Evidence Based Practice and Policy
Teachers’ Perceptions of Full- and Part-Time Nurses at School
The Journal of School Nursing 2015, Vol. 31(3) 183-195 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1059840514561863 jsn.sagepub.com
Manuelito Biag, PhD1, Ashini Srivastava, MBBS, MPH2, Melinda Landau, RN, MSN3, and Eunice Rodriguez, DrPH2
Abstract Teachers and school nurses partner together to help ensure students stay healthy and engaged in school. The purpose of this study is to generate a deeper understanding of teachers’ perceptions on the benefits and challenges of working with full- or part-time school nurses. We conducted a qualitative analysis of open-ended survey responses from 129 teachers in nine lowincome, ethnically diverse urban schools. These schools were part of a multiyear project that placed full-time nurses in four schools, while five schools with part-time nurses were used as a comparison group. Findings indicate that teachers had strong appreciation for the wide range of responsibilities undertaken by the school nurse. Teachers’ level of satisfaction was linked to the number of hours the nurse is on-site, where teachers reported greater satisfaction with nurses who worked on campus full time. Results point to factors that may improve working relations between teachers and nurses. Keywords teachers’ perceptions, school nurse, qualitative analysis, urban schools
School nurses support students’ well-being by filling in gaps in health care management (National Association of School Nurses [NASN], 2011). They play an important role in identifying and linking young people—especially those who lack access to regular medical care—to services that improve their health and educational outcomes (Baisch, Lundeen, & Murphy, 2011; Plaspohl et al., 2014; Rodriguez, Austria, & Landau, 2011). School nurses are also essential in the planning, implementing, and monitoring of the health care plans for students with chronic health conditions (Engelke, Guttu, Warren, & Swanson, 2008). Budget shortfalls, however, have forced many schools to decrease financial support for school nurses and other health professionals. National estimates show that less than half of public schools have a full-time school nurse, and about 30% of schools employ part-time nurses who work in multiple sites (NASN, 2013). There are also disparities in the ratio of students per school nurse from state to state, within states and school districts, and between urban and rural schools. For example, in California, roughly 57% of districts do not employ a school nurse or any other health staff (Baker, Davis-Aldritt, & Hebbeler, 2014). In locations where school nursing does exist, there is mounting pressure for nurses to justify their presence by producing evidence of effectiveness. Such evidence has singled out mostly student-level outcomes such as decreased emergency room use (Gapinski & Sheetz, 2014). However, documenting additional indicators of progress, including factors
that contribute to better working relations among school nurses and faculty, is equally important because they provide insight on how to improve the delivery of care to students on campus. While past research has examined the perspectives of nurses working in schools (Borja, Amidon, Spellings, Franzetti, & Nasuta, 2009), only a handful of studies have investigated how teachers view the work of school nurses—in supporting students’ health and academic success and in developing a health-promoting campus environment (Hill & Hollis, 2012; Maughan & Adams, 2011; Peery, Engelke, & Swanson, 2012). This research gap is noteworthy because teachers can partner with nurses to ensure students get the care they need to stay healthy and engaged in school. Additional studies in this area can expand knowledge of teachers’ perspectives on school nursing and help improve working relations among health personnel and faculty.
1
John W. Gardner Center for Youth and Their Communities, Graduate School of Education, Stanford University, Stanford, CA, USA 2 Department of Pediatrics, School of Medicine, Stanford University, Stanford, CA, USA 3 Health and Family Support Programs, San Jose Unified School District, San Jose, CA, USA Corresponding Author: Manuelito Biag, PhD, John W. Gardner Center for Youth and Their Communities, Graduate School of Education, Stanford University, 365 Lasuen Street, 3rd Floor, Stanford, CA 94305, USA. Email: [email protected]
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To this end, we examined survey findings from a school nursing project in nine urban schools serving a low-income, ethnically diverse population. Specifically, we investigated qualitative differences in teachers’ perceptions on the benefits and challenges of working with a full- or part-time nurse at school. While research provides evidence of the contributions of school nurses on students’ health and academic outcomes (Baisch et al., 2011), there has been less emphasis in comparing the impact of part-time versus full-time nurses (Rodriguez et al., 2013). We hypothesized that teachers would perceive the services provided by full-time nurses more positively and view the presence of full-time nurse as an effective strategy to address students’ health needs. In turn, these positive views would be reflected in greater teacher satisfaction levels in schools with a full-time nurse versus those with a part-time nurse.
Background Extending health supports in educational settings can be fraught with challenges (Lear, 2005). Since schools are charged with education and not health services, delivery of care can unintentionally be hindered by school policies and procedures (e.g., discouraging students to leave class for a health appointment during testing days). While educators recognize that healthy students are better learners, not all of them understand how health concerns (e.g., diabetes) affect students’ academic progress, and there may be insufficient professional development (PD) to improve this knowledge. Teachers may also not appreciate the value of health interventions because their impact on student achievement is often indirect. In addition, since the nurse is usually the only staff person medically trained at school, he or she may be isolated from other health professionals, lack access to social and practical supports, and hindered from addressing students’ needs in a more preemptive manner (Smith & Firmin, 2009). Since teachers have direct and frequent contact with students, they are in a unique position to facilitate efforts that help improve students’ well-being and health behaviors (Reinke, Stormont, Herman, Puri, & Goel, 2011; Walter, Gouze, & Lim, 2006). Teachers are also a key source of information on how to reform conditions at school so that students’ health needs are addressed more efficiently. Working with educators is only one of the many duties of the school nurse. Unlike their counterparts in medical settings, school nurses take on a variety of roles to meet the cognitive, physical, social, and emotional needs of students (Robert Wood Johnson Foundation, 2010). According to NASN’s (2011) Scope and Standards of Practice, responsibilities of the school nurse include health assessment, diagnosis, outcomes identification, planning, implementation, coordination of care, and health promotion. In addition, NASN has identified standards of professional performance—competencies that inform the kinds of qualities expected of the school nurse.
These include self-evaluation, integration of evidence-based research into practice, effective communication, collaboration with families of students, a focus on environmental health issues, and management of on-campus health services. There is an increasing need for nursing support in schools as the number of chronically and acutely ill students continues to climb (Engelke et al., 2008). In recent years, the rate of chronic diseases among young people has increased (Halfon & Newacheck, 2010; Van Cleave, Gortmaker, & Perrin, 2010) and accentuated disparities among different racial/ethnic groups (Mehta, Lee, & Ylitalo, 2013). For instance, childhood asthma has doubled since the 1980s and currently affects about 9% of children and adolescents (Centers for Disease Control and Prevention, 2014), with hospitalization rates higher among youth of color (Beck et al., 2014). Likewise, about 17% of children aged 2–19 years are considered obese, with even higher rates among racial/ethnic minority groups (Ogden, Carroll, Kit, & Flegal, 2012; Van Cleave et al., 2010). School nurses also play a pivotal role in supporting the health and wellness of economically disadvantaged students. Public schools are increasingly populated with poor, racial/ ethnic minority, and immigrant children who tend to be at greater risk for a variety of health concerns (Aud, Fox, & KewalRamani, 2010). Adversity experienced during childhood can have a significant influence on long-term health outcomes (Slopen, Koenen, & Kubzansky, 2014). For example, low-income children and youth are particularly at risk for bearing the consequences of chronic illnesses due to poorly managed care, such as increased absenteeism (Halfon & Newacheck, 2010; Taras & Potts-Datema, 2005). While the number of uninsured children has dropped in recent years (Sonier & Fried, 2014), schools continue to be the primary source of health services for many disadvantaged students. This is especially true in areas with high concentration of immigrants, since it is estimated that about 42% of uninsured children live in immigrant families (Seiber, 2014). In short, without the support of school nurses, many of the health needs of vulnerable students will go unmet and could undermine their well-being and ability to learn and succeed in school. The purpose of this study is to generate better understanding of teachers’ views on the facilitating and hindering conditions that influence the practice of school nursing. Using qualitative survey data, we examine what teachers report as the strengths and shortcomings of nursing services at their school. We investigate the hypothesis that teachers would favor full-time nurses over those working part time and in multiple schools. We posit if more nurse time in schools provides additional services to the students, then teachers would view full-time nurses as a more efficient strategy in helping students achieve better health and educational outcomes. By contrast, if part-time nurses are sufficient to provide the necessary support to students, then the level of satisfaction among teachers in schools with either part-time or fulltime nurses would be the same.
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Method In this article, we examined recent qualitative survey data collected as part of a larger quasi-experimental project that was designed to evaluate the influence of full-time nursing supports on students’ health and academic outcomes. Research generated from this project, including this study, was approved by the San Jose Unified School District (SJUSD) and the Institutional Review Board of Stanford University.
Description of Project The School Nurse Demonstration Project (SNDP) was funded by the Lucile Packard Children’s Hospital and the Lucile Packard Foundation for Children’s Health. Initiated in the fall of 2006, SNDP was a 6-year endeavor with two main objectives: (1) improve the medical management and health outcomes of students with chronic medical conditions such as asthma and (2) facilitate a medical home for students who lack consistent access to care, including primary care services and a stable relationship with a provider. The project was implemented in the SJUSD, a large, high-minority district in northern California that enrolled approximately 33,000 students across 53 schools. Latinos made up the largest racial/ ethnic group in the district (52%), followed by Caucasians (26%) and Asians (13%). Approximately 24% of students were nonnative English speakers, and 45% qualified for subsidized school meals. With regard to academics, 59% of students scored proficient or above in the state’s Englishlanguage arts exam, while 53% scored proficient in math. In its final year of implementation, SNDP was carried out in nine sites that enrolled a large proportion of uninsured, ethnic minority students living at or near the poverty level (Table 1). Four demonstration schools, with added full-time school nurses, were matched demographically with five comparison schools that already had in place part-time nurses.
Description of Research Sites Demonstration schools included two elementary and two middle schools; the elementary schools had the highest rates of poverty (92%) as measured by students’ eligibility for the federal free and reduced price lunch program. About 20% of students were identified as living with a chronic health condition in demonstration schools, and among these students, roughly 10% were living with asthma (Rodriguez et al., 2013). Comparison schools included four elementary schools and one middle school. Relative to demonstration schools, comparison sites had a smaller proportion of low-income and English learner students but had roughly equivalent rates as demonstration sites in the proportion of students living with asthma. Academically, a greater share of students in comparison schools scored proficient in English-language arts and math when compared to demonstration schools (Table 1). Nurses in demonstration schools were present 5 days/ week and were hired as 1.0 Full-Time Equivalent (FTE). The
nurse to student ratio in demonstration elementary schools was about 1:550, while it was closer to 1:1000 in demonstration middle schools. Nurses hired at comparison schools worked an average of 1.7 days per week (0.34 FTE) at each school. The turnover rate among nurses in comparison sites was higher, where nurses in three of the five comparison schools changed every year and only two comparison schools had the same nurse for 2 years in a row. All nurses were equally qualified and trained to manage acute and chronic conditions including asthma symptoms. However, nurses in demonstration schools were expected to do more extensive assessments, follow-ups, and coordination with other health care providers to assure continuity of care.
