LGBTQ+ Students’ Experiences of Junior High School Nursing in Finland: A Qualitative Study

Previous research shows that lesbian, gay, bisexual, transgender, queer/questioning, and other (LGBTQ+) students can experience substantial emotional- and health-related issues at school, but research into LGBTQ+ students’ experiences of school nursing is limited. This qualitative study describes the experiences of Finnish LGBTQ+ students engaging with junior high school nurses. Data were collected from 35 LGBTQ+ students using an online survey tool comprising of a set of open-ended questions. Two interconnecting themes were identified following thematic analysis: (1) junior high school nurse engagement: a mixed or unsatisfactory experience and (2) LGBTQ+ students’ needs for diversity-affirming junior high school nursing. Findings show that LGBQT+ students felt junior high school nurse engagement was often unsupportive with issues around their sexuality and gender identity. LGBTQ+ students expressed the need for diversity-affirming information and support in school settings. Further research from school nurses’ perspective is needed to increase understanding of this topic.

School nurses are key professionals in promoting and maintaining the physical and emotional health of students (Finnish Institute for Health and Welfare, 2019; National Association of School Nurses, 2018). There is evidence that students from the lesbian, gay, bisexual, transgender, queer or questioning, and other (LGBTQþ) community can experience significant health problems related to their sexual orientation or gender identity (Kosciw et al., 2017;Wilson & Cariola, 2019). These problems can encompass mental health issues related to stigma, concerns over body image, and self-esteem to emotional issues related to matters of sexuality and gender identity (Berzonsky, 2011;Boskey, 2014). The school environment should serve as a safe place where LGBTQþ students can seek help and support-particularly from school health professionals (Cicero & Wesp, 2017;Reynolds, 2011). However, there is a lack of research around how LGBTQþ students experience their engagement with school nurses and what thoughts they have on the type of things they require from school nurses-in addition no study of this type has ever been undertaken in Scandinavia. This study is designed to address this gap and identify some key issues for improving school nursing practice related to the health of LGBTQþ students.

Background
Adolescence can be a challenging time for students who identify as LGBTQþ; many of them experience stress, discrimination, stigmatization, or bullying because of their sexual orientation or gender identity (Huebner et al., 2015;Kosciw et al., 2017;Meyer, 2003). These stressors cause LGBTQþ students more depression, anxiety, and suicidal behavior than their peers (Russell & Fish, 2016). This can also cause problems around self-image, self-esteem, and confidence (Bussey, 2011;Dillon et al., 2011;Gullotta et al., 2000). Furthermore, adolescence sees young people at a stage in their life when their sexual identity is still developing-and thoughts and feelings about gender dysphoria may also come to the fore (Berzonsky, 2011). This process-which may involve complex emotional matters about how young people see themselves and the stress that realizing they are a minority in society can be substantialbe that either as a result of sexual orientation or gender dysphoria (Patterson, 2008;Stewart et al., 2019). Dealing with LGBTQþ issues comes at a time when young people are concerned with their school work, family life, but also friendship and romantic relationship issues. As such, there is quite a potential for health-related issues within this group of students (Boskey, 2014).
For healthy development, LGBTQþ students can benefit from protective and safe resources in their lives. The school environment can, and should, have a positive impact on LGBTQþ students' well-being when policies and practices support a positive climate in the school setting. A positive school climate can create feelings of safety, achievement, and positive mental health for LGBTQþ students, and it can be enhanced by the presence and visibility of information about sexual orientations and gender identities for all students (Russell & Fish, 2016). Furthermore, school personnel including school nurses are ideally placed to support the development, health, and well-being of LGBTQþ students. Previous research focusing on health professionals in primary care has shown that adolescents who identify as LGBTQþ value professionals as sources of support and information in matters of sexual orientation, gender identity, and sexual health (Hoffman et al., 2009;Rose & Friedman, 2013;Snyder et al., 2016). However, there is limited research on the experiences of LGBTQþ students in relation to school nursing.

