Articles Adolescent Pregnancy Prevention Strategies Used by School Nurses Linda J. Kobokovich, Leah K. Bonovich
ABSTRACT: This survey identifed a ronge of adolescent pregnancy prevention activities used by school nurses in selected Mid-Atlantic public schools. A purposive sample of 224 public school nurses completed the School Nurse Questionnaire odapted from an instrument used previously lo survey school nurses. Based on a 54% response rate, a task analysis revealed that respondents performed only one pregnoncy prevention octivity frequently. A sub-somple of nurses, serving students in grodes 6-12, used seven of 21 pregnancy prevention octivities frequently. Though nurses did not actually perform the remaining octivities, they felt prepared to d o so. However, the structure of school nursing services often does not allow adequate time or opportunity lo engoge in odolescent pregnoncy prevention activities. (J Sch Health. 1992;62( 1): I 1-14)
I
n the U.S., adolescent pregnancy affects all cultural, ethnic, and socioeconomic groups. The U.S.has the highest adolescent pregnancy rate of any western nation, and the rate is considerably higher than that of less developed countries. The large number of pregnant adolescents also contributes to the U.S. having the highest adolescent abortion rate among developed countries with available data.’ The Center for Population Options2 estimated the yearly government cost for all families started by adolescents as $17.93 billion. In 1986, the annual cost to the American taxpayer of each birth was $14,852. For mothers younger than age 15, the cost increased to $18,913. Adolescent childbearing also contributes disproportionately to the U.S. infant mortality rate and to the prevalence of low birthweight babies.’ In addition to the immediate effects of pregnancy for adolescents and their children, life-long consequences occur for the adolescent mother, adolescent father, and the child. The school nurse, as a public health advocate, has a logical role in health promotion and disease p r e ~ e n t i o n . ~Traditional -~ but newly emphasized preventive efforts include a focus on human sexuality education and adolescent pregnancy.’ Because the problem of adolescent pregnancy is so great, and because the special contribution of school nurses to decrease the adolescent pregnancy rate could be substantial, the extent of nurses’ use of pregnancy prevention strategies is important to define. This survey identified adolescent pregnancy prevention strategies used by school nurses and public health department nurses performing school Linda J . Kobokovich, RNC, MScN, Obstetrical Clinical Nurse Speciolist, Dartmouth Hitchcock Medical Center, One Medical Center Drive, ‘Lebanon, NH 03756-0001; and Leah K . Bonovich, RN. ScD, Assistant Professor, The Johns Hopkins University School of Nursing. 600 N. Wove St.. Baltimore, MD 21205. This article wos submitted June 10, 1991, ond accepted for publicotion September 3, 1991.
nurse services, how often pregnancy prevention activities arc performed, and nurses’ perceived ability to perform pregnancy prevention activities.
BACKGROUND Wold and Dagg6 provided a conceptual framework of five clusters of concepts that captures the scope and focus of school nursing. The public health cluster organized school nurse activities into three levels of prevention: primary prevention includes health promotion and specific protection, secondary prevention includes early diagnosis, prompt treatment, and disability limitation, and tertiary prevention focuses on rehabilitation. Because adolescent pregnancy is a public health concern, the school nurse as a public health advocate should be involved in preventive measures. School health is an important component of community health. Thus, the public health tenets of primary, secondary, and tertiary health prevention are an integral part of the school nurse r ~ l e . ~ . ~A. *special relationship exists between the school nurse and the school child. This special relationship is based on the school nurse acting as a resource person to help children adapt to their internal and external environments.6J The manner in which school nurses act as resource persons to form helping relationships, and the role school nurses play in adolescent pregnancy prevention, are undescribed. To identify school nurse activities, White9 conducted a survey to name clusters of school nurse activities and describe characteristics of these clusters. Factor analysis revealed five clusters of activities: physical care, facilitation, instruction, administration, and clerical functions. From this analysis, White concluded that physical care remains the major function of the school nurse role. Though school nurses have developed the ability to serve as resources to faculty and students in the instructive and facilitative
Journal of School Health
January 1992, Vol. 62. No. 1
11
roles, they continue to be ill-prepared to implement managerial or administrative activities t o influence change in school systems where they are employed. Lester and Cox5 defined the nurse’s role in public school human sexuality education as influencing development of curriculum components by actively pursuing school administrative support, and providing teens with accurate sexual knowledge in a comfortable environment. They note that nurses have in-depth knowledge of sexual health, and most nurses believe they have a responsibility to promote sexual health. Forrest and Silverman’O identified what U.S. public school educators teach about preventing pregnancy. This study did not target school nurses specifically, but school nurses were included in the population sampled. Sixty percent of teachers referred students to the school nurse for information about sexually transmitted