School nurses represent the primary -- and in some cases the sole -- health care provider in school districts. In South Carolina, physicians are available only as voluntary advisors and consultants, and school districts often lack social workers to make referrals. School nurses often provide direct health care for school-age children. To meet the health needs of all children, school nurses need a range of knowledge and skills to provide essential services. The degree to which school nurses meet this challenge depends on availability of quality educational programs. A statewide continuing education program was initiated to enhance the program management, physical, psychosocial, and environmental health dimensions of the school nurse's practice.
Findings on the effect of the continuing education program on role performance and intrinsic and extrinsic job satisfaction of school nurses participating in the program are reported extensively elsewhere.|1~ Participants indicated a significant positive linear trend in intrinsic job satisfaction at program completion and at nine months after project completion; an increase in extrinsic satisfaction at program completion, followed by a decrease in level of extrinsic satisfaction nine months after completion; a decrease over time in the magnitude of the relationship between role performance and extrinsic satisfaction; and maintenance of a consistent positive relationship between role performance and intrinsic satisfaction 18 months after entering the program.|1~
Providing health services to schoolchildren represents a benchmark of school nursing practice.|2-4~ The American Academy of Pediatrics recommends a comprehensive health assessment, in addition to screenings, for thorough identification of health problems.|5-7~ Health problems of school-age youth include social, emotional, behavioral, and technological issues. Many problems are preventable through direct and indirect contributions of school programs and school nurses knowledgeable in disease prevention, health promotion, and health protection.|8~ Most health problems of schoolchildren can be identified and managed by school nurses.|9~ Solutions proposed to address health problems of school-age youth include a "nationwide program of continuing education for school nurses to expand and update their health promotion, disease prevention and health protection knowledge and skills."|8~ Such effort can reduce the incidence of abuse and neglect, sexually transmitted diseases, pregnancy, substance abuse, violence, and lifestyle-related illnesses among the school-age population.|10,11~
In 1985, risk-taking behaviors of South Carolina adolescents were increasing at an alarming rate. Adolescent sexual behavior accounted for 12% of low birth-weight babies,|12~ 15% of reported cases of syphilis, and 24-70 of gonorrhea cases.|13~ Family violence and abuse rose to more than 6,000 confirmed cases.|14~ Unhealthy lifestyle behaviors and lack of preventive care became more evident with hypertension detected in 10% of teenagers.|15~ Further, the increasing number of uninsured children ineligible for Medicaid needed health services. Such threats to the health of the school-age population underscored the need for school-based interventions.
In response, a continuing education program was developed for school nurses, the health care professionals who could best address the pressing need for school-based interventions. The program assisted school nurses in developing their roles within the framework of the Standards of School Nursing Practice.|16~ These standards facilitate the purpose of school nursing "to enhance the educational process by the modification or removal of health-related barriers to learning, and by promotion of an optimal level of wellness."|16~
School nurses historically face a poorly articulated set of role expectations.|17-19~ The Standards for School Nursing Practice defined the school nurse role and reduced ambiguity. The redefined role focused on a holistic approach to health through education, health promotion, disease prevention, and early detection and management of health problems. Role ambiguity, characteristic of positions occupied by professionals, can impede the meeting of role obligations.|20~ Hardy and Conway suggest the professional ambiguity results from limited knowledge, shortage of information, and lack of clarity in role expectations.(20) While role ambiguity can lead to diminished role performance,|21~ it can provide an opportunity for role development through role redefinition and realignment.|20,21~ The continuing education program emphasized knowledge and skill acquisition in areas requiring definition such as health promotion, disease prevention, and health protection specific to physical, psychosocial, environmental health, and program management.
Ninety-eight (41%) of practicing school nurses who participated in the program reported a mean age of 38 with a range from 25-65 years. Most nurses held diplomas (50%) or associate degrees (25-70), and 25% held baccalaureate degrees in nursing. Nurses served an average of two schools with populations ranging from 1,500 to 2,500 students. Most practiced nursing for more than 15 years but practiced school nursing for less than 10 years. Of 145 school nurses who did not participate in the program, 77 (53%) completed a role performance questionnaire and provided background information about themselves. When these measures were compared with the same measures taken from participating school nurses on admission to the program, no differences were found between the two groups on measures of role performance and demographic characteristics of age, race, education, years in nursing practice, years in school nursing, school setting (urban vs. rural), and number of schools and students served.
