Abstract
In 2021, the National Association of School Nurses published an updated position statement affirming the unique position of school nurses to support the health and well-being of lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) students who are faced with a variety of health disparities rooted in experiences of stigma, discrimination, and bias. The 5-year cluster randomized controlled trial “Reducing LGBTQ+ Adolescent Suicide” leveraged school nurses as leaders to facilitate the uptake of six evidence-informed, LGBTQ-supportive practices in New Mexico high schools. We analyzed 5 years of interview data from 24 school nurses in 13 intervention schools to examine what factors impacted their ability to serve as an effective leader for this initiative. Several factors including job characteristics, leadership and organizational skills, relationships and reputation, and personal commitments emerged from analysis. Contextual factors, such as working in urban or rural school, and the size of the school also influenced nurses’ leadership.
Keywords
LGBTQ+, health equity, implementation science, leadership, school nurses
School nurses are pivotal to successfully addressing child health and achieving health equity (Gratz et al., 2021; Maughan et al., 2016; National Academy of Medicine et al., 2021; Willgerodt, Maughan et al., 2021; Willgerodt, Walsh et al., 2020). Their position in schools democratizes healthcare, ensuring that youth have access to and receive attention from a provider regardless of ability to pay or service deficits in the wider community. In addition to being frontline providers of healthcare for children and adolescents, school nurses’ capacity for leadership is widely acknowledged as a critical contribution to school and community well-being, including efforts to address not only physical health but mental and behavioral health as well as community safety and social determinants of health (Denke & Winkleblack, 2020; Doiron & Peck, 2021; Pestaner et al., 2019; Schroeder et al., 2018). School nurses also foster school connectedness, a key health-promotive factor associated with a multitude of positive physical, mental, and social–emotional health outcomes and academic success (Eugene et al., 2021; Reynolds et al., 2017; Steiner et al., 2019). The COVID-19 pandemic heightened the visibility and importance of school nurse leadership in guiding the coordination of student support services during a logistically and emotionally challenging time (Galemore et al., 2022; Rothstein & Olympia, 2020).
In 2021, the National Association of School Nurses published an updated position statement on the role of school nurses in supporting the health and well-being of lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) students (National Association of School Nurses, 2021). This statement affirmed that school nurses “are uniquely positioned to help LGBTQ youth by creating LGBTQ-affirming spaces, guiding youth towards resources, advocating for school-wide protections, and assuring youth that their identities and feelings are normal and appropriate.” The statement also acknowledged the staggering health disparities LGBTQ+ students experience compared to their heterosexual and cisgender peers, including higher rates of suicide, substance use, interpersonal violence, and housing insecurity (Deal et al., 2023; di Giacomo et al., 2018; Mackie et al., 2021; Price et al., 2023). School environments shaped by structural stigma against LGBTQ+ people perpetuate these disparities by allowing students to experience discrimination, victimization, and violence while marginalizing their identities and neglecting their health and social support needs (Kuhlemeier et al., 2021; Shattuck, Richard et al., 2022).
In the spirit of the NASN position statement and having seen these disparities in their communities, school nurses in the largely rural, culturally rich, but underresourced state of New Mexico (NM) collaborated with researchers and public health practitioners from the University of New Mexico and the Pacific Institute for Research and Evaluation to discuss solutions. Together with a wide range of community partners such as the NM Genders and Sexualities Alliance Network, the Transgender Resource Center of NM, GLSEN (formerly known as the Gay, Lesbian, Straight Educators Network), and state departments of health and public education, this Community-Academic Partnership created the “Reducing LGBTQ+ Adolescent Suicide Study” ([RLAS] ClinicalTrials.gov, NCT02875535) (Willging et al., 2016).
This cluster randomized controlled trial involving 42 public high schools aimed to implement and scale up six evidence-informed practices (EIPs) identified by the Centers for Disease Control and Prevention for their potential to enhance school climate and health outcomes for LGBTQ+ youth and their peers. Participating schools were randomly placed into either the implementation condition (n = 21) or the delayed implementation condition (i.e., the control condition, n = 21). The study also aimed to elucidate implementation strategies—methods for supporting the adoption of new programs or practices into regular practice (Proctor et al., 2013)—that would support the uptake of the EIPs. The specific EIPs centered on safe spaces for LGBTQ+ students, health education relevant to LGBTQ+ youth, policies prohibiting discrimination based on sexual orientation and gender identity, professional development for school staff, and facilitating access to healthcare and social service providers with expertise in LGBTQ+ health needs (see Table 1) (Willging et al., 2016). We describe the overall research design, methods, and key findings from RLAS elsewhere (Green et al., 2018; Gunderson et al., 2021; Willging et al., 2016). In this study, we focus our analysis on the role of school nurses in implementing LGBTQ+ supportive EIPs in our participating high schools.
