Supporting School Nurses: Training Resources to Identify Risks and Mitigate School Shooting Incidents

Since the first recorded school shooting of a University of Virginia law professor in 1840, mass school shootings have significantly increased (McIntosh et al., 2020). The increased incidence of mass shootings and school violence has greatly amplified school nurses' critical importance and ability to identify risk factors for violence among students. Promptly recognizing risk factors for violence and mitigating these risks can help prevent violence in the school environment, including mass shootings (Gonzalez-Guarda et al., 2018). In the last decade, scholars have conducted extensive research to identify the underlying causes and precursors of school violence, resulting in many recommendations for preventative and mitigating practices (DeVos et al., 2018; Gonzalez-Guarda et al., 2018; Jonson et al., 2018). Specifically, the Federal School Safety Commission (FSSC) published a report identifying best practices and recommendations for the prevention, protection, mitigation, response, and recovery associated with school shootings for educators across the United States (DeVos et al., 2018).

According to an article published by the National Institute of Justice in collaboration with the U.S. Secret Service and the U.S. Department of Education, several incidents occur before a school shooting (National Threat Assessment Center, 2002). For example, perpetrators talk about their plans, make detailed plans, have easy access to guns, show concerning behaviors, have experienced bullying and harassment, and are influenced by fellow students (National Threat Assessment Center, 2002). A school nurse must be trained to confidently identify the risk factors to mitigate them in the educational environment (Gonzalez-Guarda et al., 2018; Selekman & Melvin, 2017). In addition to identification, a school nurse must also be able to respond to individual, family, and community risk factors for mass shootings – intimate partner violence (IPV), toxic stress, bullying, and mental health problems – and address missed opportunities for individuals and systems to prevent this type of violence (Gonzalez-Guarda et al., 2018).

It is worth noting that no national standard or legislation currently dictates the minimum requirements for competencies and training among school nurses in identifying risk factors for shooting events and preventing active shooter incidents (Cahill et al., 2020). While the lack of a national standard may be troubling, school nurses currently remain underutilized assets positioned to address this public health issue.

School Shootings in America

Following high-profile cases, such as the shootings at Columbine High School in 1999, Sandy Hook Elementary in 2012, and Marjory Stoneman Douglas High School in 2018, state policymakers have sought to enact new regulations and statutes to prevent future incidents (Cahill et al., 2020). For example, Florida passed the Marjory Stoneman Douglas High School Public Safety Act to make schools safer (Florida Department of Education, 2020). However, the Act provides little information about preventive measures schools can take to prevent school violence that may escalate to school shootings. Further, the responsibility for enacting such policies lies with each state, resulting in wide variations across the U.S. regarding the types and extent of training and education offered to school district administrators, teachers, school nurses, and other staff members. In addition, in response to high-profile school shootings, most states have implemented school safety laws that have focused on preparing school staff to respond to active shooter incidents rather than implementing preventative measures (Cahill et al., 2020). Even though school nurse education and practice position them in frontline roles needed to identify and mitigate risks that may escalate to an active shooter incident, no expressly stated training by state and federal agencies exists for school nurses.

...school nurse education and practice position them in frontline roles needed to identify and mitigate risks...

School Nurses Serve Diverse Student Concerns

School nurses serve a diverse array of student concerns within schools. For example, Ugalde et al. (2018) indicated that school nurses treat several conditions, ranging from sore throats to severe medical emergencies requiring the activation of an Emergency Medical Services (EMS) response. Maughan et al. (2018) further indicated that school nurses address mental health issues such as depression, violence, and bullying among school-age children, all representing factors associated with or predictive of mass school shooting incidents (National Threat Assessment Center, 2002).

According to Ramos et al. (2013), school nurses are dynamically suited to play critical roles in identifying and prompt mitigation of risks that may lead to mass school shootings and other catastrophic incidents by providing behavioral health services within schools. School nurses are no longer on the sidelines (if they ever were). Instead, school nurses should be seen as essential members of interdisciplinary behavior threat assessment and management teams, highlighting the necessity of collaborative efforts to manage and prevent crises. In essence, the role of school nurses has evolved into a dynamically complex role encompassing much more than direct student contact in matters of individual health.

The Role of the School Nurse in Preventing School Shootings

School nurses are called to take pivotal leadership roles in preventing and mitigating school shooting incidents (DeVos et al., 2018; Selekman & Melvin, 2017). School nurses (as well as other members of staff) can demonstrate leadership in preventing mass school shootings by being involved in the identification and mitigation of risky behaviors in students (National Association of School Nurses [NASN], 2018).

Although the FSSC’s report recommending best practices for school safety mentions, in passing, the role of nurse practitioners in addressing a range of behavioral health concerns, including depression, threats of violence, and suicide, for students as well as their families, the importance of the school nurses' role in addressing these behaviors to prevent active school shooting incidents was largely absent (DeVos et al., 2018). This passing mention ignores the skills and healthcare training a school nurse can contribute to preventing shooting incidents. Because the school nurse's role in preventing violence that may escalate to a shooting incident is not explicitly stated, continual training is not being implemented to ensure that school nurses are confident in identifying risk factors and preventing violence.

