Abstract
Background
Child wellness is a multidimensional construct encompassing physical, mental, and social well-being, and schools are recognized as critical settings for integrated health promotion. School nurses play a central role within these systems; however, evidence regarding the scope, contextual variability, and effectiveness of nurse-led interventions remains fragmented. The Whole School, Whole Community, Whole Child (WSCC) framework provides a comprehensive model for understanding how school health services contribute to child wellness across multiple domains.
Objective
This systematic review aimed to synthesize recent evidence on school nurse–led interventions and evaluate their contributions to multidimensional child wellness within the WSCC framework.
Methods
A systematic review was conducted following PRISMA 2020 guidelines. Five databases (PubMed, CINAHL, Scopus, Web of Science, and PsycINFO) were searched for studies published between January 2020 and June 2025. Studies were screened independently by two reviewers using predefined inclusion criteria. Methodological quality was assessed using Joanna Briggs Institute tools. Due to heterogeneity in study designs and outcomes, a narrative thematic synthesis was performed, and findings were mapped onto WSCC components.
Results
Seventeen studies met the inclusion criteria. Interventions were categorized into five domains: health education (n = 9), mental health support (n = 6), chronic disease management (n = 7), hygiene and infection control (n = 5), and interdisciplinary collaboration (n = 8). Interventions were associated with improvements in health knowledge, behavioral outcomes, mental health indicators, and disease management. However, substantial variability in nurse roles and health system contexts limited comparability, and several WSCC components remained underrepresented.
Conclusion
School nurses play a critical role in promoting multidimensional child wellness. Nevertheless, limited evidence and contextual heterogeneity constrain generalizability, highlighting the need for standardized, context-sensitive, and longitudinal research.
Keywords
Introduction
Child wellness is a multidimensional construct encompassing physical, mental, emotional, and social well-being, and it represents a fundamental determinant of healthy development, academic achievement, and long-term population health outcomes (World Health Organization [WHO], 2020). Schools are widely recognized as critical environments for promoting child health due to their sustained access to children and adolescents and their capacity to integrate educational and health-related interventions. Despite this potential, multiple challenges continue to affect child wellness in school settings, including increasing mental health concerns, rising prevalence of chronic conditions such as asthma and obesity, and persistent gaps in health literacy and preventive behaviors (Bergren et al., 2021; Maughan et al., 2021). These challenges are particularly pronounced in resource-constrained or crisis-affected contexts, where access to healthcare services outside schools may be limited.
Within this context, school nurses play a central and strategic role in addressing child health needs. As licensed healthcare professionals embedded in educational systems, school nurses contribute to health promotion, disease prevention, early identification of health problems, and coordination of care among students, families, and healthcare providers (Bergren et al., 2021; Maughan et al., 2021). Empirical evidence indicates that school nurse–led interventions are associated with improved vaccination coverage, enhanced chronic disease management, and better mental health outcomes among students (Smith et al., 2022; Wing et al., 2024). However, the scope and implementation of school nursing practice vary considerably across countries, reflecting differences in policy frameworks, workforce capacity, training standards, and resource availability. Such variability raises important concerns regarding the comparability and generalizability of findings across diverse settings.
The Whole School, Whole Community, Whole Child (WSCC) framework provides a comprehensive model for understanding how school health systems can support child wellness through coordinated, multisectoral approaches (Lewallen et al., 2015). The WSCC framework includes ten interconnected components: health education; physical education and physical activity; nutrition environment and services; health services; counseling, psychological, and social services; social and emotional climate; physical environment; employee wellness; family engagement; and community involvement. This model emphasizes that child wellness is shaped by integrated systems rather than isolated interventions. School nurses contribute directly to several of these components, particularly health services, health education, and psychosocial support, while also facilitating collaboration across broader domains. Importantly, interventions may align with multiple WSCC components simultaneously, reflecting the multidimensional nature of child wellness.