LGBTQþ Students and School Nursing
Research evidence about LGBTQþ students in the school nursing context is limited (Arbeit et al., 2016;Rasberry et al., 2015;Rose & Friedman, 2017). This evidence indicates that school nurses still lack knowledge about LGBTQþ students' sexual orientations (Arbeit et al., 2016;Rose & Friedman, 2017), they make heterosexual assumptions of LGBTQþ students (Arbeit et al., 2016), and many school nurses have judgmental attitudes toward LGBTQþ students (Arbeit et al., 2016;Rasberry et al., 2015). However, no studies have focused on the needs of LGBTQþ students in junior high school nursing.

School Nursing in Finnish Junior High Schools
The term "junior high school" refers to the period between 13 and 15 years of age in the life of Finnish students. Finnish basic education consists of nine grades between the ages of 7 and 15 (Eyridice, 2017(Eyridice, -2018, and junior high school comprises Grades 7-9. School nursing is part of Finnish student welfare services, and school nursing works in cooperation with other school personnel to promote students' health and well-being (Finnish National Agency for Education, 2014). For example, school nurses participate in health education in the context of students' health and the development of sexuality and identity (Finnish National Agency for Education, 2014) during health checkups, and when they offer counseling at the school nurse's office. School nurses' work tasks can be divided into individual and community aspects including promoting the health of students; monitoring students' development, growth, and health; and ensuring the safety and health of school communities. School nurses work as health promotion professionals in Finnish schools and work closely with the school physician (Finnish Institute for Health and Welfare, 2019; Ministry of Social Affairs and Health and the Association of Finnish Local and Regional Authorities, 2004). In junior high schools, school nurses meet all students during health checkup appointments-during these meetings, they discuss the issues of physical development, sexuality, and sexual health with students (Mäki et al., 2014). However, as described above, despite this being a substantial school health-related topic, there is a dearth of research into LGBTQþ students' experiences of engaging with school nurses-a deficit this study is designed to address.

Method Design
The research question guiding this study is: "What are the experiences and views of Finnish junior high school LGBTQþ students in relation to school nursing?" To answer this question, a qualitative descriptive design (Holloway & Galvin, 2016) using an online survey tool consisting of open questions seeking free text responses was employed. The ethics committee of the University of Turku granted an ethical permission before the data collection (27/2015).

Survey Design and Data Collection
An online survey tool was designed to reach LGBTQþ students around Finland without restricting participation to a certain time and place and enable anonymous participation for a vulnerable group (Ahern, 2005). The survey questions were generated based on the research question, previous literature, and were designed to allow full descriptions of participants' experiences and thoughts about the topic (Turner, 2010). The survey consisted of demographic questions and three open-ended questions that asked for free text written answers from participants. To collect demographic data, we asked participants' age (16-19 years), gender identity (girl/boy/other), and their identity as LGBTQþ (

Ethical Considerations
According to the guidelines of the Finnish National Board on Research Integrity (TENK, 2019), young people aged 16 years of age can make an informed choice and informed consent in research participation. Thus, parental consent was not requested in this study. The ethical permission granted for this study allowed data collection from young people between 16 and 19 years of age given to the mutual understanding with TENK guidelines. Ethical permission was not given for under 16 years-although participants were asked questions that required them to think retrospectively. It was recognized that it would not be possible to completely prevent a participant under 16 years of age completing the survey-but mitigation against this included clear information about the age range of the study and the collection of demographic data-including participant age. Electronic informed consent was obtained prior to the survey being completed. Assurances of confidentiality were given.