diseases, and 55% referred students to the school nurse for information about contraception. Problems identified by all human sexuality educators included pressure from parents and school boards, and lack of materials for teaching. Gorosh’ identified specific components of the school nurse’s role in providing human sexuality education. Only 25.5% of the sample were actively engaged in teaching and counseling activities they endorsed as appropriate for school nurses. These nurses reported the topics most frequently discussed with students included physical development and attractiveness, the fertile period, and reliability of contraceptive methods. Presence of a school board mandate for human sexuality education was the most significant predictor of nurses’ involvement. Nurses’ willingness to perform selected functions was the second strongest predictor. Gorosh concluded that the presence of a school board mandate for human sexuality education was the most predictive of preventive efforts. She recommended that nurses willing to become involved should be included in state and local program planning.
SURVEY METHODS Subjects. The survey employed a cross-sectional descriptive design. The target population included all registered nurses in a Mid-Atlantic state who, at the time of data collection, worked in a public school system as a school nurse. The population included nurses employed by any county board of education, the state, and any county health department in the state. Some nurses who worked as the “school nurse” actually were public health nurses who devoted time to schools. Six hundred nurses were identified to receive a questionnaire distributed by their supervisors. Reports from supervisors indicated 446 nurses received questionnaires. Questionnaires were distributed to nurses in public schools in 18 of 23 school counties and a major metropolitan city. Of 446 nurses receiving a questionnaire, 246 (54.5%) returned it. Three questionnaires were returned unanswered. The response rate available for analysis was 53.7%. Instrumentation. The School Nurse Questionnaire is a self-administered instrument adapted from a tool designed and used by White9 to identify and name clusters of school nurse activities. For this survey,
12
Journal of School Health
January 1992, Vol. 62, No. 1
White’s instrument was expanded to include adolescent pregnancy prevention activities. The questionnaire was composed of three parts. The first section contained 26 items or selected activities cited in the literature as commonly performed by school nurses. The second section contained 22 items developed specifically for this survey to describe activities designated as intervention techniques for preventing adolescent pregnancy. The intervention techniques varied in that some were primary techniques used before onset of sexual activity; some were secondary techniques used after onset of sexual activity but before pregnancy occurred, and some were tertiary techniques used after pregnancy occurred in an attempt to prevent further pregnancies and encourage positive parenting. The activities also were grouped according to clusters, as initially identified by White.9 Nurses rated the first two sections in regard to how often they performed each activity: 0 = none, 1 = once or twice a year, 2 = once or twice a month, and 3 = once or twice a week. “Not applicable” was listed as a choice for activities the nurses felt should be performed by others such as physicians or clerks. Nurses then rated their perceived ability to perform each of the activities: 0 = not at all prepared, 1 = moderately prepared, and 2 = extremely well-prepared. The third section contained 18 items concerning demographic characteristics of respondents. Content validity for the original instrument was established through expert panel review. Preliminary evidence of content validity for the instrument in this survey was established by input from two content experts in questionnaire adaptation and expert panel review of the draft by 23 school nurse supervisors. The questionnaire was revised with recommendations from the panel. Additional reliability testing was not possible due t o lack of direct access t o the sample. In addition, contiguous states have different school nurse systems and could not be used for comparison. Procedure. Distribution of the questionnaire was completed in May 1989. School nurse supervisors disFigure 1 Pregnancy Prevention Strategies Facllltatlon Cluster Referring lor pregnancy counseling Referring lor pregnancy testing Counseling students individually for sex-related problems Communicating with teachers regarding a student’s performance Referring lor contraception Counseling for suspected pregnancy Referring students with behavior problems to community resource Referring lor lamily counseling Counseling students in groups lor sex-related problems Consulting lor adolescent pregnancy prevention groups Referring for treatment of suspected STD Consulting lor adolescent pregnancy prevention hotline Instruction Cluster Directing assertiveness training programs for students Providing inservice to school personnel regarding human sexuality education Teaching family lile/human sexuality education course Teaching decision-making techniques Teaching about STDs Admlnlrtrrtlon Clurtar Participating in media campaign for teen pregnancy prevention Participating in community/church teen pregnancy prevention program Coordinating activities for family life/human sexuality education Serving as resource lor curriculum in family lile/human sexuality education
tributed one questionnaire to each school nurse in their area of responsibility. Each questionnaire included a cover letter explaining the intent of the survey and a self-addressed, stamped, return envelope.