We intended for RLAS to leverage school nursing leadership (Shattuck et al., 2021; Willging et al., 2016) within the Dynamic Adaptation Process (DAP). The DAP is a multifaceted implementation approach that emphasizes contextually appropriate adaptation and implementation of practices by an implementation resource teams (IRTs) with the assistance of an implementation coach (Aarons et al., 2012). Implementation resource teams were conceptualized as small groups of school-based professionals (e.g., nurses, social workers, counselors, teachers, and administrators) in charge of planning and carrying out local implementation with the support and guidance of an implementation coach. The coaches, as external technical assistance, were not directive, but rather supported IRT leaders in facilitating a structured collaborative assessment whereby the IRT evaluated their current use of the EIPs, provided recommendations on potential action items and resources, and often reminded IRTs about their commitments to implementation. School nurses were thus centered as the school-based implementation champions—individuals committed to driving the implementation of new practices in their work contexts (Miech et al., 2018)—and leaders of the IRTs.
While school nurses have responsibility for implementing many school-based health and mental health interventions in both research and practice, RLAS represents the first study of its kind to examine the leadership of school nurses for school-wide, LGBTQ+ focused organizational change. However, as RLAS progressed, we found that almost onethird of IRTs (6 of 21) shifted their leadership of IRTs to other staff, including counselors, social workers, and librarians. Although the implementation approach favored in RLAS allowed and encouraged flexibility of IRT leadership and composition, such shifts led us to ask why some school nurses remained as leaders for the project’s duration and others did not.
Here, we report on the analysis of interviews with 24 school nurse champions from 13 schools regarding their participation in RLAS. Our objective is to elucidate the factors that school nurses reported as enabling or hindering their efforts to implement EIPs for supporting health equity for LGBTQ+ students in school settings. In doing so, our findings have practical applications toward realizing the call put forth by the NASN position statement.
For this analysis, we used data from annual semistructured qualitative interviews with IRT members that addressed barriers and facilitators to implementing EIPs. We isolated data from 5 academic years (2016–2021) of annual individual and small group interviews with nurses, resulting in data from 24 school nurses working at 13 of the 21 intervention schools. The remaining eight schools did not have a school nurse involved. Three years of the study were spent actively implementing the EIPs, with several months of preparatory activities such as forming an IRT and constructing an action plan beforehand and another year of sustainment afterward. Participating schools received $500 per year and each individual interview or small group individual participant received $50 for each data collection activity.
Using a thematic analytical approach, we coded school nurses’ responses to relevant interview questions, including “What do you think prevents you from giving the best support you can to LGBTQ students?” and “What do you currently view as the biggest barriers to meeting LGBTQ student needs at your school?” as “barriers,” or factors that got in the way of implementation or their involvement as a leader. Interview questions also asked about the level of leadership and school administration support the nurse IRT leaders experience among other common sources of support for implementing LGBTQ+ affirmative EIPs for students. Responses to these questions were coded as “facilitators,” or factors that facilitated implementation or their involvement as a leader. Other examples of facilitators were drawn from study team periodic reflections—short, structured conversations focused on successes, challenges, and changes in implementation sites—and fieldnotes by implementation coaches. Focused coding was used to identify patterns and themes within these broader codes. The resulting codes and themes were reviewed by the research team, and seven members of the Community Academic Partnership described above conducted an expert review to ensure trustworthiness of findings (Patton, 2015).
