The Journal of School Nursing2025, Vol. 41(5) 632–641© The Author(s) 2024Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405241293746journals.sagepub.com/home/jsn
Abstract
Background: School-aged children with unidentified mental illnesses experience poor health outcomes; managing this issue requires a collaborative community approach. Objectives: The objective was to implement an evidence-based mental health education and sustainment program within an underresourced school setting for staff and parents/guardians supervising children to optimize adult mental health literacy (MHL). Methods: The intervention included Youth Mental Health First Aid (YMHFA) training; measurements of pre- and post-MHL were completed with the Mental Health Literacy Scale (MHLS). Sustainment was achieved by developing a school-centered mental health toolkit and integrating a school champion. Results: There was a significant MHL score change from pretest to posttest. The toolkit bolstered sustainability by increasing the utilization of community resources. Conclusions: This mental health awareness initiative proved effective and can be expanded across similar underresourced schools to fill voids.
Keywords
mental health first aid (MHFA), mental health literacy (MHL), school-centered mental health toolkit, school-aged children
One in six children attending school suffers from mental illness, making the likelihood of a teacher encountering a struggling child high (Centers for Disease Control, CDC, 2021). The Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5-TR) defines mental illnesses as a significant disruption in an individual’s conduct, cognition, and/or regulation of emotions that can cause distress and difficulties operating in family, social, or work settings. Early identification and treatment of mental illnesses are instrumental in lessening the severity of such concerns (American Psychiatric Association, 2022). The most common mental illnesses present in school-age children are as follows: attention deficit disorder, anxiety, behavioral problems, and depression (CDC, 2021).
Mental illnesses have a significant impact on developing children. Mental illnesses can perpetuate throughout the lifespan, and without early identification and treatment, affected children can struggle at home, with their peers, and at school; such conditions can also impede healthy development (CDC, 2021). Research shows that only 50% of children with mental illnesses will receive mental health care (AAFP, 2019). Tragically, this lack of care corresponds to poor outcomes, as suicide is listed as the second leading cause of death in those 10–34 years old (CDC, 2021).
Children with mental illnesses are more likely to be absent, expelled or suspended, and unhappy (Blackorby & Cameto, 2004). Children with mental illnesses miss upwards of 18–22 days of school per academic calendar year (Blackorby & Cameto, 2004). Furthermore, children with mental health disorders are expelled/suspended three times more than their peers (Blackorby & Cameto, 2004). High school-aged youth who suffer from mental illnesses do not perform as well academically, having twice the rate of D’s and F’s comparedto their peers, deterring them from continuing education beyond high school (Blackorby et al., 2003). These data emphasize the incapacitating toll that mental illnesses place on children and why it is essential to address them.
Schools can play a vital role in children’s mental health. Schools offer supportive and safe environments for students and the opportunity to provide community referrals (CDC, 2024). The Substance Abuse and Mental Health Services Administration (SAMHSA) (2023) encourages schools to implement regular training for teachers on recognizing and responding to mental health conditions in children. The National Alliance on Mental Illness (NAMI) reinforces the recommendation for school staff to learn how to recognize and respond to children’s mental health illnesses (2024). Additionally, NAMI stresses the need for school-based mental health services, as well as the need for schools to provide community resources to children and their families (2024). The CDC (2024) emphasizes the need for schools to implement school-based strategies aimed at deterring mental illnesses and promoting well-being.
Although schools offer a promising environment for promoting mental wellness, there is a lack of mental health literacy among educators and staff and a limited capacity to provide effective mental health services. Data from the Kaiser Family Foundation, KFF, (2022) highlights barriers to school-based mental health services. One-third of schools strongly or moderately disagreed that they could provide effective mental health services (KFF, 2022). Schools most frequently reported a lack of healthcare providers as the reason for being unable to address student mental health needs. Further, many schools reported not meeting the recommended student-to-psychologist (500:1) or student-to-counselor (250:1) ratios (KFF, 2022). This report highlights the prevalent mental health deficiencies in schools and supports the need for innovative school-based mental health education and sustainment programs.
