The Journal of School Nursing2023, Vol. 39(5) 406–414© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211029252journals.sagepub.com/home/jsn
Students have the right to receive education about sexual and reproductive health and rights (SRHR). The United Nations Agenda 2030 for sustainable development includes goals regarding SRHR, including the right to universal access to sexual and reproductive health care services and gender equality. The study used a qualitative design with an inductive approach. Data were collected through semistructured interviews. The results are presented in three categories and nine subcategories. The categories were “having an open attitude,†“organizational prerequisites,†and “challenging tasks.†An open attitude was required to create confidence for both school nurses and students in SRHR conversations. Organizational prerequisites, such as planning SRHR education with others, were successful. Multicultural meetings and conversations regarding gender identity and sexual orientation were challenging tasks. Increased knowledge of SRHR and national standardized guidelines are suggested to achieve Agenda 2030 SRHR goals and to ensure equity in school health care.
Keywordsqualitative research, school health service, sexual and reproductive health, health promotion
In addition to academic subjects, students have the right to receive education and information about sexual and reproductive health and rights (SRHR). They also need support to be able to practice and understand sexual behavior that enables healthy sexuality (Breuner & Mattson, 2016). All individuals need to be respected in terms of their SRHR to live a satisfying life. However, SRHR have usually not been considered as an important part of human health due to the culturally and politically sensitive nature of sexuality (Kismödi et al., 2017; Starrs et al., 2018). SRHR describes the right to make decisions about one’s own body and it should be free from stigma, discrimination, and coercion (Kismödi et al., 2017). Furthermore, SRHR are crucial for the sustainable development of gender equality and healthy sexuality (Starrs et al., 2018). Human well-being depends, in part, on students’ ability to make decisions about their own sexual and reproductive health and to respect the choices of others (Kismödi et al., 2017; Starrs et al., 2018).
Two goals in the United Nations (U.N.) Agenda 2030 for sustainable development are about SRHR. The goals include universal access to sexual and reproductive health care services and gender equality (Starrs et al., 2018). The adoption of these goals in different countries may take various forms that reflect cultural and societal goals and values. For example, in Sweden, the U.N. Convention on the Rights of the Child became a law in January 2020 (SFS 2018:1197). This law is one of the several which govern the work of the school health service where school nurses and school physicians work. They are given a legal mission to organize and provide health monitoring, including health dialogue to promote health for all children in school (6–18 years old) (SFS 2010:800). In addition to the national standardized health record including physical variables on health, the Swedish school health service uses locally produced assessment questionnaires in health conversations to screen psychosocial health. A standardized screen for sexual health is also needed (Ståhl et al., 2011). Not every country has a national health care system, so how such countries would go about achieving goals of universal access to sexual and reproductive health care services may differ.
Adolescent students engage in more high-risk sexual behavior than in any other age through the lifespan. Early sexual intercourse has also shown an increased risk of depression (Makenzius & Larsson, 2012). The lack of knowledge related to preventative sexual health behaviors can lead to adverse sexual and reproductive outcomes, such as sexually transmitted infections, inconsistent condom use, multiple partners, and unintended pregnancy (Breuner & Mattson, 2016; CDC, 2016). Students who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ) are more likely to engage in or experience health risk behaviors than heterosexual students, such as greater odds of violence victimization and suicide attempts (Jiang et al., 2018; Johns et al., 2020; Porta et al., 2017).
Increasing students’ knowledge about SRHR imparts the ability to understand and apply informed choices to reduce sexual health risks taking (Breuner & Mattson, 2016; CDC, 2016). Yet, it is often the case that SRHR is forgotten or put aside by teachers and school nurses relative to other subjects in school. It has been shown that SRHR only accounts for 2%–4% of all health conversations between the students and the school nurses in Sweden (Golsäter et al., 2012).
Receiving relevant SRHR education is a prerequisite for school nurses to provide students support regarding SRHR issues (Brewin et al., 2014). Conversations about SRHR should be relaxed and respectful, which can be a great challenge (Breuner & Mattson, 2016; Evans, 2013). It is also important that the students trust the school nurse to have the courage to talk about their problems related to SRHR (Engh Kraft et al., 2017). When students are comfortable, conversations with the nurse are more likely to result in increased knowledge, fewer misunderstandings, reduced anxiety, and having questions answered (Breuner & Mattson, 2016).
The starting point in the health dialogue assumes that the students and school nurse agree that collaboration, respectful interaction, values, and expertise are valued in the conversation. The students then become the experts on themselves and the school nurse is responsible for imparting advice and support through their specialist knowledge (Batalden et al., 2016).