SURVEY RESULTS Sample. Descriptive statistics provided a profile of the sample. School nurses who responded to the questionnaire were primarily female (99.2%), between the ages of 40-59 (69.2%), and married (86Yo). Most were mothers (96070); 37.1 070 were mothers of teen-agers. Most respondents (83.3%) were employed by a county or city health department, worked full-time (75.4%), and held the title of school nurse (48%). The nurses served mostly elementary school grade levels K-5 (77.1To), however, 44% served in grades six-eight and the least number (35%) served a high school population (grades 9-12). The total percentage exceeds 100% because many nurses worked in multiple settings. The greatest single percentage of school nurses (32.1Yo) served up to 499 students per nurse, but 135 (55To) served between 500 and 5,000 students. One nurse reported that she worked in a school-based clinic. The highest level of professional education for respondents was almost equally divided between baccalaureate preparation (38.3%) and diploma preparation (35%). Of the remaining nurses, 11.3% were associate degree prepared and 9.2% held a master’s degree. Following initial analysis, a subgroup of the sample was created for nurses who taught in grades 6-12. Pregnancy Prevention Strategies. From the 21 pregnancy prevention strategies listed in Figure 1 , the total sample of 243 respondents reported using only one strategy frequently. Seventy-three percent of nurses “communicate with teachers regarding a student’s performance” once or twice a month to weekly. These nurses reported they feel extremely well-prepared to perform this activity. Twenty-five percent to 45 070 reported using seven additional pregnancy prevention activities weekly to monthly. Most nurses reported feeling moderately well to extremely well-prepared to perform these strategies. For five of the activities listed, however, as high as 20% of respondents indicated others should be responsible for the performance. The remaining 14 pregnancy prevention activities Table 1 Task Analysis of Most Frequently Used Pregnancy Prevention Strategies: 6-12 Actlvlty
None
Frequency ( W ) 1-2 Hmer 1-2 Hmer per year per month
1-2 tlmer per week
Relerring lor pregnancy counseling
20
21
37
20
Referring lor pregnancy testing
17
26
33
23
Counseling students individually for sex-related problems
22
21
29
27
Commuinicating with teachers regarding a student’s performance
16
26
21
35
Referring lor contraception
22
23
22
33
Counseling for suspected pregnancy
20
24
36
19
Referring students with behavior problems to community resources
15
29
30
14
were rarely or never performed by nurses. These activities were instructional, administrative, or physical. Twenty percent to 35% of respondents felt these activities should be performed by others. Though the nurses were not performing the activities, they reported feeling moderately well or extremely well-prepared to perform them. Most respondents served students in grades K-5.To describe the adolescent pregnancy prevention activities of nurses in schools with students at or past puberty, a subgroup of nurses serving students in grades 6-12 was analyzed. The task analysis was repeated for this subgroup. More than one-half the respondents who served students in the upper grade levels used seven pregnancy prevention strategies frequently (Table 1). Three of the prevention strategies related directly t o pregnancy: 58% reported “making referrals for pregnancy counseling,” 57% “referring for pregnancy testing,” and 56% “counseling students for suspected pregnancy.” As in the original analysis, the most frequently performed prevention activities were facilitative in nature. These nurses reported they felt moderately well or extremely well-prepared to perform the activities though they did not actually perform many of them. Nurses serving students in grades 6-12 also consistently perceived these activities as appropriate for the school nurse. Nurses who served students in grades K-5 indicated age of the students was the primary factor that prevented their involvement. Nurses who served students in grades 6-12 indicated school board policies or influence was the primary factor that prevented their involvement, but lack of time also was cited as a significant factor.
