School nurses and menstrual communication: Destigmatizing the stigma among adolescents

Abstract

Objective:

The purpose of this study is to understand how school nurses, often the first line of defense for menstruating adolescents, use communication to assist adolescents in destigmatizing menstruation.

Design:

I conducted semi-structured narrative interviews with nine nurses employed in a large school district in Northeast Indiana.

Methods:

Interviews were coded, categorized, and used a phronetic iterative approach.

Results:

Analysis determines that nurses assist menstruating students using steps toward accepting menstruation and suggesting ways to avoid menstrual stigmatization.

Conclusion:

This study suggests that school nurses use positive language to assist students in handling their menstruation problems, develop allyships with parents and other teachers, and stress menstrual education. This study highlights the need for more funding for menstrual products and additional school nurses.

Introduction

The lack of menstrual product access and education within US schools has health and social implications. ¹ Not all states require sex education nor do all states require menstruation education ² ; even the states that do have requirements vary on when and how many menstrual education courses are offered. ³ Access to adequate supplies and education is hindered by state laws promoting menstrual products as luxury items ⁴ or abstinence-only sex education curricula, focusing more on abstinence rather than the bodies’ biological functions. ⁵ The lack of policies surrounding sex education and states varying stances on menstruation contribute to a gap in menstruation education among adolescents. ⁶

Girls, around the country, lack adequate menstrual knowledge and guidance from home or school. ⁶ Students, as young as sixth grade, may claim to be knowledgeable about menstruation but their reflections contain a variety of misconceptions, ignorance, or incomplete knowledge. ⁷ School nurses have a complex role in treating health problems while improving the education experience. ⁸ Only 40% of schools in the United States require a school nurse. ⁹ Among those districts with school nurses, their role is to keep kids healthy so they can learn. ¹⁰ School nurses are often the only point of contact between a student and the local healthcare system, ⁹ which is why many school districts find their school nurses to be a hidden gem when it comes to helping students with menstruation needs and education. ⁶

Because of menstrual problems, many adolescents miss class. ¹¹ Others fear using the bathroom during their menstrual flow or seeking help with menstrual needs within school settings. ¹² Nearly three-fourth of nurses surveyed admitted that many school bathrooms are not stocked with menstrual products, ¹³ leaving many students to go without nor do they track down a staff member who has products. School nurses help students with their menstrual product needs by having products in their offices ¹² and are prepared to deliver menstruation education if needed. ¹¹

School nurses are instrumental in assisting and educating students about menstruation. A 2019 comprehensive review of public school nurse practices does not even mention how school nurses handle menstruation issues, ⁹ despite menstruation being linked to adolescents’ mental state. This is despite school nurses providing education and keeping menstrual products stocked in their offices.^2,11,14 One purpose of this study is to examine how school nurses communicate with menstruating adolescents to address this lack of knowledge.

Not being able to afford menstrual products to meet one’s needs impacts mental health. ¹⁵ Adolescents fear being stigmatized due to their mental health concerns, ¹⁶ hence facing possible stigmatizing with their menstruation concerns. School nurses are there to assist students with these mental health and menstruation questions. ⁹ Yet, scholarship falls short of uncovering how nurses use communication to destigmatize menstruation among adolescents. The second purpose of this study is to examine the communication school nurses use to assist adolescents with their menstrual needs.

School nurses

Many families rely on the American education system to teach their children about menstruation. ¹² This education and responsibility often fall to school nurses. ¹⁴ They are leaders in preparing and delivering comprehensive menstruation education that adequately prepares students for the experience of menstruation. ¹¹ First-time menstruators may receive their first menstruation message from the school nurse. These first messages are instrumental in what is said and how it is said as messages impact their neurological and physical development. ¹⁷ What school nurses convey to young menstruators may have lasting consequences.

While many school districts around the country epitomize school nurses as the center of menstruation education, schools face barriers when it comes to educating youth about menstruation. First, a National Association of School Nurses (NASN) report shared that approximately 40% of schools employ a full-time nurse, 35% a part-time nurse, and nearly 25% of schools have no nurse at all.^10,12 School nurses are vital to providing education and keeping kids healthy, yet nurses seem to be hard to find due to budget cuts ¹⁰ or are spread too thin. For example, a large school district in Northeast Indiana has 52 individual schools yet many of these schools share a nurse. Hence, some schools do not have a nurse on staff every day of the school week.

