The Journal of School Nursing2024, Vol. 40(3) 342–351© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405221142306journals.sagepub.com/home/jsn
School nurses are uniquely positioned to support lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) students. One approach is involvement in Gender and Sexuality Alliances (GSAs). GSAs have been found to improve outcomes for LGBTQ students. The purposes of this quality improvement project were to build infrastructure for GSAs by implementing a GSA Support Plan including a digital resource binder, GSA advisor trainings, and establishment of an Advisor Leadership Committee and increase the number of schools with a GSA. The binder was distributed electronically to 95 advisors. Fortynine participants attending virtual trainings. A statistically significant increase in all measures of participant confidence occurred between the pre- and post-training surveys. The Advisor Leadership Committee was established. This paper adds to the literature by showing that support for GSAs is important to aiding LGBTQ students. Further, authors suggest ways in which school nurses can harness their expertise to be involved with GSAs.
KeywordsLGBTQ, health/wellness, evidence-based practice, sexual minority youth, trans youth, health education
Gender and Sexuality Alliances (GSAs, also called Gay-Straight Alliances) are school clubs for lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) students and their allies. These clubs are associated with improved school climate for all students and increased school belongingness for LGBTQ students (Gower et al., 2018; Marx & Kettrey, 2016; Toomey & Russell, 2013). Jarpe-Ratner et al. (2022) noted that the presence of a GSA can be a sign of support and affirmation in for students. Further, in schools with GSAs, LGBQ students perceived their overall school environment as safer, with less homophobic bullying (Ioverno et al., 2016).
Gender and Sexuality Alliances are a source of support for LGBTQ students, who are at higher risk for adverse health outcomes such as depression and suicide when compared to their non-LGBTQ peers (Eisenberg et al., 2017; Gower et al., 2018; Johns et al., 2019; Kosciw et al., 2020). Data from the 2019 Youth Risk Behavior Survey highlighted that LGBQ youth were more than twice as likely as their non-LGBQ peers to have felt sad or depressed, considered attempting suicide, and actually attempted suicide (Centers for Disease Control and Prevention [CDC], 2020). Additionally, research shows that LGBTQ high school students experience high rates of harassment, victimization and violence, all of which have been associated with higher rates of suicidality among LGBTQ students (Espelage et al., 2016; Hillard et al., 2014; Kosciw et al., 2020).
As a trusted adult and the primary health figure in schools, school nurses are uniquely poised to advocate for safer environments and create an improved school climate for all students, including LGBTQ students. According to the National Association of School Nurses, collaboration with school teams to create healthier and more welcoming environments for LGBTQ students is the responsibility of all school nurses (2021). Advocating for changes in the school environment that promote positive mental health outcomes, such as the development and sustainment of GSAs, is one way school nurses can support their LGBTQ students (Ancheta et al., 2021).
This project took place at Chicago Public Schools (CPS), where 22.7% students self-identify as LGBTQ (DiPaolo et al., 2020). Similar to national trends, LGBT students at CPS report higher rates of depression and suicide attempts. Of LGBT high school students in CPS, 60% reported feeling depressed, 34% seriously considered suicide, and 22% attempted suicide within the past 12 months, which are all nearly three times higher than the rates of their non-LGBT peers (DiPaolo et al., 2020). Additionally, 23% missed school due to safety concerns (DiPaolo et al., 2020).
To better understand the needs of this student population, an in-depth population assessment was conducted, using the PRECEDE-PROCEED Model as the guiding framework. School-based staff who sponsor a GSA, called GSA advisors, were invited to participate in key informant interviews. Advisors acknowledged the importance a GSA plays in creating a safer space for LGBTQ students. They identified GSA meetings as a place where LGBTQ students can engage in open conversation with others and can problem solve personal and public issues that can impact their mental health, such as family acceptance and bullying. In addition, despite the documented benefits of a GSA (Eisenberg et al., 2017; Gower et al., 2018; Johns et al., 2019; Kosciw et al., 2020), most CPS schools did not have established GSAs and there was no structured process for creating one. In fact, at CPS, only 31.9% of middle and high schools reported having a GSA or similar club, compared to a median percentage of 53.9% for large urban school districts across the United States (CDC, 2019). Based on this data, CPS set an organizational goal for every school to have a GSA by 2024 (Chicago Public Schools, 2019).