SURV EY IMPLICATIONS School nurses responding to the questionnaire actually performed few adolescent pregnancy prevention activities. The activity cited most frequently by the entire sample was “communicating with teachers regarding a student’s performance.” This strategy is important as a primary prevention technique. Doing well in school and in the school environment reinforces the student’s desire to achieve. This desire may increase levels of achievement and also may decrease the possibility students will drop out of school. Both low achievement and high drop-out rates have been associated with risk of adolescent pregnancy.12 When nurses serving students in grades 6-12 were examined separately, their use of adolescent pregnancy prevention activities increased noticeably. Fifty percent to 58% of nurses serving students in grades 6-12 used seven pregnancy prevention activities frequently. Three of the seven interventions relate to confirmed or suspected pregnancy. Therefore, secondary and tertiary prevention techniques seem to dominate nurses’ efforts. One goal for school nurses could be to increase their use of primary prevention activities. School nurses serving children in grades K-5reported that their use of pregnancy prevention activities was curtailed by age of the students. These nurses perceived pregnancy prevention as appropriate only for students close to an age when sexual activity is most likely. Contrary t o these assumptions, data suggest adolescents
Journal of School Health
January 1992, Vol. 62, No. 1
13
are becoming sexually active at earlier ages.’* Jones et all noted that Swedish success at adolescent pregnancy prevention is tied to instruction in human sexuality and human relations starting in kindergarten and proceeding throughout school age. To increase the success of pregnancy prevention activities, school nurses should be aware that instruction in human sexuality and human relations for younger students is desirable. Early intervention, before intercourse begins, delays intercourse for younger students” through the provision of accurate information about sexual relations and human relations. It also involves helping children make knowledgeable and beneficial personal decisions. School board policies, pressure, and lack of time were constraints to performing pregnancy prevention activities for nurses serving students in grades 6-12. Goroshl noted that influence of school boards and presence of clear policies for human sexuality education predicted school nurses’ prevention efforts. The nurses surveyed perceived school board policies and pressures as interfering with their ability to be involved in adolescent pregnancy prevention. Increased involvement in pregnancy prevention activities by school nurses requires that their role be sanctioned by school board policy. Increased involvement also requires greater administrative activity by school nurses in writing position descriptions that make their abilities and potential functions clear to school officials. In addition, nurses should be assigned to schools in numbers that allow for realistic work responsibilities. Nurses reported they felt moderately well or extremely well-prepared to perform pregnancy activities. Nonetheless, they report actually performing very few of the activities. Thus, nurses are not being used by
14
J o u r n a l of School Health
9
J a n u a r y 1992, Vol. 62,No. 1
school systems to their full capabilities. Complex political and economic issues must be addressed before change can be effected. However, nurses themselves must seek greater administrative involvement to initiate such change. References 1. Jones EF, Forrest JD, Goldman N. Henshaw SK, Lincoln R,
Fosoff JI, et al. Teenage pregnancy in developed countries: Determinants and policy implications. Fam Plann Perspect. 1985; 1753-63. 2. Estimates of Public Costs f o r Teenage Childbearing. Washington, DC: Center for Population Options; 1986. 3. Hughes D, Johnson K, Rosenbaum S , Simons J, Butler E. The Health of American’s Children. Washington, DC: Children’s Defense Fund; 1987. 4. Collis JL, Dukes CA. Toward some principles in school nursing. J Sch Health. 1989;59(3):109-11 1 . 5. Lester B, Cox JL. Involving nurses in public school sex education. J Sch Health. 1988;58(3):108-109. 6. Wold SJ, Dagg NV. School nursing: A framework for practice. JSch Nurs. 1978;2:111-114. 7 . Oda DS. The invisible nursing practice. Nurs Outlook. 1991;39: 26-29. 8. Catchings M . Effective school nursing. J Sch Health. 1979;49(2):117-118. 9. White D. A study of current school nurse practice activities. J Sch Healfh. 1985;~ ( 2 )52-56. : 10. Forrest JD, Silverman J. What public school teachers teach about preventing pregnancy, AIDS, and sexually transmitted diseases. Fam Plann Perspecf. 1989;21:65-72. 11. Gorosh VA. Predicting school nurse involvement in meeting sexuality related needs of youth in New Jersey. Public Health Rep. 1981 ;96:363-368. 12. Hayes CD, ed. Risking the Future: Adolescent sexuality, pregnancy, and childbearing. Washington. DC: National Academy Press; 1987. 13. Zabin LS, Hirsch MB, Smith EA. Streett R. Hardy JB. Adolescent pregnancy prevention programs: A model for research and evaluation. J Ado1 Health Care. 1986;7:77-87.