If schools are lucky to have nurses, whether they have access to free menstrual products is another issue. Only one-third of states passed laws that provide school districts with free menstrual products; Republican-led states lag in passing such legislation. ¹⁸ Some menstruators faced a lack of access to products resulting in some suggesting that menstrual products be treated as essential items. ¹⁹ Lack of access to products results in some students having to choose between buying food and menstrual products. Students of color and Latinx students were impacted by menstrual product insecurity during COVID-19; returning to school made it easier to access menstrual products. ¹⁹

Even if school districts have enough nurses and do provide products, school nurses still have barriers. School nurses receive limited knowledge and skills regarding menstruation pedagogy, do not understand cultural differences regarding menstruation, or do not have access to up-to-date resources. ²⁰ First, school nurses may lack the education or skills to teach students about menstruation.^2,20 While they understand the biological functions and reasoning behind menstruation, some lack the necessary teaching or presentation skills. Despite the lack of knowledge, school nurses feel competent in advising and assisting students with menstruation-related issues. ²¹ Next, school nurses are aware that many students cannot afford to purchase menstrual products and they are not always in the position to provide products to these students since some nurses report running out of products before the end of the school year. ² College students reported not being able to afford to buy products during a semester, forcing them to choose between food and menstrual products. ¹⁵ Finally, school nurses know that menstruation contributes to absenteeism. ²² The lack of products forces some women to make do with other materials or go without. Because of this, their lack of access contributes to a menstrual stigma reinforcing the notion that menstrual issues should be kept private. ¹⁹ At the school level, school nurses lack resources to support students to help reduce these absences. ² Some students become dependent on social services or nonprofits providing menstrual products; hence, during times of school closure, they lack a resource to obtain additional products. ¹⁹

In summary, despite limited menstrual pedagogy knowledge, school nurses are a valuable resource to assist students with their menstruation questions and issues. Few studies touched on communication skills. School nurses actively listen to students’ menstrual pain narratives to assist them. ²³ This occurs even if school nurses lack community or school resources to assist the girls further. Second, research focuses on school nurses communicating at the group level ¹⁴ ; yet some argue that school nurses need to address the students at an interpersonal level. ²¹ However, school nurses may lack the skills necessary to be successful in interpersonal situations. ²³

Knowing how school nurses communicate with menstruators sets the foundation to explore how school nurses describe their communication with menstruating adolescents. Adolescents may hesitate about asking for help and first-time menstruators self-silence themselves. Lack of knowledge on reproductive issues influences the self. ²⁴ Since society’s narrative stigmatizes menstruation, ²⁵ first-time menstruators may know that menstruation is occurring but seek to isolate themselves by wanting to be alone, not wanting to be around anybody, or not seeking help. ¹⁶ This is where the school nurse comes in.

• RQ1: How do school nurses use communication with menstruating individuals?

The following section explores stigma communication and stigma management communication (SMC) as the theoretical foundation to define menstrual stigmatization.

Stigma communication

Definitions of stigma set the foundation for this study by examining definitions that encompass either the individual or society. First, Stigma is felt and enacted. ²⁶ Menstruating individuals “feel” the process starting and they “enact” the process of managing their menses. Menstruation is also “felt” as it symbolizes shame and embarrassment.^25,26 Hence, menstruators stigmatized their experiences. ²⁵ Second, communication scholarship embraces stigma as “a simplified, standardized image of the disgrace of certain people that are held in common by a community at large.” ²⁷ For nearly a century, the act of menstruation has been silenced or tabooed, conflicting with the need for many to talk about it. ²⁸

Stigmatizing menstruation paves the way to argue for a definition of menstrual stigmatization. Menstrual stigma is defined as “as the internal and external devaluation of menstruation through the power-laden communication acts of labeling, marking, assigning personal responsibility, and attributing peril.” ²⁹ Given the focus of this study is how school nurses use communication with menstruating adolescents, defining menstrual stigmatization will be focused through the lens of one’s internal thoughts and behaviors.