During key informant interviews, GSA advisors identified a need for improvements in school staff training about the unique needs of LGBTQ youth, additional district-level support for GSAs, and increased efforts to decrease bullying, harassment, and violence toward LGBTQ students. Advisors recognized the need for training about ways to support LGBTQ students. Further, implementing a method for GSA advisors to connect with one another and problem solve was a common suggestion.
Additional stakeholders from the CPS Office of Student Health and Wellness were interviewed. Staff in this office assist school staff and students in the areas of sexual health education, sexual health services, and LGBTQ support. They echoed the concerns of GSA advisors. In addition, they noted that GSAs can be a source of community-building and social support for students, but there was a lack of infrastructure for GSAs and support for GSA advisors. This mirrors a gap in the literature regarding functional methods to support school-based staff to start and maintain a GSA.
Based on the population needs assessment, LGBTQ students at CPS are at risk for poor mental health outcomes due to the lack of formal support for GSAs and GSA advisors and limited GSA availability. The purpose of this quality improvement project was to (1) build infrastructure for GSAs in CPS by implementing a GSA Support Plan, and (2) increase the number of schools that report having a GSA. Based on project results, authors offer suggestions for how school nurses can become active supporters of LGBTQ students through involvement with GSAs.
Chicago Public Schools is the third largest school district in the United States. Based on twentieth day enrollment data for school year 2019–2020, CPS served nearly 360,000 students in preschool through twelfth grade at 642 schools in CPS (Chicago Public Schools, 2020). Participants in this project were required to be CPS staff or staff of established district partners. Participants were recruited from the GSA advisor registry, which included 52 active advisors from 39 schools and 22 prospective advisors from 20 schools, and the quarterly Sexual Health Educator Newsletter. This project was reviewed by the Rush University Institutional Review Board and acknowledged as a quality improvement project.
The development and implementation of this program was guided by two frameworks. The PRECEDE-PROCEED Model was used as the implementation and evaluation framework. The Ecological Model was used as the guiding conceptual framework.
The PRECEDE-PROCEED Model is an established model to guide health promotion implementation and evaluation. The PRECEDE portion of the framework includes phases 1–4 and was used to guide a comprehensive population assessment before this project was developed (Green & Kreuter, 2005). The program implementation and evaluation components are contained in the PROCEED portion of the framework in phases 5–8. Phase 5 involves the program implementation, while the remaining phases are process evaluation, impact evaluation, and outcome evaluation (Green & Kreuter, 2005).
The Ecological Model is a conceptual model that emphasizes the interaction between human development and components of their environment (Bronfenbrenner, 1979). Bronfenbrenner (1979) determined that young people are part of a system of nested ecological levels that interact to influence their behavior and development. These levels are the microsystem, mesosystem, exosystem, and macrosystem. The microsystem is described as the individual’s immediate environment, including the individual’s relationships, activities, and roles (Bronfenbrenner, 1979; Crosby et al., 2019). The GSA and the GSA advisor exist within the microsystem of a LGBTQ youth, as well as their peers, family, and friends. The second level is the mesosystem, which represents the interaction between two microsystems (Bronfenbrenner, 1979). Parts of the environment that the individual does not directly interact with are included in the next level, the exosystem. Finally, the macrosystem refers to culture and belief systems in which the three other levels function (Bronfenbrenner, 1979). Figure 1 shows the four levels of the Ecological Model created for this project, with the student at the center. The model shows that all levels influence an individual’s behaviors, and as a result influence health and wellbeing (Bronfenbrenner, 1979; Crosby et al., 2019).