We engaged a total of 24 school nurses of 201 RLAS participants in annual data collection, with a participation range of 1–5 years (mean 2.38, SD 1.50). Table 2 details the numbers of interviews and small group interviews per year conducted with school nurses. Nearly all school nurse participants (n = 21, 88%) served as IRT leaders, 8% (n = 2) were members of their IRT, and 4% (n = 1) served as both an IRT member and an IRT lead at different times. About a third (38%) worked in rural schools and most (79%) worked full time. Regarding education level, almost all, 23/24 (95.8%), of these participants were at least bachelor’s prepared: 10 (41.7%) had completed a bachelor’s degree and 13 (54.2%) had attended or completed graduate school. Table 3 provides the school nurse sample demographics. All identified as female; they described their sexual orientation as heterosexual (80%), bisexual (8%), and lesbian or gay (8%) (4% preferred not to answer). They reported racial identity as 4% African American, African Descendent, or Black; 92% European American, White, Anglo, or Caucasian; and 8% another race (respondents could select all that applied). Hispanic ethnicity was reported separately from race, with 17% identifying as Hispanic.
Several categories of factors impacting school nurses’ ability to serve as an effective implementation leader emerged from analysis, including job characteristics, leadership and organizational skills, relationships and reputation, and personal commitments. Contextual factors, such as working in urban or rural school, and the size of the school also influenced nurses’ leadership in RLAS.
Professional Responsibilities. School nurses regularly mentioned that their roles included a wide range of responsibilities, such as taking care of medically fragile students, attending to emergencies, administering routine medications, consulting with school staff, teaching health lessons, and managing resources like a clothing bank. A nurse at a small rural school explained that in addition to the duties that fell within the scope of school nurse, she fulfilled the roles of other school staff: “Well, I have so many job responsibilities. I’m the school nurse, I’m the homeless liaison, I’m the drug free prevention coordinator. I have so many different roles and then right now we don’t have a school counselor and so sometimes I get very overwhelmed with all the responsibilities.” Especially in smaller and rural schools, the nurse’s role expanded to address a variety of school and community needs. During the pandemic, the nurse quoted above took on tasks such as delivering food and personal protective equipment and checking on people in her community.
Workforce Shortages. Staffing shortages, including among fellow nurses, health assistants, and other school personnel, impacted the ability to lead IRTs. As one nurse explained, the ratio of students to staff was unmanageable:
Hopefully, next year will be a little bit better for me and I’ll have a little bit more time because this year was just horrible, because there really should be two nurses here. It was only me for the whole first semester beginning in January for 1,800 kids and the medically fragile program, so I was just totally overwhelmed.
Understaffed school health offices were a concern for almost all schools in RLAS, including those for which the school nurse chose not to serve as the IRT leader.
Covering Multiple Schools. School nurses in NM, especially in smaller or more rural school districts, often cover multiple campuses. Many nurse participants found that serving multiple schools was a barrier to their effectively leading IRTs. As explained by one nurse, some districts have nursing staff specifically designated for covering staff shortages. Those staff found leading IRTs “very difficult” because of the part-time nature of their work and disconnection from the school community, clarifying that “I don’t have a cohesive team. I’m not a nurse at that school. I’m the flex nurse, so I go to all the schools and fill in, and I’m all over the place.”
Time. School nurses explicitly identified time as the major factor impacting their ability to lead an IRT in implementing EIPs in schools. A nurse in a small rural school stated that her biggest barriers were “finding the time and energy.” She continued, “I have 40 kids come into my office on any given day, 45 sometimes. It would be one thing if they all came in [for] two hours, but it’s like …. I’ve always had this open-door policy.” Another nurse in a large urban school echoed this view:
Time is always an issue too and that’s one of the hardest parts about working in education. There is so much need throughout the whole community. You could work 24 h a day to try to meet everybody’s needs, but of course, our jobs are finite. Sometimes you do have to triage; who can I help?
As expressed through the above quotes, time was an important yet scarce resource shaping school nurses’ ability to serve as implementation champions for LGBTQ+ supportive practices.
Something “Extra”. Despite their desire to support LGBTQ+ youth and their positioning in school systems to do so effectively, the school nurses in RLAS commonly felt that taking on the role of an IRT leader was something “extra” on top of an already heavy workload. One nurse explained her unique situation of having slightly less demanding days:
In theory, it is a great idea. In practice, as we know, nurses are really overwhelmed and have way too much on their plates as it is, and so that’s the flaw …. That’s also why I’ve been, I think, more successful …. I have a much quieter, more mellow school than probably any other school nurse that you guys are interacting with, so I have the time, and they just don’t.
Even though school nurses were ideally situated within schools to advance health equity and support LGBTQ+ youth, without dedicated time and support, this work is perceived as imposing “extra” duties as opposed to work landing squarely in their wheelhouse.
