For many years, public health nurses have practised with a focus on individuals and families, rather than communities, providing child health clinics, immunisations and home visits as well as a number of other program-focused activities according to their organisational structures (Markham and Carney, 2007, May et al., 2003, McMurray and Cheater, 2004, Wilson, 2006 and Winters et al., 2007). With the growing trend towards population health and PHC, nurses incumbent in these roles are seeking to change their roles to be more closely aligned with a population-based approach. There is broad agreement on the goals of PHC, and the values underpinning practice (Barry et al., 2007 and Besner, 2004). Many nurses are poised to act as community advocates, focusing on health promotion in integrated, generalist roles that allow them to work with the community as a whole rather than on a segmented system of predetermined public health priorities. However, the systems delivering public health care and the reporting mechanisms often work at cross-purposes to their achieving this goal. Programmatic approaches, with ‘categorical’ funding, where certain categories of activity (family planning, immunisation) dictate the role, because of funding arrangements thwart nurses’ attempts to reframe their role from specialists to generalists (May et al 2003:252).

May et al (2009) argue that the specialist model inhibits a role that would see them working in partnership with the community, holistically, in an empowering way, having cultural relevance, and targeting primary, secondary and tertiary levels of prevention to improve population health. Yet, the trend towards specialised programs is occurring in many countries and health departments, as organisational cultures favour worker productivity instead of health promotion.

This trend also constrains nurses’ attempts to enact an effective, generalist PHC role (May et al., 2003 and Toofany, 2007). Besner (2004) and Thompson (2008) contend that this makes nursing work invisible, even in population-focused approaches to care. Nurses should be empowered to move beyond existing systems to develop systematic recording systems that document social, emotional, cultural and spiritual dimensions of health, as well as their contributions to care (Besner 2004). There is widespread agreement that advanced PHC roles have engendered high patient satisfaction, improved accessibility of care, effective communication, and some short-term outcomes (Bonsall & Cheater 2007). However, there is a dearth of research evidence for the efficacy of nurse-led systems or explicit findings indicating the nature or extent of long-term outcomes directly linked to the nurse or midwife’s interventions (Bonsall & Cheater 2007).

Some nurse leaders have sought to clarify the specialist role rather than re-brand it as a generalist public health role. Fisher Robertson and Brandt Baldwin (2007) articulate such a role as an advanced community practitioner, a nurse who leads community initiatives for system-wide changes and health promotion through case management, project management, risk management, community advocacy and policy development, which is focused on high-level leadership. Lange (2006:E50) describes an alternative, the role of ‘community nurse’ who is a culture broker, liaison, advocate and activist rather than case manager or project manager. A literature review of the Australian community nursing role by Brooks et al (2004) indicated that there is still ambiguity between generalist/specialist, no role clarity, under-utilisation, underdeveloped models for professional education and research, and little power in decision-making. What all community scholars agree on, is the need for research and professional role development to provide rational arguments for changes, consistency in education and practice, and shared strategies for successful, high-quality community outcomes (Besner, 2004, Bonsall and Cheater, 2007, Markham and Carney, 2007, Fisher Robertson and Brandt Baldwin, 2007, Por, 2008 and Swearingen, 2009).

As Australia responds to the international PHC agenda (WHO 2008) with its focus on general practice in the community, the role of the practice nurse (PN) is undergoing a renaissance (ANF 2009). The PN is not a protected title but it is a specialist PHC role (Halcomb et al., 2005 and Proctor, 2006). However, because of the general practice focus on primary care, rather than the more comprehensive PHC agenda with its focus on community health promotion, most PN’s roles are confined to primary care activities such as chronic illness management (Halcomb & Hickman 2010).

The Commonwealth government defines a practice nurse as a registered or enrolled nurse who is employed by, or whose services are otherwise retained by, a general practice (Commonwealth Department of Health and Ageing, in Walker 2010). Major changes in the Commonwealth policy environment over the first decade of this century have supported the development of the PN role, to respond to the needs of the population, shortages in the health workforce, community expectations, and rising health costs (Porritt 2007). Australian scholarships, funding and changes to the Medicare Benefit Schedule (MBS) to provide practice incentives have all had an impact on the role (Keleher et al., 2007 and Porritt, 2007). Medicare funding and Practice Incentive Payments (PIP) have provided remuneration to GPs for PNs to undertake immunisations, provide wound care, cervical screening, assessments for older persons and management of conditions such as asthma, diabetes and mental health through the Chronic Disease Management Initiative (Halcomb et al., 2005, Keleher et al., 2007, Porritt, 2007 and Senior, 2009).