The COVID-19 pandemic amplified the existing mental health crisis in the United States (CDC, 2020). In 2020, mental health-related emergency department visits for children (5–11 years) and adolescents (12–17 years) rose by 24% and 31%, respectively (CDC, 2020). At least 18% of COVID-19 patients develop mental health disorders within 90 days of diagnosis, making it likely that pandemic-driven mental health repercussions will be longstanding (Taquet et al., 2021). COVID-19 has exacerbated the mental health crisis so drastically that the White House issued an executive order aimed at increasing mental health support in schools (SAMHSA, 2020). This order is multidimensional; however, two highlights are its focus on initiatives to create public health campaigns that foster a supportive mental health culture and school-based mental health programs (SAMHSA, 2020). The urgency of this crisis calls for novel community solutions. Schools present a unique environment for capturing this vulnerable population. Implementing youth MHFA within schools may serve as a means of reducing the harm associated with mental illnesses.
Successful management of mental illnesses in the school setting requires a collaborative community approach with a focus on enhancing mental health literacy (MHL) to improve outcomes. The National Council for Mental Wellbeing, formerly the National Council for Behavioral Health, developed an innovative and growing intervention, Mental Health First Aid (MHFA), that effectively mitigates mental health issues, teaching lay people to identify, respond, and provide resources to struggling individuals (2021). Specifically, youth MHFA (YMHFA) was developed to assist individuals who regularly interact with adolescents and children to identify unique risk factors and warning signs of mental health challenges specific to the population (National Council for Mental Wellbeing, 2021).
Literature evaluating the influence of MHFA training on the mental health literacy (MHL) of adults supervising adolescents/children shows compelling evidence for its use (Childs et al., 2020; Gryglewicz et al., 2018; Haggerty et al., 2019; Morgan et al., 2018, 2019, 2020; Ma et al., 2022; Noltemeyer et al., 2020). These studies explore the use of MHFA and YMHFA interventions delivered to teachers, parents/guardians, coaches, and community members with youth contact. To measure the impact of training, studies evaluated variables associated with MHL, such as mental health knowledge and confidence in delivering mental health support. These studies showed an improvement in the MHL of adults supervising children and adolescents when MHFA (or YMHFA) was implemented (Childs et al., 2020; Gryglewicz et al., 2018; Haggerty et al., 2019; Morgan et al., 2018, 2019, 2020; Noltemeyer et al., 2020). Notably, Haggerty et al. (2019) established that MHFA training has the ability to enhance the MHL of nonmental health workers to levels on par with the baseline literacy of the mental health workforce. This shows that MHFA can serve as a valuable tool for individuals with no formal mental health training.
A systematic review conducted by Morgan et al. (2018) offered strong reinforcement of the literature by demonstrating that MHFA improved recognition of mental disorders (ds 0.22–0.52), MHFA knowledge (ds 0.31–0.72), intentions to provide MHFA (ds 0.26–0.75) and confidence to help an individual struggling with a mental health problem (ds 0.21–0.58). Similarly, Noltemeyer et al. (2020) discovered that YMHFA participants had an increased acceptance and awareness of resources, and an increased willingness to help. Furthermore, Morgan et al. (2019) and Morgan et al. (2020) offered valuable insight into the longevity of MHFA impacts on MHL, as they collected data pertaining to MHL at 1, 2, and 3-year follow-ups. Analysis revealed that with time, the effect size of the intervention (MHFA) on the outcome (MHL) decreased minimally.
Ma et al. (2022) performed a systematic review of schoolbased interventions aimed at improving mental health knowledge and found statistically significant increases associated with such interventions. Additionally, three out of five studies in this systematic review evaluated the effectiveness of school-based interventions for improving participants’ ability to recognize signs and symptoms of mental illnesses and found statistically significant increases in this knowledge. Out of the sixteen studies reviewed for the effectiveness of school-based interventions on attitudes and beliefs associated with mental illnesses, six found a statistically significant reduction of stigmatizing beliefs and attitudes (Ma et al., 2022). This literature, combined with evidence that MHFA training leads to statistically significant results, suggests that implementing YMHFA within the school setting may pose lasting benefits to adults and children.
