Mental Health
Elevating the Role of School Nurses in School-Based Mental and Behavioral Health Elevating the Role of School Nurses in School-Based Mental and Behavioral Health
A Consensus Document June 2023 |
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Introduction According to a recent report from the Centers for Disease Control and Prevention (CDC), the number of adolescents experiencing poor mental health is growing, especially among LGBTQ+, female, and Black students.i In 2021 alone, 70 percent of LGBTQ+ students reported persistent feelings of hopelessness, and 25 percent of female students had made a suicide plan.ii Youth who have mental health problems are more likely to experience violence, engage in risky behavior, and struggle with school. However, CDC notes that when youth have strong feelings of connectedness with school and family, those bonds can protect their mental health.iii Given the rise in poor mental health among students—and the role school connectedness plays in protecting mental health—it is critical that schools be equipped to provide a safe environment with mental health supports. To identify key priorities and opportunities in this area, we gathered evidence from the literature and interviewed school health care providers and experts in school-based health services. Ultimately, our goal was to help schools build strong connections with students and deliver school-based mental and behavioral health (SBMH) supports to meet the growing need for them. SBMH care teams manage mental and behavioral health supports in their schools, addressing student needs ranging from stress management, safety planning, and substance use to suicide prevention and coping skills.
Supporting Youth Mental and Behavioral Health in Schools Schools play a vital role in preventing mental health problems among youth, as well as in identifying and supporting youth who do have mental health problems. SBMH providers—including social workers, psychologists, counselors, and school nurses as specialized instructional support personnel —lead the way in helping schools fulfill this role. Multi-Tiered Systems of Support (MTSS) is a common framework used by SBMH providers to assist students and match them to appropriate supports. Another framework, Positive Behavioral Interventions and Supports, provides a similar tiered approach to organizing and delivering services. Regardless of the framework, many 
schools have launched a student mental health program, and research shows that these programs help students achieve academically and build social and leadership skills, self-awareness, and positive connections to adults in their school.iv Adolescents say they are more comfortable accessing health services through school-based clinicsv
The rising number of students who have mental health concerns means that schools must prioritize time and resources when considering a student mental health program. Whether schools are just beginning to develop such a program or are seeking to expand an existing one, the SBMH providers we interviewed identified several key areas that schools can focus on to better support students (Exhibit 1). 1  |
Elevating the Role of School Nurses in School-Based Mental and Behavioral Health
Exhibit 1. Priority areas for advancing SBMH programs for students
Increasing the capacity of school-based providers to address student needs Creating a school-and district-wide approach to student mental health Sustaining funding and covering the cost of services
Collecting and acting on student health data
How school nurses can support SBMH programs and teams
School nurses have tremendous potential to work with other SBMH providers to implement school mental health programs, yet they often don’t get the opportunity. Although individual school nurses and education systems have different levels of readiness or capacity to support SBMH programs, school nurses are most successful when the SBMH care team, principals, and superintendents engage with them and understand their role.
School nurses can build their SBMH team’s capacity to deploy a multitiered system of supports that is responsive to student needs. As members of interdisciplinary teams, school nurses can collaborate with school personnel—including teachers, psychologists, social workers, counselors, and principals—to assess, identify, conduct interventions for, refer, and follow up with children who need behavioral health services.vi, vii
School nurses are key members of SBMH care teams and support student mental and behavioral health by...
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Elevating the Role of School Nurses in School-Based Mental and Behavioral Health
They also have regular access to students in school clinics and are well-positioned to identify students with potential mental health concerns, especially for “frequent visitors”—children who often present with a physical complaint, such as an upset stomach, but could have an underlying mental health issue. This touch point can increase the speed at which problems are identified and treatment can begin.
School nurses promote health by helping students access physical, mental, and behavioral health care in school and in the community.viii These emerging practices can help policymakers, school administrators and teachers, and SBMH providers think about what school nurses can contribute to their own schools and how they can advance key SBMH priorities (Exhibit 2).
Exhibit 2. Additional opportunities for school nurses to support SBMH programs
• Educate and communicate with caregivers about mental health care and resources
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Support Individualized Education Program accommodations and implement Individualized Care Plans (such as Section 504 plans and safety plans)
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Coordinate care and make referrals to school- and community-based providers
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Participate in district and state Medicaid reimbursement efforts for nursing services for Medicaid-enrolled children
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Advocate for resources from state agencies and local education entities
• Advocate for and build connections with students
• Implement school-wide mental wellness and stress management programs for students and staff
• Contribute to crisis response planning and emergency preparedness
• Participate in universal and targeted mental health screenings and follow-up
• Collect and manage health data, includ- ing information related to attendance and social determinants of health
• Update and manage student records
Opportunities for advancing SBMH programs
The protective effects of school connectedness on youth mental health firmly place SBMH providers, school nurses, and other school personnel on the front lines of responding to the growing crisis.ix However, SBMH providers including school nurses require the broader support of federal and state policymakers, local educational entities, families, and communities to fully realize their opportunity to help students who have mental health problems and those at risk.
