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Abstract

Modern wellness is a concept that has been discussed in the literature since the 1960's. To better understand wellness complexities in a school setting, a concept analysis was conducted using a modified version of Walker and Avant's method incorporating the nursing paradigm in the implications. A literature review was conducted and except for background information, the publication dates were limited to 2017–2022. Key search terms included “wellness,” “school wellness,” “wellness concept.” Additional literature reviews were conducted based on data related to the definitions, attributes, antecedents, and consequences of wellness that were collected from the reviewed studies. Defining attributes of wellness included healthy habits, conscientiousness, and optimum state of health. The antecedents, consequences, and empirical referents of wellness were identified with examples from the literature and case exemplars. Wellness is a dynamic process that has unique implications for school health and school nurses. This concept analysis lays the foundation for future research incorporating nursing domains.

Keywords

wellness school wellness wellness continuum

Wellness Concept Background

School-age children in the United States spend on average, six hours per day in school for approximately 180 days per year, which comprises a significant amount of their youth (Lee et al., 2022; (National Center for Education Statistics, n.d.). The combined academic and socialization experience, therefore, substantially impacts the student's physical and mental development (Centers for Disease Control [CDC], 2019a, 2019b). Rattermann et al. (2021) agree that there is a connection between the school environment, academic achievement, and health outcomes. The school environment is further viewed as essential in promoting healthy habits such as nutritious food consumption (Au et al., 2018; Lee et al., 2022). For example, a systematic review illustrated the correlation between health education delivery in schools and positive nutritional outcomes (Cotton et al., 2020). The United States Congress further acknowledges that schools are vital in promoting wellness (United States Department of Agriculture [USDA], 2022a). As such, per congressional legislation, schools that participate in the National School Lunch Program and/or the School Breakfast program are to provide nutrition education and have school wellness policies in accordance with the 2010 Healthy Hunger Free Kids Act (Au et al., 2018). Due to these inter-related implications, establishing evidence-based school wellness policies is critical for guiding a school district's decision-making practices as they attempt to create environments that support positive health, well-being, and optimum student learning outcomes (Bobo et al., 2022). The United Nations International Children's Emergency Fund (UNICEF) further asserts that skillsets, mental health, and safety are also contributing factors associated with a child's overall well-being (United Nations International Children's Emergency Fund [UNICEF], 2022). The purpose of this article is to examine the concept of wellness as it relates to Kindergarten (K) through 12th grade students and staff, using the Walker and Avant (2019) framework, which is the most frequently used model for conducting concept analyses in nursing (Fitzpatrick & McCarthy, 2016). School nurses are often the only health professional in the school and are well-positioned to champion wellness initiatives outside of regular school health services. As such, it is imperative to explore wellness as a concept and understand school nursing implications (National Association of School Nurses [NASN], 2020).

Search Strategy

After the concept is identified, Walker and Avant (2019) recommend data collection encompassing all aspects of the concept. The wellness literature however is vast, rendering a true systematic examination of wellness literature beyond the scope of this targeted analysis. The literature spanned wellness topics for many health conditions, age and gender cohorts. As a result, Walker and Avant's (2019) method was modified to accommodate the aims of this analysis, which was to narrow the scope of wellness to the kindergarten to high school population (K-12). A multidisciplinary search strategy was designed among the authors to limit the key search words and terms related to the following: Wellness concept AND school wellness. From these searches, studies and professional papers pertinent to school wellness issues were selected. A total of 135 articles and papers were selected for inclusion review: The Cumulative Index of Nursing and Allied Health Literature (CINAHL) (30), MEDLINE (33), PsycINFO (5), ERIC (25), Google Scholar (21), and NIH (5) were the major databases searched. Other smaller data bases and professional or scientific organizations yielded 18 additional articles. Searches were limited to English language publications. Additional literature was added through examination of the included articles reference lists and smaller specific data bases as needed. When duplicates were removed and reference lists repeated, the search was deemed completed to saturation. After themes pertinent to K-12 wellness were identified, subsequent sub searches were conducted to examine those topics.