Existing literature reviews have often focused on specific health outcomes or single intervention types, limiting their ability to capture the full scope of school nursing contributions to child wellness (Maughan et al., 2021). Furthermore, limited attention has been given to how contextual differences such as variations in school health systems, nurse roles, and policy environments may influence the effectiveness and implementation of interventions. Aggregating findings across heterogeneous contexts without adequately addressing these differences may reduce the interpretability and external validity of conclusions. In addition, the relatively small number of recent empirical studies necessitates cautious interpretation of the available evidence.
The period from 2020 onward has been particularly significant due to the COVID-19 pandemic, which expanded the responsibilities of school nurses in areas such as infection prevention, health education, contact tracing, and psychosocial support (Chen et al., 2023; Maughan et al., 2021). This expansion has underscored both the essential role of school nurses and the structural limitations within school health systems, including role ambiguity and insufficient integration into policy frameworks.
Given these considerations, a comprehensive and conceptually grounded synthesis of recent evidence is warranted. Therefore, this systematic review aims to examine school nurse–led interventions and their contributions to child wellness across physical, mental, and social domains. Specifically, the review seeks to identify the types of interventions implemented by school nurses, evaluate their reported outcomes, examine how contextual variability influences findings, and map these interventions onto the WSCC framework. By integrating recent evidence within a structured conceptual model, this review aims to provide a nuanced understanding of the role of school nurses in promoting child wellness and to inform future research, policy, and practice.
Aim of the Study
This systematic review aims to synthesize evidence on school nurse–led interventions and their contribution to child wellness. It evaluates outcomes across physical, mental, and social domains, examines contextual variability across settings, and maps interventions onto the Whole School, Whole Community, Whole Child (WSCC) framework to enhance conceptual understanding and interpretation.
Methods
Study Design
This systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA, 2020) statement. The review aimed to synthesize recent empirical evidence regarding school nurse-led interventions and their contribution to child wellness across physical, mental, social, and behavioral domains. Because substantial heterogeneity was anticipated in study designs, intervention characteristics, and outcome measures, a narrative synthesis approach was selected rather than quantitative meta-analysis.
Protocol and Registration
A review protocol was developed prior to commencement of the study to guide the review process, eligibility criteria, search strategy, screening procedures, and synthesis methods. Although the protocol was not prospectively registered in an international database such as PROSPERO, a preliminary scoping search of PubMed, CINAHL, Scopus, Web of Science, and PsycINFO was undertaken before formal screening. This search did not identify any published or ongoing systematic review specifically focused on the role and effectiveness of school nurses in promoting child wellness. The absence of formal registration is acknowledged as a methodological limitation.
Eligibility Criteria
Eligibility criteria were established using the PICOS framework. The population of interest comprised school-aged children and adolescents between 5 and 18 years enrolled in primary or secondary educational settings. Studies involving teachers, parents, or school personnel were eligible only when reported outcomes were directly related to student health or wellness.
Eligible interventions included school nurse-led or school nurse-supported initiatives such as health education, mental health promotion, chronic disease management, hygiene promotion, infection prevention, screening programs, counseling support, referral coordination, and interdisciplinary health initiatives implemented within school settings. The context included public or private school environments across all countries and healthcare systems. Outcomes of interest included indicators of child wellness encompassing physical health outcomes, health behaviors, disease control, psychological well-being, stress, anxiety, coping, school engagement, attendance, and social or behavioral functioning. Quantitative, qualitative, and mixed-methods primary research studies were eligible. Only peer-reviewed articles published in English between January 2020 and June 2025 were included. Editorials, commentaries, protocols, dissertations, conference abstracts, grey literature, and studies without direct school nurse involvement were excluded.
Information Sources and Search Strategy
A comprehensive literature search was conducted in PubMed, CINAHL, Scopus, Web of Science, and PsycINFO. Searches were completed in June 2025, and all eligible studies published from January 2020 to June 2025 were considered. Search strategies combined controlled vocabulary terms, where applicable, with free-text keywords related to school nursing, child wellness, student health, and school-based interventions. A representative search strategy used in PubMed was as follows: (“school nurse*” OR “school nursing”) AND (“child wellness” OR “student health” OR “health promotion”) AND (“school-based intervention*” OR “school program*”). To enhance comprehensiveness, the reference lists of all included studies and relevant review papers were manually screened. In addition, key journals related to school health, pediatric nursing, and public health were hand-searched to identify potentially relevant studies not captured through electronic database searches. Records identified through these supplementary methods were incorporated into the PRISMA flow diagram.