Gaining insight into school nurses' perceptions regarding their abilities to prevent, protect, mitigate, respond to, and recover from a school shooting incident may indicate the need for additional or emphasized leadership training. To date, several variables related to school nursing have been identified to impact the ability of school nurses to intervene to decrease violence. For example, educational requirements to help school nurses prevent shooting incidents, legislative support for the presence of school nurses, and the ratio of school nurses to students vary from state to state (King, 2014). In 2018, NASN called for school nurses to be involved in planning emergency responses at the community and school levels because they are well-positioned to identify children’s needs. Understanding school nurses’ perceptions of expectations of identifying and mitigating risk factors and hurdles in meeting these expectations must be considered when developing policies to prevent school shootings.

Educating School Nurses for Prevention of Violence at Schools

Prior research has suggested that school nurses should be trained to prevent and mitigate school-related violence (Gill et al., 2019; Stanley & Wolanski, 2015; Wyatt et al., 2019). Establishing a secure environment and building confidence must be undertaken well before a disaster; an active shooter incident is no exception. However, discrepancies exist in the national standardization of training materials that guide school nurses and counselors, social workers, and psychologists (Farris & Tracy, 2013; Monterey County Civil Grand Jury, 2019) to prevent violence at schools.

Critical to assuming the roles of preparation and response to disasters, including active shooter incidents, school nurses must be confident in their self-efficacy.

Critical to assuming the roles of preparation and response to disasters, including active shooter incidents, school nurses must be confident in their self-efficacy. Self-efficacy refers to the perception of readiness and educational preparedness for a given role (Bandura, 1994). Being confident in one's self-efficacy is being prepared and educated, including being confident in that preparation and education when it is most needed. Newly developed training specific to the school nurse's role in preventing shooter incidents begins with considering their specialized education, diverse patient population, and thorough knowledge of the nursing process. Specifically, the nursing process includes "assessment, planning, implementation and evaluation" (NASN, 2019, p. 1) and closely parallels the phases of emergency management of "prevention/mitigation, preparedness, response, and recovery" (NASN, 2019, p. 1). Table 1 concisely summarizes training/documents supporting school nurses in disaster preparedness, including identifying risk factors for active shooter incidents.

Table 1. Training/Documents Supporting School Nurses in Disaster Preparedness, Including Mitigating Active Shooter Incidents

Key to Organizations: USDHS: U.S. Department of Homeland Security; FEMA: Federal Emergency Management Agency; USDE: U.S. Department of Education; USDHHS: U.S. Department of Health and Human Services; USDOJ: U.S. Department of Justice; FBI: Federal Bureau of Investigation; NASN: National Association of School Nurses.

Several insights can be concluded when reviewing the diverse, versatile, and adaptive roles played and fulfilled by school nurses. School nurses are familiar with the procedures of emergency management planning (Shannon & Guilday, 2019). Their ability to respond to emergency medical events prepares them to fulfill multiple roles associated with the preparation and response to emergencies and disasters on school campuses (Rebmann et al., 2015; Rebmann et al., 2012; Selekman & Melvin, 2017; NASN, 2018; Ugalde et al., 2018).

A well-informed school nurse can also promote evidence-based education and programs related to violence prevention and decrease the effects of violence on individual students.

Since school nurses play an essential role in violence intervention, they must be highly trained to identify and mitigate violence in the school setting, especially those that may elevate to an active shooter incident. The training list in Table 1 supports school nurses in creating a safe school environment by collaborating with school personnel, parents, and community members. A well-informed school nurse can also promote evidence-based education and programs related to violence prevention and decrease the effects of violence on individual students. However, school nurses can only conduct such roles as part of an interdisciplinary team if they are supported through periodic training from the appropriate organizations, governmental policies, legislation, and training courses made available to them.

Conclusion

School nurses hold specific positions within the school environment that might enable them to identify students with individual and family risk factors (such as toxic stress, bullying, and mental health issues) associated with an increased likelihood of violent acts. However, currently, available recommendations for preventing active shooter incidents place little emphasis on defining the pivotal roles of school nurses in all phases of emergency response, including prevention. Additionally, it is unclear whether school nurses are leveraged for their expertise and leadership abilities in this current public health crisis. Furthermore, whether school nurses are adequately prepared and self-efficacious to prevent a school shooting incident effectively remains uncertain. Therefore, studies may be warranted to uncover school nurses' role before school shootings. These impact studies might also examine the effects of school shootings on school nurses and better equip their preparedness, response, and reactions. After completing specialized education, training, and emergency preparedness, school nurses will be better suited to meet the needs of a school community in preventing violence at school. In addition, this specialized training to identify risk behaviors and mitigate the risks of active shooting incidents in the school should complement school nurses' existing education and preparedness.

Author

Titilayo Idowu, Ph.D., MSN, MSL, CPN, RN
Email: ti3345@yahoo.com
ORCID ID: 0000-0002-1079-9739

Titilayo Idowu has 19 years of pediatric nursing experience. She is a clinical nurse coordinator at Nicklaus Children’s Hospital and serves as an adjunct nurse faculty for Barry University. Her research focus is on the prevention, mitigation, and preparedness of school shootings.