution to a heavy toll was the intersection between the relationshipbuilding and reporting aspects of the role: ‘They feel betrayed by you because you’ve reported [their situation] to the authorities. There’s an investigation [by child protection services] and then they get in trouble [with their families] and stop seeing you’ (P31). A heavy toll was also exacerbated when participants were disappointed with the response from other service providers:
The [deputy] principal … asked myself and the psychologist’s advice. We both said, “get her to a hospital” … They managed to get the girl to the hospital, and she was discharged. She did see a social worker, she did get a [mental health] referral, but I felt somebody needed to take care of this 15 year-old child that had been saying to men “I’ll have sex for money.” Covered in self harm, both arms, and I sometimes feel a bit let-down. (P29)
These four categories, wicked problems, persistent intensity, autonomy and isolation and a heavy toll, precipitated feelings of untenable burden. To overcome this problem participants engaged in the basic social psychological process of tactical prioritizing.
Tactical prioritizing conceptualized the active and strategic process participants engaged in to manage the problem of untenable burden. This process focussed on building and maintaining a professional relationship with their assigned school, promoting the health and developmental outcomes of vulnerable young people, and maintaining their own emotional well-being in the face of a highly complex and stressful employment role. These were conceptualized respectively as: strategic assimilation, optimizing outcomes and managing self. The process was not linear. Initially nurses were engaged in a process of strategic assimilation into their school and broader community, but nurses quickly found themselves grappling with unmet student mental health needs. Participants responded by alternating between optimizing outcomes and managing self, unless they were reallocated to a new school when the process recommenced with strategic assimilation.
Stage 1: strategic assimilation. Strategic assimilation explains how nurses build relationships so that they can function optimally in the school nursing role: ‘the whole job is about relationship-building, whether with the teachers, the admin staff or the students’ (P24). It was comprised of two aspects: being there and knowing where to send them. Being there was about the physical and emotional presence of the school nurse in the school community: ‘I want it to be known that I am here if the kids need me’ (P9). The purpose of knowing where to send them was to be able to link young people to local sources of information or help: ‘you need to know what you can do and where you can send them’ (P23). Participants had achieved strategic assimilation when they had a well-developed knowledge of locally available resources to which they could refer young people and were known within their school for their physical and emotional availability. In the context of mental health problems, stage one of the process of tactical prioritizing concluded with the referral of young people to other service providers both within and external to the school. Having engaged in these activities, many participants quickly became aware that this was often not enough. Some young people did not or could not access treatment providers to whom they had been referred, while a mental health crisis could occur at school even when a young person was appropriately engaged with a specialist service. These experiences contributed to persistent intensity: ‘[students] bounce back to you and you’re sometimes sitting there thinking “okay, I’ve referred you, you’re not getting there”’ (P3). As a consequence, participants found themselves at a tipping point, entitled grappling with unmet needs. Not unexpectedly, grappling with unmet needs exacerbated the experience of untenable burden: ‘it’s [what to do with] the kids that come and see you again and again?’ (P15).
Persistence beyond grappling with unmet needs marked the transition into stage two of the process of tactical prioritizing and was conceptualized as optimizing outcomes. While optimizing outcomes was intended to assist the young person, engaging in optimizing outcomes also provided participants with a sense of agency, purpose, and professional satisfaction. In the short-term, this diminished the experience of untenable burden. In the longer-term, participants with well-developed skills for optimizing outcomes became known as an effective support, prompting other young people to present and further escalating persistent intensity.
Stage 2: optimizing outcomes. In the second stage of tactical prioritizing referral to other service providers was no longer the end point for intervention. Appropriate referral continued as before, but optimizing outcomes was highly reliant on individualized interventions provided directly by the school nurse participant and reflected a unique and sophisticated clinical role. There were six components in optimizing outcomes: opening Pandora’s Box, safety first, life skills 101, student support, family support, and advocacy.