Data Collection In 2013, the final year of the project, teachers in all schools participated in a voluntary and anonymous online survey consisting of questions regarding their viewpoints on school nursing (Appendix A).1 Teachers were asked to assess the contributions of the school nurse in a variety of areas such as improving students’ attendance and access to primary and preventive care. The survey questions were developed by the research team in 2009 and pilot tested on 51 teachers. The survey was later refined and pilot tested again in 2010 with 59 teachers. The final survey had a total of 25 items, that is, 16 multiple-choice questions (Questions 1, 2, 5, 6a–6i, 10, 11, 15, and 16), 6 free-response questions (Questions 8, 9, 12, 13, 14, and 17), and 3 questions that had both a multiple-choice and free-response component (Questions 3, 4, and 7). We examined responses for all questions except Questions 13 and 14, which pertained to respondents’ views about the school psychologist and counselor, respectively.
Data Analysis Our analysis proceeded in two stages. First, we obtained summary statistics for all of the survey questions using SPSS Version 20. We performed w2 statistical analyses of quantitative data to assess the differences between teachers in demonstration and comparison schools. Second, we analyzed teachers’ responses to open-ended survey questions for themes, patterns, and associations. To develop categories based on teachers’ responses, we applied open and axial coding methods to the data through an iterative process of comparing and contrasting (Strauss & Corbin, 1998). We focused our qualitative analysis on five questions that explored teachers’ perceptions, interactions, and level of satisfaction with the school nurse (Questions 4, 7, 8, 9, and 12).
Results Demographics of Survey Respondents We summarize the demographic characteristics of the survey respondents by school type and grade level in Table 2.
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Table 1. Demographics of Demonstration and Comparison Schools, Compared to the District Average, 2011–2012. Demonstration
Student enrollment Number of schools Free and reduced price lunch Race/ethnicity Latino Caucasian Asian Chronic conditions Asthma Neurodevelopment Other physical English language learner Proficient in English language arts Proficient in math
Comparison
Elementary
Middle
Elementary
Middle
District
953 2 91.6%
1,832 2 78.9%
2,242 4 79.9%
1,203 1 46.5%
33,306 53 44.8%
86.4% 5.7% 3.5%
78.4% 9.0% 5.1%
80.7% 5.9% 5.6%
50.5% 34.9% 4.7%
52.4% 25.8% 12.5%
9.7% 1.6% 8.4% 61.1% 43.5% 54.3%
10.9% 4.3% 10.5% 26.7% 43.9% 33.2%
10.0% 2.5% 10.7% 76.8% 43.5% 55.4%
9.3% 6.2% 10.1% 13.0% 63.8% 47.7%
9.0% 4.0% 11.0% 23.6% 59.0% 53.0%
Source. Education data were obtained from Ed-Data 2011–2012 (http://www.ed-data.k12.ca.us) and Data Quest 2011–2012 (http://dq.cde.ca.gov/dataquest/). Health data were obtained from the San Jose Unified School District data warehouse.
Table 2. Demographics of Survey Respondents. Demonstration
Total number of survey respondents Total number of teachers Response rate Race/ethnicity Caucasian Latino Other Did not identify Grade range taught K–1 2–3 4–5 6–8 Tenure at current school Less than 1 year 1–2 years 3–5 years More than 5 years Aware of students with chronic conditions Yes No Don’t know Number of school nurse referrals Less than 3 times 3 or more times Don’t know Health education sessions attended None 1 time More than 1 time Don’t know
Comparison
Elementary
Middle
Elementary
Middle
14 41 34.1%
45 119 37.8%
47 111 42.3%
23 60 38.3%
57.1% 21.4% 21.4% 0.0%
53.3% 15.6% 20.0% 11.1%
36.2% 31.9% 8.5% 23.4%
60.9% 13.0% 13.0% 13.0%
0.0% 46.2% 38.5% 15.4%
0.0% 0.0% 2.4% 97.6%
35.1% 29.7% 35.1% 0.0%
0.0% 0.0% 0.0% 100%
14.3% 42.9% 0.0% 42.9%
13.3% 17.8% 20.0% 48.9%
12.8% 14.9% 14.9% 57.4%
0.0% 39.1% 17.4% 43.5%
78.6% 7.1% 14.3%
86.7% 8.9% 4.4%
80.9% 12.8% 6.4%
87.0% 8.7% 4.3%
7.1% 85.7% 7.1%
15.6% 80.0% 4.4%
19.1% 74.5% 6.4%
17.3% 78.3% 4.3%
14.3% 71.4% 14.3% 0.0%
66.7% 24.4% 8.9% 0.0%
42.6% 51.1% 4.3% 2.1%
43.5% 43.5% 4.3% 8.7%
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Improving attendance of students at your school** Improving student academic performance* Providing support in handling emergency medical situations with your students Providing support in handling behavioral problems with your students Comparison (n = 70)
Providing support in handling injured students
Demonstration (n = 59)
Providing support in handling students with chronic medical conditions My students' ability to focus in class The overall well-being of students with chronic conditions at your school* The overall well-being of students in school 0%
20%
40% 60% 80% Percent of respondents
100%
Figure 1. Percentage of survey respondents who reported the nurse made a ‘‘positive impact’’ on students’ outcomes. *p < .10. **p < .05.
We report results across the elementary and middle schools within demonstration and comparison sites, because there were few grade-level differences in teachers’ responses to the multiple-choice questions. A total of 129 teachers completed the survey, that is, 59 from demonstration schools (overall response rate ¼ 36%) and 70 from comparison schools (overall response rate ¼ 40%). Among those who classified their race/ethnicity, about half had identified as Caucasian (55% in demonstration schools and 49% in comparison schools). Several respondents had taught for more than 5 years in their respective sites (48% in demonstration schools and 53% in comparison schools). A large proportion of teachers (85% in demonstration schools and 83% in comparison schools) knew of a student living with a chronic health condition, and most had referred a student to the school nurse at least 3 or more times in the past school year (81% in demonstration schools and 75% in comparison schools). To assess the extent to which teachers’ demographic characteristics (e.g., age and level of experience) influenced their perceptions of the school nurse, we estimated a series of logistic regression models in which we controlled for the same demographic characteristics reported in Table 2. Our results confirmed those found using w2 tests (i.e., the demographic characteristics did not influence the differences observed between teachers in demonstration vs. comparison schools). Thus, for simplicity, we do not present a detailed table with the results from these regression models and discuss only the results of the w2 tests in the next section.
Respondents’ Ratings of the School Nurse Figure 1 depicts the percentage of respondents in demonstration and comparison sites who positively rated the school nurse on a variety of tasks; we combined the response categories very positive impact and somewhat positive impact. A majority of teachers believed their school nurse effectively managed the health needs of students. For example, about 93% of respondents in demonstration and 82% in comparison sites felt the nurse had made a ‘‘positive impact’’ in addressing the medical concerns of chronically ill students. Likewise, approximately 83% of teachers in demonstration schools and 80% in comparison schools reported that the school nurse made a positive impact in handling emergency medical situations. Relative to health-related tasks, a smaller proportion of respondents reported the nurse exerting a positive influence on improving students’ school-related behaviors and outcomes. For instance, when it came to students’ ability to focus in class, 63% of teachers in demonstration schools and 55% in comparison schools reported that the nurse had made ‘‘a positive impact.’’ Similarly, 51% of demonstration and only 38% of comparison teachers reported the school nurse making a positive impact in improving students’ behavioral problems. We found modest and statistically significant differences in teachers’ assessment of the services provided by the school nurse using w2 testing. The relationship was significant when it came to improving students’ attendance, w2(2, N ¼ 110) ¼ 3.90, p < .05, and academic performance, w2(2, N ¼ 110) ¼ 3.67, p < .05, as well as the overall well-being of those living with chronic conditions, w2(2,
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N ¼ 110) ¼ 2.70, p < .10. In these areas, teachers working with a full-time nurse were more likely to report that nurses were making a positive impact toward improving students’ health and academic outcomes. In addition to the aforementioned ratings, a majority of respondents (70% in demonstration schools and 71% in comparison schools) perceived that having a nurse on campus helped them teach more effectively (Question 7). Similarly, several teachers reported feeling ‘‘very comfortable’’ in contacting the school nurse with concerns they had about students (Question 10; 82% in demonstration sites and 70% in comparison sites). More than half of respondents felt ‘‘very satisfied’’ by the medical supports the nurse provided (Question 11; 67% in demonstration schools and 61% in comparison schools).
Emergent Themes From Open-Ended Responses To understand teachers’ perspectives on the challenges and benefits of working with full- and part-time school nurses, we analyzed their responses to five open-ended survey questions that captured their beliefs, interactions, and level of satisfaction with the school nurse. Response categories by school type and grade level are summarized in Appendix B. Question 4: What was the reason for your student referral to the school nurse? Regardless of the grade levels they taught, teachers referred students to the nurse primarily because of issues related to general illness (e.g., stomach aches and flu), medication support, and minor injuries (e.g., cuts and bruises). Teachers also referred students for other reasons, ranging from nausea to emotional counseling to students falling asleep in class. Relative to comparison sites, elementary schoolteachers in demonstration schools referred students frequently to the school nurse for health screenings (e.g., vision and hearing) and follow-up support (e.g., getting glasses). While nurses in all schools provided the same basic clinical services following the same school nurse guidelines, teachers perceived their relative importance differently in demonstration and comparison schools. The different types of assistance nurses provided can be seen in the response below from an elementary schoolteacher in a demonstration school: To have eyes checked; to see if the issues with reading were vision related; to have her follow-up on a health issue that has come up and need some follow through from the parents; to have her contact the parents about medication for a child; to rule out any health issue that might be getting in the way of the child learning.