Leadership. The school nurses in RLAS described a variety of leadership experiences. Some nurses had worked as key district-level nursing administrators or as leaders of statewide nursing organizations. Describing her experience garnering initial administrative buy-in for the project, one district-level school nurse said, “I see a lot of support at the school level with the administration there and I see a lot of support at the district level. And, you know, when we first started looking at this project and I called the superintendent, and he’s like ‘Go for it!’” This participant went on to describe their ease in bringing new superintendents and principals up-to-speed with implementation efforts evidencing comfort in their leadership role.
For other nurses, leadership was a new skill. Nurses with limited leadership experience reported that involvement in the multifaceted implementation approach of RLAS deepened their organizational and leadership capacities. For example, a nurse in a large urban school explained, “To be honest …. I don’t think I’ve ever led a committee or group in the school system and very few in my life in general …. So,it’s been good for me. I felt like I rose to the occasion actually.” However, steering such an endeavor was still challenging even for seasoned school nurses with histories of facilitating committees or implementing programs. As a school nurse in an urban high school explained, “Oh my gosh, herding cats is easier than this [leading EIP implementation] was.”
Delegation. Participants commonly expressed a tension between assuming too much responsibility and the desire and ability to delegate to others on their IRTs. Some were very successful at delegation, including those with smaller IRTs, such as a nurse from a rural school who remarked, “My team is really small. I asked [name], since she was a board member, if she could work on all the policy piece. Then [the counselor], she’s working more on the safe spaces piece. The social worker … does more of mental health piece. Then there’s me, that just tries to help with all of them.” This kind of judicious division of tasks based on IRT members’ particular capacities and connections was a key strength of school nurses in leadership positions.
In contrast, despite having a team on whom they could hypothetically rely, nurses found it hard to avoid being saddled with most of the responsibility of implementation. A nurse at a large rural school said, “I’ve pretty much been the one doing everything, as is I think often the case with these [initiatives], when you’re the lead for anything.”
A nurse at a large urban school expressed how the experience of being part of an IRT encouraged her to develop delegation skills. She commented:
I don’t like to tell people what to do. But, I’m working on that. I did better and I came up with all these ideas [that] I was going to [do]—and I thought, no [Name] you can’t do all this. You have to delegate. And so, figuring out, okay you’re going to do [this], you’re going to do [that], you’re going to do [that], and letting things go.
Sometimes decisions to delegate came at the suggestion of implementation coaches, who helped nurses stave off feeling overwhelmed. For example, a nurse at a large urban high school said:
I tasked everybody [on the IRT] with sending me resources. They all did it. The health teacher’s the one that put the Google site together. That’s what was hard in the beginning. … At first, I was overwhelmed thinking, “Oh my gosh, all this stuff I want to get done. How am I going to find the time?” They all took different little things and ran with it. So it was perfect.
Similar to developing overall leadership skills, nurse participants learned through their experience with RLAS to rely on their IRTs and to specifically organize tasks so that others could easily support the implementation of LGBT+ supportive practices in their schools.
District Support. School nurses frequently found they could leverage district-level support for implementation that encouraged, if not required, schools to take action. Speaking generally about their district-level administration, a nurse in a large rural school said, “When I approached our former superintendent and said we wanted to do this, it was great, all the support we needed there.” In other instances, nurses had established relationships with districtlevel health services leadership that supported the coordination of professional development for staff, advocated for policy changes, and informed efforts to improve referral resources for LGBTQ+ students. School nurses, especially in larger schools, were more closely aligned with districtlevel health services administration than school-specific administration. This meant that they worked within the organizational hierarchy of their schools but were still somewhat separate from school-level administration, allowing them influence not afforded to other staff directly subordinate to principals or assistant principals.
Students. School nurses’ relationships with students emerged as a major facilitator. School nurses repeatedly discussed actively striving to provide safe spaces for students, that they were trusted adults, and they cared deeply about their students. School nurses often described their relationships with students as de facto mentors attempting to get young people to think about their futures. A nurse in a small rural school explained:
In my three minutes that I have with a student …. I have some that come in four or five times a day. I started asking them, ‘What are you thinking of doing over the next ten years?’ Most of them are like, ‘I don’t know.’ I said, ‘Okay, well, that’s an assignment for you. Next time you come in here, I want you to give me one thing that you want to do over the next 10 years.’ Just little things like that to get kids thinking outside of [our town].