Finnish
LGBTQþ students were the target population in this study. Two sampling strategies were applied. First, a purposive sampling was used to reach participants with specific characteristics (LGBTQþ identities), who could contribute information to the study (Polit & Beck, 2013). This was employed by publicizing the study and providing a URL link in the LGBTI rights nongovernmental organization (NGO) in Finland Seta's (n.d.) social media outputs and their newsletter. The social media groups of Seta have 23,000 followers; the newsletter was both published on Seta's webpage, and emailed to over 500 people (E. Alatalo, personal communication, April 26, 2019). In addition to purposive sampling, snowball sampling was used to reach additional participants by encouraging participants to publicize the survey to their peers-a technique that is particularly useful when researching hard-to-reach populations (Goodman, 1961(Goodman, , 2011. In total, n ¼ 35 participants completed the online survey.

Study Participants
Eligibility criteria for participants were self-identification as LGBTQþ, age 16-19 years, having had prior experiences with junior high school nursing, Finnish or Swedish as mother tongue, and a voluntary participation. The study focused on LGBTQþ students to enhance their presentation as a minority group in research (Griffith et al., 2017). We asked about junior high school experiences retrospectively to minimize possible distress to participants.

Data Analysis
Data were analyzed with inductive thematic analysis. Inductive thematic analysis was chosen to create a description about a phenomenon which has rarely been studied, and no existing theoretical framework was found to be suitable for analysis (Braun & Clarke, 2006). The thematic analysis aimed to gain an understanding of a phenomenon related to LGBTQþ students' life (Vaismoradi et al., 2013). The six stages of the thematic analysis process described by Braun and Clarke (2006) were followed; the process is outlined in Table 2.
To ensure rigor, peer review was conducted during data analysis (Morse, 2015). First, the corresponding author (M.L.) did the data familiarization, code generation, and search of initial themes. Then initial themes and framework were reviewed by two authors (M.L., S.S.), and the final themes were identified through consensus among all authors (see Table 3). In addition, detailed records of early coding and themes were retained to ensure confirmability. In data analysis, pseudonyms were given to the participants to individualize their replies in the results.

Results
There were 35 participants completing the survey. Participants' gender identities were not described in binary terms as girl or boy: 42% (n ¼ 15) of all participants chose other as Table 2. Thematic Analysis Process Based on Braun and Clarke (2006).

Stage Description 1
Transferring the questionnaire replies into NVivo ® Version 12, getting familiarized with data, and highlighting the relevant segments of data. 2 Generation of codes from the relevant segments of data. 3 Search of themes with an interpretative approach; printing codes from NVivo, comparing, grouping together, and identifying the initial themes. Organizing the themes into an initial framework to examine relationships between codes, themes, and levels of themes. 4 Reviewing the initial framework by two authors (M.L., S.S.). Creating a preliminary thematic map and evaluating the map and its validity by all authors. Some changes were done to deepen the "story" behind the themes. 5 Defining the final themes and writing detailed narratives about the themes, their contents, and relationships with each other. 6 Preparing the final conceptual framework. 1. Please describe your perceptions of junior high school nurse's attitudes and preparedness to encounter sexual and gender minority students. 2. What kind of information and support did the junior high school nurse offer to you about the development of sexual orientation and gender identity? 3. What kind of information and support would you have desired from the junior high school nurse about the development of sexual orientation and gender identity?
their gender identity. Other gender identity enabled to write a description about it, and the participants described their gender identity with terms such as genderfluid, nonbinary, and transmasculine. Participants could choose one or several LGBTQþ identities: Almost half of the participants (49%, n ¼ 17) preferred to describe themselves diversely. Nonbinary as a gender identity outside the girl/boy binary was the most frequently chosen LGBTQþ identity (n ¼ 12). Participants who chose other LGBTQþ (n ¼ 8) identity were able to write their own descriptions, and they described themselves with terms such as pansexual and panromantic demisexual (see Table 4).
LGBTQþ students described junior high school nursing in the context of their sexuality and gender identity from multiple perspectives. From data analysis, two interconnected main themes were discovered. The first theme, "Junior high school nurse engagement; a mixed or unsatisfactory experience," focuses on LGBTQþ students' views on their engagement with school nurses and their beliefs about the preparedness of the school nurses to support them. It shows how these experiences left many students feeling unsupported in issues they were experiencing around their sexuality and gender. The second main theme, "LGBTQþ students' needs for diversity-affirming junior high school nursing," focuses on the support and information needs of the LGBTQþ students in junior high school. This theme includes how students felt that sexual and gender diversity needs to be better recognized in schools and that more sexuality and gender-related information was needed in school nursing (see Figure 1).