To have a satisfying and effective conversation with the students about SRHR, studies highlight that school nurses need to adapt to the abovementioned aspects in conversations about SRHR (Breuner & Mattson, 2016; Evans, 2013). However, there is a lack of studies describing the school nurse’s experience talking about SRHR with students. Therefore, it is important to learn more about school nurses’ experiences to identify areas of strength and those in need of greater attention to best address students’ rights and need for support with regard to SRHR.
The aim was to describe school nurses experience of talking about sexual and reproductive health with adolescents 13–19 years old.
This study used an inductive qualitative design (Polit & Beck, 2017). Individual qualitative interviews were conducted and analyzed using inductive qualitative content analysis (Graneheim & Lundman, 2004).
Purposive sampling was used with the goal to reach school nurses working with teenage adolescents (13–19 years old) in medium and larger cities and in different socioeconomic areas, to observe variation in the school nurses’ experiences. Inclusion criteria were that the school nurse had (a) at least one year of experience of working as a school nurse and (b) an education as a district nurse, school nurse, or pediatric nurse. A total of 220 school nurses were contacted. Of these 14 school nurses agreed to participate. All were women; five had worked as a school nurse between 1 and 10 years and nine more than 10 years. They were educated as school nurses (two), district nurses (eight), and pediatric nurses (four).
A total of 19 heads of the school health service in 14 municipalities spread all over Sweden were contacted. Through e-mail conversation the head of the school health service received an information letter about the study. The head of school health service either gave their consent to allow school nurses in their municipality to be asked about participation in the study (n = 17) or declined participation due to lack of time (n = 1). One head of school health service never responded.
School nurses meeting inclusion criteria were recruited in various ways. The head of the school health service forwarded the information letter about the study to the school nurses in their municipality by email. In some municipalities, the head of school health service forwarded the contact information of the school nurses who were interested in participating in the study. In other municipalities, the school nurses contacted the authors themselves. In four municipalities the authors themselves, after approval from the head of school health service, contacted all school nurses via e-mail with an attached information letter. After they were given oral and written information about the study and had time to ask questions, the school nurses gave their written informed consent.
During 6 weeks, spring 2020, qualitative data were collected through individual semistructured telephone interviews by two of the authors. The interviews started with the opening question “What is your experience of talking about sexual and reproductive health with your students?†Then areas such as positive, negative, and challenging experiences were explored. The school nurses were encouraged to talk openly about the subject and follow up questions such as—“Can you describe more?†“How do you mean?†and “Do you have any examples?†were used to deepen their answers. The interviews lasted between 16 and 32 min (mean 22 min). A pilot interview was conducted to ensure that the questions in the interview guide enabled the interviewee to give informative answers. The pilot interview was not included as the interviewee did not meet the inclusion criteria. No adjustment of the interview guide was needed (Polit & Beck, 2017). All interviews were recorded on a digital recording device and then transcribed verbatim.
Data were analyzed using inductive manifest content analysis based on Graneheim and Lundman (2004). The analysis began with reading the interviews through several times to get a sense of the content. In a second step, meaning units, that is text, that belonged together through their content and context (Graneheim & Lundman, 2004) were color coded and cut out from the text. The meaning units were then condensed, in which the text was reduced to more simplified words while preserving the central content (Graneheim & Lundman, 2004). The condensed text was then abstracted and provided with a code that described the content. Finally, codes with similar content were grouped together to form subcategories. The subcategories that were interconnected formed a category (Graneheim & Lundman, 2004). The analysis resulted in three categories with associated subcategories. Example of the analysis process is shown in Table 1.
This study followed national ethical regulations and conforms to the Declaration of Helsinki. As noted earlier, the heads of school health service gave their approval to the study prior to participant contact and data collection. The school nurses received written and oral information about the purpose of the study. They were allowed to decide which time and date to be interviewed, they were ensured confidentiality, and were told that they could withdraw from the study at any time. A written informed consent was requested.
Based on analyzed data, three categories and nine subcategories emerged (see Table 2). The results are presented in continuous text and reinforced with quotes from the interviews.
Curiosity and the fact that the school nurses updated their knowledge on their own initiative was perceived as an important aspect of being able to talk with students about SRHR. The school nurses felt that SRHR was a subject that required constant updating in order to keep up with the students’ knowledge.
… it is about knowledge, finding out and become confident … I think, in general, to get rid of fear and doubts. You read and find out. Dare to open up for conversations. Lack of knowledge makes you hesitate (5).