Safe Space. In addition to understanding their influence as informal mentors for the general student body, school nurses acknowledged their importance in supporting LGBTQ+ youth. They were confidants and resources for students struggling with coming out to their friends and families. One nurse explained:
I had one student tell me, “My Mom wants me to be gay, not trans.” She said, “Can’t you just be gay? Can’t you just be a lesbian? Come on. Just be a lesbian?” I was like, ‘Oh my gosh.’ You know, that’s like something we wouldn’t have heard five years ago. This student is telling me, ‘No, I really am. I want to transition.’ And so, that student knows they can come to me, I understood what they were talking about.
In another rural school, the nurse described the plight of a young gay student who was struggling with his family situation and having problems in school:
The one kid that I’m thinking about, the conversation among the teachers and stuff is that he is gay and struggling with it because of his home life. He comes from a ranching family and ranchers are tough. And he’s the eldest boy. I think that becomes much more of a hard place at home. From what I understand, mom knows but dad doesn’t. Over the course of the school year, he’s had some disciplinary problems at school. … But I think it’s all part of him trying to fit in. And not knowing where to stand, not knowing how to express himself … And I have a great relationship with him. We’re playful when we see one another and he comes into the office. … I don’t see him on a daily basis, so I just love him when he comes in.
Both of these cases exemplify the ways school nurses support students as de facto safe spaces for LGBTQ+ young people.
Despite the obstacles that nurses faced in supporting the uptake of the EIPs in their schools, almost all expressed a deep commitment to students in general, and LGBTQ+ students and populations specifically, often framed in terms of their own relationships with family and friends. One school nurse in an urban area reported that her success was because she “[cared] so much,” and that the topic was personal for her: “I’m in an LGBTQ choir. My daughter identifies as LGBTQ. All of these kinds of things, so it’s my whole life, so I really care about it.”
Another rural school nurse cited a similar personal motivation: “Part of the reason I took it on is because I feel very strongly. … When my nephew came out as gay, he was telling me about this [LGBTQ+] organization he belonged to at the university. So, I was asking him a lot of questions.” This nurse went on to share how she learned from her nephew’s experiences about the important role of schools in supporting LGBTQ+ youth.
Differences Between Rural and Urban Contexts. Aside from time constraints, most barriers posed heightened challenges in rural contexts and smaller schools. For instance, there were fewer local health resources in rural areas to which school nurses could refer students, especially those that were known to be LGBTQ+ affirming. Choice of providers was very limited in these areas. One nurse described how she helped figure out how to get students the appropriate health services, given the few local providers. She asserted, “It’s one thing to refer out and I mean we don’t have enough of that [healthcare]. It’s that, and getting the transportation, and then me knowing enough—because if I knew more, I could figure out how to make it work with what we have.” Other participants echoed the sentiment that they made the best of what resources they had.
School nurses in rural areas were also more likely to serve multiple schools across grade levels on one campus, such as combined elementary, middle, and high schools, or multiple school campuses. School nurses in such situations were responsible for more students and a more complex, often heavier, workload. As a result, they had less time to dedicate to “additional” efforts and expressed being disconnected from schools. All these factors negatively impacted nurses’ abilities to champion implementation.
In some rural schools, the school nurse was a go-to person for both the school and the community. This status as a trusted healthcare professional, especially in the absence of other healthcare services in smaller and rural towns, contributed to the influence that individual school nurses could have on broader communities. For example, a nurse in a small rural town became the main resource for not just care but also providing personal protective equipment, food, and clothing during the height of the COVID-19 pandemic.
Differences Due to School Size. School size was an important contextual factor impacting school nurses’ ability to lead IRTs effectively. First, smaller schools tended to have fewer school health-related staff (e.g., health assistants, other nurses, counselors, social workers) to whom nurses could delegate tasks or recruit to support LGBTQ+ focused initiatives. Second, smaller schools had fewer personnel overall, limiting the support nurses could draw. Both fewer schoolhealth professionals and staff in general meant that school nurses experienced higher workloads with less time and help.