Main Theme 1-Junior High School Nurse Engagement: A Mixed or Unsatisfactory Experience
LGBTQþ students' experiences of junior high school nursing were often unsatisfactory. These experiences were drawn from the students' own experiences of consulting with school nurses about sexuality or gender-related issues. There were two subthemes within this main theme-all connected with student experience of connecting with the school nurses.

Subtheme 1: Junior High School Nurses' Attitudes and Behaviors During Consultations
When LGBTQþ students visited the junior high school nurse's office, they sometimes felt that the school nurses were open-minded, but at times school nurses showed confusion when LGBTQþ students disclosed their identity.
[ . . . ] the school nurse asked, out of embarrassment, if I had thought about my sexual orientation, and I replied "yes." She gave a laugh and changed the topic. (Aale, 19 years old) LGBTQþ students' stories showed how discussing diversity in relation to sexuality and gender was not always familiar to junior high school nurses. The confusion of the school nurses made LGBTQþ students feel that the atmosphere in the nurse's office was awkward, and they subsequently felt uneasy to talk about their identity. If the school nurse gave a positive response to LGBTQþ student's identity disclosure, they felt free to discuss their identity and felt "normal" in the eyes of the school nurse.
LGBTQþ students had also many experiences of junior high school nurses' contradictory attitudes toward them. Junior high school nurses indicated that LGBTQþ students were too young to know their own identity or pointed out that it was "just a phase." Some school nurses were judgmental or even considered that LGBTQþ identity was problematic and in need of changing or being "fixed"; I just got a "diagnosis" of being sick because of my gender identity and sexual orientation, and the school nurse She always talked like my gender identity would match with the sex that I was assigned at birth based on my genitals.
Discussion with the school nurse Nurse's assumptions from the student's identity Assumption of student's gender identity Assumption of the student being cisgender Heteronormativity Gender norms They kept telling that your identity may vary within time, so I was not seen as a lost case.
They kept telling that your identity may vary within time, so I was not seen as a lost case.
Information gotten from the school nurse Nurse's assumptions from the student's identity Assumption that identity will vary Assumption that the student will become heterosexual Heteronormativity Negative experience from the meeting the school nurse recommended talking to a psychologist so that "the problem" could be fixed. (Sointu, 16 years old) Judgmental and even discriminatory attitudes worried LGBTQþ students since they felt these attitudes could have negative impacts on their well-being. However, LGBTQþ students also had experiences of junior high school nurses' nonjudgmental and accepting attitudes toward them regardless the school nurse's heteronormative understandings of sexuality and gender. This contradiction showed how normative definitions of sexuality and gender may influence school nurses' attitudes toward LGBTQþ identities. Moreover, if LGBTQþ students were uncertain about junior high school nurses' attitudes toward them, they did not even consider disclosing their identity. Thus, the attitudes of junior high school nurses affected gaining LGBTQþ students' trust.
LGBTQþ students frequently experienced junior high school nurses having heteronormative assumptions about them. Their sexual orientation was assumed to be LGBTQþ identity definitions: Gray-A identifies with asexuality, and experiences some or little sexual attraction. Panromantic can feel romantic emotions toward a person regardless of their gender (boy/girl/transgender/nonbinary) but does not experience sexual attraction. Asexual can feel romantic emotions or attraction to a person but does not experience sexual attraction. Queersexual is derived from the umbrella term queer. Queersexual feels romantic emotions and experiences sexual attraction to a person regardless of their gender or gender expression. Pansexual feels romantic emotions and sexual attraction toward a person in ways that do not correspond with normative ideas of sexuality and gender, especially heteronormative ones. Demisexual experiences sexual attraction only when having an emotional bond with another person. Aromantic feels little or no romantic emotions toward a person. Nongender identifies as having no gender; synonym for a gender and genderless. (Asexual Visibility and Education Network, 2019;Merriam-Webster, 2019;Nonbinary Wiki, 2019) heterosexual, sexuality was discussed solely from that perspective, and physical development was taught from a girl/ boy binary perspective in junior high school nursing: In health checkups, everyone was always heteronormative, and I was not brave enough to correct the school nurse's assumption. (Eelia, 16 years old) The false assumptions made the junior high school nurse's office uncomfortable, even distressful, and LGBTQþ students did not dare to question the school nurses. This made LGBTQþ students withdrawn, and instead of discussing with the school nurses, they just received the information the school nurse gave them. Heteronormative assumptions often led LGBTQþ students perceiving school nursing as unhelpful for their identity, health, and well-being.
LGBTQþ students found junior high school nursing actions to be partially helpful for them. Helpful actions were related to being on the LGBTQþ student's side, listening to them, and the junior high school nurse being a supportive adult in junior high school: She [junior high school nurse] supported me and she ensured that there was at least one person on my side among the school personnel. (Jooa, 17 years old) LGBTQþ students valued that junior high school nurses showed a genuine interest in helping them. Helpful actions gave LGBTQþ students a sense, that LGBTQþ students can trust, and they can get support from the school nurse if needed. However, LGBTQþ students also referred to junior high school nurse's actions as being unsupportive for them, including nonexistent discussion about gender diversity and assumptions of heterosexuality. These unsupportive actions made LGBTQþ students feel excluded in junior high school nursing and gave them a sense that their school nurses did not offer anything useful for them.