As a first step participants developed the ability to uncover wicked problems by opening Pandora’s Box: an informal, holistic, non-specific but sensitively inquisitive probe into the young person’s life which could uncover very real concerns: ‘I just had a chat with him, just exploring all aspects of why he might be feeling unwell. He relayed to me that he still wanted to die and thought about dying all the time’ (P28). Some young people were very guarded about what they disclosed, but experienced participants could work around this:
I’m sure she only tells me some things. I say “I’m reading between the lines here. There are issues at your house that you probably aren’t allowed to tell me.” She smiles at me because she knows [that] I know what’s going on. (P2)
Participants were ready to respond to the issues young people raised, but their immediate priority after opening Pandora’s Box was always the same, safety first. This could include checking that the young person was living in safe circumstances, offering a place of safety at the school health centre to decompress, and helping the young person to develop a safety plan for potential crises such as domestic violence and self-harm risk. After addressing safety first, the process was no longer linear, as participants turned their attention to addressing the young person’s unique needs, whether life skills 101, student support, family support, or advocacy. While some young people required all these components, other young people required only some.
Life skills 101 was about supporting young people to navigate their lives and develop essential skills to manage life’s complexities. This commonly included tasks such as problem solving, negotiation and conflict resolution: ‘it can be a teacher that’s giving them grief, it can be just not getting on with parents, or friendship [issues]’ (P10). Student support reflected the provision of social and emotional support. One participant described a young person who sought frequent student support in the midst of an ugly custody battle between her parents: ‘[the student] comes down [to see us]. She’ll drop in [and say] “this is what’s happening and I’m good”, or just come in and have a talk [when things aren’t good]’ (P22). Although young people were the main recipients of support, many participants reported that they provided significant social and emotional support to parents, especially when parents were struggling to care for young people experiencing mental health problems. This was conceptualized as family support:
One of the mums came in the other day and I could see … that she needed to talk to me. She’d brought her daughter [to school], they’d been for [a mental health] appointment. Mum’s body language said it all. I took her into my room, made her a cup of tea, sat down, and said ‘okay, what’s going on?’ She just sat and cried for about 20 minutes. (P20)
Advocacy for the young person related to liaison with other members of the school staff and was often strongly oriented to supporting continued school engagement. Participants were very aware that teachers could encounter significant problems educating a young person distracted by wicked problems, particularly if these also interfered with school attendance and behaviour. ‘The less they’re at school the harder it becomes to be at school because they get so far behind. [Poor academic progress brings] real challenges. Because of that you’ve got challenges in teaching, [and] you’ve got challenges in behaviour’ (P22). Advocacy could include supporting teachers to understand the realities of some young people’s lives, within the bounds of confidentiality:
If you can explain to [teachers] ‘… there’s a lot of stuff going on for Johnny at the moment. He doesn’t always know where he’s going to sleep at night. He’s not always safe. He might not rock up to school until period two [and] he’s going to turn up unprepared. He’s not going to have his homework. He’s not going to have full school uniform on. He might put his head down on the desk and sleep. But you know what? He obviously feels safe to come to your class’. (P21)
Although engaging in optimizing outcomes could be effective against experiences of untenable burden, it was not usually enough. As participants became known for their skills in optimizing outcomes, they typically experienced an increase in persistent intensity and subsequently also an increase in untenable burden. This occurred for two reasons: young people who had received school nurse care presented more frequently, and peer referrals increased, escalating the numbers of young people seeking care. These demands prompted participants to simultaneously engage in the third stage of the core process, managing self.
Stage 3: Managing Self. Managing self conceptualized how participants sought to maintain their own personal and professional well-being in the face of increasing untenable burden. Not unexpectedly, the urgency and need for managing self became more pronounced as untenable burden increased. There were three aspects which nurses frequently employed in managing self. These were sharing the responsibility, learning, learning, learning and seeking personal balance. When these three means of managing self were insufficient a fourth aspect to managing self was employed. This was conceptualized as taking extreme measures and occurred only infrequently.