Question 7: Do you think having a credentialed school nurse helps you teach more effectively? A majority of teachers in demonstration and comparison schools, regardless of grade level, felt that having an official medical professional on campus to assess health issues helped them focus more on teaching.2 As one elementary comparison schoolteacher expressed,
‘‘I don’t have to take up class time to attend to students who need a nurse. I just write out a pass and go about my lesson.’’ Respondents also felt more secure knowing there was a trained adult on campus they could rely on for support. One middle schoolteacher in a demonstration site wrote: I feel better knowing that I can just send children to her and she will cheerfully handle whatever needs they have . . . even if it’s just a Band-Aid and some sympathy! Plus, she is completely efficient in monitoring health testing, illness documentation, etc. At another school where I worked, teachers had to do all that, and it was just too much!
Faculty in comparison schools noted how a qualified onsite health professional was necessary, given the variety of issues students faced. One comparison middle school respondent wrote: I need to know that there is someone qualified to work with asthma-related issues and anaphylactic shock. I need to know there is someone to call on to help with my hearing and vision-impaired students and those with spinal bifida and cerebral palsy. I need someone to make sure my ADHD students are medicated properly.
Teachers also expressed appreciation in how the school nurse provided them with medical training, as well as advice on how to deal with health-related concerns. As one respondent in a comparison elementary school noted, ‘‘It is very helpful to go and discuss things with the school nurse and get advice on how to make a student more comfortable if they have a chronic condition, or if I am noticing an issue.’’ Question 8: In your opinion, what is the most beneficial activity performed by the nurse at your school? The activities viewed most beneficial by teachers differed based on the grade level and type of school. Demonstration schoolteachers in the elementary grades characterized the hearing and vision screenings and follow-up support as the most helpful set of activities the nurse provided students. By contrast, teachers in the middle grades, both in demonstration and comparison schools, identified the responsive care and treatment (e.g., caring for minor injuries) as the most beneficial. As one comparison school elementary schoolteacher wrote, ‘‘Monitoring our diabetic and chronically ill students and addressing injuries competently so that, if appropriate, students are able to return to class and feel confident in engaging in class activities.’’ For both demonstration and comparison schools, teachers highlighted the work of the school nurse with families. One comparison middle schoolteacher put it this way, ‘‘Contacting parents and medical professionals and sharing the information we need to help the students.’’ Similarly, a teacher in a demonstration middle school site identified the following as a set of beneficial activities performed by the school nurse: ‘‘Contacting/following up with parents about health issues such as medication, glasses, and hearing aids.’’
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Moreover, regardless of the grade level and school type, respondents expressed appreciation for how the nurse provided them with professional support that aided their ability to help students. For instance, one comparison elementary schoolteacher wrote: She trained me on the use of an epi-pen this year. She contacts doctors to confirm what limitations are really made by the doctors. She alerts me to my students’ health issues that will affect their performances in my classes.
Question 9: What additional steps can be taken to improve the health services provided at your school? When asked to identify strategies that can improve school health services, many respondents from demonstration schools replied with ‘‘I don’t know,’’ ‘‘not applicable,’’ or ‘‘nothing,’’ which may suggest that most were satisfied with the support services the full-time nurse was providing. As one teacher wrote, ‘‘The nurses have been a very important part of our staff . . . they are vital to keep on a full-time basis!’’ By contrast, teachers from comparison schools (which employed part-time nurses) identified three main areas for improvement. First, many expressed the need for better communication between teachers and the school nurse. One teacher suggested, ‘‘More communication with teachers regarding the roles of the school nurse.’’ Another expressed, ‘‘We have not had a consistent nurse this school year . . . we also haven’t really been ‘in the loop’ about being informed about the nursing situation.’’ To help improve communication, one teacher at a comparison school proposed, ‘‘creating a database that allows us to see which services each student is receiving.’’ Second, teachers in comparison schools expressed wanting the school nurse to provide more health education and conduct more schoolwide health promotion activities. As one teacher stated, ‘‘Perhaps the school nurse could be involved in a PD for new teachers to . . . recommend practices for preventing injuries and contagious illnesses.’’ Another teacher remarked, ‘‘Nutrition education, education about hygiene and their bodies.’’ Likewise, one respondent suggested teaching teachers about ‘‘ADHD and Autism.’’ Faculty also identified additional health promotion activities including ‘‘providing each classroom a first aid kit,’’ ‘‘creating posters or signs reminding students how to be more healthy,’’ and ‘‘conducting assemblies or classes for students and parents on daily healthy routines such as washing hands, covering mouth when coughing, having daily breakfast.’’ Third, faculty from comparison schools voiced their frustration in having limited support for health-related concerns. As one teacher wrote, ‘‘Our nurse is currently shared with 2 other schools. This means she oversees the medical health issues of over 3,000 students! That is insane!’’ Another respondent wrote: I believe we need to have a full-time nurse at our school sites because when our students’ emotional and physical needs are
met, they are better able to interact in our classrooms and learn. Nurses bring a sense of security and care to the hearts of our students. Also, knowing there is someone on campus in case of an emergency is critical.
Finally, when asked to offer any additional perspectives regarding the presence of a nurse at their site, respondents expressed feeling lucky to have a nurse on campus who was ‘‘always prompt with emergencies;’’ they identified how nurses were ‘‘very needed’’ at school, especially when it came to serving diverse economically disadvantaged students. For example, as one demonstration middle schoolteacher reported: All schools need a credentialed school nurse. It is in the best interest of the students to have someone who is educated and truly knowledgeable about their health issues. We don’t always need a Band-Aid. We need someone to help with the larger issues.
Question 12: Please explain why you were satisfied or dissatisfied with the services provided by the school nurse? When asked to explain their level of satisfaction with school nurse services, teachers across all school types and grade levels stated how the school nurse gave them ‘‘personable’’ and ‘‘supportive’’ assistance. They described the nurse as ‘‘efficient,’’ ‘‘positive,’’ ‘‘consistent,’’ ‘‘dedicated,’’ ‘‘helpful,’’ and ‘‘knowledgeable.’’ Teachers also cited how the nurse was willing to collaborate with them to ‘‘provide the best learning environment to our students.’’ As one teacher in a demonstration school expressed, ‘‘Our school nurse is very active and easy to contact and communicate with about student concerns. She is always willing to support me in the classrooms with concerns.’’ Compared to demonstration schools, some teachers in comparison schools were somewhat dissatisfied with the school nurse mainly because she was only on campus part time. One respondent wrote, ‘‘I am satisfied that she does a great job when she can be here. Unfortunately, she is assigned to multiple locations.’’ Another teacher noted, ‘‘We have not had a consistent school nurse this year. We need one who will get to know our families and can assist them in services for their children. Inconsistency is the biggest problem right now.’’ Given that the nurse is only at school part time, some teachers expressed not knowing which students were getting care. A comparison middle schoolteacher wrote, ‘‘It would be helpful to know which of my students are currently receiving services on a regular basis—for example, if they are not pulled out of my particular class, I might not know they are receiving services.’’
Discussion We seek to build upon previous research by examining qualitative differences in how teachers characterize the work of full- and part-time school nurses, both in supporting students’ health and academic performance and in developing a healthpromoting school environment. Greater understanding of
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teachers’ perspectives could help improve strategies that facilitate health outreach to students, since most teachers are familiar with students’ needs and concerns. With diminishing resources, particularly in disadvantaged urban settings, the extent to which students’ health-related conditions are effectively addressed will depend largely on how well teachers and nurses are able to communicate and work together (Hill & Hollis, 2012). Data indicate that while teachers in both demonstration and comparison schools were satisfied with the job performed by the school nurse, teachers in comparison schools expressed less satisfaction with the length of time the school nurse spent on campus. Responses suggest that a majority of teachers in both elementary and middle comparison schools requested for more nurse time. Findings also imply that providing full-time school nurse services was perceived positively by teachers across grades and that teachers viewed the presence of the school nurse for longer time periods as making a meaningful difference—specifically, in improving students’ attendance and academic performance. Results point to the complex and wide range of demands placed on the school nurse (e.g., working with families and other health providers, treating students’ minor injuries, and health screenings). Teachers identified the school nurse as a critical asset because he or she possessed expert medical knowledge that no one else in the school had. Teachers also commended the school nurse for his or her willingness to work with families to link students to appropriate care; this finding was especially true in elementary demonstration schools where full-time nurses provided hearing and vision screenings (at greater rates than comparison schools) and who followed up with families to ensure that students received the services they needed. Teachers perceived provision of these services as an invaluable benefit, since it enabled them to focus their time on delivering instruction. While themes found in the survey responses may not be representative of all the teachers in the SNDP, results are consistent with past research (Baisch et al., 2011; Hill & Hollis, 2012). Faculty also see the school nurse as essential in developing a health-promoting school, through instructional campus-wide activities (e.g., school assemblies) and PD trainings for teachers (Whitehead, 2006; Ryan, 2008). Studies have demonstrated the facilitating role school nurses play in promoting various health-related issues on campus, including physical activity, mental health, and the prevention of bullying (DreslerHawke & Whitehead, 2009; Smith & Holloman, 2013). However, the extent to which nurses are actively involved in PD activities will depend on the inclination of school administrators to involve them in such efforts (Barnes, Courtney, Pratt, & Walsh, 2004) and on the capacity of the nurse to be able to devote part of their work to educating school staff. It is little surprise that respondents expect the nurse to provide them with health instruction and curriculum, given that school nursing is practiced in a school setting rather than a traditional health care setting. Since the scope of work of
school nurses may vary from site to site, findings suggest the importance of clarifying the role and responsibilities of the nurse to all school personnel (Barnes et al., 2004). Better understanding of the school nurse’s role is especially important in comparison schools where medical supports are provided on a part-time basis or where the nurse’s time is split among multiple schools. Clarifying the duties of the school nurse can help improve coordination of health interventions and strategies (DeSocio & Hootman, 2004). Results also indicate the need for consistent and timely communication and contact between school nurses and teachers. Communication is essential to providing managed care to students, especially those with chronic health conditions (e.g., asthma and diabetes), hearing, vision, or other special needs (Basch, 2011a, 2011b; Peery et al., 2012). Teachers in comparison schools identified challenges in communicating with part-time nurses, given their limited presence on campus. Teachers expressed wanting to know more about the nurse’s efforts in improving students’ well-being so that they could support interventions in class. Findings indicate that attending to students’ health needs at school is a team enterprise—one that requires an organized interprofessional approach supported by a strong communication infrastructure (Lawson, 2004). As more medically fragile students come to school with increasingly complex health needs, coordination of services will be essential. In addition, schools with high enrollment of ethnic and linguistic minority children would benefit from bilingual nurses who can more effectively communicate with families and guide them toward community resources. Research on collaborative models of working between nurses and school staff in different settings (e.g., elementary, middle, and high schools) will yield useful information for developing more efficient processes, partnerships, and strategies.