Subtheme 2: Inconsistent Preparedness to Support LGBTQþ Students
LGBTQþ students' experiences of junior high school nurses' preparedness to support them were inconsistent. The preparedness of junior high school nurses was often described as low, and they were described as reticent about sexual and gender diversity. Discussion about sexual and gender diversity was rare, and especially topics of safe sex with a same-sex partner or gender diversity were nonexistent: [ . . . ] we did not discuss being trans or nonbinary at all. (Viima,16 years old) Being reticent about sexual and gender diversity gave LGBTQþ students the impression that junior high school nurses did not understand them or their sexual orientation or gender identity and therefore were not willing to discuss their identities. However, discussing gender diversity was a significant health need for LGBTQþ students and something that they did not experience universally from their school nurses.
Despite many negative experiences, a minority of students described their school nurse as sensitive and unprejudiced. These junior high school nurses were progressive, and they accepted LGBTQþ students regardless of their knowledge levels about sexual and gender diversity: The junior high school nurse took it well when I told her I'm transgender. She was fair and admitted she does not know so much about it [transgender], she listened to me, and she did not claim her assumptions to be correct. (Devi, 18 years old) Sensitive and unprejudiced junior high school nurses recognized sexual and gender diversity in their work, and they were able to recognize their own knowledge gaps about the topic. Even if these school nurses may have had knowledge gaps, LGBTQþ students preferred them as supportive if the school nurse accepted them. However, it was still uncommon for LGBTQþ students to encounter sensitive and unprejudiced junior high school nurses, and the reticent junior high school nurses made LGBTQþ students feel disappointed.

Main Theme 2-LGBTQ؉ Students' Needs for Diversity-Affirming Junior High School Nursing
LGBTQþ students often felt excluded from discussions about sexuality and gender and that junior high school nurses did not offer them support and information that was beneficial for their identity development and health. Therefore, LGBTQþ students described support and information needs which highlighted diversity-affirmation. This main theme is comprised of two related subthemes.