Implementing YMHFA training in environments with ready access to children who have the highest risk for mental illness is a crucial step toward reducing the public health concern that mental illnesses pose. Schools are ideal settings for YMHFA training as teachers are often the first to see the impact of mental health challenges on young people (National Council for Mental Wellbeing, 2020). Further, because of the collaborative environment that school settings offer, teachers and parents/guardians can work together to identify and intervene for children needing the most support (National Council for Mental Wellbeing, 2020).
This project was completed in a private school in the Western United States that did not have a school nurse and/or aide or an active school counseling program. The school population (n = 177) included children in grades preschool through eighth grade. The student population is diverse, with a 56.5% minority enrollment.
During a meeting with school leadership, administrators expressed concerns about the mental health of students. While the school does not track the number of students diagnosed with mental illness, there was anecdotal evidence and great concern about the increasing mental health challenges students seemed to be facing. Administrators reported that there was an increase in the number of parents who were reaching out to school leadership about student mental health concerns and seeking resources. Further, educators reported concerns about an increase in emotionally withdrawn pupils. Concerns about mental health grew in the school community leading up to and as the COVID-19 pandemic progressed. These concerns mirrored the data showing an increase in mental health challenges for children of all ages during this time. Reports from the Center for Disease Control’s YouthRiskBehavior Surveillance indicated that feelings of hopelessness and persistent sadness, as well as suicidal ideations and behaviors, grew by 40% over the 10 years before the pandemic (2023). These statistics worsened after the onset of COVID-19.
Despite growing concern about mental health, leadership reported that school staff did not have any training on responding to children struggling with mental illnesses. Additionally, the school did not have a school nurse, health aide, or school counseling program. Comparable surrounding schools were equipped with school counselors,
School-Based Behavioral Health staff, and nurses. This healthcare gap placed the private institution pupils at a disadvantage and highlighted the unmet mental health needs.
Compounding the lack of faculty training, data from the National Council for Mental Wellbeing (2021) noted that the local community was severely deficient in MHFA training, leading this population to be at a significant disadvantage in addressing the mental health crisis. As detailed by the CDC (2021), “screening, identifying, and referring kids and adolescents to effective treatment can help prevent or decrease the negative effects of mental disorders.” Given the significant impact of the COVID-19 pandemic on mental health, the school leadership sought to prioritize efforts in this area. Employing YMHFA training within this school provided the opportunity to address the knowledge gap and improve the overall well-being of students and the extended community.
The purpose of this quality improvement project was to implement an evidence-based mental health awareness education (YMHFA) and sustainment program at an underresourced school for teachers, staff, and parents/guardians. This intervention was chosen in response to school community concerns and based on literature supporting the implementation of YMHFA training in similar settings (schools) as a method of increasing MHL (Childs et al., 2020; Gryglewicz et al., 2018; Haggerty et al., 2019; Morgan et al., 2018, 2019, 2020; Noltemeyer et al., 2020).
The overall goal of the project was to increase participants’ MHL by employing YMHFA training to improve the overall mental health outcomes within the school community. The specific aims of this scholarly project were the following: (a) increase the percentage of school staff trained in YMHFA by 50% within three months of program implementation; (b) increase the mean MHL scores of parents/guardians and staff of the school by 50% within three months of the educational intervention; (c) establish a mental health champion at the school within three months of program implementation; (d) increase the percentage of identified community resources for the school by 20% within three months of program implementation; (e) and develop and test a mental health toolkit.
This project took place between August 2021 and January 2022 and used a pre- and post-intervention evaluation design. Additionally, a Plan–Do–Study–Act (PDSA) model was used to guide the usability testing of the project and facilitate adjustments as needed.
At this private school in the Western United States, there were 20 staff, with 10% (n = 2) identifying as male and 90% (n = 18) identifying as female. The mean age of the staff was 37.5 years. Only one of the staff members had any formal mental health training. The student-to-staff ratio varied between 1:12 and 1:16 (dependent on grade level). The staff-to-student interaction hours averaged 6.5 h per day, and the school operated 10 months out of the year.
The following inclusion criteria were used for participants: English-speaking, male and female school staff and parents/guardians of any ethnicity, who were between the ages of 18 and 65 years, had some supervisory role over children attending the school, and had no prior YMHFA training. The following were used as exclusion criteria: non-English speaking, school community staff and parents/guardians who were less than 18 years old, staff who had no supervisory roles over students, and those who had previous YMHFA training.