ABSTRACT: This survey identifed a ronge of adolescent pregnancy prevention activities used by school nurses in selected Mid-Atlantic public schools. A purposive sample of 224 public school nurses completed the School Nurse Questionnaire odapted from an instrument used previously lo survey school nurses. Based on a 54% response rate, a task analysis revealed that respondents performed only one pregnoncy prevention octivity frequently. A sub-somple of nurses, serving students in grodes 6-12, used seven of 21 pregnancy prevention octivities frequently. Though nurses did not actually perform the remaining octivities, they felt prepared to d o so. However, the structure of school nursing services often does not allow adequate time or opportunity lo engoge in odolescent pregnoncy prevention activities. (J Sch Health. 1992;62( 1): I 1-14)
I
n the U.S., adolescent pregnancy affects all cultural, ethnic, and socioeconomic groups. The U.S.has the highest adolescent pregnancy rate of any western nation, and the rate is considerably higher than that of less developed countries. The large number of pregnant adolescents also contributes to the U.S. having the highest adolescent abortion rate among developed countries with available data.’ The Center for Population Options2 estimated the yearly government cost for all families started by adolescents as $17.93 billion. In 1986, the annual cost to the American taxpayer of each birth was $14,852. For mothers younger than age 15, the cost increased to $18,913. Adolescent childbearing also contributes disproportionately to the U.S. infant mortality rate and to the prevalence of low birthweight babies.’ In addition to the immediate effects of pregnancy for adolescents and their children, life-long consequences occur for the adolescent mother, adolescent father, and the child. The school nurse, as a public health advocate, has a logical role in health promotion and disease p r e ~ e n t i o n . ~Traditional -~ but newly emphasized preventive efforts include a focus on human sexuality education and adolescent pregnancy.’ Because the problem of adolescent pregnancy is so great, and because the special contribution of school nurses to decrease the adolescent pregnancy rate could be substantial, the extent of nurses’ use of pregnancy prevention strategies is important to define. This survey identified adolescent pregnancy prevention strategies used by school nurses and public health department nurses performing school Linda J . Kobokovich, RNC, MScN, Obstetrical Clinical Nurse Speciolist, Dartmouth Hitchcock Medical Center, One Medical Center Drive, ‘Lebanon, NH 03756-0001; and Leah K . Bonovich, RN. ScD, Assistant Professor, The Johns Hopkins University School of Nursing. 600 N. Wove St.. Baltimore, MD 21205. This article wos submitted June 10, 1991, ond accepted for publicotion September 3, 1991.
nurse services, how often pregnancy prevention activities arc performed, and nurses’ perceived ability to perform pregnancy prevention activities.