From all searches, 98 articles total were included in this analysis. Exclusion criteria included topics beyond the scope of this study and those not related to the kindergarten to grade 12 population. Thirty-five professional or scientific articles were included to provide supporting background and data when required. Online Supplemental Table 1 outlines the 63 research articles chosen for this analysis with rationales.

Origins of Wellness

The modern concept of wellness was first described by Dubos (1968) who introduced multiple dimensions of optimal health that eventually evolved over the decades (Global Wellness Institute, 2021a) . Jabeen (2017) further elaborates that the concept of wellness is “individualistic in nature, involving intrinsic attributes associated with personality, experiences, and situational occurrences. Achieving wellness is an active, life-long, decision-making process” (p. 144). More recently, the Global Wellness Institute (2021b) defines wellness as: 1.) a conscious, self-directed, and evolving process of achieving full potential; 2.) multidimensional and holistic (encompassing lifestyle, mental and spiritual well-being, and the environment); and 3.) positive and affirming.

To define wellness, most concept analysis papers over the last 30 years targeted specific populations such as the elderly (McMahon & Fleury, 2012) or adolescents (Avedissian & Alayan, 2021). Numerous analyses centered on wellness-related topics involving health (Simmons, 1989) and health assets (Rotegård et al., 2010). Although school wellness policies, practices, and programs have been presented in the literature, no analyses to date, have been found to define wellness for the Pre-K-12 school population. Thus, this analysis is an attempt to address that gap in the literature, and to illustrate its relevance to the nursing metaparadigm and its four concepts involving the dynamic and fluid association between the domains of nurse, person, environment, and health.

Wellness in School Settings

School wellness initiatives date back to 1946 when the Truman Administration initiated the National School Hot Lunch program. The program was expanded when the Johnson Administration introduced breakfast grants for financially qualified students. In the 1960's, the President's Council Youth Fitness Test was promoted in schools (U.S. Department of Health and Human Services, Office of Disease Prevention [ODPHP], 2021), and in the 1980's, fitness programs were reintroduced into schools through organizations such as the Cooper Institute (Wiley, 2018). In response to the Child Nutrition Reauthorization Act of 2004, school districts were required to implement wellness policies that addressed student nutrition and physical activity. These nutrition mandates were later expanded by the Healthy, Hunger-Free Kids (HHFK) Act of 2010 (USDA, 2022a) and physical activity was encouraged through programs such as First Lady Michelle Obama's “Let's Move” campaign, which was launched in 2010 following President Obama establishment of the Task Force on Childhood Obesity (Let's Move, 2017; Wiley, 2018). In 2016, the final rule of the HHFK Act of 2010 was published to ensure public involvement, transparency, implementation, and evaluation (USDA, 2022a). This final rule requires each school district to enact minimum requirements for their school wellness policies. The district administration enforces participation of key stakeholders to revise policies and conduct mandatory wellness policy assessments. These final wellness policy regulations are meant to enhance a district's ability “to create a school nutrition environment that promotes students’ health, well-being, and ability to learn” (USDA, 2016, p. 1). Accordingly, districts or individual schools (also known as “local education agencies”) are required to evaluate their wellness policies every three years and disclose results to the public. In terms of the school district self-evaluation reliability, one small study indicated that school-reported evaluation results were fairly reliable when compared to the same direct observation result analysis (Lee et al., 2022).

School Staff Wellness

As organizations continue to curtail employee health care costs, more employee wellness programs have emerged nationwide (Song & Baicker, 2019). When considering the school environment and its implications toward student's health and well-being, it is also important to promote school employee health and wellness. Adult wellness must follow a multidimensional continuum inherent with spiritual, vocational, intellectual, and environmental health factors in addition to sleep, nutrition, and exercise needs (International Council on Active Aging [ICAA], 2022). School employees may in fact, realize improved productivity and lower healthcare expenses when they are in optimal physical and mental condition. Therefore, supporting school employee wellness also helps to support student health and academic performance (CDC, 2019a, 2019b). Since staff role model behaviors that may be adopted by students, it is duly imperative that adult wellness initiatives are promoted and sustained, and that staff are educated on strategies that students may emulate (Adams et al., 2022).