The school nurses experienced that when they managed to stay updated in SRHR the conversations became richer and they felt more confident. Their professional experience also contributed to facilitating the conversation with the students. However, some found it difficult when the students had spontaneous questions concerning SRHR.
If there are spontaneous questions and you are not prepared for it, I became unsure. Especially if they come in a group, several guys, it happens. In the beginning, when you were new, I became unsure when they posed open questions because you were inexperienced. Now I can handle it better when I have more experience and know how to respond (11).
Interestingly, a school nurse’s level of knowledge depended entirely on their own interest in the subject.
Feelings of trust facilitated the conversation and made the students feel confident asking the questions they wanted. The school nurses described that they needed to be responsive to how the students responded to the conversation as the students could not be forced into the conversation.
You really have to be responsive and sensitive so you do not step over any boundary, because then the student can shut down. Then they get embarrassed and don’t want to talk about it at all. You have to be careful about that. It also needs to be very much on their own terms (7).
The school nurses experienced that it was usually harder to talk about SRHR at the first meeting as they not yet had time to build rapport with the student. The school nurses also felt that it was hard for the student to talk about SRHR since the school nurses were adults.
You sit in a conversation with an adult and I ask them, but they are still quite young. Not many students dare to ask questions then (2).
The school nurses built trustful relationships by being sensitive, using humor and joy which in turn created confidence and permission for the students to talk about SRHR. The school nurses also needed to reduce their own biases and discomfort in SRHR conversations.
The school nurses described that it was important to have a nonjudgmental approach in order to have conversations about SRHR with the students. There is a need to approach SRHR in a natural way to decrease the possibility of students feeling embarrassed and to increase confidence in the students, so they dare to ask questions concerning SRHR that is important for them.
I don’t want to make a big deal because of the subject […]. I talk to the student just as if it was a wound or they have a stomachache (3).
The school nurse experienced that when the students felt that the climate was nonjudgmental, they returned to the school nurse more frequently with their questions about SRHR and also with follow-up questions.
… If the students come by themselves and have trust in me, it will often be a good conversation. The student opens up and listens, and it often becomes a good conversation. I don’t always have the right answers, but they feel that they have been listened to (1).
However, due to lack of knowledge within specific areas such as students with nonheterosexual orientations, the school nurses sometimes were concerned about using language that may not be inclusive. The school nurses did not want to convey their own experiences or have preconceived perceptions.
The school nurses thought that education around SRHR should be modernized and integrated into different subjects. To reach the students at a group level, the school nurses felt that more collaborative planning was required.
A good talk about SRHR needs to be well planned and planned together with student health staff, educators, and students. You make a collaborative plan on what to talk about and how to engage students. Then it usually turns out in a good way (14).
The school nurses described administrative challenges for them to arrange time for SRHR teaching during the scheduled lectures in other courses. The teachers did not want to set aside time from their lecture and the school nurses felt that their knowledge about SRHR was not utilized in teaching in the classroom. The school nurses noted that students lacked knowledge about the body, enjoyment, and love, as well as needing more knowledge about questioning hetero-normativity, women’s issues, equality, discrimination, and pornography.
The school nurses thought it was even more important to plan education about SRHR with the teachers working with students with special needs. The knowledge regarding SRHR was described to be lower among these students. When meeting with the students with special needs, the school nurses felt that it was good to have several short lectures regarding SRHR.
It’s fun {with population of special needs} because there can be many fun situations and you feel a bit like a missionary. You teach things that you are very happy to teach because the level of knowledge is very low (12).
The school nurses often planned their lectures together with the students’ by asking the students to write anonymous notes with their questions. This resulted in SRHR becoming less embarrassing and the discussions became more positive, educational, and fun.
The school nurses felt that SRHR was highlighted in discussions more at the organizational, group, and individual levels than before, yet they thought that it should be an even greater priority at the organizational level. School nurses described lack of time and some organizational insecurity regarding SRHR which led to prevention and health promotion efforts around SRHR being rarely prioritized. The school nurses also felt that their organization did not always prioritize SRHR due to other more important assignments.
It is very easy to opt the subject (SRHR) out. If you have too many kids at the school. then there isn`t enough time (4).
On an organizational level, there were no routines for working with SRHR in a health-preventive way, which made it harder to prioritize SRHR. SRHR was given priority when there was an acute problem in the school in a certain area or if the school nurses had personal interest in the subject.
