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Psychiatric-Mental Health Clinical Nurse Specialist Practice in a Public School SettingfromClinical Nurse SpecialistPosted 04/15/2003
Ann Hales, PhD, CNS, NP, Judith Karshmer, PhD, APRN, Lucy Montes-Sandoval,CNS, Frances Glasscock, CNS, Linda C. Summers, FNP, CNS, Jacquelyn Williams,CNS, NP, Leslie K. Robbins, CNS, NPIntroduction
The public school setting is increasingly becoming an entry point of contact for an arrayof healthcare services, including behavioral health services. The psychiatric-mental healthclinical nurse specialist (CNS) who combines an understanding of human growth anddevelopment, a holistic view of the individual, and knowledge of primary healthcare iswell suited to offer comprehensive mental health services within the school setting. Earlyidentification and timely intervention, which are achieved easily within the school's'captive audience,' are key components of behavioral illness prevention and treatment.
When the services take place within the school system, accessibility and efficiency of theinterventions increase, fragmentation decreases, and there is no unnecessary stigma thatoften surrounds referrals for mental health treatment.However, the psychiatric-mental health CNS in the school setting may need a venue other than behavioral health for offering these health services. Too often, students do not use behavioral health services because of the stigma attached to such services. Thus, the psychiatric-mental health CNS in the school setting may best meet behavioral healthclinical objectives by linking those services to primary healthcare services. This articlediscusses the unique role of the psychiatric-mental health CNS in providing behavioralservices in the public school system by combining such services with those of primarycare providers. The innovative partnership between the psychiatric-mental health CNSand the primary care nurse practitioner is discussed as it was used in a school-based clinicin a high school in a southwestern state in the United States.
Adolescents: A Vulnerable Population Not Receiving NeededServices
Adolescents experience a range of significant challenges and are often vulnerable tostressful situations. Being a teenager is difficult both psychologically and physically.Participation in high-risk behaviors, immaturity in seeking appropriate assistance, andlimited coping skills exacerbate their peril. Emotionally, adolescence is the stage of lifewhen one has not only the promise of finding oneself but also the threat of losingoneself.
Adolescents are challenged to successfully integrate various life experiences to achieve asense of wholeness, fulfillment, and identity. Adaptive progression during adolescenceleads to a positive self-image that allows the individual to move into adulthood with self-
assurance and confidence; whereas maladaptive progression leads to role confusion andoften to identification with a negative or deviant group.
[3, 4]
During the last 20 years, adolescence is reported as the only age group to experience anincrease in mortality rates.
Several researchers
report that the threats to teenagers'health are largely related to psychosocial factors. Adolescents have a significantly higher suicide rate when compared with the general population, and the rates have risenthroughout the past two decades.
Suicide is the third leading cause of death amongadolescents, and there are an estimated 8 to 25 attempted adolescent suicides to eachcompleted adolescent suicide.
[9, 10]
Adolescents cope with multiple crises associated with identity, peer pressures, physicalchanges, desire for independence, and self-doubt.
[5, 11, 12]
Adolescent years are a time of rapid growth and change that can be both challenging and confusing and oftenemotionally unstable. Adolescents' emotional problems are often exhibited as poor academic performance, intense teen-parent conflicts, and the inability to handle peer  pressures.
Yet, despite the challenges and attacks on their well-being, the number of adolescents entering the healthcare system is fewer than that of any other age group.
[5, 11,12]
reported on data from a recent analysis of 3 national healthcare studiesinvolving more than 46,000 children and adolescents. The data indicate that largenumbers of these young people, who had concerns ranging from behavioral problems todepression and suicidal illnesses, are not being identified nor treated by the healthcaresystem.
Sorely in need of services, adolescents either cannot or will not seek treatment.
Role of Schools In Offering Mental Health Services
The public school setting is a logical point of access for healthcare services.
The schoolis probably the most important and best positioned institution to improve a community'soverall healthcare, including mental health. In a 1999 interview with a newscorrespondent, then Surgeon General David Satcher stated that public schools should betapped to identify more children with mental health problems and get them into treatmentif needed.
The primary goal of the school system is to educate a community's youth. However, inaddition to academic expectations, the educational system influences and shapes students'social knowledge, beliefs, and behaviors.
Schools offer a familiar setting that isgenerally viewed as a safe place. School personnel are usually perceived as reliable andavailable to provide guidance and support. This center of security is particularlyimportant to adolescents who are skeptical of nonschool agencies and unfamiliar  people.
'Because learning and wellness are inextricably linked, a strategy that uniteseducation and health care programs has the potential to improve contemporary problems.'
The public school offers the attractive combination of factors that createsan environment that is well suited for providing comprehensive behavioral healthcareservices. Primary prevention programs, such as alcohol and substance abuse education,stress management, problem-solving techniques, peer counseling, and life-skills classes,can make a difference in providing adolescents with coping skills.
[9, 13]
 prevention is aptly provided through individual, group, and/or family counseling by the psychiatric-mental health CNS.
Responding to Behavioral Healthcare Concerns Via Primary Care
Literature suggests that there has been a recent expansion of interest in behavioral healthinterventions within the primary care environment.
[16, 17]
Strathdee reports that up to 25%of all primary care consultations are with people for whom psychological disturbance is asignificant component of their presenting problems,
whereas Adelman and Taylor report that as many as 50% of clinic visits are for nonmedical concerns.
Yet the potential for primary care providers to function as counselors and therapists is limited bythe primary care provider's time, expertise, and conflicting role expectations
[20, 21]
Theresult of patients having psychological needs that cannot be met but have been presentedin the primary care setting lends itself to having behavioral health professionals workingalongside primary care providers. Indeed, in some countries, eg, the United Kingdom, asmany as 31% of all general practitioners employ counselors in their practice.
Similarly, linking behavioral health services to school-based primary care services offersunique opportunities to reach an otherwise inaccessible population. School-basedhealthcare services were originally created in response to concerns about adolescent pregnancies and a desire to provide physical healthcare to underserved youth.
Soonafter opening, almost all school-based health programs found it essential to also addressmental health and psychosocial concerns.
Students seek care at the school-based clinics primarily for help with nonmedical problems, such as relationship problems, emotionaldistress, physical and sexual abuse, and problems arising from substance abuse.
Students who experience these psychological stresses are reluctant to ask for behavioralhealth services because of the stigma associated with behavior health. However, if  behavioral health services can be received under the umbrella of a school-based physicalhealthcare clinic, the student is freed of the potential stigma associated with behavioralhealth settings.
The Unique Role of the Psychiatric-Mental Health Clinical NurseSpecialist in the School System
If students are experiencing problems that impede their learning, school personnelwillingly or unwillingly must accept responsibility to help to identify and treat thestudents' problems. Research-based evidence demonstrates that attention to the emotionaland psychological needs of students can improve their academic functioning.
As theadolescent's life becomes more complex with individual, peer, family, and societalstresses, there is inevitable pressure on the school setting to respond constructively tothese emotional complexities as a step toward academic improvement.However, budget cutbacks and increases in the student population leave school districtswith inadequate resources.
Many schools attempt to add the responsibility of  behavioral health intervention to the classroom teachers who are already overburdenedwith issues of learning readiness, student motivation, and a mass of academic content.

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