Concept Analysis

Concept Analysis Methodology

Sierra and Cianelli (2019) define concepts as abstract ideas that set boundaries for phenomena under study. Walker and Avant (2019) remind us that concepts are the building blocks for theory construction and that the purpose for conducting a concept analysis is to distinguish one concept from another. Moreover, Walker and Avant further explicate that the process is dynamic, as analysis of a concept may change over time (pp. 167–168). Their eight-step concept analysis approach was chosen to identify attributes inherent in wellness and its application to the kindergarten to 12th grade school setting. The eight steps are: (1) choose a concept; (2) determine the analysis’ purpose; (3) identify the concept's uses; (4) determine the concept's attributes; (5) choose a model case; (6) identify borderline, related, contrary, and illegitimate cases; (7) identify antecedents and consequences; and (8) define empirical referents.

Defining Attributes

Presenting attributes of a concept not only provides clarity as to the boundaries of the concept, but also discriminate one concept from another. It further serves as a means to examine phenomena critically (Walker & Avant, 2019). Three prominent attributes associated with wellness found in the literature are healthy habits, conscientiousness, and achieving an optimum state of health.

Healthy Habits

Healthy habits are activities that promote individualistic health and wellness. The activities are multidimensional and incorporate eating a healthy diet, exercising, weight management, adequate sleep, stress reduction, personality traits, and social support (Anahana, 2021; Lee & Sibley, 2019). Acquiring a healthy habit lifestyle is pivotal in promoting optimum health and wellness. There are instruments to assess nutritional behaviors and physical activity behaviors as evidenced by national surveillance systems (e.g., Behavioral Risk Factor Surveillance System and Youth Risk Behavior Surveillance System), and in individual studies such as in the Small Changes, Healthy Habits Pilot Program (Adhikari & Gollub, 2021).

Balanced Nutrition

Application of good nutrition practices among children is essential for physical growth, energy production through the adequate intake of carbohydrates, lipids, protein fuel molecules, and protection from illness (Bekele, 2020; DaPoian et al., 2010). Students with higher academic scores are more likely to engage in healthy dietary habits than student peers with lower grades (CDC, 2022a, 2022b, 2022c). Students with higher grade scores are also more likely to eat breakfast seven days a week, consume vegetables one or more times a day, eat fruit or drink 100% fruit juice one or more times a day, and refrain from drinking soda (CDC, 2022a, 2022b, 2022c). Healthy eating practices among adults may improve longevity, boost immunity, strengthen bones and muscles, reduce heart disease and type 2 diabetes risks, improve digestive system function, and achieving and maintaining optimum weight goals (CDC, 2022a, 2022b, 2022c). Further, dietary patterns established during youth may track into adulthood (Movassagh et al., 2017), making it imperative that healthy eating is taught and promoted at an early age.

The position of the Academy of Nutrition and Dietetics, School Nutrition Association, and Society for Nutrition Education and Behavior indicate comprehensive, integrated nutrition programs are critical for improving the health, nutritional status, and academic performance children in preschool through high school (Hayes et al., 2018). Further, a school wellness program can contain federally compliant dietary recommendations for all foods sold on each school site during the school day, as well as policies for foods and beverages made available to students (CDC, 2022a, 2022b, 2022c). Not all students have the same opportunities to eat healthy foods. School lunches provide the healthiest meals of the day for many children by ensuring the inclusion of fruits, vegetables, and milk (Rothstein & Olympia, 2020). The schools’ ability to provide healthy options and provide the education, the student is more likely to make healthier choices that would impact their academics and lifestyle, as well as potentially affecting future health.