Study Limitations Present findings should be interpreted with consideration to the study’s limitations. Given that the surveys were voluntary, response rates were low across all sites. Our analysis was also limited to students in the elementary and middle grades, where the comparison middle school was demographically different from the other study sites (e.g., fewer disadvantaged students and more Caucasian students). Additionally, there was considerable difference in the number and proportion of elementary versus middle schoolteachers in the demonstration and comparison schools. We collected information on teachers who taught for more than 5 years in a single category. Since there could be differences among teachers who taught more than 5 years in the school, this should be considered in future studies. The rapid turnover of nurses in comparison schools was also noteworthy; reasons for this turnover should be further investigated because factors such as stress, institutional support, and workplace environment (e.g., interpersonal relationships
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with school personnel) can have a significant influence on the practice of school nursing. It is plausible that any of these (and other) factors could account for some of the differences found in teachers’ survey responses. Thus, the extent to which current results apply to other settings (e.g., suburban and rural) with different types of teachers and students should be subject of future work.
Conclusion This article investigates what teachers report as the benefits and challenges of working with full- and part-time nurses. Results suggest that while a majority of respondents have a high regard for the work of school nurses, teachers in schools with part-time nursing supports are less satisfied with the limited availability of on-site nursing staff. Quantitative survey findings indicate that the majority of teachers were appreciative of the school nurse in helping students with chronic conditions, providing first aid to injured students, and managing medical emergencies. By contrast, faculty in demonstration schools highlighted the extensive follow-up nurses provided for students screened for vision and hearing problems, which resulted in appropriate referrals to community services. Findings suggest that this level of extensive follow-up provided by full-time nurses made a notable and positive difference in the point of view of teachers in demonstration versus comparison schools; these positive assessments were reflected in their open-ended survey responses. While all the nurses in the district complied with the same clinical guidelines and practice standards, full-time nurses were in a better position to provide additional services that teachers perceived as having an important impact on their students’ ability to do better in school (e.g., ensuring that students who needed glasses or hearing aids actually received them). Results also hint at the need for regular and ongoing communication and greater coordination among nurses and faculty. Teachers desire more information about healthrelated interventions (e.g., referrals to community-based supports), so that they have better understanding of how to support students in class and are better informed to monitor progress among low-income, high minority students who often lack access to health services. As an example, schools may want to integrate the school nurse in Student Study Teams (SSTs) to help improve communication, coordination, and collaborative working between teachers and school nurses. SST meetings provide a structured opportunity for the school nurse to take part in an interdisciplinary team that helps identify struggling students (e.g., those living with mental health issues), assign appropriate interventions, and monitor students’ progress. These collaborative partnerships are particularly critical in sites serving disadvantaged ethnically diverse populations, where students frequently face obstacles that get in the way of
their learning (Engelke, Swanson, & Guttu, 2014; Haffke, Damm, & Cross, 2014).
Implications for the School Nurse This study provides evidence that the work of school nurses is respected and valued by the teachers. School personnel, particularly those working with low-income and medically vulnerable students, appreciate having full-time nurses available on-site to help address and prevent the deleterious effects of ill health on students’ learning and overall wellbeing. School nurses, along with teachers and administrators, may be able to cite findings from this study to help advocate for more full-time nursing supports, especially in schools that serve students who have less access to consistent medical care. School nurses may also be able to use the results to illustrate that working full time in one school— versus part time in multiple sites—is a preferred and potentially more efficient strategy to partner with school personnel to tackle the health concerns of students and cultivate a health-promoting school culture.
Appendix A 2012–2013 Nurse Demonstration Project Teacher Survey 1.
In which school are you currently teaching? ___________________________________________
2.
How long have you taught at your current school? Less than one year One to three years More than three years to five years More than five years
3.
Are you aware of any students in your classes with chronic medical conditions? Examples of such conditions include (but are not limited to) asthma, diabetes, severe allergies, or ADD/ADHD. No Yes Don’t know If yes, how many _____________________
4.
How many times during this school year have you referred students to the school nurse? None One time Two times Three or more times Don’t know If one or more times, what was the reason for your referral(s) ___________________
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5.
How many times during this school year have you attended a health education session or presentation at your school or the district school office? None One time More than one time Don’t know
6.
In your opinion, what impact do you think the school nurse at your school is making in: A. The overall well-being of students at your school B. The overall well-being of students with chronic conditions at your school C. Your students’ ability to focus in class D. Providing support in handling students with chronic medical conditions E. Providing support in handling injured students F. Providing support in handling behavioral problems with your students G. Providing support in handling emergency medical situations with your students H. Improving student academic performance I. Improving attendance of students at your school Very positive impact Somewhat positive impact No impact Somewhat negative impact Very negative impact Don’t know
7.
Do you think having a credentialed school nurse helps you teach more effectively? Yes No Not sure
11.
How satisfied are you with the services provided to your students by the: A. School nurse B. School psychologist C. School counselor Very satisfied Somewhat satisfied Somewhat dissatisfied Not satisfied My students have not needed these services
12.
Please explain why you were satisfied or dissatisfied with the services provided by the school nurse
______________________________________________ 13.
Please explain why you were satisfied or dissatisfied with the services provided by the school psychologist
______________________________________________ 14.
Please explain why you were satisfied or dissatisfied with the services provided by the school counselor
______________________________________________ 15.
What grade range do you currently teach? Kindergarten–First Grade Second Grade–Third Grade Fourth Grade–Fifth Grade Sixth Grade–Eighth Grade
16.
How do you identify yourself? Please check all that apply. African American or Black American Indian or Alaskan Native Asian or Asian American Latino or Hispanic Native Hawaiian or Pacific Islander White or Caucasian Other
17.
What additional steps can be taken to improve the health services at your school?
Would you like to make any comments on the questions or any issues not addressed in this survey regarding the presence of credentialed school nurses?
______________________________________________
______________________________________________
Why? Please share any examples. ______________________________________________ 8.
In your opinion what is the most beneficial activity performed by the nurse at your school? ______________________________________________
9.
10.
How comfortable do you feel contacting the school nurse with concerns about your students? Very comfortable Somewhat comfortable Neutral Somewhat uncomfortable Very uncomfortable Don’t know
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Appendix B Table B1. Major Response Categories, by School Type and Grade Level, Found in Survey Questions About the School Nurse. Demonstration Elementary N
%
Comparison
Middle N
%
Elementary N
%
Middle N
%
Question 4: How many times during this school year have you referred students to the school nurse? If one or more times, what was the reason for your referral Illness, sickness, and medication support (including contacting families) 10 43.5 29 46.8 53 73.6 21 56.7 Treatment of minor injuries 4 17.4 20 32.3 11 15.2 14 37.8 Health screenings (e.g., vision and hearing), follow-up, and support (including contacting 6 26.0 8 12.9 4 5.5 0 0.0 families) Other health/safety related issues (e.g., students feeling tired in class) 3 13.0 5 8.0 4 5.5 2 5.4 Total comments 23 100 62 100 72 100 37 100 Total respondents 9 28 27 13 Question 7: Do you think that having a credentialed school nurse helps you teach more effectively? Please share any examples Trusted professional on campus with health training and expertise, who takes care of 5 83.3 18 94.7 13 81.3 12 85.7 students’ health needs, and allows me to focus on teaching and learning More nursing support is needed at school 0 0.0 0 0.0 2 12.5 2 14.3 Other comment types (e.g., a negative or neutral response) 1 16.6 1 5.2 1 6.3 0 0.0 Total responses 6 100 19 100 16 100 14 100 Total respondents 6 16 16 11 Question 8: In your opinion, what is the most beneficial activity performed by the nurse at your school? Provides various types of medical support to all students (e.g., injury care, medication 3 20.0 28 62.2 19 43.2 13 59.0 support) Communicates with families and other medical personnel to help coordinate care for 1 6.6 5 11.1 8 18.2 2 9.1 students Conducts and follows up with hearing and vision screenings 6 40 7 15.6 6 13.6 0 0.0 Provides teachers with different types of supports (e.g., provide advice on IEPs) 4 26.6 3 6.7 7 15.9 6 27.2 Other comment types (e.g., help provide medical supplies in classrooms) 1 6.6 2 4.4 4 9.0 1 4.5 Total comments 15 100.0 45 100.0 44 100.0 22 100.0 Total respondents 12 41 37 19 Question 9: What additional steps can be taken to improve the support services provided by the health services at your school? Greater coordination and communication between nurses and teachers and the school 3 20.0 10 22.7 7 18.9 4 20.0 in general More health education and support to students and families 6 40.0 4 9.1 4 10.8 1 5.0 Maintain or increase nursing supports and the school’s capacity to address students’ 2 13.3 7 15.9 16 43.2 12 60.0 health needs None, don’t know, not sure, and not applicable 4 26.7 18 40.9 6 16.2 3 15.0 Other (e.g., more counselor involvement, more Spanish speaking nurses) 0 0.0 5 11.4 4 10.8 0 0.0 Total comments 15 100 44 100 37 100 20 100 Total respondents 11 41 35 19 Question 12: Please explain why you were satisfied or dissatisfied with the services provided by the school nurse Nurse is helpful, supportive, responsive, available, and effectively supports students and 10 83.3 21 77.7 23 69.7 11 68.8 families I am not satisfied; note enough nursing/medical support; she needs to be a better 1 8.3 2 7.4 8 24.2 3 18.8 communicator No comment, n/a, ‘‘don’t know’’ 1 8.3 4 14.8 2 6.1 2 12.5 Total comments 12 100 27 100 33 100 16 100 Total respondents 11 21 29 13 Note. Values may not add up to 100% due to rounding.
Declaration of Conflicting Interests
Funding
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this
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article: This research was partly funded by grants from the Lucile Packard Foundation for Children’s Health and the Lucile Packard Children’s Hospital, Palo Alto, California.
