The School Nurse as a Member of the School Health Team: Fact or Fiction?

Barbara Thomas, PhD

Barbara Thomas, PhD, is an Associate Professor, College of Nursing, The University of Iowa, Iowa City, Iowa.*

The purpose of this study is to determine the ex- tent to which school nurses see themselves function- ing as part of a school health team, problems they perceive in their roles as team members, and if job satisfaction is related to the reported level of team functioning.

For many years nurses have played a widely vary- ing role in school health programs across the nation. Part of this variability can be traced to the origins and development of school nursing. When Lillian Wald in 1902 sent one of the Henry Street visiting nurses to a few New York City schools to help reduce absenteeism, notably that from “nuisance diseases,” she initiated school nursing’s role as case-finding and follow-up. During the early years of the growth of school nursing, this emphasis persisted with the nurse instructed to wear a uniform as a visible proc- lamation of her authority (Kelly and Bradshaw, 1918, p 21). This stage of school nursing was centered in large urban areas with school health activities aimed as much at respect for law as at improving and main- taining the health of school children. The latter was focused primarily on communicable disease control.

As the complexity of society increased, that of society’s educational institutions increased also. New tasks were identified and assumed, and finally, role conflicts were recognized. Professional organizations such as the American Nurses Association, and the National Education Association studied the prob- lems related to school nurses’ functions, standards, and qualifications. Increasingly, “school health team,” “multidisciplinary approach to school health problems” and “collaborative relationships” are be- ing used to describe optimum school health services. I n their monograph Solutions to Critical Heal th

‘The author gratefully acknowledges the assistance and coopera tion of Faye Cleary, Department of Public Instruction School Nurse Consultant, in completing this study.

Needs, the National Council for School Nurses noted that:

There is evidence of a growing trend toward the pupil person nel team concept. Teams usually include guidance counselors, psychologists, social workers, health services personnel, health educators, physical educators and others. Each has a unique con- tribution, but cannot function independently. A systemmatic plan for communication among the various professionals is essen- tial. In these days of shortage of skilled manpower, roles and func- tions must be delegated to the most appropriate personnel. This will require continual job analysis and changes in assigned re- sponsibilities. (National Council for School Nurses, School Nurs- ing Monograph #1, 1969, p 5).

In addition, a large number of studies have been conducted to identify and analyze school nurse activ- ities. (eg, Eidens, 1963; Tipple, 1963; Hawkins, 1971; Coleman and Hawkins, 1970; Berg, Fletcher, Ford- ham, Schultz and Wallace, 1973; and Chen, 19‘15). The same trend, the need for the school nurse to func- tion as a member of a team, emerged as a major con- cern: , . . previous studies have failed to take into consideration the ex- tremely important factor of team relationships, or rather the lack of them. The nurses wanted to consider themselves as part of a team, but only rarely did they have evidence t h a t they were thought of in that way. (Hawkins, p 748.)

“Interprofessional collaboration between representatives from the fields of medicine, nursing, psychology, guidance, social work and other related disciplines must be encouraged. (Stobo, p 672.)

. . . because the nurse shares responsibilities with others in nearly all the tasks, she should function primarily as a team member. (Berg, et al, p 319.)

. . , some forms or continuing education for interdisciplinary team work provided through the school administration or professional organizations may be helpful in increasing mutual understanding. (Chen, p 175.)

If i t is agreed the team concept is essential in the provision of school health services, we need to de- termine the status of teamwork in certain areas, in- cluding who is working with whom. It seems appro- priate then to ask school nurses to report the level a t which they perceive themselves functioning as a member of a team in various areas and with signifi- cant others, the barriers identified by them in func- tioning as an active member of a team, and in general

466 OCTOBER 1976 VOLUME XLVl NO. 8

their satisfaction with their positions. This study should be regarded as exploratory because rather gross definitions of frequency of collaboration were used, and n 6 attempt was made to assess the quality of the collaborative efforts reported.

Table 1

Characteristics of School Nurse Sample (n=293)

Methodology The population to be surveyed was identified as

school nurses employed in public schools in a mid- western state during the 1972 school year. A ques- tionnaire designed for computer analysis of the data was mailed to 475 school nurses. Usable responses ,were obtained from 293 school nurses (62%) which formed the study sample. Table 1 summarizes the characteristics of the sample.

Table 1 indicates that the vast majority of the sample school nurses were 26-65 years old, married and having children, and diploma graduates, with from one to ten years experience as a school nurse. Most were employed full time in school systems with up to 5000 pupils.