Physical Activity

An effective strategy to enhance actual and perceived wellness across the age continuum is to engage in physical activity (Bezner et al., 1999; Ohuruogu, 2016). National physical activity guidelines suggest that school-aged youth can achieve substantial health benefits by engaging in regular physical activity for up to 60 min or more each day (Piercy et al., 2018). Physical education in schools develops motor skills, knowledge, and attitudes that promote healthy active living, physical fitness, sportsmanship, self-efficacy, and emotional intelligence (CDC, 2021; Lewallen et al., 2015). Additionally, mental health benefits may be accrued when physical activity is combined with a program of proper nutrition and sleep hygiene (Hosker et al., 2019). Schools promote physical exercise into student daily routines through involvement in physical education, recess, sports, and other extracurricular activities (Rothstein & Olympia, 2020). Students who have better academic grades, compared to students with lower grades, are more likely to participate in physical exercise for at least 60 min on all seven days, play on at least one sports team, and are less likely to watch television for three hours or more per day, play video games for three hours or more per day, or use a computer for three hours or more per day (CDC, 2022a, 2022b, 2022c). Students can acquire fundamental ideas and practice critical skills needed to build and sustain physically active lifestyles throughout childhood, adolescence, and adulthood through a well-designed physical education program (CDC, 2019a, 2019b). Physical activity also enhances the wellbeing of students with chronic diseases when an individualized program is developed (Coleman et al., 2018).

Further, physically active lifestyles start early (Telama et al., 2014), and students who have frequent opportunities to be active may have a greater chance to remain active later in life. Adults who engage in regular physical activity reap significant health benefits, including the prevention of chronic diseases and a reduction in stress and anxiety (CDC, 2022a, 2022b, 2022c). These habits are critical as systemic reviews illustrate how physical activity enhances the wellbeing and cognition of older adults (Ferreira Silva et al., 2022; Yen & Lin, 2018). Virtual reality physical activity games are emerging as safe exercise alternatives for the elderly to avoid physical injury and improve wellbeing (Yen & Chiu, 2021).

Weight Management

The health implications associated with obesity such as diabetes, liver disease, coronary artery disease, etc. are well documented. According to the CDC (2022b, p. 1), a simple description of obesity is “weight higher than what is considered healthy for a given height.” The most common screening tool to determine the degree of overweight or obesity is the Body Mass Index (BMI), which is a person's weight in kilograms divided by the square of height in meters (CDC, 2022b). The CDC (2022c) further explains that although a high BMI is positively correlated with the conditions mentioned previously, it remains a widely used screening tool and should be discussed in context of health history, other body measurements (such as skinfold thickness/SFT) and laboratory values with a health provider. It is now understood that obesity is a complex disease with several causes including but not limited to nutrition, sleep, activity, genetics, social determinants of health, and medication.

Furthermore, social media confounds the issue by offering weight management advice often leading to stress, weight regain, and eating disorders (Marks et al., 2020). Body mass index or weight charts do not take into account body muscle composition or degree of adiposity in key body areas such as the abdomen. It is now known that even young adults at a “normal” BMI may have a degree of adiposity and placing them at risk for cardiometabolic consequences (normal weight obesity/NWO) (Correa-Rodríguez et al., 2020). Further, another study found that young adults with normal weight obesity often are less physically active than their lean counterparts (Wijayatunga et al., 2022).

Although it is important to address weight management in the context of overall wellness, new concepts such as NWO and Health at Every Size (HAES) (Penney & Kirk, 2015) which addresses weight stigma and bias to expand traditional weight management research. Social media also promotes unreasonable expectations leading to disordered eating and weight cycling (Marks et al., 2020).

Adequate Sleep

The number of hours of sleep that is needed each day varies on one's age. For example, it is recommended that preschoolers, ages three to five years old should sleep between 10 and 13 h daily including naps. School-aged children ages six to 12 years should sleep between 9 and 12 h, teens ages 13 to 18, eight to 10 h, and adults ages 18–60, 7 or more hours of sleep per day (CDC, 2017). Sleep habits are correlated with overall health (Caldwell et al., 2020; Illingworth, 2020). Interestingly, Jansen et al. (2019) found an association regarding longer sleep midpoints during the weekend and decreased healthy dietary scores for low-income pre-school children. A later study of diverse young adults indicated that sleep quality and longer periods of insomnia may be associated with lower fruit and vegetable consumption by young men (Jansen et al., 2021).

