To Address the Mental Health Crisis, Look to School Nurses

Students in Winnetka, Ill., are checked by a nurses as shown here on return to school following illness. 1947. Credit - Bettmann Archive/Getty Images

It’s a deadly time to be a teenager. The most recent CDC Youth Risk Behavior Survey reports that in 2021, more than one-fifth of high schoolers seriously considered committing suicide. Worse, 10% tried. Even without pandemic data, rates of youth depression almost doubled over the past decade, making youth mental health a current top priority for the U.S. Surgeon General.

There are already people on the front lines to combat this teen mental health crisis: school nurses, the trusted healthcare professionals who provide holistic care for every student’s physical and mental wellbeing. But because our culture routinely separates mental health from physical health care, school nurses are commonly overlooked when funding is recommended to increase school behavioral health staff. Additionally, since school nurse positions are rarely protected by mandates, their services are too often the first to be cut when trimming education budgets. And yet, history shows that school absenteeism declines, and the collective health of our nation improves, when schools employ nurses. That remains true as we ask questions about how to address the mental health crisis youth face today.

The position of school nurse was created at the turn of the 20th century. The idea was that nurses placed in primary schools could help treat and prevent communicable diseases so that children could stay in school and receive an education. In 1902, pediatric nurse Lina Rogers became New York’s—and our nation’s—first school nurse. Funded by the Henry Street Settlement, Rogers set up clinics in four schools to care for the district’s students, all of whom lived in poverty with their families in the tenements of Manhattan’s Lower East Side.

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Drawn there by the promise of opportunity, large numbers of immigrants faced health and hygiene challenges in this densely populated area. Living conditions were overcrowded, unsanitary, and full of contagious diseases, which children then spread throughout classrooms. Before school nursing, instead of being treated, sick children were simply excluded from school. And since most parents couldn’t afford or couldn't access care, many students never returned.

Rogers’ impact was immediate. By the end of her first month, Rogers treated 829 cases, including 93 excluded students who were then able to return to school. The results were so impressive that the New York Board of Health immediately funded 12 more school nurses, each responsible for approximately 10,000 students. Between September 1902 and 1903, the combined work of these school nurses caused the number of students missing school for medical reasons to plummet from 10,567 students to 1,101. Over the next five years, health officials in other major cities, including Los Angeles, Philadelphia, Baltimore, San Francisco, and Chicago, followed suit.

During the next few decades, the school nurse model was replicated throughout the country. By 1911, over 100 cities employed school nurses. Historical databases highlight the positive influence of school nursing during the 1918 influenza pandemic as far reaching as Wisconsin, Minnesota, and North Dakota. By the years after World War II, healthcare delivery was shifting from home-based to hospital. This, combined with the discovery of multiple classes of antibiotics to treat bacterial infections, shifted the school nurse role to focus more on health education over treatment, with emphasis on cleanliness, good nutrition, dental care, and sleep—the beginnings of the Coordinated School Health Program model used today.

Then came widespread vaccination thanks to the 1962 Vaccination Assistance Act, which led to the practical eradication of diphtheria, tetanus, pertussis, polio, smallpox, and measles. By 1980, every U.S. state required children to be vaccinated to enroll in school. Through the use of state registries to maintain records, facilitate vaccine compliance, and identify at-risk unvaccinated students during disease outbreaks, school nurses were and are at the very heart of this progress in communicable disease prevention.

Legal changes also affected the relationship between school nursing and youth wellness. The passage of The Rehabilitation Act of 1973 and The Education for all Handicapped Children Act of 1975 helped clarify that all students were entitled to and worthy of a public education. Disabled children were mainstreamed into traditional school systems with individual health plans (IHPs), student-specific plans of care created by the school nurse. While IHPs made the school nurse role more personalized, they also made nursing services less visible, as most of the individualized care became clinic based, hidden from school administrators and any parent whose child didn’t have an IHP. “Parents whose children benefit from daily school nursing—like those with diabetes and asthma—know it’s school nurses who enable their children to remain in school and focus on learning,” explained Suzanne Winefordner, RN, a Virginia-based school nurse.

This hidden healthcare put nursing positions on the chopping block during education budget cuts—despite the fact that 40% of school-aged children have a chronic health condition—resulting in widespread school nurse disparities throughout the country. Rural communities remain disproportionately affected with only 56.2% employing a full-time school nurse compared to 70.3% of their urban counterparts.

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The COVID-19 pandemic elucidated these gaps when school nurses were brought to the forefront of this public health emergency. For schools lucky enough to have a nurse, these RNs were heralded as key players in stopping the virus’s spread in schools and communities, reminding society that they stand ready to battle widespread disease. But, assisting with mitigating the risk of medical contagions is only one aspect of the school nurse role in population health. RNs also have the skills to address the mental health crisis.

“Too often, schools silo student mental health to the counselor,” says Yale professor Joanne Iennaco, a psychiatric nurse practitioner with a Ph.D. in chronic disease epidemiology. “Instead, the school nurse must be considered an integral member of a school’s behavioral health care team.

The skyrocketing rates of adolescent depression disproportionately affect girls, LGBTQ youth, and Black teens. As experts debate what to do, from limiting social media and smartphone usage to reducing stress, adolescent mental health continues to suffer. “Depression is treatable, especially when caught early,” Dr. Iennaco explains. And since 50% of mental illnesses begin by age 14, “this high-risk zone for developing psychiatric illness is where a professional school nurse can make all the difference with early assessment and care coordination.”

With over 22% of youth in the U.S. meeting criteria for a mental disorder with severe impairment across a lifetime, school nurses like Winefordner are doing this work already. “Students often start with me,” she reflects, “because there isn’t any stigma associated with visiting the school nurse. Plus, I usually have a previously established relationship with them, so they feel comfortable with me as a trusted adult.”

Winefordner’s experience aligns with the National Association of School Nurses Position Statement on student behavioral health: “school nurses are often the initial access point to identify concerns, determine interventions, and link families to school and/or community resources.”

The U.S. Surgeon General’s Advisory Report recommends the expansion of school-based mental health workforce through federal funds to increase staff, including nurses. Full-time nurses currently cover only 65.7% of public schools. Passing the One School, One Nurse Act, a bill that would provide every public school in America with a full-time RN, would be a cost-effective, equitable, and efficient way to shore up the remaining front line. When school nurses have proven themselves time and time again as integral to combating public health emergencies, why turn away from them now? School nurses are the "vaccine" needed to target the youth mental health crisis, and every student deserves access to one.

Sherrie Page Guyer, MSN, RN, a former school nurse, holds a master’s degree in mental health nursing from Yale University and is currently enrolled in the doctor of nursing practice program at the University of Virginia School of Nursing.

Made by History takes readers beyond the headlines with articles written and edited by professional historians. Learn more about Made by History at TIME here. Opinions expressed do not necessarily reflect the views of TIME editors.

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