In contrast, more sizable schools tended to have the capacity for larger IRTs. One school nurse explained that having more larger IRTs meant more voices included in discussions, yet also posed challenges for coordination. Speaking about her favorite part of leading the IRT at her urban school, she said:
Just that they all are willing to come together and when they are able. Not everybody was able to go to every single one but the enthusiasm they brought to the table and just the different perspective. We had me as a nurse. We had teachers. We had social workers, counselors. … It was nice getting the different viewpoints of the different professional roles that they play. Even the principal, she made most of the meetings.
In this study, we analyzed interview data from 24 school nurses who participated in a statewide study that aimed to implement EIPs to make schools safer and more supportive of LGBTQ+ students. We identified multiple barriers limiting school nurses’ ability to participate as leaders in this initiative. School nurses are theoretically well positioned to support LGBTQ+ youth in schools, and both the National Association of School Nurses and National Academies of Sciences, Engineering, and Medicine (NASEM) endorse the vital role of school nurses in advancing child and adolescent health equity (Maughan et al., 2016; National Academy of Medicine et al., 2021); however, this study provides an important glimpse into the real and present obstacles to school nurses’ attempts to serve as leaders in supporting LGBTQ+ students. To our knowledge, this study is the first to identify structural issues that impede school nursing leadership in advancing health equity related to LGBTQ+ youth. As illuminated through interviews with school nurses, successful participation as nurse leaders in this initiative was facilitated by numerous factors. Successes were more evident when school nurses had a personal commitment to working on school policies and practices supportive of LGBTQ+ youth. Those comfortable with and skilled in delegation were more effective in ushering in the EIPs, provided they had school staff available to assign tasks for this initiative. School nursing leadership was made possible when nurses had available time and support from their school administration to allocate work time to these efforts. Lastly, leadership skills and comfort with a leadership role were essential for school nurse participants to take the helm of their IRTs. Our findings underscore the calls for more leadership training for nurses as essential for the emergence of robust nurse leadership in collaborative efforts such as this one to address social determinants of health.
Our findings are also consistent with the calls for baccalaureate-level preparation for school nurses so that they are well equipped for the range of responsibilities in the school setting, including leadership roles and delegation responsibilities. Virtually every school nurse (95.8%) who participated in RLAS held a bachelor’s degree and they came from every region of the state; yet in a 2022 workforce study of school nurses in NM, only 71% of school nurses statewide held a bachelor’s degree or higher (Ramos et al., 2022; Shattuck, Sebastian et al., 2022; Willgerodt et al., 2018). Nationally, two-thirds of school nurses hold a bachelor’s degree or higher (Willgerodt et al., 2018). Through baccalaureate-level preparation, school nurses may better obtain the requisite skills and experience to be effective in leading organizational change and policy and practice initiatives in school settings.
Structural changes are also needed to realize the promise of school nurses advancing health equity related to LGBQ+ youth. School nurses in the United States are paid substantially less than nursing colleagues who work in other settings, which can deter nurses from entering or remaining in the specialty of school nursing. Most school nurses are the only nurse in their school and many cover two or more school campuses; with nurses in rural schools typically covering three or more schools (Ramos et al., 2022; Shattuck, Sebastian et al., 2022; Willgerodt et al., 2018). As RLAS shows, many school nurses cover multiple school types, across different age groups, that is, elementary school mixed with secondary school (middle or high school). In addition to the distance traveled between multiple schools, different school populations may experience different sorts of social determinants of health. When school nurses are spread thinly, workload demands may limit their capacity to develop the relationships in school settings necessary for collaborative leadership in addressing social determinants of health or to develop expertise with certain ages or populations of students.
As noted previously, school nurse workloads are largely influenced by school health services decisions falling within state and district educational systems. These decisions are often made by school professionals who lack the knowledge necessary to effectively funnel resources to school health needs (Willgerodt et al., 2018). Lack of time, workload, and caseload has all been identified previously as barriers to school nurses participating in public health practices and our study echoes these findings (Davis et al., 2021).
The 2021 NASEM report, The Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity (National Academy of Medicine et al., 2021) includes in one of its key recommendations that “by 2023, state and federal government agencies, health care and public health organizations, payers, and foundations should initiate substantive actions to enable the nursing workforce to address social determinants of health and health equity more comprehensively regardless of practice setting.” As of 2023, it appears little progress has been made on this front, at least in terms of enabling school nurses to lead efforts to make schools safer and more supportive of LGBTQ+ students.
