The Double Bind of School Nurses and Policy Implementation: Intersecting the Street-Level Bureaucracy Framework and Teaching Sexual Health Education

Abstract

As described in the Framework for 21st Century School Nursing Practice, school nurses bridge the realities of health and education policy within the school community every day. This role is inclusive of helping teach sexual health education (SHE) to students. We were interested in characterizing how school nurses navigate requirements of health education policy to provide their students with the SHE content that they need. Using data from a larger study, we organized a subset of school nurse data within the street-level bureaucracy framework to better understand the many challenges school nurses face in implementing SHE policy. School nurses’ involvement in SHE policy implementation was congruent with characteristics of the framework. This included using their professional discretion to manage dilemmas, working with inadequate resources, unclear policy expectations, lack of support, and ambiguous policy goals. Trusted relationships with teachers and students helped school nurses with their SHE policy implementation responsibilities.

Effects of School Policies and Programs on Violence Among All High School Students and Sexual and Gender Minority Students

“…38 In schools that do teach sexual health education, there are often district or administrative pressures to exclude teaching about homosexuality or other LGBTQ-related content. 47 Furthermore, there are no standardized policies or curricula for delivering sexual health education inclusive of LGB and TGNC students, and many educators feel ill-equipped to provide this education. 48,49 Substantial research is needed to understand the effects of specific curricula, how they are being implemented, and the extent to which use of LGBT-inclusive sexual health curricula directly effects sexual violence and the extent to which the effect is mediated by school climate.…”

“…Although comprehensive sexual health education is recommended by the CDC, only 42.8% of high schools in the United States teach all recommended topics 38 . In schools that do teach sexual health education, there are often district or administrative pressures to exclude teaching about homosexuality or other LGBTQ‐related content 47 . Furthermore, there are no standardized policies or curricula for delivering sexual health education inclusive of LGB and TGNC students, and many educators feel ill‐equipped to provide this education 48,49 .…”

A structural equation modeling of reproductive health promoting behaviors among female adolescents in the Philippines

“…School nurses provide health education, offer counseling, and monitor students' reproductive health (Brewin et al, 2014; Dickson & Brindis, 2021). In the United States, school nurses must have a registered nurses' license, a bachelor's degree, and more than 1000 h of clinical experience.…”

Nurse champions as street-level bureaucrats: Factors which facilitate innovation, policy making, and reconstruction

“…Indeed, they frequently balance a high demand for their services with a limited supply of resources while responding to the individual needs of their patients ( Hughes and Condon, 2016 ). Especially of interest is their conflict deriving from the obligation to provide high quality health services and their performance measurement, e.g., through accreditation processes, when there are contrasting standards ( Dickson and Brindis, 2019 ). Among their important duties, nurses act to informally reconstruct their organizations’ policies and agendas ( Newans and Siddiqui, 2021 ), and as such they influence the quality of life of many people ( Lipsky, 1980 , 2010 ; Cohen, 2018 ).…”

“…In recent years, the SLB framework has been applied to nurses working in hospitals ( Hoyle, 2014 ; Hoyle and Grant, 2015 ); in community settings ( Walker and Gilson, 2004 ; Bergen and While, 2005 ; Hughes and Condon, 2016 ; Cuthill and Johnston, 2019 ); and to clinical educators ( Visekruna et al, 2017 ) or school nurses ( Dickson and Brindis, 2019 ). However, application of the SLB framework to nurses’ roles and impact was made in anecdotal empirical studies, usually focusing on individual nurses and their behaviors as relatively stable individual characteristics.…”