Convenience sampling was used to recruit participants for the YMFHA training. School staff were recruited through staff emails and with a formalized invitation from the school principal. Participation was voluntary and staff were not required to undergo training by leadership. School community parents/guardians were recruited through a school email and flyers sent home with students. Participation for parents/guardians was voluntary.
To test the usability of the toolkit, convenience sampling was used to recruit five individuals who participated in the YMHFA training; participants were recruited through an email from the Principal and Project Leader. Evidence suggests that a minimum of five users were needed to find usability problems (Usability.gov, 2020). Similar to the YMHFA intervention, involvement in the usability testing was voluntary.
Youth Mental Health First Aid Training. Following George Washington University Institutional Review Board approval, participants were recruited via email. Individuals who were interested and met the inclusion criteria were instructed to email the Project Leader to express interest. From there, the Project Leader arranged a meeting (in-person or via video conferencing) with the interested party to perform informed consent.
Consenting participants were sent two surveys. The first survey was the Mental Health Literacy Scale (MHLS), a selfreport survey used to assess general population attitudes and knowledge about mental health that assists in the identification, management, and deterrence of mental illnesses (O’Connor & Casey, 2015). A second demographic survey requested participants’ age, ethnicity, educational level, and insurance status. The surveys were sent electronically to the participants via the Research Electronic Data Capture, REDCap, (version 8.10.20) secure web application (2021). Paper copies were provided for those without access to technology. Any surveys completed on paper were completed anonymously, enclosed in a sealed file envelope, and left in a locked cabinet in the school office for the Project Leader to pick up upon completion. Participants were asked to complete surveys within 72 h of receipt. After completing the MHLS survey, participants were electronically surveyed through REDCap about their preferred dates/times for the YMHFA training. The most frequently requested day/time was scheduled for training. Concurrent with surveying participants, the Project Leader interviewed the school leadership and administration to gather data on what community resources were being used by students.
Youth Mental Health First Aid training was delivered once to all participants. Each participant completed 7.5 h of YMHFA training. The first two hours were completed online independently by the participants. The remaining 5.5 h were completed in person, as a group, delivered by the Project Leader who was an accredited YMHFA instructor. This class used the participant manual from the National Council for Mental Wellbeing (2021). To engage participants, best practices for adult learning were employed. In addition to structured lectures, the training also included case studies, videos, role plays, group discussions, and self-reflection.
The training was developed by the National Council for Mental Wellbeing and teaches participants to recognize symptoms of common mental illnesses (and substance use disorders), safely de-escalate crisis situations, and initiate timely mental health referrals within the community (National Council for Mental Wellbeing, 2021). The National Council for Mental Wellbeing (2021) authorizes training to transpire either virtually or in person on the school campus with Youth Mental Health First Aid accredited trainers.
To evaluate the impact of the training the participants were asked to take the MHLS survey three months post-training. An email reminder was sent to participants at week 12, and the survey was deployed electronically via REDCap.
Mental Health Toolkit and Usability Testing. The second part of the intervention was the creation of a YMHFA toolkit housed on an independent website for school staff and parents/guardians. Toolkits offer resources for organizations or communities and permit simple distribution of materials (Hempel et al., 2019). This toolkit provides evidence-based mental health aids for school staff and parents/guardians, general mental health resources, local community resources, and resources to sustain MHL.
All participants were surveyed two weeks after YMHFA training to determine the materials that would best help them sustain their MHL. Data analysis showed that the most frequently requested content for the toolkit was evidence-based resources, community resources, information on maintaining mental health awareness, tools to assist the staff and parents in responding to students, and access to credible local youth mental health data. Based on the needs assessment, the toolkit was developed by the Project Leader. Weebly’s website development platform (professional version) was used to develop the website and incorporate the participants’ feedback (Weebly, n.d.). To promote equitable access to the toolkit, the completed website was checked for American Disabilities Act (ADA) compliance with Weebly’s preexisting ADA compliance scanner (Weebly, n.d.).