BACKGROUND Wold and Dagg6 provided a conceptual framework of five clusters of concepts that captures the scope and focus of school nursing. The public health cluster organized school nurse activities into three levels of prevention: primary prevention includes health promotion and specific protection, secondary prevention includes early diagnosis, prompt treatment, and disability limitation, and tertiary prevention focuses on rehabilitation. Because adolescent pregnancy is a public health concern, the school nurse as a public health advocate should be involved in preventive measures. School health is an important component of community health. Thus, the public health tenets of primary, secondary, and tertiary health prevention are an integral part of the school nurse r ~ l e . ~ . ~A. *special relationship exists between the school nurse and the school child. This special relationship is based on the school nurse acting as a resource person to help children adapt to their internal and external environments.6J The manner in which school nurses act as resource persons to form helping relationships, and the role school nurses play in adolescent pregnancy prevention, are undescribed. To identify school nurse activities, White9 conducted a survey to name clusters of school nurse activities and describe characteristics of these clusters. Factor analysis revealed five clusters of activities: physical care, facilitation, instruction, administration, and clerical functions. From this analysis, White concluded that physical care remains the major function of the school nurse role. Though school nurses have developed the ability to serve as resources to faculty and students in the instructive and facilitative
Journal of School Health
January 1992, Vol. 62. No. 1
11
roles, they continue to be ill-prepared to implement managerial or administrative activities t o influence change in school systems where they are employed. Lester and Cox5 defined the nurse’s role in public school human sexuality education as influencing development of curriculum components by actively pursuing school administrative support, and providing teens with accurate sexual knowledge in a comfortable environment. They note that nurses have in-depth knowledge of sexual health, and most nurses believe they have a responsibility to promote sexual health. Forrest and Silverman’O identified what U.S. public school educators teach about preventing pregnancy. This study did not target school nurses specifically, but school nurses were included in the population sampled. Sixty percent of teachers referred students to the school nurse for information about sexually transmitted diseases, and 55% referred students to the school nurse for information about contraception. Problems identified by all human sexuality educators included pressure from parents and school boards, and lack of materials for teaching. Gorosh’ identified specific components of the school nurse’s role in providing human sexuality education. Only 25.5% of the sample were actively engaged in teaching and counseling activities they endorsed as appropriate for school nurses. These nurses reported the topics most frequently discussed with students included physical development and attractiveness, the fertile period, and reliability of contraceptive methods. Presence of a school board mandate for human sexuality education was the most significant predictor of nurses’ involvement. Nurses’ willingness to perform selected functions was the second strongest predictor. Gorosh concluded that the presence of a school board mandate for human sexuality education was the most predictive of preventive efforts. She recommended that nurses willing to become involved should be included in state and local program planning.
SURVEY METHODS Subjects. The survey employed a cross-sectional descriptive design. The target population included all registered nurses in a Mid-Atlantic state who, at the time of data collection, worked in a public school system as a school nurse. The population included nurses employed by any county board of education, the state, and any county health department in the state. Some nurses who worked as the “school nurse” actually were public health nurses who devoted time to schools. Six hundred nurses were identified to receive a questionnaire distributed by their supervisors. Reports from supervisors indicated 446 nurses received questionnaires. Questionnaires were distributed to nurses in public schools in 18 of 23 school counties and a major metropolitan city. Of 446 nurses receiving a questionnaire, 246 (54.5%) returned it. Three questionnaires were returned unanswered. The response rate available for analysis was 53.7%. Instrumentation. The School Nurse Questionnaire is a self-administered instrument adapted from a tool designed and used by White9 to identify and name clusters of school nurse activities. For this survey,
12
Journal of School Health
January 1992, Vol. 62, No. 1