Notes 1. Given the small number of administrators who completed the survey (n ¼ 10), we focused our analysis on teachers’ survey responses. 2. http://www.ctc.ca.gov/credentials/leaflets/cl380.pdf
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Author Biographies Manuelito Biag, PhD, is a Research Associate at the John W. Gardner Center for Youth and Their Communities, Graduate School of Education, Stanford University, Stanford, CA, USA. Ashini Srivastava, MBBS, MPH, is an Evaluation Coordinator in the Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA. Melinda Landau, RN, MSN, is the Manager of the Health and Family Support Programs in the San Jose Unified School District, San Jose, CA, USA. Eunice Rodriguez, DrPH, is an Associate Professor (teaching) in the Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
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Teachers’ Perceptions of Full- and Part-Time Nurses at School
The Journal of School Nursing 2015, Vol. 31(3) 183-195 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1059840514561863 jsn.sagepub.com
Manuelito Biag, PhD1, Ashini Srivastava, MBBS, MPH2, Melinda Landau, RN, MSN3, and Eunice Rodriguez, DrPH2
Abstract Teachers and school nurses partner together to help ensure students stay healthy and engaged in school. The purpose of this study is to generate a deeper understanding of teachers’ perceptions on the benefits and challenges of working with full- or part-time school nurses. We conducted a qualitative analysis of open-ended survey responses from 129 teachers in nine lowincome, ethnically diverse urban schools. These schools were part of a multiyear project that placed full-time nurses in four schools, while five schools with part-time nurses were used as a comparison group. Findings indicate that teachers had strong appreciation for the wide range of responsibilities undertaken by the school nurse. Teachers’ level of satisfaction was linked to the number of hours the nurse is on-site, where teachers reported greater satisfaction with nurses who worked on campus full time. Results point to factors that may improve working relations between teachers and nurses. Keywords teachers’ perceptions, school nurse, qualitative analysis, urban schools
School nurses support students’ well-being by filling in gaps in health care management (National Association of School Nurses [NASN], 2011). They play an important role in identifying and linking young people—especially those who lack access to regular medical care—to services that improve their health and educational outcomes (Baisch, Lundeen, & Murphy, 2011; Plaspohl et al., 2014; Rodriguez, Austria, & Landau, 2011). School nurses are also essential in the planning, implementing, and monitoring of the health care plans for students with chronic health conditions (Engelke, Guttu, Warren, & Swanson, 2008). Budget shortfalls, however, have forced many schools to decrease financial support for school nurses and other health professionals. National estimates show that less than half of public schools have a full-time school nurse, and about 30% of schools employ part-time nurses who work in multiple sites (NASN, 2013). There are also disparities in the ratio of students per school nurse from state to state, within states and school districts, and between urban and rural schools. For example, in California, roughly 57% of districts do not employ a school nurse or any other health staff (Baker, Davis-Aldritt, & Hebbeler, 2014). In locations where school nursing does exist, there is mounting pressure for nurses to justify their presence by producing evidence of effectiveness. Such evidence has singled out mostly student-level outcomes such as decreased emergency room use (Gapinski & Sheetz, 2014). However, documenting additional indicators of progress, including factors
that contribute to better working relations among school nurses and faculty, is equally important because they provide insight on how to improve the delivery of care to students on campus. While past research has examined the perspectives of nurses working in schools (Borja, Amidon, Spellings, Franzetti, & Nasuta, 2009), only a handful of studies have investigated how teachers view the work of school nurses—in supporting students’ health and academic success and in developing a health-promoting campus environment (Hill & Hollis, 2012; Maughan & Adams, 2011; Peery, Engelke, & Swanson, 2012). This research gap is noteworthy because teachers can partner with nurses to ensure students get the care they need to stay healthy and engaged in school. Additional studies in this area can expand knowledge of teachers’ perspectives on school nursing and help improve working relations among health personnel and faculty.
1
John W. Gardner Center for Youth and Their Communities, Graduate School of Education, Stanford University, Stanford, CA, USA 2 Department of Pediatrics, School of Medicine, Stanford University, Stanford, CA, USA 3 Health and Family Support Programs, San Jose Unified School District, San Jose, CA, USA Corresponding Author: Manuelito Biag, PhD, John W. Gardner Center for Youth and Their Communities, Graduate School of Education, Stanford University, 365 Lasuen Street, 3rd Floor, Stanford, CA 94305, USA. Email: [email protected]
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To this end, we examined survey findings from a school nursing project in nine urban schools serving a low-income, ethnically diverse population. Specifically, we investigated qualitative differences in teachers’ perceptions on the benefits and challenges of working with a full- or part-time nurse at school. While research provides evidence of the contributions of school nurses on students’ health and academic outcomes (Baisch et al., 2011), there has been less emphasis in comparing the impact of part-time versus full-time nurses (Rodriguez et al., 2013). We hypothesized that teachers would perceive the services provided by full-time nurses more positively and view the presence of full-time nurse as an effective strategy to address students’ health needs. In turn, these positive views would be reflected in greater teacher satisfaction levels in schools with a full-time nurse versus those with a part-time nurse.
Background Extending health supports in educational settings can be fraught with challenges (Lear, 2005). Since schools are charged with education and not health services, delivery of care can unintentionally be hindered by school policies and procedures (e.g., discouraging students to leave class for a health appointment during testing days). While educators recognize that healthy students are better learners, not all of them understand how health concerns (e.g., diabetes) affect students’ academic progress, and there may be insufficient professional development (PD) to improve this knowledge. Teachers may also not appreciate the value of health interventions because their impact on student achievement is often indirect. In addition, since the nurse is usually the only staff person medically trained at school, he or she may be isolated from other health professionals, lack access to social and practical supports, and hindered from addressing students’ needs in a more preemptive manner (Smith & Firmin, 2009). Since teachers have direct and frequent contact with students, they are in a unique position to facilitate efforts that help improve students’ well-being and health behaviors (Reinke, Stormont, Herman, Puri, & Goel, 2011; Walter, Gouze, & Lim, 2006). Teachers are also a key source of information on how to reform conditions at school so that students’ health needs are addressed more efficiently. Working with educators is only one of the many duties of the school nurse. Unlike their counterparts in medical settings, school nurses take on a variety of roles to meet the cognitive, physical, social, and emotional needs of students (Robert Wood Johnson Foundation, 2010). According to NASN’s (2011) Scope and Standards of Practice, responsibilities of the school nurse include health assessment, diagnosis, outcomes identification, planning, implementation, coordination of care, and health promotion. In addition, NASN has identified standards of professional performance—competencies that inform the kinds of qualities expected of the school nurse.
These include self-evaluation, integration of evidence-based research into practice, effective communication, collaboration with families of students, a focus on environmental health issues, and management of on-campus health services. There is an increasing need for nursing support in schools as the number of chronically and acutely ill students continues to climb (Engelke et al., 2008). In recent years, the rate of chronic diseases among young people has increased (Halfon & Newacheck, 2010; Van Cleave, Gortmaker, & Perrin, 2010) and accentuated disparities among different racial/ethnic groups (Mehta, Lee, & Ylitalo, 2013). For instance, childhood asthma has doubled since the 1980s and currently affects about 9% of children and adolescents (Centers for Disease Control and Prevention, 2014), with hospitalization rates higher among youth of color (Beck et al., 2014). Likewise, about 17% of children aged 2–19 years are considered obese, with even higher rates among racial/ethnic minority groups (Ogden, Carroll, Kit, & Flegal, 2012; Van Cleave et al., 2010). School nurses also play a pivotal role in supporting the health and wellness of economically disadvantaged students. Public schools are increasingly populated with poor, racial/ ethnic minority, and immigrant children who tend to be at greater risk for a variety of health concerns (Aud, Fox, & KewalRamani, 2010). Adversity experienced during childhood can have a significant influence on long-term health outcomes (Slopen, Koenen, & Kubzansky, 2014). For example, low-income children and youth are particularly at risk for bearing the consequences of chronic illnesses due to poorly managed care, such as increased absenteeism (Halfon & Newacheck, 2010; Taras & Potts-Datema, 2005). While the number of uninsured children has dropped in recent years (Sonier & Fried, 2014), schools continue to be the primary source of health services for many disadvantaged students. This is especially true in areas with high concentration of immigrants, since it is estimated that about 42% of uninsured children live in immigrant families (Seiber, 2014). In short, without the support of school nurses, many of the health needs of vulnerable students will go unmet and could undermine their well-being and ability to learn and succeed in school. The purpose of this study is to generate better understanding of teachers’ views on the facilitating and hindering conditions that influence the practice of school nursing. Using qualitative survey data, we examine what teachers report as the strengths and shortcomings of nursing services at their school. We investigate the hypothesis that teachers would favor full-time nurses over those working part time and in multiple schools. We posit if more nurse time in schools provides additional services to the students, then teachers would view full-time nurses as a more efficient strategy in helping students achieve better health and educational outcomes. By contrast, if part-time nurses are sufficient to provide the necessary support to students, then the level of satisfaction among teachers in schools with either part-time or fulltime nurses would be the same.
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Method In this article, we examined recent qualitative survey data collected as part of a larger quasi-experimental project that was designed to evaluate the influence of full-time nursing supports on students’ health and academic outcomes. Research generated from this project, including this study, was approved by the San Jose Unified School District (SJUSD) and the Institutional Review Board of Stanford University.
Description of Project The School Nurse Demonstration Project (SNDP) was funded by the Lucile Packard Children’s Hospital and the Lucile Packard Foundation for Children’s Health. Initiated in the fall of 2006, SNDP was a 6-year endeavor with two main objectives: (1) improve the medical management and health outcomes of students with chronic medical conditions such as asthma and (2) facilitate a medical home for students who lack consistent access to care, including primary care services and a stable relationship with a provider. The project was implemented in the SJUSD, a large, high-minority district in northern California that enrolled approximately 33,000 students across 53 schools. Latinos made up the largest racial/ ethnic group in the district (52%), followed by Caucasians (26%) and Asians (13%). Approximately 24% of students were nonnative English speakers, and 45% qualified for subsidized school meals. With regard to academics, 59% of students scored proficient or above in the state’s Englishlanguage arts exam, while 53% scored proficient in math. In its final year of implementation, SNDP was carried out in nine sites that enrolled a large proportion of uninsured, ethnic minority students living at or near the poverty level (Table 1). Four demonstration schools, with added full-time school nurses, were matched demographically with five comparison schools that already had in place part-time nurses.
Description of Research Sites Demonstration schools included two elementary and two middle schools; the elementary schools had the highest rates of poverty (92%) as measured by students’ eligibility for the federal free and reduced price lunch program. About 20% of students were identified as living with a chronic health condition in demonstration schools, and among these students, roughly 10% were living with asthma (Rodriguez et al., 2013). Comparison schools included four elementary schools and one middle school. Relative to demonstration schools, comparison sites had a smaller proportion of low-income and English learner students but had roughly equivalent rates as demonstration sites in the proportion of students living with asthma. Academically, a greater share of students in comparison schools scored proficient in English-language arts and math when compared to demonstration schools (Table 1). Nurses in demonstration schools were present 5 days/ week and were hired as 1.0 Full-Time Equivalent (FTE). The
nurse to student ratio in demonstration elementary schools was about 1:550, while it was closer to 1:1000 in demonstration middle schools. Nurses hired at comparison schools worked an average of 1.7 days per week (0.34 FTE) at each school. The turnover rate among nurses in comparison sites was higher, where nurses in three of the five comparison schools changed every year and only two comparison schools had the same nurse for 2 years in a row. All nurses were equally qualified and trained to manage acute and chronic conditions including asthma symptoms. However, nurses in demonstration schools were expected to do more extensive assessments, follow-ups, and coordination with other health care providers to assure continuity of care.