Study Selection
All retrieved citations were exported to reference management software for duplicate identification and removal. Screening was conducted in two sequential stages consisting of title and abstract review followed by full-text eligibility assessment. Two reviewers independently assessed all records against the predefined inclusion and exclusion criteria. Any disagreements were resolved through discussion and consensus, and when required, a third reviewer was consulted.
Inter-reviewer agreement for full-text screening was high, with a Cohen’s kappa coefficient of 0.84, indicating strong consistency between reviewers. Reasons for exclusion at the full-text stage were documented to ensure transparency and reproducibility.
Data Extraction
Data extraction was performed independently by two reviewers using a standardized extraction template developed for this review. Extracted variables included author name, year of publication, country, study design, sample size, participant characteristics, description of school nurse roles, intervention content, duration of intervention, measured outcomes, key findings, and contextual factors influencing implementation. Where discrepancies in extracted data occurred, the original article was rechecked and agreement was reached through discussion. Final extracted data were verified before synthesis.
Methodological Quality Appraisal
Methodological quality was assessed using the Joanna Briggs Institute Critical Appraisal Tools appropriate to each study design. These instruments evaluate methodological domains such as sampling adequacy, validity and reliability of measurements, management of confounding factors, completeness of follow-up, and appropriateness of statistical analysis.
Two reviewers independently appraised study quality. Studies meeting 70% or more of applicable criteria were categorized as high quality, those meeting 50% to 69% were categorized as moderate quality, and those meeting less than 50% were categorized as low quality. No studies were excluded on the basis of quality appraisal; however, appraisal findings informed interpretation of the overall evidence base.
Risk of Bias Assessment
Risk of bias was considered at the individual study level through the JBI appraisal process. Common methodological concerns included reliance on self-reported outcomes, non-randomized designs, short follow-up periods, small sample sizes, and inadequate adjustment for confounding variables. Because of heterogeneity in methods and outcomes, publication bias assessment and meta-analytic statistical tests were not appropriate.
Data Synthesis
A narrative synthesis was undertaken following established guidance for synthesizing heterogeneous evidence. The synthesis process involved repeated reading of included studies, coding of intervention characteristics and outcomes, grouping findings into thematic categories, and comparing patterns across studies.
Five overarching themes were identified: health education and promotion, mental health support, chronic disease management, hygiene and infection control, and interdisciplinary collaboration. These themes were subsequently mapped to the WSCC Framework to examine how school nurse-led interventions contributed to multidimensional child wellness. Studies were permitted to align with more than one WSCC component where appropriate, reflecting the integrated nature of school nursing practice. Findings were interpreted cautiously in light of contextual variability across countries, differences in school health systems, and methodological diversity among included studies.
Ethical Considerations
Ethical approval was not required because this study involved analysis of previously published literature and did not include direct participation of human subjects.
Results
Study Selection
The study selection process was conducted in accordance with the PRISMA 2020 statement. A total of 1,992 records were identified through electronic database searching across PubMed, CINAHL, Scopus, Web of Science, and PsycINFO. In addition, 12 records were identified through other methods, including manual reference list screening (n = 8) and hand-searching of relevant journals (n = 4). Following removal of duplicate records (n = 1,083), 921 unique records remained for title and abstract screening. During the initial screening stage, 816 records were excluded because they did not meet the predefined eligibility criteria. Common reasons for exclusion included lack of relevance to school nurse-led interventions, outcomes unrelated to child wellness, non-school-based settings, and non-empirical publications.
