School Nurses' Experiences in Dealing with Adolescents Having Mental Health Problems.

Introduction: An increased number of adolescents experience mental health problems. School nurses have described spending more than 50% of their time working with mental health in students. The lack of knowledge and necessary training to meet students' mental health needs has been described previously. School nurses have a responsibility to find and guide those who need help with mental health problems.
Objectives: The aim of this study was, therefore, to explore school nurses' experiences with mental health and how they in this work identify, talk, and intervene with adolescents having mental health problems.
Methods: A qualitative study was conducted with 21 school nurses using focus group interviews which were analyzed by means of content analysis.
Results: Three descriptive categories emerged: Health-promoting or preventive approaches, Enabling students to talk about feelings, and Collaborating partners.
Conclusion: School nurses highlight their mandate to work with health promotion and prevention but also draw attention to their difficulties in identifying those who need help. School nurses use their creativity, intuition, and knowledge but have difficulty identifying those students who need help with mental health problems. They also highlight collaboration with other professionals both in schools and in the health system.

Background

School health services play an essential role in students’ healthcare by promoting health, preventing health problems, and addressing diverse health issues (American Nurses Association & National Association of School Nurses, 2015; Blackborow et al., 2014). Health promotion includes universal focus like providing a supportive environment and individual focus like opportunities to make healthy choices (World Health Organization, 2020). Furthermore, a preventive focus may avert the onset of a diagnosable mental health condition (World Health Organization, 2020). School nurses in Norway are registered nurses with a one-year postgraduate education in public health nursing (Ministry of Health and Care Services, 2003). In Norway, every municipality is obliged to have a school health service to take care of the health of school-aged children and young people stated in the Act of Public Health from 2012. The service is funded by the municipality. The school nurses have responsibility for children of all ages, adolescents, and families (Norwegian Parliament, 2011). School nurses also have the responsibility to reveal early signals of dissatisfaction and abnormality related to physical and mental health (Norwegian Directorate of Health, 2017). Mental health problems among adolescents have increased worldwide (World Health Organization, 2022). In Norway, approximately 10–20% of the adolescent population experience mental problems (Bakken, 2020). Results in 2021 describe the situation among adolescents as approximately the same as in previous years, except for girls, reporting more mental health problems (Bakken, 2021). Mental health problems are defined as having symptoms such as depression and anxiety, eating disorders, conduct disorders, attention-deficit/hyperactivity disorder, and self-harming behaviors (Bakken, 2020). Mental health problems not meeting the criteria for a mental health disorder are described as the feeling that everything is an effort, difficulties in falling asleep or staying asleep, feeling blue, feeling tense, feeling worried, and worried about the future (Bakken, 2021).

School nurses are in a position to meet all students and work with mental health within the frame of health promotion and prevention (Granrud, Anderzen-Carlsson, et al., 2019a, 2019b). The school nurse carries out individual health visits and works with groups of students. In addition, students are welcome to visit the school nurse either spontaneously or for a scheduled visit (Ekornes, 2020; Holm et al., 2016). This open-door policy is previously described as important when reaching out to boys (Granrud et al., 2020). The recommended norm per full-time school nurse position is 300 students in primary schools, 550 in lower secondary schools, and 800 in upper secondary schools (Norwegian Directory of Health, 2016). The norm is not fulfilled in all municipalities (Norwegian Directory of Health, 2016). Current regulations require a school nurse to have routines for cooperation with general practitioners (GPs), school personnel, pedagogic psychological services, and specialist health services (Ministry of Health and Care Services, 2003).

Review of Literature

Reuterswärd and Hylander (2017) have described school nurses’ uncertainty about how different professionals in schools collaborate in a team. Granrud et al. (2019a) describe the school nurses’ collaboration with staff in schools as a collaboration with difficulties, stating that school nurses have to make their competence more visible. The school nurses’ collaboration with other personnel in school was considered meaningful, comprehensible, and manageable if professional roles on the team were clearly communicated (Reuterswärd & Hylander, 2017).

Although mental health and mental health problems are one of many subjects in school nurse education, this is not a key subject (Ministry of Health and Care Services, 2003). Reports from both Finland and Norway indicate that school nurses lack the necessary training and knowledge to meet adolescents’ mental health needs (Putkuri et al., 2021; Skundberg-Kletthagen & Moen, 2017). They have stated that they spend more than 50% of their time working with students having emotional or mental health problems (Moen & Skundberg-Kletthagen, 2017). Furthermore, school nurses described having responsibility for students with mental health problems who actually needed help from other health professionals (Glavin & Erdal, 2018; Moen & Skundberg-Kletthagen, 2017).