The evidence-based intervention was a GSA Support Plan consisting of three components that were implemented between May and August of 2020. The three components were a digital resource binder, GSA advisor trainings, and establishment of the Advisor Leadership Committee. The inclusion of these three components was determined based on data gathered during the needs assessment. In addition, these methods were selected because the Office of Student Health and Wellness frequently uses digital resources, toolkits, and trainings to meet the needs of their staff. All components were distributed or held virtually as CPS had transitioned to virtual learning throughout much of 2020. The overall outcome objective of the project was to increase the number of new GSAs in the district by October 2020. Process objectives were developed in alignment with project components.
Digital resource binder. Digital resources have been used with success among school-based staff as they can be easily distributed and adapted to suit their needs (Tang, 2020). The digital resource binder for this project was created to provide GSA advisors, students, and caregivers of LGBTQ students with information to support LGBTQ youth and establish GSAs. Specific resources in the binder included LGBTQ book and movie lists, LGBTQ curricula, and tip sheets (see Table 1). The digital resource binder was created on Google Drive and was shared via email to all current and prospective advisors on the registry and all who signed up for the trainings. The associated process objective was to distribute the binder electronically to all current GSA advisors and prospective GSA advisors who registered for the GSA advisor training by August 2020.
GSA advisor trainings. Virtual trainings are an established learning methodology that make learning more accessible for audiences (Fairburn et al., 2017; Woodcock et al., 2015). The GSA advisor trainings were developed based on guidelines from GSA Network (2020) and GLSEN (2020), two nationally recognized GSA and LGBTQ support organizations. Two separate 90-min GSA advisor trainings were offered virtually via Google Meet. Training content remained the same in both, but participants were separated by high school and elementary/middle school teachers and staff. Training topics included: welcome and introductions, GSA terminology and important statistics, information on pronouns, GSA basics, creating an inclusive space, communicating with others, breakout activities to allow for small group discussions, and questions. Materials were designed for those who had a basic understanding of the LGBTQ population and expressed desire to support LGBTQ students. A process objective was set for all training participants to report an increase in confidence related to starting and maintaining a GSA at the end of the trainings in August 2020. To determine whether this objective was met, advisors who participated in the training were asked to complete a pre- and post-training survey that measured their confidence in ten areas of GSA and LGBTQ+ student support by Likert Scale. These surveys were developed using key components of GSA support highlighted by a leading GSA organization, GSA Network (GSA Network, 2020).
Advisor leadership committee. The purpose of the Advisor Leadership Committee was to promote peer support and collaboration among GSA advisors throughout the district. An underlying assumption of Advisor Leadership Committee membership is that based on their experiences leading GSAs, advisors possess valuable information that is beneficial to students and other GSA advisors (Beck et al., 2018; Graybill et al., 2015; Watson et al., 2010). The Advisor Leadership Committee created a forum to share this knowledge. The role and responsibilities for Advisor Leadership Committee members was developed based on guidelines from the William and Mary College of Education (2011) and modeled after committee roles and responsibilities from the Alliance for a Healthier Generation (2020) and the Massachusetts GSA Leadership Council (2020), with a focus on collaboration and student support. Members of the Advisor Leadership Committee were recruited from the list of current GSA advisors. The process objective was at least six advisors would attend the inaugural Advisor Leadership Committee meeting by August 2020.
Distribution of the binder and completion of the Advisor Leadership Committee meeting were evaluated by collection and analysis of descriptive data. Outcomes of the trainings were evaluated by comparing pre- and post-training surveys to measure participants’ confidence in ten areas of GSA and LGBTQ+ student support. The ten-item pre-post survey measured confidence on a 5-point scale Likert Scale [1 = not at all confident and 5 = extremely confident]. Pre-training surveys also gathered demographic data, and post-training surveys gathered data related to the training quality. Pre- and post-training data were analysed using a paired T-test. An additional digital survey was sent two months after the training to determine if schools without a GSA established one.
The digital resource binder was distributed electronically via email link to 95 individuals. Specifically, it was distributed to 64 current GSAs at 46 different schools and 31 prospective advisors at 28 schools.