Subtheme 1: LGBTQþ Health and Support Needs Recognition
For LGBTQþ students, junior high school was a period of understanding and reflecting on their own identity, sexual orientation, and gender identity. The identity reflection appeared in in three ways: (1) Sexual orientation and gender identity issues were not current for LGBTQþ students, (2) LGBTQþ students were reflecting on their identity, (3) LGBTQþ students identified as an LGBTQþ person: I never felt myself as a girl/woman even though I had female anatomy [ . . . ] I didn't want to define my own gender [ . . . ] (Nova, 18 years old) Nova's story illustrates how LGBTQþ students gave consideration to their identity. For each LGBTQþ student, identity was unique, and they wished that junior high school nurses would understand their uniqueness, ask about and discuss their identity, and confirm that LGBTQþ students were as normal as their peers: The confirmation of normality was important as it could have increased LGBTQþ students' understanding about diverse identities, the existence of LGBTQþ people, and feeling equal to their heterosexual and cisgendered peers (students who identify as their sex at birth) in junior high school nursing. Identity-related discussion with the junior high school nurses was a way to support LGBTQþ students, their mental health and well-being. Since LGBTQþ students had often had experiences of junior high school nurses' heteronormative assumptions, it was relevant that encounters with the school nurse would be free from assumptions: I would have wished that the junior high school nurse had at least talked about "partner" [ . . . ] she could have used genderneutral terms when talking about me [ . . . ] because she can't know someone's gender identity. (Miska,16 years old) LGBTQþ students pointed out that assumptions-free encounters with the junior high school nurses would increase the feeling of junior high school nursing as a place to discuss and seek support. Furthermore, assumptions-free encounters would reduce the negative feelings including distress about counseling the school nurse as an LGBTQþ student.
LGBTQþ students indicated that their peers and school personnel were often unaware of sexual and gender diversity, and students had to educate others about it. They felt that educating others was required of them if they wanted to be at all understood in the junior high school.
LGBTQþ students wished that junior school nurses would take a more active role as adult advocates in talking generally about sexual and gender diversity: Everyone could be taught about sexual and gender minorities, because many don't understand anything at all about them. It could maybe decrease bullying and prejudice. (Paiste, 16 years old) LGBTQþ students considered that by advocating diversity, junior high school nurses could address the intolerance of peer students and school personnel, thereby promoting a safe and inclusive junior high school environment and reducing the risk of bullying.

Subtheme 2: The Need for Diversity-Affirming Information
Information related to sexual and gender diversity was an important part of junior high school nursing for LGBTQþ students' identities, health, and well-being.
LGBTQþ students stated that the information junior high school nurses offer needs primarily to base on open-mindedness about students' diversity.
LGBTQþ students desired that junior high school nurses talk openly about sexual orientations, gender diversity, and the existence of LGBTQþ people in Open-mindedness would demonstrate that sexual and gender diversity was included in junior high school nursing as normal part of adolescence. Open-mindedness would also signal that LGBTQþ students are accepted as themselves and can ask about topics that are relevant for their identity and taking care of their own health and well-being.
LGBTQþ students often searched independently for information about sexual and gender diversity. Internet was a common information source, but finding the relevant information was problematic since most of the available information was in English.
LGBTQþ students valued having information in their mother tongue: I have found [ . . . ] information about gender identity issues from the internet, and most of it was in English. [ . . . ] All adolescents do not necessarily have such good skills in English that they could find enough information. (Viima, 16 years old) Finding relevant information in your own language was considered important, and LGBTQþ students appreciated information that could be easily accessible in junior high school nursing. They suggested several ways to offer information at the nurse's office, such as posters and leaflets: In Lei's description, we can see that not all LGBTQþ students were ready to talk about their identity with junior high school nurses. These students valued the possibility to access information through nurse's office without identity disclosure. This would enable LGBTQþ students to access information easily, give them privacy and space to consider their identity.
LGBTQþ students expressed a wish of getting comprehensive health information in junior high school nursing. Comprehensive health information included topics covering sexuality and gender identity. Sexual health was important to LGBTQþ students, but heterosexuality-focused information did not support taking care of sexual health. Especially safe sex practices and the risk of sexually transmitted infections among female couples were topics on which LGBTQþ students needed information: I would have liked to hear about protection in sex with women maybe a few years earlier. (Kajo,18 years old) When LGBTQþ students could not get the relevant health information from junior high school nursing, they got the information later. This caused insecurity about own sexual health, and LGBTQþ students stated that if they wanted to have sex in a same-sex relationship, they had to adapt the heterosexuality-focused information to their own needs. This put them in a more unequal situation in comparison with their heterosexual peers. Gender diversity was a significant topic for LGBTQþ students who identified as nonbinary or other genders than boy or girl, but also other LGBTQþ students valued this topic in junior high school nursing: LGBTQþ students alone with their thoughts and sometimes uncertain about their gender identity.
LGBTQþ students wished that gender diversity was a permanent topic when discussing development in adolescence; this could have increased their feeling of being equal with their cisgendered peers.