Through the advocacy of the Australian Nurses Federation (ANF: www.anf.org.au/nurses_gp) national competency standards have been developed for PNs (Keleher et al., 2007 and Porritt, 2007). These reflect a rapidly evolving role which has changed from where PNs undertook simple tasks, to a complex, knowledge-based practice with many different contextual challenges (Walker 2010). Although teamwork is a major aspect of their role, PNs work under the supervision of a GP, and in many cases, roles are negotiated between the nurse and the practice (Keleher et al 2007). The scope of practice varies according to the nurse’s expertise and experience, practice arrangements, the GP’s understanding of the role and the needs of the local population (Halcomb et al., 2005 and Keleher et al., 2007). In rural and remote areas, PN roles are rapidly expanding because of shortages of GPs (Halcomb et al., 2005 and Porritt, 2007). As of 2007, 60% of Australian practices had employed at least one PN (Keleher et al 2007). In addition to the funding support for practices to employ a PN, establishment of a national professional PN association and increasing professional development opportunities, including national conferences, have all fostered rapid development of the role (Australian General Practice Network [AGPN] 2007).

Although there is no strong evidence yet on effectiveness, efficiency or outcomes of PN practice (Keleher et al 2007) the research agenda of PNs has been evolving over the past decade (Halcomb et al 2005; Mills & Fitzgerald 2009; Patterson and McMurray, 2003, Phillips et al., 2008 and Senior, 2009). The research agenda for practice nursing was outlined in a Delphi study conducted in 2009, which identified 53 areas for future PN studies, including clinical, educational and practice management issues (Halcomb & Hickman 2010). The PN research agenda will also be strengthened by the efforts of the national professional organisation (Australian Practice Nurses Association), and the Australian General Practice Network (AGPN). These two organisations, and the development of a mentoring network, are all helping to enhance the visibility of the role and establish its place in PHC (AGPN 2007; Mills et al., 2010 and Porritt, 2007).

Practice nursing in New Zealand is also growing in strength and numbers. When the New Zealand Primary Health Care Strategy was released in 2001, it was clearly indicated that nurses were seen as crucial to its implementation (MOHNZ 2001). In 2003 the Expert Advisory Group on Primary Health Care Nursing created a framework for activating PHC nursing practice in New Zealand in order to realise the potential of nurses to achieve the goals of the PHC Strategy (Expert Advisory Group on Primary Health Care Nursing 2003).

The framework provided a definition of PHC nursing and a set of corresponding goals. PHC nurses were defined as registered nurses with knowledge and expertise in PHC practice. They work autonomously and collaboratively to promote, improve, maintain and restore health, in roles that encompass population health, health promotion, disease prevention, wellness care, first-point-of-contact care and disease management across the life span. Their models of practice are determined by the setting and the ethnic and cultural grouping of their clientele. They practise in partnership with people —individuals, whānau, communities and populations — to achieve the shared goal of health for all, which is central to PHC nursing. The goals of practice therefore include aligning nursing practice with community need, innovative models of nursing practice, governance, leadership and career development (Expert Advisory Group on Primary Health Care Nursing 2003:9).

Many nurses practising in PHC settings have grasped the framework as a guide for developing their PHC nursing practice including district nurses, public health nurses and practice nurses. Practice nurses (PNs) in New Zealand were originally employed in the mid-1970s in GP practices, largely to provide support to GPs. Since that time, the role of the PN has evolved substantially. The Primary Health Care Strategy and subsequent framework for activating PHC nursing were seen as providing opportunities for PNs to demonstrate the impact they could have on population health. However, by 2007 the New Zealand Nurses Organisation and the College of Nurses (Aotearoa) suggested that significant work was still required to achieve the potential of PHC nursing in line with the original framework suggested by the Expert Advisory Group (New Zealand Nurses Organisation & the College of Nurses Aotearoa (NZ) Inc 2007).