Menstrual stigmatization

First, menstrual stigmatization can occur internally within the stigmatized individual. Societal menstruation narratives focus on the cultural beliefs, actions, thoughts, and feelings of community members with power. ²⁹ New menstruators are exposed to this narrative either directly or indirectly. Internalizing menstrual stigma occurs as menstruators want to challenge these beliefs and actions but remind themselves that we do not talk about menses. Menstruation silence leads to negative self-talk, which then impacts one’s mental health. As mental health problems are labeled as a stigma among school-age children, they are less likely to seek out assistance within their schools. ²⁹ Rather than seek out help or assistance at school, menstruators are known to be late, leave early, or be absent more than non-menstruators.^11,30

Next, internalized menstrual stigmatization addresses the four components proposed through the model of stigma communication. ²⁷ Marks, or describing visible symptoms, are nonverbal cues that identify stigmatized individuals.^27,31 Marks, in terms of menstruation, could be the presence of blood in one’s underwear, leakage to outerwear, or even the presence (or absence) of menstrual materials. The materials are necessary to manage the concealment of menstruation; but should a mark be presented, menstruators may feel shame, a felt stigma. ²⁵ Second, menstruating stigma contains labels, identifying or naming a stigmatized group. ²⁷ New menstruators label themselves as “one who menstruates,” distinguishing themselves from those who do not. ²⁵ As a result, a distinction forms between those who menstruate and those who do not.

Etiology explains why people have a stigmatized condition. Etiology explores the violation of social responsibilities or engaging in taboo activities. ³¹ Talking about menstruation is considered a taboo. ³² Many new menstruators are told not to talk about menstruation with others; if they do so, they engage in a taboo activity.

The presence of more scholarship addressing the interpersonal context of stigma communication, moving away from strictly intergroup communication, and how it is managed interpersonally. ³³ Interpersonal stigma communication research mainly has examined infectious diseases. Humans generate stigmas for and stigmatize people presenting a threat to effective group functioning. ³³ If a non-stigmatized individual has a negative reaction, such as disgust, they are likely to start rumors. ³¹

Menstruating stigma is “felt” and enacted by many menstruators, can occur internally, and addresses the four components from the model of stigma communication. ²⁷ Hence, this study addresses how menstrual stigmatization is managed within the school environment. Specifically, this study explores how school nurses use communication to address how to manage the receiver of stigmatized communication, in this case, a menstruating student. But first, the school nurse must be able to decipher that a student is seeking help with menstruation.

• RQ2: How do school nurses perceive how stigma is communicated by adolescents within the school nurse’s office?

SMC

Stigmatized individuals use communication strategies to manage how they communicate their stigma within groups as described through the SMC model. ³⁴ SMC is based on two criteria: (1) an individual’s attitude about the stigma and (2) the individual’s attitude toward the public applicability to themselves. ³⁴ The criteria break down the management of stigma into four categories: accepting, avoiding, evading, and denying. I am focusing on accepting and avoiding because these two categories are most applicable.

Accepting the stigma translates to individuals accepting the public narrative and expectations regarding the stigma. ³⁴ Individuals must believe the stigma applies to them and then incorporate it into their identity. Accepting the stigma may also occur when one determines that society’s narrative of the stigma is justified and valid. ³⁵ Avoiding is a result of accepting the stigma but questioning if it applies to one’s self. ³⁴ If they do not think the stigma applies to them, they may avoid the stigma. Some avoid the stigma by hiding the mark, avoiding places, leaving the conversation when the stigma is discussed, or making comparisons between themselves and others.^16,34 Each category focuses on how the individual handles the stigma. But what about when the individual does not realize they are being stigmatized?

The management of the stigma focuses on how individuals and organizations, such as school, “respond to, resist, and re(construct) the communicative enactment of stigma.” ³⁴ The management of stigma communication is contextual. ³⁶ For example, veterans with post-traumatic stress disorder (PTSD) test the water when it comes to managing their PTSD stigma, to determine the temperature of the room regarding mental health. ¹⁶ Others in the room may accept the stigmatized individual accepting that others in the room may have PTSD but may not acknowledge that the stigma applies to them. ¹⁶ Yet, what about the group accepting the stigma on behalf of the individual? Just coming to light is how the other uses communication to assist the stigmatized individual. ³⁷

Research demonstrates that there are groups that challenge the stigma of others^37,38 and act as allies. I argue that school nurses may use communication to help new menstruators manage their stigma, hence becoming an ally. ³⁹ An ally is a person whose power or privilege ⁴⁰ allows them to stand against injustice toward others. Allies have solidarity with an individual who has yet to accept the stigma. ³⁹ Nurses may use communication to assist new menstruators; therefore, nurses’ communication could be considered a form of health ally communication (HAC).^37,39 An allyship occurs when the school nurse uses their position to stand with, or empathize with, students experiencing menstruation. ³⁹ However, there is a need to focus on the communication used between the nurse and the student to form this allyship. This study addresses this gap by examining how communication is used by “the other,” in this case, the school nurse, in helping the stigmatized, young school-age menstruators, manage their menstruation.