Discussion
Our study yielded an understanding of Finnish LGBTQþ students' experiences of junior high school nursing, the needs they required from school nurses, and their views on the school nursing support they experienced. Our findings illustrated new insights about LGBTQþ students in the 21st century, who are reconstructing the conventional definitions of sexuality and gender (Bosse & Chiodo, 2016;Paasonen & Spišák, 2018). Furthermore, our study shows that although some junior high school nurses were valued as supportive professionals, information sources, and diversity advocates in junior high school-many others did not provide suitable and appropriate care for LGBTQ þ students.
In our study, LGBTQþ students identified themselves diversely: 40% of students reported their gender identity beyond girl/boy binary, and nearly half (49%) of the LGBTQþ students chose to describe themselves as LGBTQþ with several identities. This shows how understanding of sexuality and gender may have moved beyond conventional sexual orientation and gender identity categories: LGBTQþ students rather see identities as fluid descriptions of their present selves without categorizing themselves too strictly (Paasonen & Spišák, 2018). The presence of gender minority students in our study is also novel since gender minorities are often underrepresented in school health studies (Laiti et al., 2019). This diversity may challenge the discussions about the development of sexuality and gender in school nursing practice since sexual orientation and gender identity may be more complex (Bosse & Chiodo, 2016;Paasonen & Spišák, 2018). In future school nursing, sexuality and gender of students could be considered as fluid, nuanced concepts (Bosse & Chiodo, 2016), which shape over time and culture, and reflect each student's unique growth.
LGBTQþ students' information needs in junior high school nursing highlighted diversity-affirmation. To be able to offer diversity-affirming information, school nurses need to encounter LGBTQþ students without making assumptions about them; this would give space for open discussion about sexuality and gender, and signal LGBTQþ identities are considered as normal.
LGBTQþ students need comprehensive information from junior high school nurses about sexuality and gender. Gender diversity was especially important for participants in this study, and it was often identified as a missing topic in school nursing and school.
LGBTQþ students' emphasis of the importance of gender diversity was novel in school nursing research, and it demonstrates possible changes in defining gender identity among 21st-century adolescents. These changes need more research in the field of nursing and health care to create an updated understanding about adolescence and adolescents' needs from health professionals.
Engagement with junior high school nurses was often a mixed or unsatisfactory experience to LGBTQþ students: School nurses' attitudes were confused or even negative toward them, nurses had heterosexual preconceptions about them, and these findings were similar to previous studies of school nursing practice (Arbeit et al., 2016;Rasberry et al., 2015). This demonstrates how there are still the need to ensure inclusive and equal school nursing services for LGBTQþ students, and these issues need to be considered when developing school nursing practices globally. Furthermore, our study demonstrated that if LGBTQþ students were unsure about junior high school nurses' attitudes toward their sexual orientation or gender identity, they did not disclose it, or health issues related to these identities. This finding highlights the importance of health professionals' open-minded and accepting attitudes in creating a safe and confidential relationship with patients, especially with adolescents (Carlisle et al., 2006;Hoopes et al., 2017) and minority groups (Hausmann et al., 2011;Morris et al., 2016). Thus, junior high school nurses' need reflect on the way they create a welcoming and nonjudgmental environment for students, as well as their professional skills and knowledge about sexuality and gender.
In addition to being open-minded, confidential professionals and providers of information, junior high school nurses were sometimes seen as advocates of sexual and gender diversity. This was an interesting finding, and it indicates that LGBTQþ students think advocating school nurses can affect in creating a safe school environment for LGBTQþ students. Literature supports this finding (Cicero & Wesp, 2017;Kosciw et al., 2017), and ensuring safety in schools is defined as school nurses' professional responsibility (Finnish National Agency for Education, 2014). Furthermore, ensuring a safe school is a significant way of reducing LGBTQþ students' experiences of bullying, discrimination, and harassment at school (Kosciw et al., 2017). Therefore, it is crucial that junior high school nurses provide open support for LGBTQþ students and take active roles in ensuring a safe and inclusive school environment.