Evaluation data indicate that there are ongoingbarriers to enacting the PN role, such as hierarchical employment structures, limited access to education and poor funding of nursing initiatives, all of which require urgent attention (New Zealand Nurses Organisation & the College of Nurses Aotearoa (NZ) Inc 2007). Professional development of PNs has largely been initiated and implemented by the New Zealand Nurses Organisation (NZNO). The organisation developed a strategic plan for PNs in 1996–1998, identifying a career pathway, a marketing plan to enhance the professional profile and adequate employment conditions. The College of Practice Nurses (a college under the NZNO) now offers a comprehensive accreditation program for PN members, a journal and various other publications and support processes (New Zealand Nurses Organisation, Online. Available: www.nzno.org.nz/groups/colleges/college_of_practice_nurses/about_us 23 February 2010). In 2010 the College of Practice Nurses is about to be reformed as the College of Primary Health Care Nurses broadening its membership base to include all nurses working in primary health care setting including district nurses, public health nurses school nurses and occupational nurses. Professional development programs for PNs are also becoming increasingly common, largely established within PHOs.

Formal evaluation of nursing developments in PHC in New Zealand from 2001 to 2007 demonstrated that the barriers identified by the NZNO and College of Nurses did indeed exist, and their recommendations included a need for leadership, mentoring, governance, and recruitment and retention of PNs (Finlayson et al 2009). Despite the barriers, the profession was able to demonstrate examples of excellence in practice nursing, including substantial growth in the development of nursing roles and capability within PHOs. Particular strengths of the PNs included the management of long-term conditions and, as mentioned above, working with under-served and vulnerable population groups (Finlayson et al 2009). Among these vulnerable populations are older persons in residential care settings, who too often are overlooked in the PHC agenda. This is being redressed through ongoing discussion of models of PHC in Australia and New Zealand, especially in the evolution of nurse practitioner roles. The care of older persons, like that of younger population groups, should be included in the PHC agenda, with appropriate needs assessment, care coordination, health promotion and disease management.

Because of population ageing and increasing rates of diseases such as cardiovascular disease and diabetes, the management of chronic conditions has become, and will continue to be, a major element of community health practice, especially for PNs. Most models of chronic condition management are based on the PHC principle that the client is the centre of the health care system. This places the emphasis on patient choice, shared decision-making and the psychosocial and health promotion aspects of care delivery (Commonwealth of Australia, 2009 and Forbes and While, 2008). The WHO (2005) explains that the major goal of chronic disease management programs should be empowering people towards self-management. This is also incorporated into new models of care in the UK, such as the community matron role described above, which is intended to promote self-reliance among people living with chronic illness in the community (Harrison and Lydon, 2008 and Swiadek, 2009). Self-management applies across the continuum from prevention and early risk identificationto the way existing chronic conditions are managed, typically with a patient care plan tailored to individual needs. A variety of models have been developed for chronic condition management. All identify clear roles for nurses, placing the nurse as a manager or coordinator who works horizontally, to manage people through and between health systems, and vertically, providing preventative care, self-care support and education, case finding and identification, managing therapeutic interventions and complications, and case management (Forbes & While 2008). Health literacy features in all models as a cornerstone of health promotion.

A major review of nurses’ activities in managing chronic conditions in the community reveals that nurses are in fact, participating in this important element of practice, engaging with people holistically, targeting marginalised or excluded groups and leading a variety of interventions (Forbes & While 2008). In communities everywhere, nurses’ health promotion activities at primary, secondary and tertiary levels have had significant impacts on people’s lives and their capacity for self-management.Their role has helped bridge service gaps, brought interdisciplinary teams together, promoted access and appropriate use of technologies, and forged collaborative teams to address the care systems within which people deal with chronic conditions (Forbes & While 2008). Because of the growing importance of chronic illness in the population, various models of care have been developed. One model for managing chronic illness in the community is the Chronic Disease Self-Management Program (CDSMP) that has been adapted by Queensland health professionals from an American model of chronic care (Catalano et al 2009). The CDSMP uses health professional leaders and peer leaders working together to provide self-management courses. The program provides a four-day leader training program for peer leaders who themselves have a chronic disease. They subsequently act as role models for other participants, under the guidance of the professional leaders in a type of ‘expert patient’ model. This has major potential for health education.

Another model widely used in community management of chronic illnesses is the ‘Flinders Model’ (Commonwealth of Australia 2009). This model identifies core skills for the PHC workforce in terms of promoting patient capabilities, fostering behaviour change and developing organisational and systems capabilities. Its focus on capabilities rather than competencies illustrates current benchmarking trends that move away from the procedural and technical focus of competencies to a broader, capabilities orientation, that may be comprised of many competencies (Gardner et al 2007). The model (see Table 4.2) also refrains from referring to chronic ‘disease’, instead expressing patients’ needs in terms of chronic conditions.