The program was provided over a three-year period beginning in 1985. Each year about 33 school nurses participated in the program and were taught in small groups of 10-12 nurses. The curriculum was taught by two nurses holding master's degrees in community health nursing with nurse practitioner skills and with expertise in school nursing. Faculty stability in the teaching role provided consistency in content and teaching strategies.
The program provided practicing school nurses with an experience to enhance their abilities to meet the health needs of South Carolina schoolchildren and the Standards of School Nursing Practice. The curriculum helped participants increase knowledge and skills in assessment and management of personal and environmental health for individuals, at the aggregate level, and across all school levels; acquire knowledge and skills in developing and implementing health programs; examine role issues in the context of ethics, legal rights and restraints, and interdisciplinary collaboration; and implement the redefined role through supervised clinical practice. Role acquisition was further enhanced by project faculty providing consultation services to participating nurses at their schools.
The curriculum included 80 hours of intensive didactic instruction, 40 hours of clinical instruction, instructor consultation in the nurses' schools, and two one-day seminars. Participants could elect to complete the didactic and clinical components over three consecutive weeks or over a three-month period with one-week of instruction each month. All components of the curricula including consultation and seminars were implemented over a nine-month period. Six state-supported colleges located across the state provided the instructional settings with practice conducted in local schools. Participating school nurses often were instrumental in developing a practicum site for their region.
Data were collected from each group of school nurses during their first day of orientation, after completing the program at nine months, and on follow-up 18 months after the program. After completing the program, school nurses improved their practice and demonstrated considerable change in the physical (p = .0001), psychosocial (p = .01), and environmental (p = .01) health dimensions of their role. No significant change occurred in program management skills (p = .32). Trend analysis indicated role performance improved significantly from entry to completion and was maintained over 18 months later in all areas except program management.
Program participants enhanced their role performance in physical, psychosocial, and environmental health. Skills and abilities acquired in these areas were well-integrated at nine months and maintained 18 months after the program. The program addressed knowledge issues and modification and expansion of attitudes and behavior needed for role acquisition. The integration of new knowledge, skills, and concepts into the school nurse role contributed to role transition and redefinition.
The program did not alter management skills. School nurses did not accept responsibility for planning and implementing comprehensive school health programs. Historically, school nurses do not engage in program development and management activities to the extent the role requires.|2,22~ Results from this program suggest acquisition of program management skills requires commitment of the school nurse and an organizational structure that supports active participation in school health policy decisions, program development, and program implementation. Nurses who develop and use management skills can better shape their roles. They must understand the need for change and develop strategies to reduce organizational barriers and market their expertise to school administrators and the community.|23~ While participants could redefine their roles, the program did not assist redefinition in the critical area of program management.
Lack of performance change in the program management dimension suggests the strategies taught were not used or were ineffective. However, follow-up discussions indicated the program lacked strategies for successful coalition building, perhaps providing school nurses with insufficient resources for acquiring a power base adequate for role redefinition in a complex area such as program management. Complexity of this program dimension, coupled with lack of integration in practice, calls for a continuing education focus with extensive theoretical content and experiential application. For role realignment to occur, barriers to school nursing such as nurse-to-student ratio, coordination of resources, and lack of administrative support need to be addressed fully on an individual basis.
Continuing education programs can positively influence role transition and, ultimately, role redefinition. The outcomes indicate a more extensive educational program is necessary for the full scope of school nursing practice to emerge. Other initiatives aimed solely at reducing role ambiguity and altering perceptions held by administrators also are indicated. Experienced school nurses with more education could provide key leadership to resolve ambiguity associated with program management aspects. Thus, school district administrators need to know what school nurses can do and what can be expected of school nurses in managing their roles.
School nurses need to consider ways to further reduce role ambiguity and implement role redefinition to effect positive change in the school.|24~ Partnerships with administrators and parents were not addressed in the program but could provide a climate for school nurses to improve health policies and develop programs for the school, which translate into children with improved health, improved readiness to learn, and improved academic performance.
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Gwen M. Felton, PhD, RN, CS, Associate Professor; and Mary Ann Parsons, PhD, RN, CS, Professor, College of Nursing, University of South Carolina, Columbia, SC 29208. This project was funded by Division of Nursing, Dept. of Health and Human Services, Special Projects grant #ID10 NU24212. This article was submitted December 16, 1992, and revised and accepted for publication April 12, 1993.…