School Nurses: The Unsung Heroes of Student Well-being
"A Realist Evaluation Reveals How School Nurse Programs Can Better Support Children's Health"
School nurses play a vital role in supporting the health and well-being of school-aged children, acting as a crucial link between healthcare and education. Historically, their focus was on communicable diseases and basic health needs, but the role is rapidly evolving to address a wider range of physical, mental, and social challenges students face today. With an increasing number of students entering schools with complex health needs, it's more important than ever to understand how school nurse programs can effectively support these young people.
Recognizing the need for a more focused and efficient approach, Scotland's Chief Nursing Officer (CNO) recommended a reorganization of the school nurse role in 2013. This refocused program emphasizes nine care pathways designed to improve pupils' health and overall well-being. To understand the impact of this new program, a realist evaluation was conducted in two early adopter sites in Scotland. The goal was to assess how, for whom, and under what circumstances the program works, providing valuable insights for training and national implementation.
This article delves into the findings of that realist evaluation, exploring the contexts, mechanisms, and outcomes that influence the effectiveness of school nurse programs. By examining the experiences of school nurses, managers, and students, it uncovers the challenges and opportunities for optimizing these programs to better serve the health and well-being of school-aged children. Discover how streamlining referrals, standardizing services, and providing targeted training can empower school nurses to make a real difference in the lives of their students.
Measuring Student Well-Being
A 2025 Journal of School Health study reported that 76% of school nurse respondents felt responsible for identifying depression. The same study found that 40% reported their school had naloxone, 22% reported an emergency preparedness and response plan for opioid overdose, and 18% had screened for bullying in the past year. NASN's Every Student Counts! initiative encourages school nurses and districts to build health data capacity and use data to guide practice, while emphasizing that student well-being is connected to the broader school community.
Pathways and Limitations
The reviewed literature includes scoping and systematic reviews that examine well-being among student nurses and challenges in clinical learning. In school settings, nurses reported that the mental health and well-being pathway was sometimes used as a catch-all when an appropriate pathway was difficult to identify. A 2025 JAMA Health Forum article describes school nursing as increasingly focused on the relationship between student health, educational progress, and overall well-being, particularly for students who may otherwise have limited access to health care.
From Care to Community Wellness
A historical study examines the origins and evolving role of school nurses from New York City to rural Virginia counties between 1900 and 1925. School nurses traditionally cared for students experiencing illness or injury during the school day within the educational setting. Over time, the role shifted toward health education for students, staff, and the community, with stronger emphasis on nutrition and mental health, and school nurses became nationally recognized for contributing to students' health and well-being.
Key Findings: Enhancing Early Identification and Streamlining Referrals
The realist evaluation revealed that the refocused school nurse program enhanced opportunities for early and improved identification of health and well-being needs. The program's nine pathways streamlined the referral process, connecting relevant cases to school nurses more efficiently. This led to positive outcomes by extending the reach of school nurses and improving children's engagement with wider support services.
- Streamlined Referrals: The nine pathways helped direct students with specific needs to school nurses more efficiently.
- Improved Engagement: Connecting school nurses and children with broader services yielded better results.
- Mental Health Focus: The mental health pathway was the most used, highlighting the increasing need for mental health support in schools.
- Training Gaps: Nurses need more training to handle mild to moderate mental health issues.
Expanding Evidence on Nurse-Led Care
A 2025 CDC-published review found that nurse-led mental health interventions for college students show promise for enhancing student well-being, although approaches varied and further studies are needed. A 2025 Journal of School Health study examined how prepared school nurses and schools were to identify and manage mental health conditions and psychological stressors. More recent work, including a 2026 review and a 2026 NASN position statement, frames school nurses' role as supporting child wellness and students' behavioral, social-emotional, and mental health alongside academic achievement and community safety.
Resilience Under Pressure
The available sources emphasize that nursing students and school nurses face meaningful challenges rather than presenting school nursing as an uncomplicated success story. A qualitative study of nursing students examined the challenges and supports influencing resilience during clinical education, defining resilience as the capacity to adapt to adversity, overcome setbacks, and remain committed to high-quality patient care. Accounts of school nursing likewise describe demands ranging from managing chronic conditions to providing emotional support, while other coverage identifies school nurse challenges and proposed ways to resolve them.
Connecting Health and Achievement
Research on school nursing increasingly considers students' physical and emotional well-being together rather than treating them as separate concerns. A review notes that studies linking nursing interventions and student well-being to academic achievement remain essential because this relationship is still insufficiently documented. In parallel, a 2024 article highlights CDC surveys designed to assess student behaviors and school health policies and programs for school nurses, health personnel, and other stakeholders.
The Future of School Nursing: Building Capacity and Addressing Gaps
The realist evaluation underscores the importance of tailoring school nurse programs to meet the specific needs of the school community. While the refocused program in Scotland showed promise in enhancing early identification and streamlining referrals, it also revealed areas where further development is needed.
A Whole-School Perspective
School nursing can be understood as a broad well-being role that connects health care, education, and the school community. The available material suggests that nurses contribute across physical health, mental health, prevention, and health education. Because approaches and evidence vary, conclusions about effectiveness should remain appropriately measured and supported by continued evaluation.
Building the Evidence Base
Future progress will likely depend on stronger data collection, clearer evaluation of interventions, and closer coordination between schools and health professionals. Research may also clarify how school nurse services affect mental health, educational participation, and wider student well-being. These directions should be treated as priorities for investigation rather than established outcomes.
Health Within the School System
School nurses work within systems shaped by access to care, educational priorities, community conditions, and available support. Student well-being is therefore unlikely to be isolated from the well-being of school staff, families, and the broader community. Addressing systemic challenges requires attention to the surrounding school ecosystem as well as to individual student needs.
Care Beyond the Clinic
The human value of school nursing lies in bringing health support into students' everyday educational environment. Nurses may serve as accessible points of assessment, care, guidance, and emotional support during the school day. Their impact is best understood not only through individual encounters but also through the trust and continuity they help create within school communities.
Moving forward, capacity-building strategies should prioritize enhancing school nurses' intervention delivery skills, particularly in the area of mental health. This may involve providing additional training, resources, and support to equip nurses with the tools they need to address low to moderate mental health issues effectively. Furthermore, efforts should be made to ensure that all members of the school health team understand their roles and responsibilities within the program.
By addressing these challenges and building on the successes of the refocused program, school nursing can continue to evolve as a vital resource for supporting the health and well-being of school-aged children. Realist evaluation provides a valuable framework for understanding the complex factors that influence program effectiveness, ensuring that interventions are tailored to meet the unique needs of each community.