Data Collection In 2013, the final year of the project, teachers in all schools participated in a voluntary and anonymous online survey consisting of questions regarding their viewpoints on school nursing (Appendix A).1 Teachers were asked to assess the contributions of the school nurse in a variety of areas such as improving students’ attendance and access to primary and preventive care. The survey questions were developed by the research team in 2009 and pilot tested on 51 teachers. The survey was later refined and pilot tested again in 2010 with 59 teachers. The final survey had a total of 25 items, that is, 16 multiple-choice questions (Questions 1, 2, 5, 6a–6i, 10, 11, 15, and 16), 6 free-response questions (Questions 8, 9, 12, 13, 14, and 17), and 3 questions that had both a multiple-choice and free-response component (Questions 3, 4, and 7). We examined responses for all questions except Questions 13 and 14, which pertained to respondents’ views about the school psychologist and counselor, respectively.
Data Analysis Our analysis proceeded in two stages. First, we obtained summary statistics for all of the survey questions using SPSS Version 20. We performed w2 statistical analyses of quantitative data to assess the differences between teachers in demonstration and comparison schools. Second, we analyzed teachers’ responses to open-ended survey questions for themes, patterns, and associations. To develop categories based on teachers’ responses, we applied open and axial coding methods to the data through an iterative process of comparing and contrasting (Strauss & Corbin, 1998). We focused our qualitative analysis on five questions that explored teachers’ perceptions, interactions, and level of satisfaction with the school nurse (Questions 4, 7, 8, 9, and 12).
Results Demographics of Survey Respondents We summarize the demographic characteristics of the survey respondents by school type and grade level in Table 2.
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Table 1. Demographics of Demonstration and Comparison Schools, Compared to the District Average, 2011–2012. Demonstration
Student enrollment Number of schools Free and reduced price lunch Race/ethnicity Latino Caucasian Asian Chronic conditions Asthma Neurodevelopment Other physical English language learner Proficient in English language arts Proficient in math
Comparison
Elementary
Middle
Elementary
Middle
District
953 2 91.6%
1,832 2 78.9%
2,242 4 79.9%
1,203 1 46.5%
33,306 53 44.8%
86.4% 5.7% 3.5%
78.4% 9.0% 5.1%
80.7% 5.9% 5.6%
50.5% 34.9% 4.7%
52.4% 25.8% 12.5%
9.7% 1.6% 8.4% 61.1% 43.5% 54.3%
10.9% 4.3% 10.5% 26.7% 43.9% 33.2%
10.0% 2.5% 10.7% 76.8% 43.5% 55.4%
9.3% 6.2% 10.1% 13.0% 63.8% 47.7%
9.0% 4.0% 11.0% 23.6% 59.0% 53.0%
Source. Education data were obtained from Ed-Data 2011–2012 (http://www.ed-data.k12.ca.us) and Data Quest 2011–2012 (http://dq.cde.ca.gov/dataquest/). Health data were obtained from the San Jose Unified School District data warehouse.
Table 2. Demographics of Survey Respondents. Demonstration
Total number of survey respondents Total number of teachers Response rate Race/ethnicity Caucasian Latino Other Did not identify Grade range taught K–1 2–3 4–5 6–8 Tenure at current school Less than 1 year 1–2 years 3–5 years More than 5 years Aware of students with chronic conditions Yes No Don’t know Number of school nurse referrals Less than 3 times 3 or more times Don’t know Health education sessions attended None 1 time More than 1 time Don’t know
Comparison
Elementary
Middle
Elementary
Middle
14 41 34.1%
45 119 37.8%
47 111 42.3%
23 60 38.3%
57.1% 21.4% 21.4% 0.0%
53.3% 15.6% 20.0% 11.1%
36.2% 31.9% 8.5% 23.4%
60.9% 13.0% 13.0% 13.0%
0.0% 46.2% 38.5% 15.4%
0.0% 0.0% 2.4% 97.6%
35.1% 29.7% 35.1% 0.0%
0.0% 0.0% 0.0% 100%
14.3% 42.9% 0.0% 42.9%
13.3% 17.8% 20.0% 48.9%
12.8% 14.9% 14.9% 57.4%
0.0% 39.1% 17.4% 43.5%
78.6% 7.1% 14.3%
86.7% 8.9% 4.4%
80.9% 12.8% 6.4%
87.0% 8.7% 4.3%
7.1% 85.7% 7.1%
15.6% 80.0% 4.4%
19.1% 74.5% 6.4%
17.3% 78.3% 4.3%
14.3% 71.4% 14.3% 0.0%
66.7% 24.4% 8.9% 0.0%
42.6% 51.1% 4.3% 2.1%
43.5% 43.5% 4.3% 8.7%
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Improving attendance of students at your school** Improving student academic performance* Providing support in handling emergency medical situations with your students Providing support in handling behavioral problems with your students Comparison (n = 70)
Providing support in handling injured students
Demonstration (n = 59)
Providing support in handling students with chronic medical conditions My students' ability to focus in class The overall well-being of students with chronic conditions at your school* The overall well-being of students in school 0%
20%
40% 60% 80% Percent of respondents
100%
Figure 1. Percentage of survey respondents who reported the nurse made a ‘‘positive impact’’ on students’ outcomes. *p < .10. **p < .05.
We report results across the elementary and middle schools within demonstration and comparison sites, because there were few grade-level differences in teachers’ responses to the multiple-choice questions. A total of 129 teachers completed the survey, that is, 59 from demonstration schools (overall response rate ¼ 36%) and 70 from comparison schools (overall response rate ¼ 40%). Among those who classified their race/ethnicity, about half had identified as Caucasian (55% in demonstration schools and 49% in comparison schools). Several respondents had taught for more than 5 years in their respective sites (48% in demonstration schools and 53% in comparison schools). A large proportion of teachers (85% in demonstration schools and 83% in comparison schools) knew of a student living with a chronic health condition, and most had referred a student to the school nurse at least 3 or more times in the past school year (81% in demonstration schools and 75% in comparison schools). To assess the extent to which teachers’ demographic characteristics (e.g., age and level of experience) influenced their perceptions of the school nurse, we estimated a series of logistic regression models in which we controlled for the same demographic characteristics reported in Table 2. Our results confirmed those found using w2 tests (i.e., the demographic characteristics did not influence the differences observed between teachers in demonstration vs. comparison schools). Thus, for simplicity, we do not present a detailed table with the results from these regression models and discuss only the results of the w2 tests in the next section.
Respondents’ Ratings of the School Nurse Figure 1 depicts the percentage of respondents in demonstration and comparison sites who positively rated the school nurse on a variety of tasks; we combined the response categories very positive impact and somewhat positive impact. A majority of teachers believed their school nurse effectively managed the health needs of students. For example, about 93% of respondents in demonstration and 82% in comparison sites felt the nurse had made a ‘‘positive impact’’ in addressing the medical concerns of chronically ill students. Likewise, approximately 83% of teachers in demonstration schools and 80% in comparison schools reported that the school nurse made a positive impact in handling emergency medical situations. Relative to health-related tasks, a smaller proportion of respondents reported the nurse exerting a positive influence on improving students’ school-related behaviors and outcomes. For instance, when it came to students’ ability to focus in class, 63% of teachers in demonstration schools and 55% in comparison schools reported that the nurse had made ‘‘a positive impact.’’ Similarly, 51% of demonstration and only 38% of comparison teachers reported the school nurse making a positive impact in improving students’ behavioral problems. We found modest and statistically significant differences in teachers’ assessment of the services provided by the school nurse using w2 testing. The relationship was significant when it came to improving students’ attendance, w2(2, N ¼ 110) ¼ 3.90, p < .05, and academic performance, w2(2, N ¼ 110) ¼ 3.67, p < .05, as well as the overall well-being of those living with chronic conditions, w2(2,
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N ¼ 110) ¼ 2.70, p < .10. In these areas, teachers working with a full-time nurse were more likely to report that nurses were making a positive impact toward improving students’ health and academic outcomes. In addition to the aforementioned ratings, a majority of respondents (70% in demonstration schools and 71% in comparison schools) perceived that having a nurse on campus helped them teach more effectively (Question 7). Similarly, several teachers reported feeling ‘‘very comfortable’’ in contacting the school nurse with concerns they had about students (Question 10; 82% in demonstration sites and 70% in comparison sites). More than half of respondents felt ‘‘very satisfied’’ by the medical supports the nurse provided (Question 11; 67% in demonstration schools and 61% in comparison schools).
Emergent Themes From Open-Ended Responses To understand teachers’ perspectives on the challenges and benefits of working with full- and part-time school nurses, we analyzed their responses to five open-ended survey questions that captured their beliefs, interactions, and level of satisfaction with the school nurse. Response categories by school type and grade level are summarized in Appendix B. Question 4: What was the reason for your student referral to the school nurse? Regardless of the grade levels they taught, teachers referred students to the nurse primarily because of issues related to general illness (e.g., stomach aches and flu), medication support, and minor injuries (e.g., cuts and bruises). Teachers also referred students for other reasons, ranging from nausea to emotional counseling to students falling asleep in class. Relative to comparison sites, elementary schoolteachers in demonstration schools referred students frequently to the school nurse for health screenings (e.g., vision and hearing) and follow-up support (e.g., getting glasses). While nurses in all schools provided the same basic clinical services following the same school nurse guidelines, teachers perceived their relative importance differently in demonstration and comparison schools. The different types of assistance nurses provided can be seen in the response below from an elementary schoolteacher in a demonstration school: To have eyes checked; to see if the issues with reading were vision related; to have her follow-up on a health issue that has come up and need some follow through from the parents; to have her contact the parents about medication for a child; to rule out any health issue that might be getting in the way of the child learning.