The core skills identified above are aimed at developing community capabilities across all specialised PHC roles and settings. These settings and roles are described in the section to follow.

Child health nursing is a specialised area of nursing in the community. In some areas, including different Australian states, the role is variously designated ‘child health nurse’, ‘community health nurse’, ‘child and youth health nurse’, ‘maternal and child health nurse’, ‘child and family health nurse’ or ‘family and child health nurse’ (Kruske et al 2006). Although all Australian child health nurses aspire to a PHC philosophy as prescribed by the Child and Family Health Nurses Association (CAFHNA 2000), confusion arises from the lack of consistent nomenclature and role description, which is influenced by the service structure within which they practise as well as different credentials and levels of preparation.

Most child health nurses in Australia consider themselves specialists. Many run child health clinics, and since the establishment by state health departments of universal home visiting, most nurses also conduct home visits (Briggs 2006–07).Some child health nurse specialists provide a range of PHC activities in primary schools, especially where there is no designated school nurse. These include student screening, health education for teachers and parents, and community engagement activities.

This PHC aspect of practice promotes the idea that the school should be seen as a resource for the community’s health as well as its education. Another type of specialised child health practice involves acting as the expert resource person in special schools for children with disabilities. In this context, the nurse’s health promotion activities extend from primary and secondary care of the child to ongoing tertiary care for the entire family. On occasion this includes hospital visiting and grief counselling for family members and fellow students.

Other child health nurses are attached to a variety of programs, some as part of comprehensive parenting or early learning centres that function as a referral point for parents. Others are part of outreach programs such as the Community Mothersprogram (in Western Australia) or the NSW Family Partnership Training program, both of which are aimed at developing parenting capacity. The model of child health care in these and other programs is comprehensive and enabling, in that nurses provide anticipatory guidance, education and skills development to parents simultaneously with their surveillance and monitoring of the child’s health status (Munns et al 2004). In the Community Mothers model this is achieved through a partnership between the Western Australian Department of Health, child health specialists at Curtin University, a network of volunteer mothers and new mothers (Munns et al 2004). In other cases, child health nurses promote parenting capacity through group work and adopting a family advocacy role, where parents are put in touch with resources and community support systems (Carolan 2004–05). Groups include support networks following childbirth, some of which grow into important self-sustaining social networks for mothers in particular (Carolan 2004–05).

Although there have been some studies of the scope of practice there remains a dearth of research into the impact of their roles. Kruske et al (2006) found that the role in New South Wales is diverse, even within that state, with some child health nurses emphasising the historical programmatic focus on growth assessment and monitoring, and others undertaking a ‘strengths’ based approach to supporting parenting (Kruske et al 2006:59). The latter indicated that the nurses worked in an egalitarian partnership with families, acknowledging their strengths and expertise, with the nurse seeking to play a facilitative, reinforcing role and providing psychosocial support (Briggs 2006–07, Kruske et al 2006). Other researchers have found that Australian child health nurses have a major impact on parenting capacity, through the support and guidance they provide (Barnes et al., 2003 and Rowe and Barnes, 2006). Similarly, New Zealand child health nurses practising as ‘Well Child’ or ‘Tamariki Ora’ nurses or within the Royal New Zealand Plunket Society (RNZPS) as ‘Plunket’ nurses provide family parenting support in home visits, and undertake an expanded, PHC role with families, particularly disadvantaged groups (Comino and Harris, 2003 and Yarwood, 2008). Plunket nurses, Well Child and/or Tamariki Ora nurses are required to complete specialised post-graduate education in PHC nursing either prior to or on appointment to child health positions. The ‘Parent Advisor Model’ currently used by Plunket nurses in New Zealand and many health visitors in the UK has been demonstrated to improve the knowledge of helping and listening skills of nurses, improve outcomes for parents and children, and sensitise health visitors to the needs of families (Bidmead et al 2002). Research by Clendon (2009) suggests that it is the interaction between nurse and mother, rather than the information, that is the key element in determining the success of the relationship between the two.