School nurses seldom work full-time in the same school (Granrud et al., 2019a; Waldum-Grevbo & Haugland, 2015), and adolescents describe school nurses as being inaccessible (Steffenak et al., 2015). Students ask for the presence and availability of school nurses as they experience that their needs are not met (Granrud et al., 2019b). Nevertheless, students having mental health problems use the school health service only to a small extent (Moen & Hall-Lord, 2018). They may have limited knowledge of available resources (Skundberg-Kletthagen & Moen, 2017), and stigma-related factors may prevent them from seeking help for mental health problems (Tharaldsen et al., 2017). Adolescents who had used the school health service once were also likely to use the service more than others (Moen & Hall-Lord, 2018). There are gaps in knowledge in descriptions of how the school nurses identify adolescents having mental health problems and what action they take. The aim of this study was to explore school nurses’ experiences of their work with mental health and how they in this work identify, talk and intervene with adolescents having mental health problems.

Methods

Design

The study used a qualitative descriptive inductive design to gain a deeper understanding and investigate the school nurses’ experiences (Elo & Kyngas, 2008).

Research Recruitment and Sample

The managers of school nurses in four Norwegian municipalities were asked to supply information on the study to school nurses in their districts. School nurses (n = 21) who wanted to participate contacted the researcher and consented to participate (Table 1).

Table 1.

Description of Participants.

Participants (n = 21)	Mean	Range
Age	48	30–61
Work experience as school nurse	13 years	2–30
Education as school nurse	n = 21
Other further education related to mental health	n = 11
Job extent (%)	64	10 − 100
Schools in their responsibility	1	1 − 3
How many students in their responsibility	535	80 − 1050
Extent of time used with pupils having emotional or psychological problems (%)	66	20 − 90

The school nurses differed in age (from 30 to 61 years) and length of job experience as a school nurse (newly graduated to 30 years). Fourteen had more than one degree in postgraduate education, and eleven in mental health and child development. They were all women, mirroring the gender distribution of school nurses working at schools in Norway with students aged from six to nineteen years old. The municipalities where they worked were rural or urban and varied in terms of geographical extent. The schools were all public schools with both girls and boys as students, primary schools, lower secondary schools, and upper secondary school, mirroring schools in Norway. The number of students at the participants’ schools also differed.

Data Collection

Focus group interviews were conducted, by the last author, at the school nurses’ workplace with three groups with six participants and one group with three participants (n = 21). Focus groups were used because the discussion between the participants can provide rich and various data (Jayasekara, 2012). The participants were informed that the interview would take the form of a dialog with open questions and reflections. The initial question was: “Can you describe your work with mental health promotion and prevention, and how do you identify and work with students having mental health problems?”

Follow-up questions such as: “Will you, please explain…?” “Will you please tell us more…?” and “Is it always like this?”. The interviews lasted a median time of 54 min, ranging from 45 to 59 min. The interview guide was pilot tested prior to the interviews with school nurses not participating in the study working in another municipality, and no adjustments were required.

Data Analysis

The interviews were audio-recorded, transcribed verbatim, and all the data were analyzed as a whole (Elo & Kyngas, 2008). The analysis was performed as content analysis with an inductive approach, by the first author with the last author carefully followed-up the whole analysis process and categorization, in line with the four phases described by Elo and Kyngas (2008). The processing phase entailed selecting meaning units. The organizing phase involved open coding, a coding structure, grouping, and categorization. The meaning units were coded to describe the content of the meaning units, and codes with corresponding content were grouped into sub-categories and generic categories. The manifest content was discussed several times between the two authors, and it was agreed that each generic category was unique and did not represent the same content. Analytic closure was reached when nothing new emerged from further reading and rereading of transcripts and condensations. The three generic categories have associated sub-categories. The analysis was discussed by the two authors. The checklist Consolidated Criteria for Reporting Qualitative Research (COREQ) was used (Tong et al., 2007).

Ethical Considerations

The study was approved by the Norwegian Centre for Research Data, reference number: 144640. Ethical considerations were applied with regard to the confidentiality, integrity, and voluntariness of the participants (World Medical Association, 2008). The school nurses received verbal and written information and gave their written informed consent. During the transcription, the participants were deidentified and data were stored at a server at the university with an access code. Data that could identify the participants were stored separately from the interview data.