Stress Reduction

Stress is a “normal psychological and physical reaction” to life's occurrences (Mayo Clinic, 2022), or the relationship of a person and the environment when they perceive they have inadequate resources to confront demanding situations (Araiza & Lobel, 2018). Stress is a prevalent phenomenon in the U.S. that can trigger physical and mental issues, as well as unhealthy behavioral practices. This reaction is exemplified through comfort food eating habits, also referred to as emotional eating wherein, caloric intake exceeds the body's physiological needs (Araiza & Lobel, 2018). To improve well-being and reduce stress, mindfulness-based stress reduction interventions are typically used in clinical and non-clinical settings (Keng et al., 2021).

Personality Traits

Although there is no clear consensus as to how to define personality (Bergner, 2019), the American Psychological Association (2022) defines personality as exemplifying individual characteristics and patterns of behavior that encompass “thinking, feeling, and behaving,” and that to acquire deeper meaning into one's personality, requires an understanding of how each of these characteristics relate to the person as a whole. There are numerous models that help to explain the association between personality and health outcomes (Wiebe et al., 2018). In fact, it has been asserted that personality fluctuates as “new behaviors are rewarded” and become habitual (McCloskey & Johnson, 2021, p. 1). Moreover, studies have been conducted that examined the link between personality and food choice and consumption habits (Machado-Oliveira et al., 2020).

Social Support

Reblin and Uchino (2008) describe how modern health research has explicated the role of social and emotional support as a protective factor for health and wellness. Why this relationship exists however, is an area for more inquiry (Reblin & Uchino, 2008). More recently, social support research from the COVID-19 pandemic has brought more clarity. For example, Zwart and Hines (2022) studied social support on physical activity in community recreation (biking, rock climbing, and paddling) and discovered prominent themes of a shared experience in nature as well as the group interaction in a community event. Similarly, socialization and spirituality were found to increase coping mechanisms that enhanced psychological wellbeing and healthy habits during the COVID-19 restriction period (Saud et al., 2021). While different age groups may have varied effectiveness, social support has been positively correlated with healthy behaviors and perceived wellbeing (Mo et al., 2022).

Conscientiousness

From a neurological perspective, consciousness has been defined as an inherent function of the brain that receives information, processes the information, and either rejects the information or stores it into memory through processes associated with reasoning, creativity and emotion, and the incorporation of the body's five senses (sight, sound, smell, taste, and touch) (Vithoulkas & Muresanu, 2014). Conscientiousness, as a personality construct, entails moving from awareness to goal-directed behavior that can be viewed as an indicator of performance and health outcomes (Duggan et al., 2014; Roberts et al., 2012). In Sawhney et al. (2020), higher levels of conscientiousness were associated with lower levels of loss of control of food intake, and lower BMI. In a recent study that examined whether gender differences impacted compliance with health measures, it was asserted that women scored higher in the application of conscientiousness in preventative health measures during a public health crisis, such as COVID-19 (Otterbring & Festila, 2021). Stieger et al. (2020) suggest when examining the correlation between conscientiousness and behavioral change associated with a physical activity intervention that individuals with a lower level of conscientiousness may benefit from enriched interventions that will ultimately increase conscientiousness.

Optimum State of Health

The World Health Organization (WHO) (2022) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” The WHO further elaborates that achieving an optimum state of health is a fundamental standard afforded to all humans despite differences in race, religion, political perspective, or socio-economic conditions. Sterling (2021) contends that when introduced to stressors, the body will attempt to adapt through physiological responses aimed at achieving physiological homeostasis, or a steady state. As it relates to school health, the WHO's Health Promoting Schools (HPS) framework is a whole-school health promotion approach that recognizes associations between health and education and the surrounding community in which schools reside (Langford et al., 2017).