• RQ3: How do school nurses communicate an allyship with new menstruators to assist in managing menstrual stigmatization?

Method

I conducted nine face-to-face virtual semi-structured interviews with nurses employed in a local school district. The Purdue University Institutional Review Board approved this study (#2023-6). Participants were recruited through a centralized office within the school district and were initially contacted by email. Only those who responded to the emails were interviewed for this project.

Participants

A convenient, or opportunistic, sample was used for this study. This method was chosen as the district and the researcher is collaborating on a menstruation product project. The nurses were convenient and easy to access. ⁴¹ A gatekeeper in a school district’s administrative offices sent an email on behalf of the research team to the district school nurses informing them of the study. Nine of the nurses agreed to participate. The district has 41 school nurses among 52 schools. The only criterion to be a participant was to be a nurse or nursing assistant within the district.

Eight females and one male participated in the study. The nurses represented elementary (n = 3), middle (n = 3), and high school (n = 3). The nurses ranged in experience at the school level from 1 to 20 years. Each participant was assigned a pseudonym based on popular movies with a menstruation storyline (Are You There God? It’s Me Margaret and Turning Red).

Procedures

On obtaining approval from the Purdue University Institutional Review Board, participants were recruited via email through a school district’s Department of Health and Wellness Office and individualized emails sent by a research assistant. Because of a pre-existing partnership between the Department of Health & Wellness and the lead researcher, a specific population was targeted for recruitment; all participants had to be school nurses, nursing assistants, or substitute nurses within the district. Data were collected between January and April 2023.

In-depth one-on-one interviews via Zoom were conducted to collect the data. The lead researcher conducted all interviews using a semi-structured interview protocol. The protocol was designed based on previous research regarding menstruation and communication between students and school nurses. The questions were framed to pay special attention to the communicative habits of the participants. Each participant was asked, “How would you describe your role when it comes to menstrual communication within the school?” “How would you describe how you communicate trust with students?” and “How would you describe your use of comforting language?” The guide also included questions asking how they perceive students communicating about menstruation. These questions included “How do you perceive students talking with you about menstruation?” “What are some barriers you think keep students from talking to you?” and “How would you describe how students communicate about menstruation in general?”

Interviews continued until data saturation was achieved. All interviews were recorded, and transcripts were downloaded through a password-protected Zoom website. Each transcript was downloaded, generating 142 pages of single-spaced pages. After verifying the transcripts with the video recordings, all recordings were deleted.

Data analysis

Data were analyzed using phronetic iterative approach (PIA), which “alternates between emic, or emergent, readings of the data, and an etic use of existing models, explanations, and theories.” ⁴¹ I entered the data process with the SMC ³⁴ as the theoretical focus of the coding. After collecting the data, I read through the data holistically, reminding myself of the interviews and key points. Next, I wrote memos in the margins as I read through the transcripts. I began coding the data by looking for words or phrases that I identified as intrinsically meaningful to SMC. This was the primary coding process as I jotted down the lists of phrases and meanings from the participants’ transcripts. During the secondary coding process, I consulted SMC’s quadrants and began identifying patterns within the data.

Results

The current study explores how school nurses handle adolescent menstruation during school hours and examines how school nurses use communication to assist adolescents with their menstrual stigmatization. Specifically, this study seeks to address three research questions: (1) How do school nurses use communication with menstruating individuals? (2) How do school nurses perceive menstrual stigmatization to be communicated? and (3) How do school nurses communicate an allyship to menstruating students to help manage menstrual stigmatization? A thorough analysis of the data found two management categories present: accepting the stigma and reducing the responsibility of it. However, the categories focus on the stigmatized individual, not someone helping the stigmatized individual. Analysis determines that nurses assist menstruating students using accepting communication and communication that helps students avoid being stigmatized.