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Elevating the Role of School Nurses in School-Based Mental and Behavioral Health
The data we gathered from literature reviews and interviews highlight opportunities for state, regional, and community stakeholders to further embed school nurses into existing student support structures, amplify current efforts to address students’ mental and behavioral health needs, and improve systems of care. Exhibit 3 shows opportunities for administrators and policymakers to make substantive changes at the state and regional levels, as well as actions providers and educators at the local and community level can take to support student mental health. We acknowledge that each school nurse and education system might have different level of readiness or capacity to support mental and behavioral health. Nevertheless, adopting some or all the following recommendations can increase system-wide capacity and create a more capable, integrated, holistic, and interconnected system of care.
Exhibit 3. Considerations for leaders in health and education fields
For administrators and policymakers
Federal and state
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Include school nurses and state school nurse consultants as state-level health policy advisors for SBMH
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Expand access to Medicaid school-based services to build a sustainable funding stream
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Direct federal and state grants to increase the workforce of school nurses and SBMH providers
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Create data-sharing agreements with providers and medical systems to facilitate care coordination in schools and with community providers
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Update policy and guidance documents to clearly define that school nurses have the licensure and credentials to support SBMH programs
For providers and educators
School
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Involve school nurses in care-planning meetings to boost the capacity of SBMH providers and staff
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Designate school nurses as leaders for identifying students at risk for mental health problems and referring them to the SBMH team
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Involve school nurses in care coordination, case management, service documentation, and billing for the entire SBMH care team
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Invite school nurses to speak in classrooms,
at back-to-school nights, and at school–family engagements to educate families about student mental health risks and in-school supports
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Regional, district, and school
• Update guidance to explicitly name the school nurse as a key provider and member of SBMH teams
• Designate school nurses as leaders for administering school- and district-wide mental health screening
• Provide tools for school nurses and SBMH providers to document Medicaid services for federal reimbursement
• Provide professional development opportunities for school nurses and other school staff to develop a shared approach to student mental health
Community
• Connect community mental health programs to after-school programs to bolster student supports
• Invite school nurses to local board of health meetings and share school health data
• Integrate school nurses and SBMH teams into community mental health advisory boards to highlight student mental health needs
• Share information on community-based mental health services and educational resources with school nurses and SBMH providers
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Elevating the Role of School Nurses in School-Based Mental and Behavioral Health
Methods and Approach
We completed a literature scan to identify (1) current SBMH models and (2) descriptions of the school nurse’s role in supporting student behavioral and mental health. We analyzed data for common themes, existing programs, opportunities, and challenges to integrating school nurses into SBMH teams.
We held two meetings to discuss the role of school nurses in SBMH care teams and opportunities for further support and integration. The first meeting included school nurses in K–12 schools and school nurse leaders from regional and state-level educational entities. The second meeting involved leaders from national organizations with a vested interest in K–12 mental and behavioral health, including alliances, associations, and councils representing stakeholders from health- and education-based organizations. We analyzed data from these meetings to identify opportunities at the system, community, and school levels to strengthen how school nurses work with other providers to support students’ mental and behavioral health, with an eye toward further integrating school nurses in existing structures.
Note: In this document, the terms mental health and mental and behavioral health are used interchangeably to refer to the supports that school nurses provide in mental health and behavioral health, including substance use.
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Elevating the Role of School Nurses in School-Based Mental and Behavioral Health
Acknowledgments
NASN contracted with Mathematica to engage school nurses and other valuable partners in discussions on enabling school nurses to help provide SBMH supports. The following individuals participated in these discussions and contributed to the content of this consensus document. They shared their lived experiences supporting student mental health and identified policy and structural opportunities to further integrate school nurses into SBMH delivery models.