The results are presented with three generic categories with associated sub-categories describing how the school nurses work with mental health in schools: Health-promoting or preventive approaches, Enabling students to talk about feelings and Collaborating partners (Table 2).

Table 2.

Results.

Generic categories	Health-promoting or preventive approaches	Enabling students to talk about feelings	Collaborating partners
Subcategories	Groups with a focus on mental health promotion	Being in a position to meet everyone	Availability
	The use of gut feeling and experience	Alliance building in being a supportive adult	Due to confidentiality
		The building of a language for feelings	The involvement of parents

Health-Promoting or Preventive Approaches

The school nurses primarily wanted to work on mental health promotion, and they pointed out the differences and opportunities that existed when working with students in groups as opposed to individually more associated with prevention.

Groups with a focus on mental health promotion focus on mental health as a part of everybody's health and is a useful topic to discuss in groups or classes. The nurses described organized programs for group activities such as “Girls talk” or “Fuel box.” In these groups, the school nurse focuses on mental health promotion and prevention, what is good mental health and how adolescents build their self-esteem and mental health. The prevention of bullying is also highlighted and there is a focus on networks and friendship. As one expressed: “I spend time on the preventive part of bullying. With the use of video, we can focus on what that means to a person. How can the students describe and see that a person is sad, or what does the person express in body language and how would you feel in the same situation?”

Some used target groups such as “Divorce groups” or “Sorrow groups” with a focus on how to cope with these situations and on encouraging students to talk together about their thoughts and feelings. The use of group or class activities was described as an opportunity to get in touch with those who have mental health problem, but the students must dare to talk about it in the group or talk with the school nurse after the session.

The use of gut feeling and experience describes how the school nurses met students’ mental health issues. The school nurse's role is difficult to define in the mental health work in schools, they are supposed to work with prevention and health promotion. But a question that arises is whether the screening of every student solves mental health problems or whether the focus should be on general health promotion and prevention. They did not wish to be the ones looking for difficulties but to be part of a low-threshold service offered to students so they can come and talk. The school nurses claimed that the “health conversation” they have with every student in eighth grade constituted a kind of screening. They realized that students having mental health problems were their responsibility, but how long and to what extent should they have this responsibility of their own? Some had a limit of five conversations, others described that they relied on their gut feeling in finding those who needed further follow-up. The importance of gut feeling was described as follows: “The more knowledge and experience I have, the more intuition I acquire. The justification and course of action are built on my knowledge, and this makes me the professional person I am.” These competencies were described as based on knowledge and experience. The use of experience and gut feeling was described as a way of sensing who needed more help than the school nurses could give. As one described: “You can feel it as they enter the room, the air gets thick and heavy to breathe in.” Those who were new in their job asked for assessment tools while those with a postgraduate education in mental health did not need this in their encounters with adolescents.

The school nurses ask for more knowledge of the etiology and symptoms of mental health problems, as these topics have not been highlighted in their education or in courses after their graduation. The use of assessment tools is described as helpful in meetings with adolescents where the school nurse does not see any positive progress, and those with experience see that they cannot handle the situation by themselves. But there is no standardization, and many assessment tools are described as questions handled over by a psychologist at Child and Adolescent Psychiatry clinic or questions from Beck’s Depression Inventory (BDI). As one said: “Maybe a suitable assessment tool may improve the quality of the service and make the service more standardized.” However, these were described as unsuited to the work of school nurses since they are designed for psychologists or other specialists, not nurses. As one said: “Sometimes I have used BDI and it's not really made for our use, because we are not in psychiatry. We do it to get a little clue about how bad it is and then refer to the GP.”

However, when using an assessment tool in the conversations, the school nurses said they can use the scores to look for changes in the students and use it in the reference to the GP or the Child and Adolescent Psychiatry clinic.

Enabling Students to Talk About Feelings

The school nurses highlighted their unique position in being able to meet every student and enabling students to talk about their feelings. But they also questioned their ability to identify those who really needed someone to talk to or who needed appropriate help from other professionals.

Being in a position to meet everyone describes the unique opportunity the school nurse has to invite all students to a conversation as a part of a health appointment. “I don't think I would have found those who really need follow-up without seeing them all.” After the first talk, the students got to know the school nurse and knew where to turn to talk about difficult matters. “We do not really know who needs to have someone they trust to talk to. When you first know them, it's easier to take them into your office when they’re standing crying in the hall.”