Participants. Forty-nine participants attended two virtual GSA advisor trainings. Of the 49 training attendees, 55.1% (n = 27) completed both the pre- and post-training surveys. The demographic data presented represents only participants who completed both the pre- and post-training surveys. The majority (55.6%, n = 15) of participants worked at high schools and were teachers (51.9%, n = 14). Most were between the ages of 25–34 (44.4%, n = 12) and 35–44 (44.4%, n = 12). Of the participants, 85.2% (n = 23) were White or European American and most identified as female (74.1%, n = 20). Finally, the majority of the training participants were current advisors (74.1%, n = 20). Demographic data is presented in Table 2.
Survey findings. The following data analysis is based on only those who responded to both pre- and post-training surveys (n = 27). Figure 2 includes data for all ten measures of participant confidence. On a 1 to 5 Likert Scale, the average pre-training confidence rating on all ten questions was 3.94, whereas the average post-training rating was 4.47. The measures of confidence that had the highest post-training average results included: discussing pronouns with staff and students (4.74), supporting youth while holding a GSA meeting (4.70), and communicating with teachers and administrators regarding the importance of a GSA (4.63). Of 27 participants who completed the pre- and post-training surveys, 96% (n = 26) reported feeling very or extremely confident in all three measures on the post-training survey.
There was a statistically significant increase in all ten measures of participant confidence (see Table 3). Results that showed the largest percent increase from pre- to post-training responses included confidence in relation to establishing a GSA (20.4%), communicating with parents regarding the importance of a GSA (19.6%), and supporting youth to recruit new members (18.6%) (see Table 3). The measures for supporting youth to recruit new GSA members and letting youth lead a GSA remained low following the training when compared to other measures of confidence.
Post-training follow up. There were 11 training participants from schools that did not have a GSA at the time of training. Seven responded to the follow up survey asking if they started a GSA after the training. Advisors from three schools reported that they established a GSA after the training. At the time of the post-training survey, two already had their first meeting. For the seven who did not start a GSA, reasons reported were difficulty figuring out a day/time to meet, difficulty meeting in the virtual environment, concerns for student safety, and no time to meet or plan a GSA.
By August 2020, six GSA advisors committed to being members of the Advisor Leadership Committee and four attended the first meeting. As of June 2022, the Advisor Leadership Committee had over ten members, meets bi-monthly, and has established three subcommittees: Direct Committee, Cultural Committee, and Structural Committee. The Direct Committee is charged with planning a GSA summit, which has occurred annually since June of 2021. The Cultural Committee works to engage and support CPS parents of LGBTQ students. The Structural Committee functions to bring together GSAs in the district and improve and increase resources available to GSAs and LGBTQ students. The Advisor Leadership Committee meets twice per month. The first monthly meeting is as a full team to engage in community-building activities and problem-solve school-specific issues. The second monthly meeting is focused on completing tasks for the subcommittee projects.
The purpose of this project was to develop district-wide infrastructure to support GSAs and increase the number of schools with a GSA. Results of this project demonstrate that a targeted GSA support plan can positively impact district-wide efforts to support LGBTQ students. This project resulted in significant improvement in confidence of GSA advisors to provide support to the LGBTQ student population. Within two months of training sessions, three new GSAs were started.
This project addresses an identified gap in GSA support for the district. Current literature shows that lack of support for GSAs can hinder their establishment and growth (Fetner & Elafros, 2015; Watson et al., 2010). Further, prospective GSA advisors fear that due to limited training and support, they lack credibility (Graybill et al., 2015). In contrast, GSA advisors who have received training report greater knowledge and efficiency to support LGBTQ youth (Poteat et al., 2015). This GSA Support Plan provided structured support for GSA advisors through targeted resources, training, and district-level aid. Results from this project mirror the literature showing that increased supports positively impact GSA advisor knowledge and confidence (Graybill et al., 2015; Watson et al., 2010).