The most critical aspect of managing self was sharing the responsibility with other school-based service providers: ‘we have a Student Services team [and] we have a meeting to catch up on all the students that are needing extra support. We share information there and decide which student needs whose help [as a multidisciplinary team]’ (P9). School-based case collaboration diminished the experience of untenable burden because it reduced feelings of isolation and provided participants with collegial support: ‘That’s my saving grace, because if I didn’t have that, I don’t know how well I would be able to do the role over a period of time’ (P31). The second activity participants engaged in to manage the experience of untenable burden was learning, learning, learning. This ranged from self-directed reading activities to formal postgraduate studies, all of which helped participants to grow a repertoire of sophisticated knowledge and clinical skills specific to the care of young people. Although this toolbox was helpful for intervening with wicked problems, it also increased persistent intensity and a heavy toll, because the more skilled a participant became, the more likely young people sought them out with complex issues. In addition to professional measures such as sharing the responsibility and learning, learning, learning, participants also engaged in seeking personal balance. This comprised of active personal coping strategies that ranged from exercise and finding meaning in the work, to taking time off and seeking temporary alternative employment. A key means for seeking personal balance was recalling occasions when school nursing interventions had clear benefits for the student. Participants described these moments with clarity, even if they had occurred many years ago.
Although participants routinely engaged in these three strategies for managing self, occasionally participants took the additional step of taking extreme measures. This typically occurred in the context of a serious ethical conflict and involved making a decision inconsistent with health service policy: ‘A colleague [and I] ended up taking [the student] to the [mental health] hospital, which is really against the policy’ (P3). Participants who disclosed taking extreme measures reflected that this had been necessary for managing self: ‘[I did it so] I could sleep at night … [the only way to] get something to happen [for the student] was to go against the policy …. [The student] ended up in [the adolescent inpatient psychiatric inpatient] unit’ (P3).
The aim of this study was to explore the experiences of secondary school nurses who encountered young people with mental health problems and develop a substantive theory to explain these experiences. The researchers identified that school nurses engage in tactical prioritizing to overcome the experience of untenable burden. In common with other studies (Jönsson et al., 2017; Larsson et al., 2014; Skundberg-Kletthagen & Moen, 2017), school nurses in the current study frequently encountered young people experiencing mental health problems and perceived this work as a very important part of their role. Notably, the sense of unease reported by school nurses in previous research (Jönsson et al., 2017) was also evident in the current study.
The study reported here extends on previous findings and identifies that the experience of untenable burden reflects the complexity of cases, the intensity and acuity of the workload, the feelings of isolation experienced by being the only nurse in the school, and the emotional burden school nurses negotiate caring for this group of young people. The study findings also illustrate that school nurses are far from passive when experiencing untenable burden. School nurses engaged in a three-stage process of tactical prioritizing to overcome to the experience of untenable burden. Strategic assimilation explains how nurses build relationships with their school so that they can function optimally in the school nursing role. Previous research has identified that the process of socialization to the school nurse role and the influence of a school’s culture on the practice of school nursing are important (Maughan & Adams, 2011). In the current study participants undertook strategic assimilation quite deliberately, but the process has not previously been described in the literature.
Optimizing outcomes described the unique interventions school nurses undertook with young people experiencing mental health problems. Both planned and unplanned, these nursing interventions were highly individualized, and varied from social support to skill development and advocacy. Several studies have focussed on how school nurses implement structured or manualized interventions with young people experiencing mental health problems (Ginsburg et al., 2021; Muggeo et al., 2017; Turner & Mackay, 2015), but exploring the activities that school nurses independently implement in their daily practice has had less attention. Previous research identified that therapeutic engagement, the development of trust, health counselling and interprofessional collaboration were key activities school nurses undertook with individual students (Dina & Pajalic, 2014). Similarly, Markkanen et al. (2021) identified that individual counselling, crisis intervention and assessment of emotional or behavioural problems were frequent school nurse activities. Participants in the current study described undertaking similar tasks, but these were conceptualized in goal-directed terms and oriented to optimizing outcomes in the young person’s life.
Finally, managing self describes the strategies school nurses engaged in to assertively manage their own emotional well-being in the face of untenable burden. Nurse well-being has been a significant focus of attention in the literature, and much emphasis has been placed on increasing nurse resilience (Yu et al., 2019). Participants in the current study were highly experienced nurses even before becoming a school nurse and they employed a broad range of active personal and professional coping strategies. This did not always mitigate the experiences of untenable burden. There is also some evidence that experiences akin to untenable burden may prompt school nurses to leave their employment (Sendall et al., 2011, 2014). This suggests that more assertive system level supports for managing the experience of untenable burden may be required.