A total of 105 full-text reports were sought for retrieval, all of which were successfully obtained and assessed for eligibility. After full-text review, 88 reports were excluded for the following reasons: failure to address the research question (n = 35), ineligible population (n = 15), non-original research design such as editorials or opinion papers (n = 6), limited relevance to the topic or outcomes of interest (n = 22), and inaccessible or incomplete full-text information (n = 10). Ultimately, 17 studies met all inclusion criteria and were included in the qualitative synthesis. The full study identification, screening, eligibility assessment, and inclusion process is presented in Figure 1. PRISMA 2020 flow diagram describing study selection for systematic review
Characteristics of Included Studies
The included studies (n = 17) were published between 2020 and 2025 and represented diverse geographical contexts, including North America, Europe, Asia, and the Middle East. The United States contributed the largest number of studies (n = 5), followed by South Korea (n = 2) and Jordan (n = 2). Additional studies were conducted in Portugal, Egypt, Vietnam, Spain, Kuwait, Taiwan, the United Arab Emirates, and the United Kingdom.
Characteristics, School Nurse Roles, Outcomes, and Methodological Quality of Included Studies (n = 17)
Methodological Quality
Quality appraisal using Joanna Briggs Institute (JBI) tools indicated that 11 studies (65%) were of high methodological quality, while 6 studies (35%) were rated as moderate. High-quality studies demonstrated clearly defined objectives, appropriate study designs, and valid outcome measures. However, several methodological limitations were identified, including reliance on self-reported data (Nguyen & Tran, 2021), limited follow-up periods (Lee et al., 2023), and inadequate control of confounding variables (Ahmed et al., 2025). These limitations should be considered when interpreting the findings (Table 1).
Thematic Synthesis of School Nurse–Led Interventions
Five major themes were identified through narrative synthesis: 1. Health education and promotion (n = 9) 2. Mental health support (n = 6) 3. Chronic disease management (n = 7) 4. Hygiene and infection control (n = 5) 5. Interdisciplinary collaboration (n = 8)
Mapping of School Nurse–Led Interventions to WSCC Components and Child Wellness Domains (n = 17)
Health Education and Promotion
Nine studies examined nurse-led educational interventions targeting nutrition, physical activity, and general health literacy. These interventions were associated with improved health knowledge and behavioral changes, including increased fruit and vegetable intake (Nguyen & Tran, 2021) and enhanced parental perceptions of children’s health behaviors (Pereira et al., 2023).
Mental Health Support
Six studies focused on mental health interventions, including screening, psychoeducation, and referral coordination. Interventional studies reported reductions in stress and anxiety and improvements in coping strategies (Lee et al., 2023; Rawahneh et al., 2025). Qualitative findings further highlighted the role of school nurses in early identification and support of psychological distress (Baker & Thompson, 2020).
Chronic Disease Management
Seven studies addressed chronic disease management, including asthma, epilepsy, and obesity. Interventions involving individualized care plans and family education improved disease control and adherence (Hasan et al., 2025; Wing et al., 2024), while school-based obesity interventions resulted in improved body mass index and dietary behaviors (Al-Mutairi et al., 2022).
Hygiene and Infection Control
Five studies evaluated infection prevention interventions. These were associated with improved hygiene practices, increased knowledge, and reduced infection rates (Chen et al., 2023; Kamal et al., 2023). These interventions combined educational and service-based components, reflecting their multidimensional nature.
Interdisciplinary Collaboration
Eight studies emphasized collaboration between school nurses, teachers, families, and healthcare providers. Collaborative interventions improved physical activity levels (Johnson & Harris, 2024), enhanced policy awareness (Chrisman et al., 2024), and strengthened referral systems (Rodriguez & Clark, 2021).
Mapping to the WSCC Framework
Mapping of interventions to the Whole School, Whole Community, Whole Child (WSCC) framework demonstrated that school nurse–led interventions most frequently aligned with Health Education, Health Services, Counseling/Psychological Services, Physical Environment, Family Engagement, and Community Involvement (Lewallen et al., 2015).