Steps to accepting menstrual stigma

Accepting that menstruation is occurring and helping the student is not about school nurses labeling the student with a stigma. Rather, school nurses use communication, broken down into steps, that assist the student with acknowledging the reality of menstruating. The original typology explained accepting in negative terms, such as self-blaming, isolation, and remaining silent. ³⁴ The steps detailed below demonstrate how nurses use communication to educate students on how others see menstruation as a stigmatized act, but that menstruation is not a stigmatized act and there is nothing wrong with the student using more positive connotations.

Accepting

The first-way school nurses assist menstruating adolescents is through language that communicates accepting menstruation. Accepting menstrual stigmatization means students may apply menstruation to themselves and incorporate it as part of their being ³⁴ but not see menstruation as a stigma. School nurses perceive that younger students are not aware of what is happening with their bodies. Preya, a middle school nurse, explains that young girls are getting their periods earlier and menstruating ties into the self-esteem aspect of their lives. Gretchen, an elementary school nurse, explained that younger students feel alone and that they are the only person in their class menstruating; hence, they feel isolated and different than their classmates. The start of a young adolescent menarche can be deemed difficult, hence why nurses have these conversations in private. ²⁰ That is why Abby, an elementary school nurse, explained that her number one role in assisting students with understanding and accepting menstruation is to try and keep the student calm. Abby explains:

Make her realize it’s not a. . .you know. We all deal with this. Make it a normal thing because I feel like when I was growing up, it is. . .was such a hidden thing. I mean like we don’t talk about it. We hide our past. We hide this, you know, and I feel like even it’s just becoming a little bit more. . .you knowing something that we can talk openly about.

Abby is one of the nurses who shuffles between two elementary schools within the district. She had a second-grade student start her period and come to her office. In that instance, Abby felt a little bit of panic as she recalled “It was difficult for me because it was not on my radar at all. That that could happen that early, I mean. Obviously, it can, but not something I ever thought I would see.”

When students first arrive with menstruating symptoms, the participants stressed that their role is to be open and engaging but also to provide some privacy if there are other students around. By providing privacy, the nurses work to “out” the menstruator to others. Janie, a third elementary school nurse, stresses that the nurse should mention menstruation first. Once the nurse and student are in a private environment, the nurse asks questions, such as:

Is this your first time?

How bad are the cramps?

Is there breakthrough bleeding?

Do you have supplies at home?

The participants stressed that during this time they use language that iterates that each girl is not alone. Some of the nurses even share personal experiences, such as Gretchen, who shared “I remember those days in high school myself,” and she shares that with them while simultaneously stressing “that they are not the only one, and that you know a lot of girls do this.” By being open and engaging with the students, the nurse is bonding with the students. Those suffering from the stigma will bond with others as a way of dealing with their stigma. ³⁴ In this case, many of the nurses have felt the stigmatization and can empathize. By being open with the students and sharing their stories, they bond with the students as a way of helping the students accept the stigma surrounding menstruation.

Parental communication

The second step in handling menstrual stigmatization is to communicate with the parents. Participants explained that they only call the parent if the child wants them to. Other participants mentioned that they will call the parent to see if the child has support, and sometimes products, at home. If the child in question is experiencing signs of endometriosis or other serious menstruation/uterus problems, the school nurse would refer the parents to seek out a doctor. For example, Mariam, a nurse at a large high school in the southside of the district, explained how many of her students are at the age where they are communicating symptoms of endometriosis and she wished she had a doctor or even a clinic, that she could suggest they go and see. There were a few participants who had the parent calling the nurse to see if they could help their student. One told the story of how their child texted the parent from class, the parent called the nurse to get their student some help, and the nurse had student services discreetly give the student some products and an old sweatshirt from lost and found. By bringing in the parent, the nurse and parent can co-manage menstrual stigmatization.

Ask questions

Some of the nurses stressed that they ask students what they already know. For example, the second grader mentioned above told Abby that she and her mom had talked about it a little. When asking questions, nurses speak in a way that the students will understand. Janie, a nurse at an elementary school in one of the highest poverty zip codes of the district, said not to use scientific language. Mariam took it one step further and suggested that school nurses not get too medical with their language when talking about menstruation. Robért, the lone male nurse in the sample, reiterated this but also said that nurses need to use accurate language.