So, we let the problems direct us. Not on health promotion. So, I have prioritized SRHR when it has been something special. It has probably been more that I have taken it from the needs that arise (9).
The school nurses were concerned about the lack of priority, particularly when students had low knowledge about SRHR combined with impressions from the Internet and social media. It often resulted in students receiving a distorted picture of SRHR since the information about SRHR tended not to come from a safe and reliable source.
The information that young people have and the image they have of sexuality can often be very skewed … It’s sad to meet sixteen seventeen-year-olds who have only received information from … from the internet, from porn … What’s about the body, pleasure and love need more space in school [education] (5).
The school nurses described that they needed to be humble and acknowledge their own limited knowledge in certain areas. Therefore, they sometimes referred the students to the youth clinic where the students could meet professionals with specialized knowledge around SRHR. Collaboration with the youth clinic was important when students needed a consultation, or the school nurses needed to consolidate their knowledge.
I contact the midwives at the youth clinic, as they deal with these issues every day. I can just phone them and say—“I have a girl here who needs to visit youâ€. It is very important that we have good relationships with the youth clinic (6).
The school nurses described that they often encouraged the students to independently visit specific websites. They felt that students became more confident in asking questions if they initially were able to search for information on their own.
There is a website called Youmo.se. I show that website to all my students regardless of whether they speak Swedish or not. Then they can sit at home in peace and quiet and read everything through. Then I encourage the students to come back if they wonder or want to talk about something after visiting the website (10).
The school nurses described that they mainly worked alone, but they felt confident and safe that they had a network with whom they could collaborate such as the youth clinic and the school physicians and women’s clinics.
All school nurses invited the students to specific individual health conversations where they asked the student questions from a health dialogue questionnaire. The questionnaire is a structured, locally designed inquiry form, used to ensure that health conversations touch on various topics, such as sexual health. However, there were not many questions that focused on SRHR. The questions used in the questionnaire were described as too general, which required the school nurses to ask follow-up questions. During this conversation, not many students had questions of their own around SRHR. The school nurses experienced that it was up to them to direct the conversation through the follow-up questions they asked the students.
I think that the health conversation requires you to ask follow-up questions. The questions are quite general in the questionnaire. The conversation will be short if you do not ask follow-up questions and you need to have a conversation about the various topics (5).
The school nurses highlighted that it was very important to talk about SRHR, yet there could be great challenges in the individual conversation. In particular, school nurses experienced a mixture of both concern and frustration in conversations with students’ who had been exposed to abuse or other discrimination. The school nurses felt that the students were experiencing challenges and the nurse wanted to help. However, students were often not open to talking about the challenges and both the students and the nurse were insecure. The school nurses did not know how to proceed.
Multicultural Meetings. The school nurses experienced that students from certain cultures had little knowledge around SRHR. They described that it was difficult to talk about SRHR with students from some cultures as this was a sensitive subject which the students often wanted to avoid. One reason was related to cultures in which female premarital sex can be seen as shameful for the entire family and met with violence. The school nurses described that they met some students’ where the relatives wanted to control the female student’s sexuality. The school nurses wanted to support these girls, but experienced it as challenging and difficult when the student did not want to talk about it.
It may be students I have met for a long time and you can see that there is something that is bothering them, but because of the culture of honor, they cannot tell nor seek help and that is horrible. I can end up in a situation where I fear that the youth will be murdered by their family (13).
Above all, it was difficult for the girls from certain cultures to talk about SRHR as their culture of origin forbid sex before marriage. The school nurses thought it was important to ask the girls from other cultures if they were circumcised. Sometimes the school nurses felt anxious to ask because the girls could be ashamed and felt it was a taboo to talk about genital mutilation. The school nurses felt it would be easier if there had been a question in the health questionnaire about circumcision as it would be more natural to ask about it then. If the student turned out to be circumcised and had problems related to that, it was difficult to get the students to seek support.
I always talk to them [about genital mutilation]. But not everyone is open to talk about it themselves. At least not initially. It’s also like a shock to some of these girls as they do not know that not all girls do it. So, the first conversation can be quite emotional because many of them react like—‘What! Not everyone is?!’ (10).
Many of the students speaking foreign languages needed an interpreter. Therefore, these conversations were often experienced as superficial. In addition, the school nurses felt the interpreter sometimes added their own values. Such challenges made these meetings particularly problematic when approaching SRHR topics.
The school nurses experienced a great challenge to succeed to be inclusive and free from heteronormative biases in SRHR conversations. School nurses needed to have a positive attitude about students’ differences in the conversations in order to be able to access the students’ innermost feelings. They felt that students thought it was taboo to be sexually diverse which made it challenging to talk about gender identity and sexual orientation issues.