Studies were mapped to WSCC components based on intervention characteristics, objectives, and reported outcomes. Importantly, several studies aligned with multiple WSCC domains simultaneously. For example, hygiene interventions were associated with Health Education, Health Services, and Physical Environment (Chen et al., 2023; Kamal et al., 2023), while mental health interventions aligned with Counseling Services and Social and Emotional Climate (Lee et al., 2023). Figure 2 illustrates this multidimensional alignment, demonstrating that school nurse–led interventions operate across interconnected WSCC domains rather than within a single category. Despite this, several WSCC components particularly employee wellness and system-level policy integration were underrepresented, indicating gaps in the current evidence base. Mapping of school nurse-led interventions to components of the whole School, Whole Community, Whole Child (WSCC) framework
Consideration of Contextual Variability
Substantial variability was observed across studies in school health systems, nurse roles, and policy environments. In high-income countries, school nurses often operated within structured systems with clearly defined roles and multidisciplinary support (Bergren et al., 2021). In contrast, studies from resource-limited contexts emphasized basic preventive and educational services (Kamal et al., 2023). This variability influenced both implementation and outcomes. Although synthesis allowed identification of common intervention patterns, aggregation of heterogeneous studies should be interpreted cautiously, as contextual differences limit comparability and generalizability. The relatively small number of included studies further constrains the strength of conclusions.
Discussion
This systematic review synthesized evidence from 17 studies published between 2020 and 2025 examining the role and effectiveness of school nurses in promoting child wellness across physical, mental, social, and behavioral domains. Overall, the findings indicate that school nurses make meaningful contributions to student well-being through health education, chronic disease management, mental health support, infection prevention, and interdisciplinary coordination. However, the strength and transferability of these findings should be interpreted in light of contextual variability, methodological heterogeneity, and the relatively limited number of recent empirical studies.
A major finding of this review was the consistent contribution of school nurses to health education and health promotion. Several included studies reported improvements in nutrition knowledge, hygiene practices, health literacy, and positive behavioral change following nurse-led educational interventions. For example, students exposed to structured health promotion activities demonstrated increased healthy eating behaviors and stronger adherence to preventive practices. These findings align closely with the Health Education component of the WSCC Framework, which emphasizes the importance of evidence-based instruction that supports lifelong health behaviors (Lewallen et al., 2015). Prior literature has similarly shown that school nurses are well positioned to deliver accessible and developmentally appropriate health education within school environments (Maughan et al., 2021).
Mental health support emerged as another prominent theme. Included studies examining stress management, emotional support, referral systems, and anxiety reduction reported favorable outcomes, particularly where school nurses were integrated into multidisciplinary student support systems. These findings are especially relevant given the increasing prevalence of emotional distress, anxiety, and school-related stress among children and adolescents worldwide. Within the WSCC model, these functions correspond primarily to Counseling, Psychological, and Social Services as well as the Social and Emotional Climate domain (Lewallen et al., 2015). Previous evidence has highlighted that school nurses often serve as early identifiers of psychological distress and trusted first points of contact for students reluctant to seek formal mental health care (Bergren et al., 2021). Therefore, strengthening the mental health capacity of school nurses may represent a practical strategy for improving early intervention in school settings.
The review also demonstrated the importance of school nurses in chronic disease management. Studies involving asthma, epilepsy, obesity, and other ongoing health conditions reported improvements in medication adherence, symptom control, reduced absenteeism, and enhanced family communication. These findings strongly reflect the Health Services component of the WSCC framework, which emphasizes coordinated care, access to services, and continuity of support for students with health needs (Lewallen et al., 2015). Existing evidence has similarly shown that effective management of chronic illness in schools is associated with improved academic attendance, classroom participation, and quality of life (Wing et al., 2024). As the prevalence of pediatric chronic conditions continues to rise globally, the role of school nurses in long-term monitoring and individualized care planning is likely to become increasingly important.