Alliance building in being a supportive adult is described as the main component of the school nurses’ work. Alliance building may take some time and needs time to mature, involving the students trusting the school nurse, and the school nurse being predictable, flexible, and creative. When the alliance was strong enough and students felt that they were seen and taken seriously, they could talk about difficult matters.

Some students were described as open-minded and could easily talk about their feelings and inner thoughts. In individual conversations, the way school nurses were seated, not looking directly at the student, could help to open up the conversation. Conversely, other students were more silent, and the school nurse needed some physical objects to get the conversation going in the right direction. The school nurses used their creativity to create a setting in which students were able to talk about feelings. “I have a holder with napkins, so the student can pick a napkin and fiddle with it, and then they may be able to talk.” In addition, the school nurses said that they might pick questions from a screening assessment tool or use some questions from games or cards describing different emotions as examples to start the conversations and a tool to lead the way in the conversations. The use of drawings was useful for some of the students, while others preferred the use of pictures made by others to visualize their feelings. A “spider's nest” showing the student's social relationships could be used and the student asked to talk about their position in the spider's nest. Others requested courses in how to make good conversation with students and wanted suggestions as to appropriate conversation questions. They described the importance of being a good listener and daring to ask difficult questions without being rude or too direct.

The building of a language for feelings is based on two focuses: firstly, identifying and normalizing feelings, and secondly describing feelings. The school nurse may help the students to feel less shameful or worthless when struggling with difficult emotions by normalizing bad feelings and confirming that it is not unusual to feel sad and alone—everything is not necessarily attributable to anxiety and depression. Often the adolescent's feelings were most likely related to the shifting sides of life like “having a broken heart” or performance anxiety. The school nurses used metaphors like: “having the bastard on my back” or “walking up and down stairs, reflecting the shifts in mood and life itself,” to encourage adolescents to share their feelings. The youngest students in particular may not have a language or experiences to convey these difficult emotions and using metaphors was described as a way of helping them to develop their ability to speak about emotions. The school nurses stated that many students felt surprised at having so many different feelings and hearing that this was normal. Inviting them to talk about it may ease their pain and let them see that having difficult feelings, thoughts, and shifting moods is a part of life itself and a part of an adolescent's development phase. The participants wanted to emphasize that the “Instagram life” did not necessarily reflect real life. They also focused on the importance of confronting difficult thoughts and acknowledging that we have different levels of tolerance and ability. As one participant said: “The adolescents may articulate difficult feelings, such as being angry or outspoken in relation to others, through their behavior.”

One way of helping adolescents on an individual basis was to give them a home assignment on how to sort their thoughts and find out what the core problem was. This gave the adolescents a responsibility to reflect on their own life. In short, their own thoughts matter most. The school nurses were also clear that some adolescents had mental health problems they needed help to solve or live with, and this required help from other professionals. As one participant said: “Of course, some of our students have mental health problems. Our challenge is how to find those who need more help than we are presently giving them.”

The need for a second opinion from a specialist was highlighted as they felt they had weighty responsibilities. They agreed that they did not have the right competence or mandate to give treatment and follow-up to adolescents with mental health problems. They are obliged to identify those who need help from specialists, but they cannot refer every adolescent who comes to them with difficult feelings or thoughts.

Collaborating Partners

This is a generic category describing how the school nurses collaborated with different partners, for example, school personnel, GPs, specialist health services, or parents. They also described a lack of collaborative partners, and that collaboration was person dependent. One participant said: “The multidisciplinary collaboration is based on individuals, and some are easier to collaborate with than others.”

Availability describes the importance of having an open-door policy in reaching those suffering from mental health problems. “When they break down in tears, it's important to be available.” However, the school nurses said that they had so many tasks to deal with that the door was mainly closed. Many adolescents came to them in their open-door time with physical pain-related problems, especially boys, as a gate-opener to talk about their mental health. They highlighted the importance of making time in the schedule for open-door sessions when they were available just for a talk and could establish a relationship.

The teachers sometimes ask the school nurse to speak with students they do not know how to help or deal with. The school nurses had varying perceptions of this, as some asked why the teacher could not talk to the student themselves, whereas others found it a suitable way to get in touch with adolescents who needed someone to talk to, who was not their teacher or parent.

Due to confidentiality describes when the confidentiality requirements had to be discussed with the student or their parents. One participant stated: “When I clarify what I can tell others, I have seldom experienced that the adolescent or their parents do not want us to share.” Some school nurses had multidisciplinary collaboration teams where they could discuss cases anonymously and they highlighted the importance of having colleagues to discuss cases with. In small communities, maintaining the anonymity of the case may be hard and obtaining consent makes the job easier. One participant said: “I try to get the parents’ consent, and in this way, we can put the puzzle together with the professionals at school. We can then give appropriate help and follow-up.”