The work reported in this paper has several limitations. First, data are from a single-state study and may not account for facilitators and barriers present elsewhere in the United States. Second, we did not interview students or other school staff, and thus we do not know their perspectives about the efforts of school nurses. Third, despite attempting to establish solid rapport and encouraging honesty from school nurse participants in interviews, there is always the possibility of social desirability bias. However, we believe that we decreased the likelihood of this bias by assuring confidentiality of qualitative data and using interviewers who did not have a direct influence on implementation processes (e.g., research staff with whom participants did not have a sustained relationships). Many participants also expressed appreciation for being able to speak candidly about the challenges they faced. Despite these potential limitations, RLAS as a whole is the first study of its kind focused on the position of school nurses as leaders for organizational change in schools to address LGBTQ+ health equity. Future work may benefit from multiple state contexts and the integration of student and other school staff perspectives.
Structural support for the school nursing profession is essential to realizing the promise of school nurses serving as effective change leaders in their schools, including when those change efforts are geared toward health equity. School nurses may have the passion to serve as leaders for health equity implementation efforts in schools, but all too often they are not afforded the time, resources, or educational opportunities support to assume such responsibilities and develop their leadership skills. One study implication for practice is the necessity of improving staffing for school nurses, ensuring that every school has appropriate numbers of nurses to address the needs of every student. Such an improvement may require that more robust funding and staffing of school health professionals be legislatively mandated.
In conclusion, we found that school nurses hold an incredible potential for advocating for and leading large-scale practice changes in schools to improve culture and climate for LGBTQ+ adolescents. However, multiple barriers prevent them from assuming leadership as effectively as they possibly could. These barriers tend to be structural in nature, encompassing limited resources such as time and staffing that stretch nurses thin in and across school campuses. When provided with appropriate support, along with significant systemic changes to the way school health is funded and staffed, school nurse advocacy and leadership in support of LGBTQ+ youth, as outlined by NASN, may be more fully realized. Nevertheless, our study illustrates that school nurses are powerful allies for LGBTQ+ and other marginalized student populations and are critical to their health and well-being.
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 funded by the National Institute of Child Health and Human Development (R01HD83399).
Daniel Shattuck https://orcid.org/0000-0003-4689-863X
Mary M. Ramos https://orcid.org/0000-0002-5260-7395
Cathleen E. Willging https://orcid.org/0000-0001-6446-5083
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Daniel Shattuck is a Research Scientist with the Southwest Center of the Pacific Institute for Research and Evaluation. His work focuses on anthropological and implementation science approaches to addressing sexual and gender minority health disparities.
Dr Mary M. Ramos is an academic public health pediatrician whose focus is on improving school health services to address pediatric and public health disparities.
Bonnie O. Richard is an applied medical anthropologist focused on research, evaluation, and implementation of health promotion and disease prevention programs. Specializing in qualitative and mixed methods, she is an Associate Research Scientist at the Louisville Center of the Pacific Institute for Research and Evaluation.
Janie Lee Hall is a retired nurse and lifelong public health worker. Prior to serving as a research associate with the Southwest Center of the Pacific Institute for Research and Evaluation, she spent the majority of her 40-year nursing career working as a school health advocate for the New Mexico Department of Health, and a directing a community health nursing program for the Navajo Nation Health Foundation.
Rhonda Sparks, BSN, RN is a retired public school Director of Nursing and Health Services with 38 years of combined hospital Pediatric and School Health practice. She currently consults for SivicSolutions Group on their education team with a focus on nursing documentation.
Cathleen E. Willging is a Senior Research Scientist and Director of the Southwest Center of the Pacific Institute for Research and Evaluation. She specializes in Medical Anthropology, Implementation Science, and mixed-method research to advance health equity.
1 Southwest Center, Pacific Institute for Research and Evaluation, Albuquerque, NM, USA
2 Department of Pediatrics, University of New Mexico, Albuquerque, NM, USA
3 Louisville Center, Pacific Institute for Research and Evaluation, Louisville, KY, USA
4 New Mexico School Nurse Association, Clovis, NM, USA
Corresponding Author: Daniel Shattuck, Pacific Institute for Research and Evaluation, Southwest Center, 851 University Boulevard, Albuquerque, NM 87106, USA. Email: dshattuck@pire.org