Once developed, usability testing of the website was conducted. Five staff volunteers who completed the YMHFA training participated in this part of the intervention. Usability testing was done to assess and enhance effective use of the toolkit (Usability.gov, 2020). The usability testing was conducted using a PDSA framework, where the Project Leader planned the website navigation testing, implemented the plan, studied the results, and made repeated adjustments to the toolkit site until there was a 100% participant task completion rate and satisfaction with ease of use.
Using the guidance delivered from Usability.gov (2020), a usability test was planned by using the following steps:
(1) Defining the scope by clearly outlining what is being tested: The toolkit
(2) Outlining the purpose of the test: “Can users navigate to important information from the home page?”
(3) Establishing a date and time for testing
(4) Clearly explaining session(s), outlining length and/or commitment to participants
(5) Advising of specific technology needed: laptop or computer
(6) Defining specific participants to test the product
(7) Establishing subjective metrics: participant satisfaction with ease of use
(8) Establishing quantitative metrics: successful task completion rates
(9) Clearly defining who would participate in usability
The Concurrent Think Aloud technique was used as the moderating method to test the usability of this toolkit (Usability.gov, 2020). This method encourages participants to speak out loud as they work, providing real-time feedback (Usability.gov, 2020). Once participants were recruited, steps 1–5 were relayed to the participants. Usability testing transpired in person. Each participant underwent testing individually to prevent influence from other participants (Usability.gov, 2020). During the usability session, the participant satisfaction with ease of use and successful task completion rate data was collected by the Project Leader observing task completion abilities and asking participants the following question: “Are you satisfied with ease of use?” Participants were given “yes” or “no” as response choices; if they answered “no” they were encouraged to freely state reasons why, this allowed the Project Leader to narrowly target necessary changes. A pilot test was conducted 1–2 days prior to the usability testing to alleviate any technical issues that could have impaired the usability testing (Usability.gov, 2020).
Mental Health Champion. As recommended by the CDC, American Academy of Pediatrics (AAP), and National Council for Mental Wellbeing, a mental health champion was established at the school. This occurred three months after the YMHFA training and after the mental health toolkit had been developed and tested for usability. One school staff member was recruited to be the mental health champion/lead for the school. The invitation to voluntarily serve in this capacity was sent out via an email from the principal. The literature emphasizes that this individual does not have to have any special training or skills (AAP, 2016; CDC, 2021; National Council for Mental Wellbeing, 2021). Hence, there were no prerequisites, outside of being a school staff member and a participant in the project, for the individual selected for this role. The role of the mental health champion was to take the lead on implementing school-based mental health programs tailored to the school’s needs, with the end goal of improving mental health outcomes for students.
The measures for this project encompassed structure, process, and outcome measures. Two structure measures were identified: (a) improving access to community resources and the number of community/mental health resources for the school and (b) assessing the community’s crucial needs to incorporate within the mental health toolkit. The process measure was targeted towards increasing the percentage of individuals completing YMHFA training. The outcome measures were focused on increasing the mean MHL score of participants, developing a usable toolkit, establishing a mental health champion at the school, and utilizing community resources.
The staff YMHFA training rate was calculated as a percentage of all eligible staff that successfully completed training. The average pre and post-intervention MHL scores were compared, and the difference between the two was calculated as a percentage, a paired t-test was used to assess the differences in MHL scores before and after the YMHFA training. To determine the elements needed within the toolkit, the median needs identified by surveying the project participants were analyzed for inclusion. For usability testing, the task completion rate and participant satisfaction with ease of use were analyzed in real time. The task completion rate was calculated as a percentage of all participants who successfully completed assigned tasks, and the participant satisfaction with the ease-of-use rate was calculated as a percentage of all participants who found the toolkit easy to navigate/use, as directed by the Concurrent Think Aloud method (usability.gov, 2020).
The establishment of a mental health champion at the school was determined after surveying the school leadership and inquiring whether a mental health champion was established at the school three months post-intervention. The percentage of utilized community resources rate was calculated as a percentage of community resources utilized at project completion and compared to baseline data for change.