The involvement of parents were highlighted. The school nurses wanted to build good relations and to help the families in their relations. As one school nurse said: “I think occasionally it should be the parents, not the adolescent, who get guidance. The adolescent may carry the family's burden.” They also want to assist them in negotiating the health system since the school nurse may be the first professional they speak to about difficult matters. Cooperation with other professionals in the help system was described as making it easier for the school nurse to be a good guide for the families.

Discussion

In their work with mental health promotion and prevention, school nurses are in a unique position to meet almost every adolescent during their time at school. To identify those adolescents having mental health problems, the school nurses in this study used their creativity in interaction skills and professional experience to build an alliance for sharing difficult thoughts and feelings. They described how some adolescents also needed to build a language for sharing difficult feelings both within groups of students and individually before they could verbalize their mental health problems. Moreover, they described their work as a balancing act between mental health promotion, problem prevention, and treating mental illness. Identifying those in need of help was mostly based on intuition, gut feeling, and experience. There was a need for enhanced knowledge about mental health problems, etiology, and symptoms. School nurses can also guide adolescents in the chain of care in the healthcare system.

The school nurses had a clear focus on health promotion and prevention. National guidelines specify this as their main task, rather than treatment of mental health problems (Norwegian Directorate of Health, 2017). The school nurses in the present study argued that it was important to establish a relationship of trust with the adolescents and to invite them to talk about feelings, also discussed by Putkuri et al., 2021. On the other hand, they also questioned whether they were able to successfully identify students having mental health problems. Ellertsson et al. (2017) also questioned Swedish school nurses’ ability to identify students having mental health problems. There may be no adequate assessment tools to support them in their decision-making as the school nurses frequently used elements from games, questions from assessment tools, or visualization elements to get the adolescent to speak about feelings and difficult thoughts. There are a number of psychometric validated assessment instruments and questionnaires, and Kern et al. (2017) recommend the screening of every adolescent. The school nurses in the current study claimed that the screening of every adolescent using an assessment tool was not a part of their mandate for working in the field of health promotion and prevention.

In the current study, the decision on who needed more help from a specialist was based on intuition, gut feeling, and experience. The term “gut feeling” may fit the understanding of intuition developed by expert nurses described by Benner (1984). This may reflect the finding from the current study where the more experienced school nurses were more confident in their decision-making whereas the more inexperienced asked for assessment tools and knowledge on mental health problems and how to identify those who need follow-up. Moyes et al. (2022) describe students with mental health problems as wicked problem describing complex problems with multiple causes and giving no correct solutions. The Finnish study stated that good interaction skills are not enough in the work of school nurses with adolescents having mental health problems. School nurses need more competence in mental health (Putkuri et al., 2021). Vejzovic et al. (2022) asked for clearer guidelines outlining responsibilities to recognize mental illness in Sweden. The lack of knowledge has previously been explored and described both in Norway and Finland (Moen & Skundberg-Kletthagen, 2017; Putkuri et al., 2021; Skundberg-Kletthagen & Moen, 2017).

In the current study, the authors also found that a relationship of trust was a key factor in getting students to talk. This reflects the importance of the school nurses’ being available and having knowledge of how to help the adolescents to share their thoughts. Many adolescents came to them in their open-door time with physical pain-related problems as a gate-opener to talk about their mental health. Borgman et al. (2020) found a significant association between having pain and having depressive symptoms, meaning adolescents reporting pain may have other problems as well. The school nurses in the current study wanted to make a difference by showing how much they care about adolescents’ mental health and to be a supportive adult with an open-door policy, which is described by Granrud et al. (2020) as being an important way of reaching out to boys. The importance of the open-door policy was emphasized by the school nurses also in previous studies in Sweden and Norway (Morberg et al., 2012; Skundberg-Kletthagen & Moen, 2017). Adolescents with mental health problems are reported to use the school health service only to a small extent (Moen & Hall-Lord, 2018). Fargas-Malet and McSherry (2018) describe those adolescents in Northern Ireland having mental health problems do not seek help as they do not have a language for describing their difficulties. The school nurses described in this study the importance of training the adolescents in a language to speak about difficult feelings and thoughts and may be one of many prevent mental health problems or help them in the pathway in the help system (World Health Organization, 2020). Fostering positive peer relationships in group interventions may promote mental health for all adolescents (Butler et al., 2022).