Case Examples

The exemplars presented below represent model, borderline, related, and contrary cases. Walker and Avant's (2019) method also mentions the use of illegitimate and invented cases. All the cases below are invented but based on realistic scenarios from a school setting. Although the concept of wellness is vast, it is not likely to be used out of context, so a separate example of an illegitimate case was not used.

Model Case (Embeds All Defining Attributes)

Megan is eight years old, in the second grade, and her parents recently separated. Megan is an only child and developed Type 1 diabetes at age five. Both of Megan's parents are actively involved with her diabetes care, and they attend counseling as a couple and as a family. Megan can operate her insulin pump with adult supervision. She counts her carbohydrates at every meal and snack with her parents or school nurse. She explained diabetes to her class and described how she and her mother use the MyPlate information sent home from school to plan meals. Megan participates in soccer, dance class, and softball and socializes with a wide circle of peers. After some initial weight loss and unstable glucose fluctuations after diagnosis, Megan has maintained a healthy BMI and stable hemoglobin A1C levels. She exhibited signs of stress and insomnia after her parents separated, but talking to her school social worker weekly has alleviated this. The social work visits are now only as requested by Megan or her parents.

Megan is an example of how one may be a model case with a chronic condition. She exhibits all the defining attributes of healthy habits, conscientious choices, and an optimal state of health. Megan is incorporating wellness habits and choices that will maintain her health through adolescence and adulthood.

Borderline Case (Embeds Most of the Defining Attributes, but One or More May Differentiate It From a Model Case)

Ashley is 16-year-old and in eleventh grade. She is an honor student and a three-sport athlete. During the summer Ashley swims and is active as a counselor at the local YMCA children's program. Academic work comes very easily to Ashley, so she states there is only occasional school-life stress. She does not use drugs alcohol or tobacco and her diet includes five to seven fruit and vegetables per day. Over the last two years, her BMI has increased from 23 to 27. Her cholesterol and glucose were normal at her last physical. Ashley's mother is a type 2 diabetic, her maternal grandmother has been diagnosed with hypothyroidism and her paternal grandfather has had bypass surgery for five arterial blockages. Ashley's pediatrician has referred her to an adolescent endocrinologist.

Ashley is a borderline case because like the model case, Harry, she is mentally and physically healthy except for her increasing BMI which may have a genetic complication factor that is more difficult to control. Ashley consciously maintains healthy habits but needs further medical evaluation to ascertain if medical intervention is needed for her to stay in optimal health.

Related Case (May Include Some of the Defining Attributes, but Also May Include Some Attributes That Are Commonly Mistaken for the Defining Attributes of the Concept. The Borderline Case Includes Some, but Not All, of the Defining Attributes)

Josh is a 10-year-old boy in the fourth grade. His mother is a dietitian at the local hospital and provides Josh and his five-year-old sister with a balanced diet. Josh is active in all the community sports and plays outdoors most afternoons with neighborhood friends. He is close to his father who coaches some of his sports teams. In the past, Josh has done well academically with no behavior issues. Today at his yearly physical, Josh's BMI is in the 60th percentile. His mother tells the pediatrician that Josh's paternal grandfather (with whom he was very close) died unexpectedly last month in a motor vehicle accident. The parents are concerned because Josh wakes at all hours of the night crying from nightmares, is tired during the day, and is unable to concentrate in school or during homework time. The school counselor has reached out because Josh was in a fight yesterday during recess. Josh says, “The counselor is only for kids with problems, and everyone will make fun of me.” The pediatrician has referred the Josh to a center with professionals for grieving children and has scheduled a follow up office visit in two weeks.

Josh is a related case and if not for his school altercation, could be overlooked. On outward appearance he has healthy habits consistent with an active, well-nourished child. He needs assistance with sleep hygiene and stress management. Josh's mother has signed a FERPA/HIPAA release forms for the grief counselor to communicate with the school counselor for continuity of care. With the conscious assistance of Josh's mother, teachers, and health provider, he will be given assistance to work through his grief and return to his former optimum state of health.