After institutional review was concluded it was determined that this project did not meet the definition of human subject research. The risks of this study were related to psychological distress and privacy. Measures were employed to neutralize the potential risks. The topic of mental health can sometimes cause psychological distress for participants. Participants were allowed to take breaks from the class as needed and/or not participate in any sections that elicited discomfort. The risk of an invasion of privacy was offset by maintaining confidentiality. This inquiry was void of conflicts of interest. Participation was entirely voluntary and withdrawal from the project could occur at any time without consequence. The potential benefits outweighed the risks associated with this project.
The sample size for this project was 15; participants consisted mainly of school staff (n = 10), with a sample of parents (n = 5). The most frequently occurring age group was 35–44 (66.7%), with the remainder consisting of 18–24 (6.7%), 25–34 (13.3%), 45–54 (6.7%), and 55–64 (6.7%). The majority of the participants were female (80%), with 20% being male. One hundred percent of the participants identified as Caucasian. Most participants held a Baccalaureate degree (53.3%), while the remainder (46.7%) held a Graduate degree. All of the participants identified as being medically insured.
As a result of this project, 50% (n = 10) of school staff were trained in YMHFA.
Mental health literacy scores increased for all participants. The mean pre-MHLS score was 104.4. The mean post-MHLS score was 150, demonstrating a 44% increase. Although the objective to increase scores by 50% was not met, a paired t-test showed a statistically significant difference between pre- and post-MHLS scores, p < 0.001.
All objectives related to toolkit development and usability testing were met. Five participants engaged in usability testing. In the first round of testing, 80% reported satisfaction with ease of use. The remaining user asked that instructions on accessing the links to the various sites be explained on the website. The Project Leader made these adjustments as requested. Following this, 100% (n = 5) of the participants noted satisfaction with ease of use. All participants maintained a 100% task completion rate during the first round of usability testing. After usability testing, the toolkit was made available on a school-based website.
School leadership reported that a school staff member was identified as a mental health champion. This action met the objective of establishing this role within three months of project implementation.
Prior to project implementation, the school used two community resources for students with mental health concerns. Three months post-implementation, the school utilized two additional community resources. This increased the percentage of utilized community resources by 100%, exceeding the goal of 20%. Furthermore, as a result of this project, the number of mental health and wellness aids, in school services that support student mental health and overall wellness, increased from one to three, tripling availability for students. The school implemented afterschool clubs (which were nonexistent prior to the project) to improve overall wellness (fitness, art, and cooking clubs).
The purpose of this project was to implement an evidencebased mental health awareness education (YMHFA) and sustainment program at an underresourced school for teachers, staff, and parents/guardians. Training the school community on YMHFA led to a significant improvement in MHL. A mental health champion was easily identified. The use of community resources increased, as did school-based resources, with the addition of two mental health and wellness aids. Sustainability was facilitated with the development of a mental health toolkit. The success of the project highlights the impact a mental health-focused, evidence-based project can have on a school community.
MHL. Notably, the results of this project mirrored results reported in the literature, showing significant increases in the adults’ MHL after completing similar training (Childs et al., 2020; Gryglewicz et al., 2018; Haggerty et al., 2019; Morgan et al., 2018, 2019, 2020; Noltemeyer et al., 2020). The YMHFA curriculum provides content appropriate for nonhealthcare workers, which aided in the success of this project. These findings are congruent with those of Haggerty et al. (2019), who found that MHFA training can feasibly enhance the MHL of nonmental health workers. Although some parents/guardians did participate, the numbers were limited (n = 5). Reasons for the low parent/guardian participation could be due to childcare restraints, lack of availability that matched the educators’ schedules, and/or lack of understanding of the importance of this content. Future projects could employ measures to offer multiple training dates and deploy educational campaigns to enforce the importance of this subject matter.
Mental Health Champion. The integration of a mental health champion into this underresourced school setting was important for program sustainability. To create comprehensive school mental health systems, experts emphasize the need for champions to listen, offer resources, and educate (AAP, 2021). Additionally, champions are sought as leaders; they can educate others about available resources and the importance of enhancing community mental health literacy (AAP, 2021). Champions work with the school administration to make strategic decisions regarding sustainable initiatives (AAP, 2021). In this particular school, where resources were scarce, the champion became the primary point of contact for the school community when questions arose about resources. They organized school-based awareness initiatives. In school settings where school nurses are not on-site daily, integrating a local staff member as a mental health champion could offer on-campus support to the school nurse.