Robért works at a high school with a very culturally diverse population of students. He explained that sometimes when female students come down, they are uncomfortable talking to him because he is a male, so they whisper the problem or write it down on a piece of paper. “I can hear them say that they don’t want to talk about it with me because I’m a guy,” he told me, suggesting that female students may feel males cannot empathize with what they are going through. To counter this, Robért just tries to be open and discuss it in accurate terms. “Especially if there’s no other kids in the clinic, just being open and engaging that conversation with them just to try to kind of show it is okay to talk to males about or other health care professionals.”

Just talk

The fourth step in accepting menstruation as a stigma is to provide some basic education. Janie stressed that she sees her role as being a reinforcer of menstrual education, which occurs offsite at a nonprofit in town. Mei explained that when it comes to education “it’s not just menstrual. It’s supplies. It’s talking to them about education. It’s talking about menstrual cramps. That’s a really big thing in middle school.” Some of the nurses have had to explain how to use products, mainly pads because most of the schools have more pads than tampons on hand.

Nurses talk to the students about the steps they should take to help handle their cycle in the future, such as drinking more water to stay hydrated, using a heating pad, or even using a rice pillow. The nurses asking the students what they already know and then providing basic education to fill in the gaps are ways to help students accept the stigma associated with menstruation. They are trying to help the students accept that menstruation applies to them, but menstrual stigmatization can also occur to others. The use of education assists the nurse in helping the student handle and address the student’s negative self-talk.

Ending the avoidance

Avoidance, a tactic of SMC, means accepting the stigma and accepting that it applies to oneself. The previous section focused on how nurses use communication to assist in students accepting menstrual stigmatization, but menstruation happens to them and does not stigmatize them. This theme focuses on a tactic nurses use to help students avoid menstrual stigmatization.

The school nurses work hard to have products available for students. When talking with Robért, he mentioned how he ran out of brand name products and students were using what he obtained from the district’s warehouse. Robért suggested that the students found the non-brand name products uncomfortable in terms of size. Despite not having the brand name products, though, he continued to make sure his desk and the clinic’s bathroom had products.

Making sure products were available was instrumental for all the nurses involved. Preya explained that when a first-time menstruator came to her clinic, “I showed her where the stuff was, because I keep, and this is another educational component, I keep the pads out and everything in the bathroom.” Preya went on to explain that when “little dudes” use that bathroom, they ask, “What’s this?” and Preya uses those moments to educate the boys. Nurses shared that they had “regulars” who would come in and get what they needed, not needing to talk to the nurse or make a big deal out of it. Others mentioned students who were at the clinic first thing in the morning obtaining enough products to get them through the day. Even the elementary school nurses shared that their female students knew they could find products in the second drawer of their desks. . .a fact that quickly made its way to most of the upper-level elementary grades. Even Tyler, an outlier within the sample, had a basket of products available outside her office so that students could grab one. This is important to mention as Tyler shared that she used sarcasm and shame when students visited her office asking for products, while the other participants talked about using supportive and compassionate communication. By having the product basket in the hallway, students could avoid seeking assistance and hence be shamed for needing the products and not being able to provide their own.

By having products available for students, the nurses communicate that students do not need to apply the label of period poverty or menstrual stigma to themselves. The nurses communicate preparedness, provide reassurance, and are mindful that each student has different circumstances in life. As mentioned in the literature review, many menstruators leave school early, arrive late, or just do not attend at all because of their cycle and not having products at home. The product availability communicates that the school has these menstruators’ backs and that they will help these menstruators get their education.

Getting others involved

When talking with Janie, she mentioned that she saw herself as the second point of contact for menstruation help within the school. “I think of the elementary school teachers, you know, especially the females, play a huge role in that [unexpected menstrual cycle]. You know they have a more maternal type role just being part of the classroom.” Yet, Janie did not know if these same teachers carried products within their classrooms. This is why other school nurses are working to implement programs in the school to get others involved.

Mariam explained that some teachers within her school are comfortable giving out supplies and that students feel comfortable seeking these teachers out. When questioned about how students know what teachers to approach, Mariam told me that these instructors have little backpacks with supplies in them. “If you need to take the knapsack and use the restroom, please do” is something Mariam assumes teachers may communicate with their students:

I know that dance teacher, she her little, teeny, tiny backpack that hangs next to her bathroom pass, saying: the girls are allowed you know they just take the knapsack. They take the bathroom pass, do the business, and then put everything back.