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Thank you to our school nurse participants |
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State |
Participant |
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Thank you to our participants from national organizations |
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Organization |
Participant |
Alaska
California
Colorado
Connecticut
DC
Florida
Hawaii
Kansas
Maine
Minnesota
New Jersey
Nevada
Ohio
Pennsylvania
Virginia
Washington
Wisconsin
Wendy DeGraffenried, BSN, R.N, NCSN, HN-BC
Dawn Anderson, MA, BSN, RN, PHN and Katie Nilsson, MSN, RN, PHN, CPN, RCSN
Stephanie Faren, MSN, MPH, RN, NCSN; Kelli Mueller, MS, BSN, RN, NCSN
Mary Emerling, RN, MPA
Elizabeth McDermott, BA, BSN, RN, NCSN
Amy Ponce, MSN, RN
Abbie Neves, PhD, APRN-Rx, PMHCNS- BC; Bobbie Jo Beyerle, MSN, APRN-Rx, NP-C; Jamie Boling, MPH, MSN, APRN- Rx, FNP-BC, PMHNP-BC; and Deborah Mattheus, PhD, APRN-Rx, CPNP, FAAN
Paula K Bunde, MS Ed, BSN, RN
Pat Endsley, PhD, MSN, RN, NCSN and Tammy Diaz, MPH, RN, NCSN
Magen Borkenhagen, BSN, RN, PHN, LSN and Denise Herrmann, DNP, RN, CPNP, FNASN
Sheila Caldwell, , BSN, RN, CSN-NJ, FNASN
Breana Taylor, RN, MSN
Ann Connely, MSN, RN, LSN, NCSN and Jean McGraw, RN, BSN
Rebecca Kilfoy, MSN, ACNP, NCSN and Jennifer McCulloch, M.Ed, BSN, RN, CSN
Angela Knupp BSN, RN; Karen Mask, RN, BSN, MPH; Rachell Myhr, RN; Joanna Pitts, BSN, RN, NCSN, CNOR; and Heather Shea Pugh, BSN, RN
Annie Hetzel, MSN, RN, NCSN ; Tessa McIlraith, MS, BSN, RN; and Lynn Nelson, MSN, RN, NCSN
Louise Wilson, MS, BSN, RN, LSN, NCSN
American Academy of Pediatrics
American Federation of Teachers
The JED Foundation
Kaiser Permanente
Mental Health America
Mental Health School Professional Grant Program
National Alliance for Medicaid in Education
National Association of Elementary School Principals
National Asssociation of School Psychologists (NASP)
National Association of School Psychologists (NASP)
National Association of Secondary School Principals (NASSP)
National Center for School Mental Health
National Education Assoc.
National Parent Teacher Association
School Social Work Association of America
School-Based Health Alliance (SBHA)
State of New Mexico
The School Superintendents Association (AASA)
Sonya O'Leary, MD, FAAP, American Academy of Pediatrics Council on School Health
Chelsea Prax, MHP, CHP, Assistant Director, Children’s Health & Well-Being
Katherine Duncan, MBA, Senior Director, Strategic Partnerships
Niti Kadakia, MBA, Director, Student Behavioral Health
EmSkehill, BS, Director of Public Awareness and Education
Tawanda Avery, M.Ed.-SPED, ProgramLead
Jenny Milward, Ed.D, Executive Director
David Griffith, M.Ed., Associate Executive Director, Policy and Advocacy
Nick Affrunti, PhD, Director of Research
Kathleen Minke, PhD, NCSP, ExecutiveDirector
Ronn Nozoe, M.Ed., CEO, Chief ExecutiveOfficer
Jill Haak Bohnenkamp, PhD, Assistant Professor
Karuna Antani, MPH, Senior Health & Safety Specialist
Emily Smith, LICSW, Manager, Programs & Strategic Initiatives
Maria Badillo Diaz, DSW, LCSW, Adjunct Professor, Board Member
Robert Boyd, MCRP, Mdiv, President and CEO; Andrea Shore, MPH, CPO; and Katy Stinchfield, MS, LPC, Director of Behavioral Health Programs
Susan Acosta, BS, RN, NM State SN Consultant
Kayla Jackson, MPA, Project Director
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Elevating the Role of School Nurses in School-Based Mental and Behavioral Health
This publication is supported by the Centers for Disease Control and Prevention (CDC) of the U.S. Department of Health and Human Services (HHS) as part of as part of a financial assistance award No. 47QFSA21F0044-G2S008, totaling $200,000 with 100 percent funded by CDC/HHS. The contents are those of the authors and do not necessarily represent the official view of, nor an endorsement by, CDC/HHS, or the U.S. Government.
Endnotes
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i CDC. (2023). Youth Risk Behavior Survey: Data Summary & Trends Report 2011–2021,https://www.cdc.gov/healthyyouth/data/yrbs/pdf/YRBS_Data-Summary-Trends_Report2023_508.pdf.
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ii Ibid
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iii Ibid
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iv Youth.gov. (n.d.). “School-Based Mental Health.” https://youth.gov/youth-topics/youth-mental-health/ school-based.
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v Ibid
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vi Reaves, Samantha, et al. “Associations between School Mental Health Team Membership and Impact on Service Provision.” School Mental Health, vol. 14, no. 3, 2022, pp. 672–684., https://doi.org/10.1007/s12310-021-09493-z.
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vii SAMHSA and CMS. Guidance to States and School Systems on Addressing Mental Health and Substance Use Issues in Schools | SAMHSA Publications and Digital Products, 1 July 2019, https://store.samhsa.gov/product/guidance-states- and-school-systems-addressing-mental-health-and-substance-use-issues.
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viii Hoskote, A.R., Croce, E., & Johnson, K.E. (2023). “The evolution of the role of U.S. school nurses in adolescent mental health at the individual, community, and systems level: An integrative review.” The Journal of School Nursing, 39(1), 51-71. doi: 10.1177/10598405211068120 https://doi.org/10.1177/10598405211068120.
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ix CDC. (2022). Toolkit for Schools: Engaging Parents to Support Student Mental Health and Emotional Well-Being.https://www.cdc.gov/healthyschools/connectedness/connectedness_toolkit.htm.