White’s instrument was expanded to include adolescent pregnancy prevention activities. The questionnaire was composed of three parts. The first section contained 26 items or selected activities cited in the literature as commonly performed by school nurses. The second section contained 22 items developed specifically for this survey to describe activities designated as intervention techniques for preventing adolescent pregnancy. The intervention techniques varied in that some were primary techniques used before onset of sexual activity; some were secondary techniques used after onset of sexual activity but before pregnancy occurred, and some were tertiary techniques used after pregnancy occurred in an attempt to prevent further pregnancies and encourage positive parenting. The activities also were grouped according to clusters, as initially identified by White.9 Nurses rated the first two sections in regard to how often they performed each activity: 0 = none, 1 = once or twice a year, 2 = once or twice a month, and 3 = once or twice a week. “Not applicable” was listed as a choice for activities the nurses felt should be performed by others such as physicians or clerks. Nurses then rated their perceived ability to perform each of the activities: 0 = not at all prepared, 1 = moderately prepared, and 2 = extremely well-prepared. The third section contained 18 items concerning demographic characteristics of respondents. Content validity for the original instrument was established through expert panel review. Preliminary evidence of content validity for the instrument in this survey was established by input from two content experts in questionnaire adaptation and expert panel review of the draft by 23 school nurse supervisors. The questionnaire was revised with recommendations from the panel. Additional reliability testing was not possible due t o lack of direct access t o the sample. In addition, contiguous states have different school nurse systems and could not be used for comparison. Procedure. Distribution of the questionnaire was completed in May 1989. School nurse supervisors disFigure 1 Pregnancy Prevention Strategies Facllltatlon Cluster Referring lor pregnancy counseling Referring lor pregnancy testing Counseling students individually for sex-related problems Communicating with teachers regarding a student’s performance Referring lor contraception Counseling for suspected pregnancy Referring students with behavior problems to community resource Referring lor lamily counseling Counseling students in groups lor sex-related problems Consulting lor adolescent pregnancy prevention groups Referring for treatment of suspected STD Consulting lor adolescent pregnancy prevention hotline Instruction Cluster Directing assertiveness training programs for students Providing inservice to school personnel regarding human sexuality education Teaching family lile/human sexuality education course Teaching decision-making techniques Teaching about STDs Admlnlrtrrtlon Clurtar Participating in media campaign for teen pregnancy prevention Participating in community/church teen pregnancy prevention program Coordinating activities for family life/human sexuality education Serving as resource lor curriculum in family lile/human sexuality education
tributed one questionnaire to each school nurse in their area of responsibility. Each questionnaire included a cover letter explaining the intent of the survey and a self-addressed, stamped, return envelope.
SURVEY RESULTS Sample. Descriptive statistics provided a profile of the sample. School nurses who responded to the questionnaire were primarily female (99.2%), between the ages of 40-59 (69.2%), and married (86Yo). Most were mothers (96070); 37.1 070 were mothers of teen-agers. Most respondents (83.3%) were employed by a county or city health department, worked full-time (75.4%), and held the title of school nurse (48%). The nurses served mostly elementary school grade levels K-5 (77.1To), however, 44% served in grades six-eight and the least number (35%) served a high school population (grades 9-12). The total percentage exceeds 100% because many nurses worked in multiple settings. The greatest single percentage of school nurses (32.1Yo) served up to 499 students per nurse, but 135 (55To) served between 500 and 5,000 students. One nurse reported that she worked in a school-based clinic. The highest level of professional education for respondents was almost equally divided between baccalaureate preparation (38.3%) and diploma preparation (35%). Of the remaining nurses, 11.3% were associate degree prepared and 9.2% held a master’s degree. Following initial analysis, a subgroup of the sample was created for nurses who taught in grades 6-12. Pregnancy Prevention Strategies. From the 21 pregnancy prevention strategies listed in Figure 1 , the total sample of 243 respondents reported using only one strategy frequently. Seventy-three percent of nurses “communicate with teachers regarding a student’s performance” once or twice a month to weekly. These nurses reported they feel extremely well-prepared to perform this activity. Twenty-five percent to 45 070 reported using seven additional pregnancy prevention activities weekly to monthly. Most nurses reported feeling moderately well to extremely well-prepared to perform these strategies. For five of the activities listed, however, as high as 20% of respondents indicated others should be responsible for the performance. The remaining 14 pregnancy prevention activities Table 1 Task Analysis of Most Frequently Used Pregnancy Prevention Strategies: 6-12 Actlvlty
None
Frequency ( W ) 1-2 Hmer 1-2 Hmer per year per month
1-2 tlmer per week
Relerring lor pregnancy counseling
20
21
37
20
Referring lor pregnancy testing
17
26
33
23
Counseling students individually for sex-related problems
22
21
29
27
Commuinicating with teachers regarding a student’s performance
16
26
21
35
Referring lor contraception
22
23
22
33
Counseling for suspected pregnancy
20
24
36
19