The study findings therefore have significant implications for school nurses, school administrators, nurse managers and school health services. The strategies described in strategic assimilation, optimizing outcomes, and managing self can be replicated, enhanced, refined, disseminated, and evaluated as structured approaches to professional, educational, and clinical school nursing support. For example, knowledge and clinical skills to underpin optimizing outcomes have the potential to be taught in school nursing preparation programs. The importance of strategic assimilation suggests this process should be planned, structured and assertively supported. Warm introductions to stakeholders internal and external to the school – including parents, students, education staff and external service providers – might facilitate and enhance the process of strategic assimilation.
The study findings also suggest myriad opportunities for further school nursing research. The substantive theory of tactical prioritizing to overcome the experience of untenable burden reflects more than 240 years of Western Australian school nursing experience. It is a potentially powerful framework for facilitating and supporting school nursing efforts to provide care to young people experiencing complex issues, but it is untested. In the first instance the substantive theory should be tested in the Western Australian public sector school health service. It should then be tested in other models of school nursing internationally, in privately funded schools and in elementary schools. The various components of tactical prioritizing also require further investigation. In the current study all three components – strategic assimilation, optimizing outcomes and managing self – were important, but their relative importance to stakeholders is likely to be different. Ideally interventions for optimizing outcomes would be linked to a comprehensive suite of outcome measures of importance to school nursing. While health stakeholders will want to include specific health and developmental outcomes, education stakeholders will also want to consider outcomes related to student behaviour, management of self-harm and suicide risk, and overall student academic achievement. In jurisdictions where the school does not employ the school nurse directly – such as Western Australia – the intersectoral collaboration required between health and education sectors will also require further investigation.
The main limitation in this study is the recruitment and selection of participants, all of whom were government funded secondary school nurses in Western Australia. It is not clear if the findings apply to school nurses working in other school health service models in Australia or internationally. Further, the study information sheet identified the research topic as young people’s mental health. Participants may have had an interest in speaking about this topic and may therefore not be representative of school nurses generally.
The mental health of young people is an increasing concern in the global context and secondary school nurses are wellpositioned to intervene with this cohort. The current study confirms that school nurses perceive their role with young people experiencing mental health problems to be very important, but there are significant personal and professional impacts in consequence. This was conceptualized as the experience of untenable burden. To overcome this problem nurses engaged in tactical prioritizing, a three stage process comprising strategic assimilation, optimizing outcomes and managing self. This study provides insight into the complex clinical workload secondary school nurses in Western Australia undertake with young people experiencing mental health problems, the efforts they engage in to build effective relationships in their school communities and the assertive strategies they employ to maintain their own well-being. These findings have potentially significant implications for school nurses, school administrators, nurse managers and school health services. Strategies that support school nurses to engage in the process of tactical prioritizing have the potential to improve not only the well-being of the school nurse workforce, but also the mental health and wellbeing of young people.
The authors would like to thank the Child and Adolescent Health Service and the WA Country Health Service in Western Australia for providing governance approval to conduct the study. School nurses who took part in the research are sincerely thanked for their participation.
Interests 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 Australian Government Higher Degree by Research Fee-Offset Scholarship (grant number N/A).
Ethics approval for the study was granted by the Child and Adolescent Health Service Human Research Ethics Committee in Western Australia: approval number RGS00056, and Curtin University’s Human Research Ethics Committee, approval number HRE2017-0280.
Anita Moyes https://orcid.org/0000-0003-4924-8827
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Anita Moyes, RN, PhD is a lecturer at Edith Cowan University in Perth, Western Australia.
Shirley McGough RN, PhD is a lecturer at Curtin University in Perth, Western Australia.
Dianne Wynaden RN, PhD is Professor Emeritus at Curtin University in Perth, Western Australia.
1 Edith Cowan University, Joondalup, Perth, Western Australia, Australia
2 Curtin University, Perth, Western Australia, Australia
Corresponding Author:Anita Moyes, PhD, Edith Cowan University, 270 Joondalup Drive, Joondalup, Perth, Western Australia, Australia.Email: A.Moyes@ecu.edu.au