In other countries, the child health role is broad-ranging and diffuse (Forbes et al 2007). Some practise in case management; for example, working with social workers and other disciplines to provide counselling, consultation and referrals for children in foster care (Schneiderman 2006). Many work as generalist public health nurses, rather than as specialists, focusing on health promotion and family guidance. In the UK midwives and health visitors provide this type of child and family orientation, also connecting their activities to community development work (Forbes et al 2007). In all cases, developing a sense of connectedness with the family is paramount, and this is typically based on a close and trusting relationship in which information is freely shared. This important role of child health nurses is aimed at fostering health literacy, therapeutic communication, preventative treatment and health education (Briggs 2006–07; Forbes et al 2007).

Telephone support lines for parents, currently available as a 24-hour service, have been an important vehicle for all of these aspects of the communication role in Australia, New Zealand and other countries. Both the Plunket Society and the New Zealand Ministry of Health provide telephone support lines for parents of young children (Online. Available: www.healthline.co.nz and www.Plunket.org.nz [accessed 23 August 2009]). Twenty-four hour telephone support is also available in all Australian states (Online. Available: www.cyh.com/SubContent/aspx?p=102 [accessed 13 August 2009]). In 2009 the Australian governmentannounced a further extension of telephone support provided by child and family support nurses and midwives through a helpline for pregnant women and new mothers. The initiative is sponsored by four organisations: Post and Antenatal Depression Australia (PANDA), SIDS and Kids Australia, Stillbirth and Neonatal Death Support (SANDS) and the Bonnie Babes Foundation (Australian Labor Party media, Online. Available: www.alp.org.au/media/0709/msheag240.php [accessed 10 August 2009]). Telephone access provides immediate counselling for new parents with a range of needs, including breastfeeding, infant crying, sleeping and nutrition guidance, referrals and emotional support (Rowe & Barnes 2008; Sheehan & Barclay 1999). In 2007–2008 Plunket Society nurses answered 70000 calls from parents and caregivers needing advice and support in areas such as breastfeeding, sleeping, nutrition and child behaviour (Plunket Society 2008).

The school nurse (SN) is a PHC practitioner who combines the roles of public health liaison or community nurse, child and family nurse, mental health nurse, occupational health nurse, case manager, and team coordinator (Brooks, Kendall et al 2007a; Journal of School Nursing [JOSN] 2008; NASN 2005; Smith & Firmin 2009). It is a specialised, advanced, complex practice role that revolves around promoting students’ wellbeing, their academic success, normal development and lifelong achievement, as well as intervention for actual and potential health problems (Downie et al 2002; JOSN 2008). The way SNs’ roles are organised depends on whether the SN is employed in a primary or secondary school, by the health service or the education department.

What all SNs have in common is a role as the ‘navigator’ who helps the child along the school journey (Brooks, Kendall et al 2007:226). The major focus of the role in primary school is to ensure students are safe, healthy and ready to learn. School nurses working in the primary school setting undertake developmental screening for conditions affecting learning, such as vision and hearing. They also respond to children’s needs for support in relation to diet, behaviours at school, issues related to the home environment, and coping with stress, even in very young children. High school nurses tend to deal with student needs that revolve around adolescent ‘acting out’, problems with parental relationships and other issues that affect students’ mental health. These can include issues related to sexuality, risky behaviours or other areas where peer pressure causes conflict between the young person’s struggle for identity formation and family or group norms.

Contrary to popular perceptions, SN practice does not typically include dispensing bandaids or headache tablets. The role is multidimensional, requiring a wide breadth of activities and a current knowledge base that includes understanding clinical and technological developments affecting health, and maintaining current knowledge of health, education and professional policies (Barnes et al 2004a; Wainwright et al 2000). SNs in high schools have to maintain current knowledge of adolescent behaviours and the changing nature of their social world. For example, the immediacy of young people’s communication tools means that the school day is extended through computers, texts, mobile phones and social networking. SNs know that this can translate into students coming to school with no respite from any of the previous day’s troubling relationships. This type of insight is crucial to maintaining strong and trusting relationships with students.

SNs also need a working knowledge of education systems and the processes and protocols of their school. They often work towards maintaining a boundary between themselves and the teaching staff, but some find that they are more effective when they work as part of the school resource team, becoming an integral part of the school culture.

Within this culture SNs try to balance the proactive part of their role that focuses on relationships and student capacity development, with the need to respond quickly to any immediate health needs of students, teachers and school administrative staff. It can be a careful balancing act, one that requires strong leadership and management skills, as well as extensive networks for liaising with a wide range of personnel, family members and community resources (Smith & Firmin 2009). Most SNs practise relatively autonomously, but not in isolation from others. A major challenge is the immediacy of demands on their time because of unscheduled student access and the fact that many SNs work part-time (Smith & Firmin 2009).