Referring students with behavior problems to community resources
15
29
30
14
were rarely or never performed by nurses. These activities were instructional, administrative, or physical. Twenty percent to 35% of respondents felt these activities should be performed by others. Though the nurses were not performing the activities, they reported feeling moderately well or extremely well-prepared to perform them. Most respondents served students in grades K-5.To describe the adolescent pregnancy prevention activities of nurses in schools with students at or past puberty, a subgroup of nurses serving students in grades 6-12 was analyzed. The task analysis was repeated for this subgroup. More than one-half the respondents who served students in the upper grade levels used seven pregnancy prevention strategies frequently (Table 1). Three of the prevention strategies related directly t o pregnancy: 58% reported “making referrals for pregnancy counseling,” 57% “referring for pregnancy testing,” and 56% “counseling students for suspected pregnancy.” As in the original analysis, the most frequently performed prevention activities were facilitative in nature. These nurses reported they felt moderately well or extremely well-prepared to perform the activities though they did not actually perform many of them. Nurses serving students in grades 6-12 also consistently perceived these activities as appropriate for the school nurse. Nurses who served students in grades K-5 indicated age of the students was the primary factor that prevented their involvement. Nurses who served students in grades 6-12 indicated school board policies or influence was the primary factor that prevented their involvement, but lack of time also was cited as a significant factor.
SURV EY IMPLICATIONS School nurses responding to the questionnaire actually performed few adolescent pregnancy prevention activities. The activity cited most frequently by the entire sample was “communicating with teachers regarding a student’s performance.” This strategy is important as a primary prevention technique. Doing well in school and in the school environment reinforces the student’s desire to achieve. This desire may increase levels of achievement and also may decrease the possibility students will drop out of school. Both low achievement and high drop-out rates have been associated with risk of adolescent pregnancy.12 When nurses serving students in grades 6-12 were examined separately, their use of adolescent pregnancy prevention activities increased noticeably. Fifty percent to 58% of nurses serving students in grades 6-12 used seven pregnancy prevention activities frequently. Three of the seven interventions relate to confirmed or suspected pregnancy. Therefore, secondary and tertiary prevention techniques seem to dominate nurses’ efforts. One goal for school nurses could be to increase their use of primary prevention activities. School nurses serving children in grades K-5reported that their use of pregnancy prevention activities was curtailed by age of the students. These nurses perceived pregnancy prevention as appropriate only for students close to an age when sexual activity is most likely. Contrary t o these assumptions, data suggest adolescents
Journal of School Health
January 1992, Vol. 62, No. 1
13
are becoming sexually active at earlier ages.’* Jones et all noted that Swedish success at adolescent pregnancy prevention is tied to instruction in human sexuality and human relations starting in kindergarten and proceeding throughout school age. To increase the success of pregnancy prevention activities, school nurses should be aware that instruction in human sexuality and human relations for younger students is desirable. Early intervention, before intercourse begins, delays intercourse for younger students” through the provision of accurate information about sexual relations and human relations. It also involves helping children make knowledgeable and beneficial personal decisions. School board policies, pressure, and lack of time were constraints to performing pregnancy prevention activities for nurses serving students in grades 6-12. Goroshl noted that influence of school boards and presence of clear policies for human sexuality education predicted school nurses’ prevention efforts. The nurses surveyed perceived school board policies and pressures as interfering with their ability to be involved in adolescent pregnancy prevention. Increased involvement in pregnancy prevention activities by school nurses requires that their role be sanctioned by school board policy. Increased involvement also requires greater administrative activity by school nurses in writing position descriptions that make their abilities and potential functions clear to school officials. In addition, nurses should be assigned to schools in numbers that allow for realistic work responsibilities. Nurses reported they felt moderately well or extremely well-prepared to perform pregnancy activities. Nonetheless, they report actually performing very few of the activities. Thus, nurses are not being used by
14
J o u r n a l of School Health
9
J a n u a r y 1992, Vol. 62,No. 1
school systems to their full capabilities. Complex political and economic issues must be addressed before change can be effected. However, nurses themselves must seek greater administrative involvement to initiate such change. References 1. Jones EF, Forrest JD, Goldman N. Henshaw SK, Lincoln R,
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