It is becoming more and more common for us to meet young people who actually identify themselves as LGBTQ. We do not have enough knowledge around this, we need to read and learn more about it (13).
The school nurses revealed it was important to raise the issue of gender identity and sexual identity and invite students to talk about it. The school nurses described that SRHR was not only about sex, but also about mental health, which in turn was related to sexuality.
It’s not just about sex. Mental illness has also increased significantly. It can be related to sexuality if you are not sure of who you are (11).
It was a difficult balancing act in how to ask questions about partnership to include everyone and not offend anyone with the questions. It was more difficult to talk to the students who did not know their sexual orientation. Lack of knowledge and education on how to talk to the students who did not know their sexual orientation was a big concern for the school nurses.
The purpose of this study was to describe school nurses’ experience of talking about SRHR with students 13–19 years old. In the SRHR conversation with the students, the school nurses described that they needed to update their knowledge on their own initiative and have an open attitude. Organizational prerequisites had a big impact on the SRHR conversation, like planning education in SRHR with teachers, social workers, and students. There were also some challenging tasks in the conversation such as talking to students from varied cultural backgrounds and having an inclusive approach free of heteronormative bias.
SRHR was a subject for which the school nurses needed to take responsibility to update their knowledge. School nurses described their knowledge in SRHR as important in order to build trust and create confidence with the students when talking about SRHR. Others have found that students also consider it important that school nurses have knowledge about SRHR (Pound et al., 2016; Pound et al., 2017; Rasberry et al., 2015). An extensive Swedish survey showed a lack of education in SRHR in higher educational programs including nursing, which can lead to a lack of accountability and a failure to meet the needs from the students (Areskoug-Josefsson et al., 2019). A dedicated course in SRHR was shown to raise school nurses’ level of preparedness, knowledge, comfort, and confidence in delivering competent sexual health care to students (White et al., 2020), and made the students feel more confident in asking questions about SRHR (Aranda et al., 2017; Bender & Fulbright, 2013; Pound et al., 2016; Smith & Stepanov, 2014).
The school nurses in this study experienced the importance of having an open attitude towards the students to build a trustful relationship and thereby strengthen the students’´ confidence to talk about SRHR. Students have described it embarrassing when SRHR was discussed in school. Sex is a subject that can provoke feelings of being upset, anxious, embarrassed, and vulnerable (Pound et al., 2016). Therefore, it is even more important to take into consideration that comfort and trust are descriptors of a trustful relationship which make the students feel comfortable and confident in the SRHR conversation (Dickson et al., 2019; Smart et al., 2012). The school nurses in this study experienced difficulty in finding inclusive language to create a trusting environment for SRHR conversation when they felt they lacked knowledge. Students consider that school nurses are more suitable in SRHR education as they are considered to have competence in the subject and are more open minded than other educators (e.g., teachers). It is therefore important that the school nurses update their knowledge to meet the students’ expectations regarding SRHR education (Pound et al., 2016).
We found that organizational prerequisites had a huge impact on the conversations with the students about SRHR. School nurses felt planning for discussions about SRHR in schools was best when there was collaboration with teachers, social workers, and students. Alternatively, Dickson et al. (2019) found that school nurses experienced barriers to implementation of education in SRHR when there was a nonsupportive attitude from, for example, teachers and the school administration, when coworkers did not understand the importance or need of SRHR education, or when there was a lack of resources. School nurses in our study confirmed these barriers. They felt that teachers rarely wanted to give away time from their lessons to focus on SRHR. Therefore, to facilitate the implementation of SRHR education in school, supportive collaboration is needed to balance maintaining academic content while also including SRHR education (Dickson et al., 2019).
School nurses in this study described some challenging tasks. One of these was when talking about SRHR with students from varied cultural backgrounds. In some cultures, conversations concerning SRHR could be forbidden. Therefore, the school nurses in this study felt that it was a sensitive subject to discuss and that students from certain cultures avoided these conversations. Students that live in families that practice their religions strictly can perceive SRHR as a contentious subject (Farrag & Hayter, 2014). As described in the results, the school nurses often felt that students from such families distanced themselves from the conversation regarding SRHR. This sometimes made the school nurses feel anxious and hesitant to ask certain questions. Cultural competence and critical reflection on one’s beliefs, behaviors, and values that are culturally rooted facilitates open, flexible, and responsive encounters with students from varied cultural backgrounds (Campinha-Bacote, 2002; Löfgren-Mårtenson & Ouis, 2019). This can be seen as a prerequisite for school nurses to not have to feel anxious in conversations (Campinha-Bacote, 2002).