Collaboration with teachers was described as important with teachers asking students, they wanted a second opinion to see the school nurse. Supportive teacher–student relationships may promote mental health (Butler et al., 2022), with the school nurse as a collaborative partner giving the teachers the possibility to ask the student, they worry about, to see the school nurse. Frauenholtz et al. (2017) claim that school staff have limited knowledge about children’s and adolescents’ mental health and thus do not recognize mental health problems in their students, a study conducted in the United States. Vejzovic et al. (2022) describe a lack of consensus between the school nurse and other professionals and teachers miss signs of mental health problems in students. Reuterswärd and Hylander (2017) describe school nurses’, in Sweden, uncertainty about how different professionals in schools collaborate in a team. The school nurses must define what their role is and describe this to their collaborative partners (Morberg et al., 2012). Clearer team meeting routines and clearer expectations and descriptions of the school nurses’ role may be a solution.

Confidentiality was highlighted and not seen as an obstacle and the school nurses described written consent from both the adolescents and their parents as an important way of achieving relationships of trust in collaborative work. However, Granrud et al. (2020) described boys questioning the school nurses’ confidentiality as some school nurses confided in other professionals. The use of anonymous discussions is described in the current study, but according to Granrud et al. (2020), this can be difficult in small communities in Norway where everybody knows all the students and can easily work out who they are talking about. School nurses in the current study underlined the use of permission to share their knowledge with collaborative partners, from the adolescent and his/her parents.

Personal relations and a relationship of trust were described as essential in collaboration in the current study. The individuality in collaboration has also been described in other studies (Moen et al., 2014; Reuterswärd & Hylander, 2017; Skundberg-Kletthagen & Moen, 2017), while the headmaster's leadership role is of equal importance in creating a collaborative climate in school (Reuterswärd & Hylander, 2017). School nurses do not work alone with adolescents—teachers, social workers at school, and the school nurse are perceived as resources in the promotion of adolescents’ mental health (Larsen et al., 2016; Morberg et al., 2012). They need a close collaboration with the parents, the school personnel, and other health professionals.

Strengths and Limitations

All the participants worked in schools as school nurses in both urban and rural schools. Their experience as school nurses varied in extent and years of practice, which gives variation in descriptions of the phenomenon (Elo et al., 2014). In this study there were 21 participants reflecting school nurses working in the field, giving a purposive sample (Elo et al., 2014).

The interviews were conducted in groups and the discussion provided rich and various data. Individual interviews cannot provide a variety of experiences between group members and then the reflections may be brought to a meta-level (Barnard et al., 1999). Group interviews may be limited due to one person acting as “the carrier of the truth” (Webb & Kevern, 2001). However, in the current study, the informants reflected together and became acquainted with their colleagues’ experiences of their role as a school nurse.

The credibility of the findings was also assessed using open-ended questions that enabled the school nurses to freely describe and discuss their experiences. Quotations were used to strengthen the confirmability (Sandelowski, 1986).

Throughout the entire analysis process, the authors reflected critically on the content of the experiences and the descriptive categories in terms of gaining trustworthiness (Sandelowski, 1986). The data were analyzed in line with inductive content analysis by (Elo & Kyngas, 2008) to help maintain auditability (Sandelowski, 1986). Additionally, an analysis form was used that made it possible for others to follow the analysis steps and to help ensure that the generic categories were mutually exclusive (Elo et al., 2014).

Conclusions and Clinical Implications

The school nurses work with mental health promotion and prevention and not necessarily treatment. Even so, the school nurses describe their work with individual students having mental health problems as containing elements of treatment. Some adolescents need someone to talk to in a short period of time, others need help from specialist health services. How to identify those who need help from others than the school nurse is questioned. The school nurses use their creativity, intuition, and knowledge but have difficulty identifying those students who need help with mental health problems from other professionals. Interaction skills and the use of suitable standardized assessment tools may help the school nurses in their decision-making if suitable assessment tools are available. School nurses need a close collaboration with the parents, the school personnel, and other health professionals. Collaboration with the personnel in schools needs to be more formalized.

Further Research

Further research is needed from projects with school nurses in which decision-making assessment tools and knowledge platforms are developed and used. Furthermore, the use of supervision groups to develop expert clinical judgment and knowledge exchange between newly graduated school nurses and experienced school nurses is another area that should be explored.