Mei, a middle school nurse, told me what she would like to do at her school:

I enacted a program at our school that a lot of our teachers have supplies. And so we’re trying to make it less awkward in our building, and so that those girls I want them really to feel comfortable that they can come to me, or they can see one of the other adults out, and we have signs posted, and the girls bathrooms with names of the teachers that hey “these teachers have supplies.” I’m trying to make it so that they [the students] don’t feel so uncomfortable.

Mei started the program because she claimed there is no worse feeling in the world than starting your period and not having supplies. Imagine that happening in a school where you must walk a distance to get to the nurses’ office. Having teachers with supplies may help students from traveling too far within the school to seek out assistance.

Finally, many of the nurses communicated that they make sure students have supplies over the weekend, as they do worry about students having access to supplies when school is not in session. If students see Nurse Margaret on a Friday, “I would make sure they have supplies to take home.”

Discussion

The goal of this study was twofold: to examine how school nurses work with menstruating adolescents during school hours and to examine the communication school nurses use during these times. Specifically, this study sought answers to three research questions: (1) How do school nurses use communication with menstruating individuals? (2) How do school nurses perceive menstrual stigmatization to be communicated? and (3) How do school nurses communicate an allyship to menstruating students to help manage menstrual stigmatization? While the strategies used by school nurses support two of the four quadrants in SCM, the school nurse and adolescent communication focuses on educating the adolescent on menstrual stigmatization management strategies and accepting “membership” into a new population.

Nurses communication

The first research question focused on how nurses used communication regarding adolescents’ visits for menstruation. The data determined that nurses use four steps: accepting language ⁴² , getting the parents involved, asking questions, and just talking. First, nurses use language that assists students in accepting menstruation themselves and provides ways to incorporate menstruation as part of their identity. The data found that nurses managed adolescent menstrual stigmatization by normalizing menstruation or sharing their menstruating experiences. Second, nurses communicate with parents as a way for the adults in the adolescents’ lives to co-manage the menstruating stigma. By communicating with the parents, the nurse and the parent can use a single stigma management strategy for the students. For example, both the parent and the nurse can provide social support. ⁴³ Nurses and parents may then be able to co-manage with the adolescent. I use the word may since only a parent who has/had a uterus understands menstrual stigmatization and has been stigmatized, whereas non-uterus-bearing parents may not.^37,41 Using co-stigma management provides resources for adolescents at home and at school. The third step is to seek from the students what they already know. By gauging what students already know, nurses know where and how to fill in the blanks of their knowledge. The fourth step is providing some basic education. For most of the nurses, this means demonstrating how to put products on or how to handle menstrual cramps. They conclude by talking to students about how to handle future menstrual flows.

Perceiving menstrual stigmatization

The second research question examines nurses’ perception of adolescents’ menstrual stigmatization. Analysis suggests that nurses perceive younger students as not adequately prepared for menstruation. Each of the nurses stressed that students visit a local health nonprofit and receive education and that they may touch on it in health class in the upper grades but also claimed that not enough education is being provided. This is especially important as trips to the health nonprofit do not begin until fifth grade and students, as young as 8 years, start menstruating before they get the education. Nurses perceive the students as feeling alone, isolated, and different from their classmates. These findings support Smith’s ²⁷ original definition of stigma communication. First, students feel different from their classmates supporting two of the stigma communication content cues: (1) distinguishing them by the spots in their underwear or the stains on their outer clothes and (2) they are a different social entity. By getting their period before their classmates, they feel different and have a responsibility when it comes to their bodies. Society stresses that we should not talk about menstruation ²⁸ ; therefore, these students do not know which of their friends to discuss this development with or where to necessarily seek out assistance.

Nurses perceive students as feeling embarrassed or fearful. This became evident when nurses described how the students communicated why they were in the nurses’ office. Embarrassment is known to occur because of marks on their clothes or lack of knowledge regarding the menstruation act. Students are known to whisper or write down that they are menstruating. Some students believe they may be dying because there is blood in their underwear, and they do not understand why. It is in these instances that nurses work to calm the students and assure them that things will be okay.