Health promotion is a significant element of the SN role (Moses et al 2008; St Leger 1999). In this role SNs negotiate primary prevention initiatives on the basis of their understanding of the social determinants of health, promoting positive parenting, providing advice, support and counselling, and maintaining a student-centred, partnership approach (Brooks et al 2007a). Many see their role as helping young people become resilient adults by encouraging them to develop self awareness and the ability to find solutions and options to the issues that challenge them. This often requires the nurse to make the first overture towards students who seem to need support for a physical or emotional issue. Their approach is one of deliberate engagement, building trust, taking advantage of the ‘teachable moments’ and whatever opportunities arise to convey the message that they are there to help. One of the main challenges is the vast number of students, many of whom have multiple issues. In addition to counselling for students and staff with emotional health problems, some also engage with educational staff in planning and delivering health-related curriculum components (Barnes et al., 2004a and Barnes et al., 2004b; Green & Reffel 2009; JOSN 2008; NASN 2005; Wainwright et al 2000).

In many cases the health promotion role of SNs is poorly understood, with education authorities expecting a behavioural, healthy-lifestyle approach rather than a broader focus on school and student capacity building (Ryan, 2008 and Whitehead, 2006a). The Health Promoting Schools (HPS) framework developed by the WHO in 1995 (WHO 1996) was intended to strengthen health promotion in schools at local, regional, national and global levels using a whole-of-school approach (St Leger 1999). The guidelines for health promotion were developed to address the school, its policies, social environment, community and health service relationships as well as personal health skills. In many cases the HPS model has been adopted as a guide to connecting the school community to the wider environment and its resources (Barnes et al., 2004a and Barnes et al., 2004b; Moses et al 2008; Victorian Government 2004). However, most HPS programs have retained the focus on changing students’ behaviours rather than developing an empowering approach to promoting the health of schools and students. One exception is the development in the UK of the National Healthy School Standard (NHSS); a PHC framework aimed at reducing inequalities, promoting social inclusion and raising educational standards (DeBell, 2006 and Wicklander, 2005). In this context, the SN has an important role in integrating services, coordinating activities and relationships, bridging health and education services, and promoting partnerships to build whole-of-school capacity as well as deliver programs with specific themes (Wicklander 2005). Another new initiative is the development in 2010 of professional standards for school nursing established by the Department of Health and Social Services in Victoria, Australia (Victorian School of Nurses [VSN] 2010). The 12 standards, which are classified within the domains of professional practice, provision and coordination of care, collaborative and therapeutic practice, and critical thinking and analysis, are listed in Table 4.3.

In some cases the nurse is the first person to provide early detection of children with developmental disabilities, which requires sensitive communication between parents, other health professionals and education staff (Wallis & Smith 2008). Where the school accommodates children with disabilities, the SN role extends to helping them with independent living needs and ensuring they have opportunities to participate in the educational experience, including field trips (NASN 2005). To achieve this, there is often a need to ensure educational staff as well as parents are fully apprised of the students’ needs and potential, and help them plan for both the home and learning environment to accommodate their needs. Like the child health nurses mentioned previously, SNs working in schools where young people have disabilities often act as the mediator between the health and education systems. This includes liaising with teachers, parents, peers and others affected by the child’s journey along the health and development continuum.

Research in the US indicates that up to 25% of school students have special needs, including asthma, diabetes, epilepsy or cancer, some of whom have the need for intermittent acute care and tertiary prevention (NASN 2005). In addition, many SNs are experiencing a rapid increase in helping students manage mental health issues and chronic conditions, particularly with growing rates of childhood obesity, stress-related illnesses and bullying (St Leger 1999; NASN 2005). Students can bring to school a wide range of vulnerabilities and social issues such as family crises, immigration or refugee-related problems, poverty and violence (Barnes et al 2004a; DeBell 2006; JOSN 2008). Adolescents in particular, can have serious mental health needs, sometimes requiring early detection of, and intervention for, substance abuse, family relationship challenges, adolescent pregnancy and/or sexually transmitted infections, or a risk of suicide (Brooks et al 2007a; JOSN 2008; NASN 2005; Tkaczyk & Edelson 2009).