We found school nurses wished for a structured health questionnaire adapted for students from varied cultural backgrounds which could guide and support the school nurses’ ability to highlight SRHR. Prior research also highlights the importance of further education, guidelines, and supervision in the health promotion and educational work regarding SRHR with students from varied cultural backgrounds (Löfgren-Mårtenson & Ouis, 2019).
School nurses also experienced challenges in having an inclusive approach in conversations with students that have questions about gender identity and sexual orientation. They pointed out that it was especially important to have an inclusive approach due to the close connection between sexuality and mental health. Rasberry et al. (2015) found that students described a willingness to talk to the school nurse about sex in general, but often felt unsafe when talking about attraction to the same gender. Students perceived that school nurses were heteronormative in their approach to conversations (Rasberry et al., 2015). Mahdi et al. (2014) found that school nurses, compared to other school health professionals, had the lowest level of knowledge about LGBTQ student’s behavioral health risks and the lowest level of confidence and experience in discussing sexual orientation and behavioral health concerns with LGBTQ students. This is particularly concerning given prior research that showed that LGBTQ students are more likely to engage in health risk behaviors (Jiang et al., 2018; Porta et al., 2017).
In this study, 14 school nurses participated out of 220 nurses who were emailed information about the study. A potential reason for this relatively low level of participation could include the timing of recruitment as this occurred at the onset of the SARS-2 (COVID-19) pandemic and school nurses’ workload, which often includes responsibility for large numbers of students. Another potential reason involves using email for recruitment, which can be overlooked or ignored. Nonetheless, the 14 school nurses who participated revealed rich experiences that they willingly shared leading to theoretical saturation.
Data were collected through individual semistructured telephone interviews. Telephone interviews were considered to be less costly and easier to implement than in-person interviews due to geographical distance and an acceptable method since the authors had no prior personal contact with the informants (Polit & Beck, 2017). The mean length of the interviews was 22 min, which could be considered short. Qualitative interviews often are longer and researchers often find that informants’ sharing of experiences often starts after lengthy conversations (Polit & Beck, 2017). However, we found that our participants were forthcoming and interested in sharing their experiences and that the data acquired was rich for our data analysis.
The school nurses described that they needed more knowledge to be able to meet the student needs in conversations about SRHR in a safe and respectful way that provided security and confidence. Throughout the study, the school nurses described challenges in being able to instill confidence in the students who dared to talk about SRHR. School nurses also felt that they lacked knowledge and structural assistance, such as questionnaires, in order to talk about SRHR in a comprehensive way. The school nurses’ level of knowledge was dependent on their own interest in SRHR. This emphasizes the importance of national standardized guidelines and a modern, inclusive, and culturally informed knowledge base in higher education. This would ensure equitable school health care about SRHR, incorporate the rights of all children (United Nations), and facilitate the achievement of global public health goals concerning sexual and reproductive health (Starrs et al., 2018).
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The authors received no financial support for the research, authorship, and/or publication of this article.
Martina Silivri, RN, RSCN (MSc) https://orcid.org/0000-0002-3928-8617
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Martina Silivri, MSc is a pediatric nurse. She works as a pediatric nurse at The National Board of Institutional Care, Sweden.
Therese Wirf, MSc is a pediatric nurse. She works as a school nurse in the Student Health Care, Prastangsskolan, Sweden.
Eric A. Hodges, PhD, FNP-BC, FAAN is an associate professor at the School of Nursing, The University of North Carolina, Chapell Hill, USA.
Ylva S. Fredholm, PhD is a district nurse and works as a lecturer at Jönköping University, Sweden.
Maria Björk, RN is a pediatric nurse and associate professor at Jönköping University, Sweden. She is a member of the CHILD research group.
1 The National Board of Institutional Care, Eksjö, Sweden
2 Student Health Care, Prastangsskolan, Eksjö, Sweden
3 School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
4 Department of Nursing Science, School of Health and Welfare, Jönköping University, Jönköping, Sweden
5 CHILD Research Group, Jönköping University, Jonkoping, Sweden
Corresponding Author:Martina Silivri, RN, RSCN (MSc), The National Board of Institutional Care, SiS ungdomshem Långanäs, 575 96, Eksjö, S- Jönköping, Sweden.Email: martina.silivri@stat-inst.se