Limitations
Our study included some limitations. As data were collected anonymously, the researcher could not contact participants to ask any further information or confirm the actual age of participants. Anonymous data collection was an ethical decision to protect participants' privacy, and it may have encouraged LGBTQþ students to participate. The generalizability of the findings (Morse, 2015) could have been increased if nonrespondents (e.g., students questioning their sexuality or gender) had been reached to participate. However, the study was publicized through an NGO, which reaches substantial number of LGBTQþ people in Finland, and this can be a strength in data collection and getting a thick description the phenomenon (Morse, 2015) in LGBTQþ students' lives.

Implications for School Nursing and Future Research
We suggest three areas of development in school nursing based on the findings in this study. First, school nurses need more education about sexual and gender diversity, LGBTQþ identities, sexual health of this group, and gender diversity. Education needs to be available both graduated school nurses and students to increase understanding of diversity in adolescent sexuality and gender and to create school nursing accepting and supportive for all students. Second, to be able to create safe and confidential relationships with LGBTQþ students, school nurses would benefit from training for improving their skills to care LGBTQþ students. Training would include dimensions of sensitive and inclusive engagement and creating an open discussion atmosphere about sexuality and gender in school nurse's office. Third, policies and practice guidelines for school nursing need to be updated to cover wider aspects of sexuality and gender to recognize diversity in adolescence. Then school nursing can offer access to health information and service, which promotes every student's health and development (United Nations Convention on the Rights of the Child, 1989).
Further research is needed from junior high school nurses' perspective, since this study focused on LGBTQþ students. Research focusing on junior high school nurses' perceptions about sexual and gender diversity would increase the evidence base about LGBQTþ students as school nursing patients and sexuality and gender in the school nursing context. School nursing practice could then be developed to become more inclusive for LGBTQþ students.

Many
LGBTQþ students' experiences of junior high school nursing varied, and LGBTQþ students' negative experiences left them feeling that school nurses could not be relied upon for support and advice. Where students did receive supportive care, they felt valued and accepted within the school community. Diversity-affirming information and support in school nursing was significant for their health and well-being, and junior high school nurses can play a significant role in promoting both inclusive and safe school environment for LGBTQþ students. Further research is needed from junior high school nurses' perceptions to create comprehensive evidence about sexual and gender diversity in the school nursing context.

Author Contributions
Minna Laiti, Heidi Parisod, and Salla Salanterä were involved in the conception or design of the manuscript. The manuscript was drafted by Minna Laiti and Mark Hayter. All authors contributed to the acquisition as well as analysis of data, critical revisions, gave final approval, and agreed to be accountable for all aspects of work ensuring integrity and accuracy.

Declaration of Conflicting Interests
The author(s) declared that there is no conflicts of interest with respect to the research, authorship, and/or publication of this article.

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