Resources/Toolkit. The development of the toolkit to house school resources was an integral component supporting the functional role of the mental health champion. As outlined, one of the mental health champion’s duties was to serve as a leader who knows what resources are available, and direct others towards such resources. The toolkit was developed to house the resources to be easily accessible for both the champion and the school community. It is crucial to provide struggling students and/or guardians with resources and community referrals, as this cultivates a sense of safety and encourages improved behavioral and academic outcomes (SchoolSafety.gov, n.d.). Moreover, toolkits are a compilation of resources or information designed to ease dissemination across organizations (Hempel et al., 2019). Research has shown that toolkits correlate with improved health literacy and high participant satisfaction (Hempel et al., 2019). Congruent with these findings, the project participant satisfaction with the toolkit was high (100%), and health literacy showed improvement, with resource utilization increasing by 100%, and the number of wellness aids available to students tripling. Similarly, underresourced school settings with mental health champions, or schools that do not have a nurse available on campus daily, could rely on these toolkits to disseminate evidence-based resources.
Applicability to Other Contexts. The United States is facing a severe mental health crisis. COVID-19 has created substantial mental health repercussions and amplified the already existing crisis. In a grief and anxiety-stricken society, mobilizing lay people as mental health first aid responders serves as a powerful tool to curb the mental health crisis. Healthy People (2030) seeks to extinguish this costly and burdensome threat with early identification and intervention. Implementing YMHFA practices within communities affords the opportunity to meet Healthy People (2030) initiatives and achieve the Institute for Healthcare Improvement (IHI)’s, Triple Aim (2021) approach to optimize the community’s health system. This mental health awareness initiative proved effective and could be expanded across similar school settings.
This project included limitations related to recruitment and participation. Recruitment posed challenges due to varying staff and parent/guardian schedules. Identifying universally desired training dates was difficult. As a result, participation was lower than desired.
Improved MHL leads to earlier identification and treatment of mental health concerns in the school setting, thereby translating to the prevention of poor mental health outcomes and reduced healthcare-associated costs. In underresourced school settings (without access to a school nurse or an active school counseling system), programs such as this evidence-based mental health awareness education (YMHFA) and sustainment program can be implemented to fill the void. This project assisted the community in meeting the IHI (2021) Triple Aim initiative: Improving the health of the population and experience of care and decreasing healthcare costs (through early identification and treatment).
The National Association of School Nurses (NASN) has called for the prioritization of mental health, resilience, and well-being of children (NASN, 2021). Often, the school nurse is the first to identify related concerns. However, considering that school nurses are often responsible for overseeing hundreds of pupils at their facilities, addressing mental health cannot fall on the shoulders of the school nurse alone; the school community must be involved. NASN (2021) recommends that the interdisciplinary education team should work collaboratively with the school nurse to provide early identification, intervention, and referral support for student behavioral health needs. Even in wellresourced schools, developing programs to improve the overall community MHL could lead to improved student health outcomes.
The NASN 21st Century School Nursing Framework for Practice (2024) integrates layers of support for the school nurse, with students’ well-being at the core. One such layer is community/public health. According to the framework, a few ways the community can support the student is through integrating programs aimed at improving health literacy and offering health surveillance and outreach; both modalities align with the aims of this project (NASN, 2024). Furthermore, programs such as this have the potential to foster a strong school nurse–school staff–guardian working relationship aimed at improving mental health outcomes. Although this particular project was aimed at implementing a program to fill a resource and knowledge gap, school nurses could implement a similar education and sustainment program as needed. In order to train the school community specifically in YMHFA, school nurses would need to undergo instructor certification through the National Council, or have a certified instructor deliver the training to the community. These strategies would require buy-in and support from the school leadership.
This project helps realize the call from the AAP to heighten the collaboration between educational settings and healthcare providers to uphold child health. Furthermore, this project speaks to the National Association of Pediatric Nurse Practitioners (NAPNAP) position statement emphasizing the need for equitable and collaborative primary healthcare services for all children within school settings (2021). Through integrating this mental health knowledge and sustainment program, the school was able to bridge care gaps, address health inequities, and create channels to connect pupils to healthcare providers, thereby enhancing the school/provider alliance. The results of this project added to the body of literature supporting YMHFA specifically, which provides additional support for policymakers seeking to translate this research into policy.