Contrary Case (Does Not Contain Any of the Identified Defining Attributes)

Sarah is a 14-year-old girl who just began her first year of high school. She reports low energy and trouble sleeping. Sarah feels irritable when around others and develops headaches frequently. She typically skips breakfast and has a slice of pizza at school. On her way home she likes to run to the gas station for an energy drink. She typically makes a ham sandwich for dinner and occasionally takes a light walk around neighborhood with her dog. Her BMI is in the 65th percentile (normal weight). Her blood pressure and glucose are elevated for her age. Sarah is struggling to understand why she is feeling so groggy throughout the day. She is not overweight and “looks just like everyone else.” Her mom would like her to meet with a healthcare provider to improve her health. Sarah is hesitant because she believes she is healthy because of her normal body size.

Sarah is a contrary case. Her body weight is normal, but her lifestyle habits are poor and leading to negative health effects. She does not exhibit any healthy habits, consciously does not see a need for change, and physiologically and emotionally is not striving for an optimal state of health despite a normal BMI. An argument might be made that Sarah is an example of an illegitimate case if normal BMI is the only defining attribute one assigned to wellness.

Antecedents and Consequences

According to Walker and Avant (2019), antecedents are events that take place prior to the concept's occurrence, whereas consequences are the result of the occurrence of a concept. As such, antecedents cannot be a defining attribute (p. 178).

Antecedents

The following attributes and/or events must take place before the concept of wellness is achievable. The individual:

Genetic composition (Ding et al., 2009; Green et al., 2022; Morris et al., 2019)

Engages in good nutritional and lifestyle behaviors (Lee & Sibley, 2019).

Builds upon strengths and optimizes potential (McMahon & Fleury, 2012).

Connects with others (McMahon & Fleury, 2012; Watson, 2018).

Seeks meaning (McMahon & Fleury, 2012; Watson, 2018).

Has a support system in place (e.g., interpersonal level—family, peers; institutional level—schools, teachers, community events) (Mann et al., 2021; Salman et al., 2021; Watson, 2018).

Walker and Avant (2019) define consequences as the “result or the outcomes” of the concept (pp. 178–179).

Consequences

Possible consequences associated with wellness acquisition include:

Healthy behaviors are maintained that become habits (Adhikari & Gollub, 2021).

Increased fruit/vegetable consumption and exercise (Lee & Sibley, 2019).

Maintaining a healthy diet (Lee & Sibley, 2019).

Increased life expectancy (Green et al.; McMahon & Fleury, 2012; Morris et al., 2019).

Empirical Referents

Walker and Avant (2019) advocate identification of empirical referents (ER) to measure any manifestations of the concept. Empirical referents are ‘‘classes or categories of actual phenomena that by their existence demonstrate the occurrence of the concept itself’’ (p. 179). The ERs should demonstrate or link the defining attributes. There are many ways to identify ERs most appropriate to the school setting. The first and foremost is the regular mandated evaluation of the school wellness policy (every three years). Through data collection and review processes, the most appropriate ERs might be identified for that school or district (USDA, 2016). For example, we identified the defining attributes of wellness as healthy habits, conscientiousness, and achieving optimal health. Robust staff and student knowledge of a healthy nutrition model such as MyPlate national nutrition guidelines (USDA, 2022a, 2022b) might be chosen as an ER through documented education and surveys. Education initiatives such as MyPlate serve as a conscious effort to promote healthy habits leading to optimal health for both students and staff.

The School Health Index (SHI): Self-Assessment & Planning Guide (CDC, 2019b) is another tool the school wellness committee may use to identify ERs. The SHI was developed by the CDC in partnership with key school and community stakeholders to assist schools in identifying health promoting behaviors. Currently the SHI focuses on seven topics which are applicable to all in a school setting. Common wellness initiatives such as physical activity and nutrition are addressed along with chronic conditions, drug/alcohol use, injuries/violence, and sexual health. Many school districts use the SHI in conjunction with the wellness policy to identify ERs such as education, activities, and services.