Question 7: Do you think having a credentialed school nurse helps you teach more effectively? A majority of teachers in demonstration and comparison schools, regardless of grade level, felt that having an official medical professional on campus to assess health issues helped them focus more on teaching.2 As one elementary comparison schoolteacher expressed,
‘‘I don’t have to take up class time to attend to students who need a nurse. I just write out a pass and go about my lesson.’’ Respondents also felt more secure knowing there was a trained adult on campus they could rely on for support. One middle schoolteacher in a demonstration site wrote: I feel better knowing that I can just send children to her and she will cheerfully handle whatever needs they have . . . even if it’s just a Band-Aid and some sympathy! Plus, she is completely efficient in monitoring health testing, illness documentation, etc. At another school where I worked, teachers had to do all that, and it was just too much!
Faculty in comparison schools noted how a qualified onsite health professional was necessary, given the variety of issues students faced. One comparison middle school respondent wrote: I need to know that there is someone qualified to work with asthma-related issues and anaphylactic shock. I need to know there is someone to call on to help with my hearing and vision-impaired students and those with spinal bifida and cerebral palsy. I need someone to make sure my ADHD students are medicated properly.
Teachers also expressed appreciation in how the school nurse provided them with medical training, as well as advice on how to deal with health-related concerns. As one respondent in a comparison elementary school noted, ‘‘It is very helpful to go and discuss things with the school nurse and get advice on how to make a student more comfortable if they have a chronic condition, or if I am noticing an issue.’’ Question 8: In your opinion, what is the most beneficial activity performed by the nurse at your school? The activities viewed most beneficial by teachers differed based on the grade level and type of school. Demonstration schoolteachers in the elementary grades characterized the hearing and vision screenings and follow-up support as the most helpful set of activities the nurse provided students. By contrast, teachers in the middle grades, both in demonstration and comparison schools, identified the responsive care and treatment (e.g., caring for minor injuries) as the most beneficial. As one comparison school elementary schoolteacher wrote, ‘‘Monitoring our diabetic and chronically ill students and addressing injuries competently so that, if appropriate, students are able to return to class and feel confident in engaging in class activities.’’ For both demonstration and comparison schools, teachers highlighted the work of the school nurse with families. One comparison middle schoolteacher put it this way, ‘‘Contacting parents and medical professionals and sharing the information we need to help the students.’’ Similarly, a teacher in a demonstration middle school site identified the following as a set of beneficial activities performed by the school nurse: ‘‘Contacting/following up with parents about health issues such as medication, glasses, and hearing aids.’’
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Moreover, regardless of the grade level and school type, respondents expressed appreciation for how the nurse provided them with professional support that aided their ability to help students. For instance, one comparison elementary schoolteacher wrote: She trained me on the use of an epi-pen this year. She contacts doctors to confirm what limitations are really made by the doctors. She alerts me to my students’ health issues that will affect their performances in my classes.
Question 9: What additional steps can be taken to improve the health services provided at your school? When asked to identify strategies that can improve school health services, many respondents from demonstration schools replied with ‘‘I don’t know,’’ ‘‘not applicable,’’ or ‘‘nothing,’’ which may suggest that most were satisfied with the support services the full-time nurse was providing. As one teacher wrote, ‘‘The nurses have been a very important part of our staff . . . they are vital to keep on a full-time basis!’’ By contrast, teachers from comparison schools (which employed part-time nurses) identified three main areas for improvement. First, many expressed the need for better communication between teachers and the school nurse. One teacher suggested, ‘‘More communication with teachers regarding the roles of the school nurse.’’ Another expressed, ‘‘We have not had a consistent nurse this school year . . . we also haven’t really been ‘in the loop’ about being informed about the nursing situation.’’ To help improve communication, one teacher at a comparison school proposed, ‘‘creating a database that allows us to see which services each student is receiving.’’ Second, teachers in comparison schools expressed wanting the school nurse to provide more health education and conduct more schoolwide health promotion activities. As one teacher stated, ‘‘Perhaps the school nurse could be involved in a PD for new teachers to . . . recommend practices for preventing injuries and contagious illnesses.’’ Another teacher remarked, ‘‘Nutrition education, education about hygiene and their bodies.’’ Likewise, one respondent suggested teaching teachers about ‘‘ADHD and Autism.’’ Faculty also identified additional health promotion activities including ‘‘providing each classroom a first aid kit,’’ ‘‘creating posters or signs reminding students how to be more healthy,’’ and ‘‘conducting assemblies or classes for students and parents on daily healthy routines such as washing hands, covering mouth when coughing, having daily breakfast.’’ Third, faculty from comparison schools voiced their frustration in having limited support for health-related concerns. As one teacher wrote, ‘‘Our nurse is currently shared with 2 other schools. This means she oversees the medical health issues of over 3,000 students! That is insane!’’ Another respondent wrote: I believe we need to have a full-time nurse at our school sites because when our students’ emotional and physical needs are
met, they are better able to interact in our classrooms and learn. Nurses bring a sense of security and care to the hearts of our students. Also, knowing there is someone on campus in case of an emergency is critical.
Finally, when asked to offer any additional perspectives regarding the presence of a nurse at their site, respondents expressed feeling lucky to have a nurse on campus who was ‘‘always prompt with emergencies;’’ they identified how nurses were ‘‘very needed’’ at school, especially when it came to serving diverse economically disadvantaged students. For example, as one demonstration middle schoolteacher reported: All schools need a credentialed school nurse. It is in the best interest of the students to have someone who is educated and truly knowledgeable about their health issues. We don’t always need a Band-Aid. We need someone to help with the larger issues.
Question 12: Please explain why you were satisfied or dissatisfied with the services provided by the school nurse? When asked to explain their level of satisfaction with school nurse services, teachers across all school types and grade levels stated how the school nurse gave them ‘‘personable’’ and ‘‘supportive’’ assistance. They described the nurse as ‘‘efficient,’’ ‘‘positive,’’ ‘‘consistent,’’ ‘‘dedicated,’’ ‘‘helpful,’’ and ‘‘knowledgeable.’’ Teachers also cited how the nurse was willing to collaborate with them to ‘‘provide the best learning environment to our students.’’ As one teacher in a demonstration school expressed, ‘‘Our school nurse is very active and easy to contact and communicate with about student concerns. She is always willing to support me in the classrooms with concerns.’’ Compared to demonstration schools, some teachers in comparison schools were somewhat dissatisfied with the school nurse mainly because she was only on campus part time. One respondent wrote, ‘‘I am satisfied that she does a great job when she can be here. Unfortunately, she is assigned to multiple locations.’’ Another teacher noted, ‘‘We have not had a consistent school nurse this year. We need one who will get to know our families and can assist them in services for their children. Inconsistency is the biggest problem right now.’’ Given that the nurse is only at school part time, some teachers expressed not knowing which students were getting care. A comparison middle schoolteacher wrote, ‘‘It would be helpful to know which of my students are currently receiving services on a regular basis—for example, if they are not pulled out of my particular class, I might not know they are receiving services.’’
Discussion We seek to build upon previous research by examining qualitative differences in how teachers characterize the work of full- and part-time school nurses, both in supporting students’ health and academic performance and in developing a healthpromoting school environment. Greater understanding of
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teachers’ perspectives could help improve strategies that facilitate health outreach to students, since most teachers are familiar with students’ needs and concerns. With diminishing resources, particularly in disadvantaged urban settings, the extent to which students’ health-related conditions are effectively addressed will depend largely on how well teachers and nurses are able to communicate and work together (Hill & Hollis, 2012). Data indicate that while teachers in both demonstration and comparison schools were satisfied with the job performed by the school nurse, teachers in comparison schools expressed less satisfaction with the length of time the school nurse spent on campus. Responses suggest that a majority of teachers in both elementary and middle comparison schools requested for more nurse time. Findings also imply that providing full-time school nurse services was perceived positively by teachers across grades and that teachers viewed the presence of the school nurse for longer time periods as making a meaningful difference—specifically, in improving students’ attendance and academic performance. Results point to the complex and wide range of demands placed on the school nurse (e.g., working with families and other health providers, treating students’ minor injuries, and health screenings). Teachers identified the school nurse as a critical asset because he or she possessed expert medical knowledge that no one else in the school had. Teachers also commended the school nurse for his or her willingness to work with families to link students to appropriate care; this finding was especially true in elementary demonstration schools where full-time nurses provided hearing and vision screenings (at greater rates than comparison schools) and who followed up with families to ensure that students received the services they needed. Teachers perceived provision of these services as an invaluable benefit, since it enabled them to focus their time on delivering instruction. While themes found in the survey responses may not be representative of all the teachers in the SNDP, results are consistent with past research (Baisch et al., 2011; Hill & Hollis, 2012). Faculty also see the school nurse as essential in developing a health-promoting school, through instructional campus-wide activities (e.g., school assemblies) and PD trainings for teachers (Whitehead, 2006; Ryan, 2008). Studies have demonstrated the facilitating role school nurses play in promoting various health-related issues on campus, including physical activity, mental health, and the prevention of bullying (DreslerHawke & Whitehead, 2009; Smith & Holloman, 2013). However, the extent to which nurses are actively involved in PD activities will depend on the inclination of school administrators to involve them in such efforts (Barnes, Courtney, Pratt, & Walsh, 2004) and on the capacity of the nurse to be able to devote part of their work to educating school staff. It is little surprise that respondents expect the nurse to provide them with health instruction and curriculum, given that school nursing is practiced in a school setting rather than a traditional health care setting. Since the scope of work of
school nurses may vary from site to site, findings suggest the importance of clarifying the role and responsibilities of the nurse to all school personnel (Barnes et al., 2004). Better understanding of the school nurse’s role is especially important in comparison schools where medical supports are provided on a part-time basis or where the nurse’s time is split among multiple schools. Clarifying the duties of the school nurse can help improve coordination of health interventions and strategies (DeSocio & Hootman, 2004). Results also indicate the need for consistent and timely communication and contact between school nurses and teachers. Communication is essential to providing managed care to students, especially those with chronic health conditions (e.g., asthma and diabetes), hearing, vision, or other special needs (Basch, 2011a, 2011b; Peery et al., 2012). Teachers in comparison schools identified challenges in communicating with part-time nurses, given their limited presence on campus. Teachers expressed wanting to know more about the nurse’s efforts in improving students’ well-being so that they could support interventions in class. Findings indicate that attending to students’ health needs at school is a team enterprise—one that requires an organized interprofessional approach supported by a strong communication infrastructure (Lawson, 2004). As more medically fragile students come to school with increasingly complex health needs, coordination of services will be essential. In addition, schools with high enrollment of ethnic and linguistic minority children would benefit from bilingual nurses who can more effectively communicate with families and guide them toward community resources. Research on collaborative models of working between nurses and school staff in different settings (e.g., elementary, middle, and high schools) will yield useful information for developing more efficient processes, partnerships, and strategies.