Evaluation of pre- and post-training data identified areas of success and opportunities for growth. There was a statistically significant increase in all ten measures of participant confidence when pre- and post-training responses were evaluated with a paired t-test, indicating that the training positively impacted participant confidence. It has been noted that advisors sometimes feel underqualified to support LGBTQ youth (Watson et al., 2010). This project addressed this barrier by increasing confidence for CPS GSA advisors.
The measures of confidence for supporting youth to recruit new GSA members and letting youth lead a GSA remained low following trainings. Poteat et al. (2015) noted that if advisors maintain control, it robs members of the chance to lead the GSA. This action can hinder the development of the GSA into a club that empowers youth to be efficient (Poteat et al., 2020). Yet, youth empowerment and leadership are core tenets of a strong GSA (GSA Network, 2021; Mayberry, 2013; Russell et al., 2009). As noted with this project, empowering youth to recruit and lead GSA meetings are areas where many advisors struggle. Because confidence in these areas started low and did not increase as much as others, there is a need for further exploration of strategies that may increase GSA advisor confidence. While the demographic characteristics and advocacy efforts of advisors have been explored in the literature (Graybill et al., 2015; Watson et al., 2010), strategies for building confidence in GSA advisors to promote student leadership in GSA activities, are not found in the literature. Based on this project, creating separate learning modules for current and prospective advisors specific to youth empowerment and leadership could be a strategy to address this challenge moving forward.
Additionally, the post-training follow-up survey demonstrated the need to address challenges that advisors faced when attempting to start a GSA. While this project had a positive impact on GSA advisor confidence to support LGBTQ students, new advisors who completed the follow up survey acknowledged that it was difficult to start a GSA. Commonly cited challenges included difficulty figuring out when to meet, difficulty meeting in the virtual environment, concerns for student safety, and lack of time to meet or plan a GSA. These findings differ from previous literature, which identified some of the major barriers advisors face as resistant school administrators and parents (Graybill et al., 2015; Watson et al., 2010). One explanation for this deviation from current literature is that CPS remained entirely virtual during the first two quarters of the 2020–2021 school year. Although resistant administrators and parents may still be barriers within CPS, the challenges noted by potential advisors at the time of this project implementation appear to be related to starting a GSA in the virtual environment. Moving forward it will be important to include strategies in the GSA Support Plan for overcoming these barriers in virtual and face-to-face environments.
While two nurses who worked at school health clinics participated in the trainings, it should be noted that no school nurses participated. Although school nurses are not found in the literature to commonly lead GSAs, they have deep-rooted connections with students and the school community that make them an important figure within the schools (Anderson et al., 2018; NASN, 2016). School nurses have the expertise to and have been called upon to support LGBTQ students in a variety of ways such as affirming their sexual orientation and gender identities, creating safer spaces, guiding them toward resources and advocating for school-wide protections of LGBTQ youth (Ancheta et al., 2021; NASN, 2021). Further research is needed to better understand the role of the school nurse in GSAs. The lack of school nurse participation in this project that supports a population they serve highlights the importance of including this content in the school nursing literature.
Many lessons were learned with this quality improvement project. Building GSA infrastructure is not the only solution to the challenges faced by advisors and staff seeking to support LGBTQ students. Challenges to establishing a GSA are multifaceted. While GSA advisor training is important, other barriers such as lack of time and concerns for student safety also need to be a part of district-wide infrastructure.
The success of this project demonstrates the importance of engaging with stakeholders during the development, implementation, and evaluation phases of the project. Solicitation of stake-holder feedback during the needs assessment served several purposes; it provided the project team with information essential in the planning of the project and it provided stakeholders an opportunity to engage with the project in the early stages which encouraged their buy-in. Moving forward, this approach should be considered with all new district-wide initiatives to promote engagement and buy-in from key stakeholders. Further, staff buy-in with this project facilitated sustainability. Due to project engagement, all GSA Support Plan components have been incorporated into the workstream of the Sexual Health Team within the Office of Student Health and Wellness, assuring sustainability. Considering the dearth of available literature on the topic, this project provides important insight that can be used as a foundation for similar projects in other districts.