Hygiene promotion and infection prevention were also frequently identified, particularly during the review period spanning the COVID-19 pandemic. Included studies reported improved hand hygiene, infection awareness, and preventive behaviors following school nurse-led interventions. During the pandemic, school nurses assumed expanded responsibilities including symptom surveillance, health communication, contact tracing support, vaccination coordination, and guidance for safe school reopening (Chen et al., 2023; Maughan et al., 2021). These functions align with multiple WSCC domains, including Health Services, Health Education, and Physical Environment. The pandemic highlighted both the essential value of school nurses and the structural limitations faced in some systems, such as workforce shortages, role ambiguity, and insufficient policy integration.
Interdisciplinary collaboration represented another important theme. Several studies showed that partnerships between school nurses, teachers, families, administrators, and external healthcare providers were associated with stronger referral pathways, improved physical activity initiatives, and broader health promotion outcomes. This finding is consistent with the Family Engagement and Community Involvement domains of the WSCC framework, which recognize that child wellness is influenced by coordinated relationships extending beyond the classroom (Lewallen et al., 2015). School nurses frequently function as connectors between education and healthcare sectors, translating clinical needs into practical school-based support plans. Consequently, maximizing their effectiveness may depend not only on individual competence but also on the strength of collaborative systems surrounding them.
Despite these positive findings, several WSCC domains were comparatively underrepresented in the included evidence base, including employee wellness, organizational policy leadership, and broader nutrition service systems. This may suggest that school nurses are often concentrated in direct student-facing clinical and educational roles rather than leadership or systems-level functions. Expanding school nurse involvement in strategic planning, policy development, and staff wellness initiatives could strengthen whole-school approaches to health promotion and generate broader institutional benefits.
Contextual variability across countries and school systems must also be considered. Studies from higher-income settings often described clearer professional scopes of practice, stronger staffing models, and greater access to multidisciplinary resources. In contrast, studies from resource-limited contexts more commonly emphasized essential preventive services and basic health education. These differences likely influence both implementation fidelity and measured outcomes. Accordingly, findings should not be interpreted as uniformly transferable across all educational systems. Context-sensitive adaptation is particularly important in underserved, rural, humanitarian, or conflict-affected settings where child health needs may be substantial but institutional resources remain constrained.
The methodological quality of included studies was generally moderate to high; however, several limitations remain within the evidence base. Many studies relied on cross-sectional or quasi-experimental designs, self-reported outcomes, relatively short follow-up periods, and heterogeneous outcome measures. These issues limited direct comparability and precluded meta-analysis. Therefore, although the overall direction of evidence was favorable, stronger causal conclusions require cautious interpretation. Future research should prioritize longitudinal and experimental designs, standardized wellness indicators, and economic evaluations to better estimate the sustained impact of school nurse-led services.
Strengths and Limitations
This review has several strengths, including adherence to PRISMA 2020 guidance, inclusion of multiple international databases, structured quality appraisal using Joanna Briggs Institute tools, and conceptual mapping of findings to the WSCC framework. Nevertheless, limitations should be acknowledged. Only English-language studies were included, unpublished literature was excluded, the number of eligible studies was modest, and substantial heterogeneity existed across interventions and outcomes. These factors may limit generalizability and introduce publication bias.
Implications for Practice and Research
The findings support continued investment in school nursing as an essential component of child wellness systems. Policymakers and educational leaders should consider strengthening staffing capacity, clarifying professional roles, and integrating school nurses into mental health, chronic disease, and emergency preparedness planning. Future studies should examine outcomes in low-resource settings, compare staffing models, and evaluate long-term effects on both health and academic performance.
Conclusion
School nurses play a substantial and multidimensional role in promoting child wellness. Their contributions are most evident in health education, mental health support, chronic disease management, infection prevention, and collaborative care. The WSCC framework provides a useful lens for understanding these diverse functions. Strengthening evidence quality and ensuring context-responsive implementation will be essential to maximize the future impact of school nursing services.
Footnotes
Acknowledgements
We would like to express our sincere gratitude to all individuals who have contributed to this research.
Author Contributions
all author contributed equally to the conception, design, data collection, analysis, and writing of this manuscript. authors read and approved the final version of the paper.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.