Addressing the increase in the incidence and severity of mental health issues for young people requires a multifaceted approach that includes collaboration between families and the school community. When planned in partnership with the school community, interventions to support mental health in students can be impactful. Not only did this project improve the overall mental health literacy on campus and increase access to and use of local and national resources, but it also mobilized the school to maximize their use of internal resources to create and foster both mental health prevention strategies and additional support measures to assist students that may be struggling. The results of this project proved that translating this evidence-based research into practice and implementing a mental health education and sustainment program in vulnerable school settings can fill knowledge gaps and sustain awareness on campus.
Kate Wachutka: Conceptualization; Formal analysis; Investigation; Methodology; Project administration; Supervision; Writing – original draft; Writing – review & editing. Mercedes Echevarria: Conceptualization; Formal analysis; Supervision; Writing – review & editing. Jennifer Walsh: Conceptualization; Supervision; Writing – review & editing.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Kate Wachutka https://orcid.org/0000-0003-2046-3590
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Kate Wachutka, DNP, APRN-RX, FNP-C, Assistant Professor at Colorado State University (Pueblo), is a Family Nurse Practitioner with 18 years of experience in nursing. She holds a DNP from The George Washington University. She is board certified by the American Academy of Nurse Practitioners and is involved in various professional organizations, to include the American Association of Nurse Practitioners, Sigma Theta Tau International Honor Society of Nursing, and the National Organization of Nurse Practitioner Faculties (NONPF). In addition to her faculty role, she continues to practice as a Family Nurse Practitioner. She concentrates on enhancing family practice outcomes through practice, education, implementing evidence based practice, and research.
Mercedes Echevarria is an Associate Professor at George Washington University School of Nursing. Her research and clinical interests include the improvement of health outcomes with an emphasis on the pediatric population, childhood developmental surveillance and screening, childhood obesity, and advanced nursing practice. She is board certified as an Adult Nurse Practitioner and a Family Nurse Practitioner by the American Academy of Nurse Practitioners and as a Pediatric Nurse Practitioner by the Pediatric Nursing Certification Board. She has sustained an active practice as a Nurse Practitioner while maintaining full-time faculty and administrative responsibilities at the School of Nursing and presently remains active in the clinical setting through her work as an Advanced Practice Nurse at a FQHC in New Jersey. She has served on several boards including a two-year commitment as a Board Member at Large for the National Organization of Nurse Practitioner Faculties (NONPF) and as a member of the Rutgers Health Group. Her DNP scholarly project “Health Promotion in School-Aged Hispanic Children through a Culturally Competent Nutrition and Exercise Family-School Program” grew out of her dedication to the improvement of health outcomes and population health. Participation in this community-based program prompted caregivers to engage in healthier nutrition practices and increase physical activity; it also led to weight reductions for caregivers, improvement in body mass index (BMI) among children, and improvement in blood pressure. She has conducted research and has published on mental health issues within primary care and pediatric specific topics including developmental screening and surveillance and recognizing delirium. She was instrumental in the design, development, and launch of the post-Baccalaureate to DNP Nurse Practitioner pathway and the redesign of DNP scholarly projects at GWSON and has served as primary or secondary advisor on thirty-two DNP student scholarly projects.
Jennifer Walsh, DNP, CPNP-PC, CNE, Assistant Professor, is a pediatric nurse practitioner and nurse educator with over 28 years of experience. She holds a DNP from George Washington University and an MSN from The Catholic University of America, with additional training in pediatric mental health care. She is board-certified by the PNCB and NLN and actively involved in numerous professional organizations, including her role as President-Elect of the Virginia National Association of Pediatric Nurse Practitioners (NAPNAP). A 2019 DAISY Faculty Award recipient and 2024 NurseTRUST Fellow, she focuses on improving pediatric outcomes through teaching, research, advocacy, and leadership.
1 School of Nursing, The George Washington University, Washington, DC, USA
Corresponding Author: Kate Wachutka, School of Nursing, The George Washington University, 2121 I St NW, Washington, DC 20052, USA. Email: kwachutka27@gwu.edu