Furthermore, because of the COVID-19 pandemic, all interactions, trainings, and materials were provided virtually. This limited the ability to obtain a 100% response rate on the pre- and post-training survey. An attempt to increase the response rate was made by encouraging participants to complete the pre-training survey during the first ten minutes of the training and send the post-training survey in follow up emails. Although there was a loss of potential data associated with virtual implementation, this format kept costs low and facilitated participation.
In 2021, the National Association of School Nurses updated their position statement on the role of the school nurse in working with and supporting LGBTQ students. In that statement, NASN advocates for a comprehensive approach to supporting LGBTQ students through culturally competent care and affirming policies. Further, NASN recognizes the school nurse role in addressing bullying, health risk behaviors and supporting students should they suffer rejection from family and friends (NASN, 2021). School nurses are uniquely placed to have a positive impact on health, mental health, and life outcomes for LGBTQ students.
The role of the school nurse in this area can be realized through operationalizing the Framework for Twenty-First Century School Nursing Practice. Among other care components, this framework includes health promotion, studentcentered care and advocacy as key aspects of school nursing practice (NASN, 2016). Understanding the physical and mental health needs of LGBTQ students and advocating for safer and supportive school environments is in alignment with the role of the twenty-first century school nurse. School nurses can use their expert assessment and program development skills to develop health promotion activities specific to the population. Through a student-centered approach, school nurses can ensure that LGBTQ student voices are heard and needs are met.
Laiti et al. (2024) noted that providing care and support for LGBTQ students can be complex due to a lack of knowledge or understanding about this student group. School nurse attendance at GSA training and other LGBTQ focused professional development opportunities should be encouraged or required by school districts. Sponsoring a school GSA is a way that nurses could better understand and relate to their school’s LGBTQ population, while simultaneously taking action to create a safer, inclusive space at their school. Other ways in which school nurses can support GSAs and LGBTQ students include serving on GSA advisory committees to provide a nursing perspective on health needs of the population or simply advertising GSA meetings and events in their offices.
The positive impact of GSAs is well-documented (Gower et al., 2018; Marx & Kettrey, 2016; Toomey & Russell, 2013). However, there is limited literature on how to operationalize support for GSAs at the school district-level. This project demonstrates that support for GSA advisors is an important aspect of building GSAs that aid LGBTQ youth in schools. Additionally, it shows that support implemented via a virtual platform can successfully reach a large audience of advisors. Together, these findings can be used by school nurses and school districts to support LGBTQ youth in schools.
We thank the CPS GSA advisors and Office of Student Health and Wellness staff who were thought partners in this quality improvement project.
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 support for the research of this article: This quality improvement project was supported by Cooperative Agreement number 6 NU87PS004311, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.
Makayla Boyd https://orcid.org/0000-0002-2820-7826
Heide R. Cygan https://orcid.org/0000-0003-2811-2170
Mallory Bejster https://orcid.org/0000-0002-6313-495X
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Makayla Boyd, DNP, RN is an alum of the Rush University College of Nursing, Chicago, IL.
Heide R. Cygan, DNP, RN, PHNA-BC is a professor in the Department of Community, Systems and Mental Health Nursing at the Rush University College of Nursing, Chicago, IL.
Booker Marshall, MPH is the LGBTQ+ and Sexual Health Program Manager in the Office of Student Health and Wellness, Chicago Public Schools, Chicago, IL.
Derrick Little, BA is the LGBTQ+ Support Specialist in the Office of Student Health and Wellness, Chicago Public Schools, Chicago, IL.
Mallory Bejster, DNP, RN, is a professor in the Department of Community, Systems and Mental Health Nursing at the Rush University College of Nursing, Chicago, IL.
1 Community, Systems and Mental Health Nursing, Rush University College of Nursing, Chicago, IL, USA
2 Office of Student Health and Wellness, Chicago Public Schools, Chicago, IL, USA
Corresponding Author:Makayla Boyd, DNP, RN, Advanced Public Health Nurse, Rush University College of Nursing, 600 S. Paulina St., Chicago, IL 60612, USA.Email: mboyd9227@gmail.com