Developing an allyship

The final research question sought to understand how nurses use communication to form an allyship or assist adolescents in managing their menstruation.^{37 –39} The data supported my argument that school nurses act as allies with their students and with parents as seen in Research Question 1. An allyship is also formed through nonverbal tactics, such as having products.

Next, nurses communicate allyship by educating adolescents by building solidarity in addressing menstruation. One-way nurses do this is by having products available for their students and showing the students where the products are for future visits. The availability of products helps to eradicate communicating that the student forgot products or that the student is not able to afford products. Product availability could assist in decreasing late arrivals, early dismissals, or even absences because of menstruation, communicating that the school nurse is an ally in the adolescent’s education.

In addition to providing products, nurses want to get other teachers and staff involved in assisting menstruating adolescents. By working to get other teachers and staff involved, nurses are using their social power to help address injustices in the school building. For example, many bathrooms may not have product dispensers or the trek to the nurse’s office means missing more class time because of the distance. When school employees collaborate, they assist students in handling their menstrual problems and also getting the education they deserve.

Implications

The findings of this study lead to practical implications that may assist school districts, families, and individuals. The first implication is school districts reworking their budget to supply more and better-quality products for school nurses. These products are not a luxury for many of the schools these nurses represented and many of the nurses supplement their supplies using personal funds. Nearly 78% of students in the district represented in this piece receive free or reduced lunch; school districts must understand that those families who cannot afford food can also not afford menstrual products. Hence, schools should make sure products are available not only during school hours.

Second, school districts, and in some cases, state legislators, should reevaluate how menstruation education is handled. First, state legislators need to provide districts with more funding so that each school has a nurse. But more importantly, state legislators must work with school districts to develop a comprehensive sex education curriculum that does not just focus on sex but rather offers extensive information on puberty. State legislators and school districts should also offer continuing education credits for nurses to receive the education they need to teach sex and menstrual education. Finally, nurses represented in this study provided good information about what is working within their schools. However, there was an outlier within the sample whose words “sarcasm and shame” stick with me to this day. Nurses should be provided education on how to talk about menstruation with students and not just education courses. The school nurse may be the first adult a new menstruator may encounter, and they should not encounter negative or degrading language as a result.

Introductions to the school nurse should happen at the beginning of the academic year and parents should be aware of why and when school nurses will call home. This will assist parents and nurses in developing partnerships to assist students with their health and education needs. Assisting menstruating individuals is not just the parents or the school’s job but rather should be seen as a joint effort so that menstruating adolescents get the same education as their non-menstruating counterparts.

This study highlights the importance nurses play in adolescents’ physical, and in turn mental, health. Using encouraging and calming language, nurses communicate trust and this allows for the students to disclose more. By accepting the adolescent’s word as truth—that they are experiencing menstruation—the nurse uses language to help the student feel less isolated and alone, thereby assisting them with their mental health. By assisting with the physical and educating about the mental, school nurses play an instrumental role in assisting adolescents with all menstrual health needs.

Limitations

Despite the potential benefits of examining school nurse communication with menstruating adolescents, limitations do arise. This study used a convenience sample, recruiting nurses from a large school district in the Midwest. Therefore, the results of this study are ungeneralizable to a greater population. Furthermore, only 17% of schools were represented in the study, and 18%, when removing the early childhood education centers (n = 2). The results were also skewed toward nurses who were more comfortable discussing menstrual-related issues with students. Future research should bring in the voices of those who do not have the same level of comfort and teachers from various grade levels. Finally, best practice is to have more than one coder; since this was a single-author study, only one coder was used. Future research should try to include additional coders.

Conclusion

The communication school nurses use with menstruating individuals is important. While working on this piece, two little events came to my attention. A father messaged me to let me know his daughter had a menstrual accident at school and did not know where to go. She wanted a locker that held supplies. I responded with “until that happens, have her visit the nurse.” She told her dad that many of her friends did not realize they could go to the nurse for help. The second story came out of a high school. One of the participants reached out and said she had students who were working with middle schoolers, educating them about menstruation. The fact that high school students are helping middle school students highlights the importance of having a supportive nurse.

School nurses are unsung heroes in the fight against menstrual stigmatization. As this study demonstrates, they are on the front line using communication to help destigmatize menstruation.