Implications for School Nurses

Nursing is grounded in health promotion and health restoration (American Nurses Association [ANA], 2021). The philosophical worldview of the discipline embodies the ontological relationship across four domains involving nurse, person, environment, and health. This dynamic relationship puts into perspective that nursing has and continues to contribute to the health and well-being of the population its serves across nursing roles and varying environments (Bender, 2018). As a nursing sub-specialty, school nursing employs the public health model where population health management is central when implementing interventions targeted at school-aged children (National Association of School Nurses [NASN], American Nurses Association [ANA], 2020; Jameson et al., 2022; Schaffer et al., 2016). The National Academies of Sciences, Engineering, and Medicine (2021) acknowledge “school nurses bridge the gap between health care and educational institutions” (p. 108). As such, the health of students is vital, and school nurses strive to ensure that students are afforded the opportunity to achieve optimum health and optimum academic success through the school nurse's application of nursing knowledge, expertise, skills, primary health management, and prevention education. It has been affirmed that student readiness to learn is strongly correlated with health, and that education is a social determinant aligned with resources and conditions capable of predicting future health outcomes and success achievement (Davis et al., 2021; Johnson, 2017; Lloyd et al., 2019; Rattermann et al., 2021; Reising & Cygan, 2022).

School nurses also have a key role in the health of their communities and are essential resources to school districts (Bobo et al., 2022; Johnson, 2017) since they possess a clinical perspective on wellness that is anchored in holism, social determinants, barriers to health, early risks, and disease indicators (Bobo et al., 2022). Lee et al. (2022) assert that due to the interdisciplinary nature of the school environment, school nurses are positioned to advocate for school-based wellness environment assessments, and policy promotion. Enabling school nurses to be champions of wellness in schools empowers school nurses to develop and implement health policies that promote healthy eating habits, reduce obesity, and improve student academic achievement (Schultz & Thorlton, 2019), and to be part of the school-led team that evaluates whether wellness programs and/or interventions are achieving desired outcomes (Lee et al., 2022).

Conclusion

Wellness, from the context of school settings, is a phenomenon that is insufficiently studied. In this concept analysis paper, wellness is presented through defining attributes encompassing the practice of engaging in individualistic healthy habits, conscientiousness, as a personality construct that moves individuals from awareness to goal-directed behavior, and the achievement of realizing holistic optimum state of health at the physical, mental, and social measures. Empirically based antecedents and consequences are presented, along with empirical referents. In alignment with the nursing metaparadigm involving the domains of nurse, person, health and environment, school nurses as leaders and advocates can help bridge the gap between student health and educational outcomes through interdisciplinary wellness programing, policy endorsement, and assessment endeavors.

Supplemental Material

sj-docx-1-jsn-10.1177_10598405231165510 - Supplemental material for Exploring Wellness Through Concept Analysis

Supplemental material, sj-docx-1-jsn-10.1177_10598405231165510 for Exploring Wellness Through Concept Analysis by A. Skarbek, PhD, RN, P. Endsley, MSN, PhD, RN, NCSN, M.S. Chrisman, PhD, M. Hastert, MS, RD, LD, and C. Stellwagen, RN, BSN in The Journal of School Nursing

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

P. Endsley

M.S. Chrisman

C. Stellwagen

Supplemental material

Supplemental material for this article is available online.

Author Biographies

A. Skarbek, PhD, RN is the RN-BSN Program Director and Clinical Associate Professor at The University of Missouri, Kansas City.

P. Endsley, MSN, PhD, RN, NCSN is the school nurse at Wells High School, Wells ME, USA.

M.S. Chrisman, PhD is an Assistant Professor in the Health Studies Program, University of Missouri, Kansas City School of Nursing and Health Studies, Kansas City, MO, USA.

M. Hastert, MS, RD, LD is a PhD student, research coordinator, and Registered Dietitian at the University of Kansas Medical Center, Kansas City, Kansas, USA.

C. Stellwagon, RN, BSN is an RN to BSN graduate of the University of Missouri, Kansas City, USA.

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