Study Limitations Present findings should be interpreted with consideration to the study’s limitations. Given that the surveys were voluntary, response rates were low across all sites. Our analysis was also limited to students in the elementary and middle grades, where the comparison middle school was demographically different from the other study sites (e.g., fewer disadvantaged students and more Caucasian students). Additionally, there was considerable difference in the number and proportion of elementary versus middle schoolteachers in the demonstration and comparison schools. We collected information on teachers who taught for more than 5 years in a single category. Since there could be differences among teachers who taught more than 5 years in the school, this should be considered in future studies. The rapid turnover of nurses in comparison schools was also noteworthy; reasons for this turnover should be further investigated because factors such as stress, institutional support, and workplace environment (e.g., interpersonal relationships
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with school personnel) can have a significant influence on the practice of school nursing. It is plausible that any of these (and other) factors could account for some of the differences found in teachers’ survey responses. Thus, the extent to which current results apply to other settings (e.g., suburban and rural) with different types of teachers and students should be subject of future work.
Conclusion This article investigates what teachers report as the benefits and challenges of working with full- and part-time nurses. Results suggest that while a majority of respondents have a high regard for the work of school nurses, teachers in schools with part-time nursing supports are less satisfied with the limited availability of on-site nursing staff. Quantitative survey findings indicate that the majority of teachers were appreciative of the school nurse in helping students with chronic conditions, providing first aid to injured students, and managing medical emergencies. By contrast, faculty in demonstration schools highlighted the extensive follow-up nurses provided for students screened for vision and hearing problems, which resulted in appropriate referrals to community services. Findings suggest that this level of extensive follow-up provided by full-time nurses made a notable and positive difference in the point of view of teachers in demonstration versus comparison schools; these positive assessments were reflected in their open-ended survey responses. While all the nurses in the district complied with the same clinical guidelines and practice standards, full-time nurses were in a better position to provide additional services that teachers perceived as having an important impact on their students’ ability to do better in school (e.g., ensuring that students who needed glasses or hearing aids actually received them). Results also hint at the need for regular and ongoing communication and greater coordination among nurses and faculty. Teachers desire more information about healthrelated interventions (e.g., referrals to community-based supports), so that they have better understanding of how to support students in class and are better informed to monitor progress among low-income, high minority students who often lack access to health services. As an example, schools may want to integrate the school nurse in Student Study Teams (SSTs) to help improve communication, coordination, and collaborative working between teachers and school nurses. SST meetings provide a structured opportunity for the school nurse to take part in an interdisciplinary team that helps identify struggling students (e.g., those living with mental health issues), assign appropriate interventions, and monitor students’ progress. These collaborative partnerships are particularly critical in sites serving disadvantaged ethnically diverse populations, where students frequently face obstacles that get in the way of
their learning (Engelke, Swanson, & Guttu, 2014; Haffke, Damm, & Cross, 2014).
Implications for the School Nurse This study provides evidence that the work of school nurses is respected and valued by the teachers. School personnel, particularly those working with low-income and medically vulnerable students, appreciate having full-time nurses available on-site to help address and prevent the deleterious effects of ill health on students’ learning and overall wellbeing. School nurses, along with teachers and administrators, may be able to cite findings from this study to help advocate for more full-time nursing supports, especially in schools that serve students who have less access to consistent medical care. School nurses may also be able to use the results to illustrate that working full time in one school— versus part time in multiple sites—is a preferred and potentially more efficient strategy to partner with school personnel to tackle the health concerns of students and cultivate a health-promoting school culture.
Appendix A 2012–2013 Nurse Demonstration Project Teacher Survey 1.
In which school are you currently teaching? ___________________________________________
2.
How long have you taught at your current school? Less than one year One to three years More than three years to five years More than five years
3.
Are you aware of any students in your classes with chronic medical conditions? Examples of such conditions include (but are not limited to) asthma, diabetes, severe allergies, or ADD/ADHD. No Yes Don’t know If yes, how many _____________________
4.
How many times during this school year have you referred students to the school nurse? None One time Two times Three or more times Don’t know If one or more times, what was the reason for your referral(s) ___________________
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5.
How many times during this school year have you attended a health education session or presentation at your school or the district school office? None One time More than one time Don’t know
6.
In your opinion, what impact do you think the school nurse at your school is making in: A. The overall well-being of students at your school B. The overall well-being of students with chronic conditions at your school C. Your students’ ability to focus in class D. Providing support in handling students with chronic medical conditions E. Providing support in handling injured students F. Providing support in handling behavioral problems with your students G. Providing support in handling emergency medical situations with your students H. Improving student academic performance I. Improving attendance of students at your school Very positive impact Somewhat positive impact No impact Somewhat negative impact Very negative impact Don’t know
7.
Do you think having a credentialed school nurse helps you teach more effectively? Yes No Not sure
11.
How satisfied are you with the services provided to your students by the: A. School nurse B. School psychologist C. School counselor Very satisfied Somewhat satisfied Somewhat dissatisfied Not satisfied My students have not needed these services
12.
Please explain why you were satisfied or dissatisfied with the services provided by the school nurse
______________________________________________ 13.
Please explain why you were satisfied or dissatisfied with the services provided by the school psychologist
______________________________________________ 14.
Please explain why you were satisfied or dissatisfied with the services provided by the school counselor
______________________________________________ 15.
What grade range do you currently teach? Kindergarten–First Grade Second Grade–Third Grade Fourth Grade–Fifth Grade Sixth Grade–Eighth Grade
16.
How do you identify yourself? Please check all that apply. African American or Black American Indian or Alaskan Native Asian or Asian American Latino or Hispanic Native Hawaiian or Pacific Islander White or Caucasian Other
17.
What additional steps can be taken to improve the health services at your school?
Would you like to make any comments on the questions or any issues not addressed in this survey regarding the presence of credentialed school nurses?
______________________________________________
______________________________________________
Why? Please share any examples. ______________________________________________ 8.
In your opinion what is the most beneficial activity performed by the nurse at your school? ______________________________________________
9.
10.
How comfortable do you feel contacting the school nurse with concerns about your students? Very comfortable Somewhat comfortable Neutral Somewhat uncomfortable Very uncomfortable Don’t know
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Appendix B Table B1. Major Response Categories, by School Type and Grade Level, Found in Survey Questions About the School Nurse. Demonstration Elementary N
%
Comparison
Middle N
%
Elementary N
%
Middle N
%
Question 4: How many times during this school year have you referred students to the school nurse? If one or more times, what was the reason for your referral Illness, sickness, and medication support (including contacting families) 10 43.5 29 46.8 53 73.6 21 56.7 Treatment of minor injuries 4 17.4 20 32.3 11 15.2 14 37.8 Health screenings (e.g., vision and hearing), follow-up, and support (including contacting 6 26.0 8 12.9 4 5.5 0 0.0 families) Other health/safety related issues (e.g., students feeling tired in class) 3 13.0 5 8.0 4 5.5 2 5.4 Total comments 23 100 62 100 72 100 37 100 Total respondents 9 28 27 13 Question 7: Do you think that having a credentialed school nurse helps you teach more effectively? Please share any examples Trusted professional on campus with health training and expertise, who takes care of 5 83.3 18 94.7 13 81.3 12 85.7 students’ health needs, and allows me to focus on teaching and learning More nursing support is needed at school 0 0.0 0 0.0 2 12.5 2 14.3 Other comment types (e.g., a negative or neutral response) 1 16.6 1 5.2 1 6.3 0 0.0 Total responses 6 100 19 100 16 100 14 100 Total respondents 6 16 16 11 Question 8: In your opinion, what is the most beneficial activity performed by the nurse at your school? Provides various types of medical support to all students (e.g., injury care, medication 3 20.0 28 62.2 19 43.2 13 59.0 support) Communicates with families and other medical personnel to help coordinate care for 1 6.6 5 11.1 8 18.2 2 9.1 students Conducts and follows up with hearing and vision screenings 6 40 7 15.6 6 13.6 0 0.0 Provides teachers with different types of supports (e.g., provide advice on IEPs) 4 26.6 3 6.7 7 15.9 6 27.2 Other comment types (e.g., help provide medical supplies in classrooms) 1 6.6 2 4.4 4 9.0 1 4.5 Total comments 15 100.0 45 100.0 44 100.0 22 100.0 Total respondents 12 41 37 19 Question 9: What additional steps can be taken to improve the support services provided by the health services at your school? Greater coordination and communication between nurses and teachers and the school 3 20.0 10 22.7 7 18.9 4 20.0 in general More health education and support to students and families 6 40.0 4 9.1 4 10.8 1 5.0 Maintain or increase nursing supports and the school’s capacity to address students’ 2 13.3 7 15.9 16 43.2 12 60.0 health needs None, don’t know, not sure, and not applicable 4 26.7 18 40.9 6 16.2 3 15.0 Other (e.g., more counselor involvement, more Spanish speaking nurses) 0 0.0 5 11.4 4 10.8 0 0.0 Total comments 15 100 44 100 37 100 20 100 Total respondents 11 41 35 19 Question 12: Please explain why you were satisfied or dissatisfied with the services provided by the school nurse Nurse is helpful, supportive, responsive, available, and effectively supports students and 10 83.3 21 77.7 23 69.7 11 68.8 families I am not satisfied; note enough nursing/medical support; she needs to be a better 1 8.3 2 7.4 8 24.2 3 18.8 communicator No comment, n/a, ‘‘don’t know’’ 1 8.3 4 14.8 2 6.1 2 12.5 Total comments 12 100 27 100 33 100 16 100 Total respondents 11 21 29 13 Note. Values may not add up to 100% due to rounding.
Declaration of Conflicting Interests
Funding
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this
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article: This research was partly funded by grants from the Lucile Packard Foundation for Children’s Health and the Lucile Packard Children’s Hospital, Palo Alto, California.
Notes 1. Given the small number of administrators who completed the survey (n ¼ 10), we focused our analysis on teachers’ survey responses. 2. http://www.ctc.ca.gov/credentials/leaflets/cl380.pdf
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Author Biographies Manuelito Biag, PhD, is a Research Associate at the John W. Gardner Center for Youth and Their Communities, Graduate School of Education, Stanford University, Stanford, CA, USA. Ashini Srivastava, MBBS, MPH, is an Evaluation Coordinator in the Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA. Melinda Landau, RN, MSN, is the Manager of the Health and Family Support Programs in the San Jose Unified School District, San Jose, CA, USA. Eunice Rodriguez, DrPH, is an Associate Professor (teaching) in the Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
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