Respondents were asked to indicate how often they work with others regarding both physical and psychosocial problems in the school environment, on a scale of Frequently, Sometimes, and Never. This self-report data is summarized in Table 2. I t is apparent school nurses report working with teachers more frequently than with any other entity. Least contact is reported for the Dental and Medical Societies, Mental Health Centers, and the State De- partment of Health Regional Supervisors. Although school nurses report more frequent collaboration in the area of physical concerns than for psychosocial matters, the persons and groups contacted most and least are the same for each area.

The fact that self-report data are frequently biased in the direction of desirable responses raises the ques- tion of whether these data are perhaps an overesti- mate of collaborative relationships. There are two indications that they are. First, the rather high leSels of No Response in an instrument requiring little discrimination in the responses required. It is sug- gested that respondents who should have had little difficulty in deciding among the categories Fre- quently, Sometimes, Never may have made a de- cision not to respond because of their reluctance to report, Never. In some instances, of course, the No Response level is indicative of nonavailability of per- sonnel, eg, school social worker or perhaps service clubs.

The notion that the Never category is under re- ported in certain respects is given further support by the school nurses’ reports of problem areas asso-

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Variable n 70

- Age No Response Under 25 26-45 46-65 66 and older

Marital status Single Married Separated, Divorced, Widowed

Children None One-9

Educational preparation No Response AD Diploma BSN RN+ BA or BS MA, EdS, EdD, PhD

Yrs. Experience No Response in 1st year 1-5 years 6-10 years 10-20 years 21 years or more

Employment No Response Full-time Part-time

School size No Response Under 1000 1000-5000 500 1-10,000 10,oo 1-20,000 20.001 or over

25 12

118 136

2

9 255

29

32 26 1

3 4

239 17 24 6

2 27

108 95 50 11

2 205

86

1 1 107 112 32 16 15

9 4

40 46

1

3 87 10

11 89

1 1

82 6 8 2

1 9

37 32 17 4

1 70 29

4 36 38 11 5 5

467

Table 2 Frequency Of Collaboration Between School Nurses afld Significant Others

(1~293)

Physical Matters Psychosocial Matters

N.R* F’ S’ N’ N. R. F S N Persons/GrouDs n 9’0 n 90 n 90 n 90 n 9’0 n 90 n 90 n %

Parents 4 1 192 66 90 31 7 2 39 13 152 52 100 34 2 1 Teachers 3 1 243 83 47 16 0 0 40 14 163 56 81 28 9 3 Principal 5 2 187 64 93 32 8 3 42 14 132 45 106 36 13 4 Other Admin. 15 5 78 27 175 60 25 8 50 17 58 20 148 50 37 13 Counselors 21 7 131 45 116 40 25 8 58 20 90 31 120 41 25 8 School Psychologist 29 10 67 23 154 52 43 15 69 24 49 17 135 46 40 14 Non-Prof Staff 22 8 100 34 140 48 31 10 56 19 65 22 128 44 41 15 Volunteers 62 21 22 8 128 44 81 28 98 33 17 6 101 34 77 26 Speech & Hearing Clinician 5 2 140 48 135 46 13 4 47 16 83 28 138 47 25 8 Rdg . Cons . -Specialist 47 16 53 18 134 46 59 20 81 28 37 13 116 40 59 20 School Social Worker 145 49 28 10 63 22 57 19 167 57 22 8 54 18 50 17 Dentist 47 16 39 13 153 52 54 18 80 27 33 11 126 43 54 18 Dental Society 69 24 21 7 95 32 108 37 102 35 10 3 96 33 85 29 Physician 21 7 112 38 142 48 18 6 60 20 69 24 148 50 16 5 Med. Society 50 17 21 7 100 34 122 42 87 30 16 5 93 32 97 33 Service Clubs 56 19 33 11 139 47 65 22 89 30 25 8 117 40 62 21 Public Health Nurse 38 13 72 24 160 55 23 8 77 26 61 21 127 43 28 10 St. Dept. Health Reg. Sup. 23 8 24 8 154 52 92 31 62 21 24 8 141 48 66 22 Social/Co. Welfare Agencies 18’ 6 60 20 171 58 44 15 62 21 50 17 155 53 26 9 Mental Health Centers 45 15 19 6 115 39 114 39 83 28 17 6 110 38 83 28 Other Health Centers 214 73 19 6 33 11 27 9 227 77 13 4 29 10 24 8

NR No Response F Frequently

ciated with their positions. These are summarized in Table 3.

The analysis of the coded responses indicated that the major problem areas were reported to be minor and nonessential duties, time and workload problems, and, ranked third: staff communication- teamwork breakdown and lack of facilities for nurs- ing services. The “other” response, however, con- tained such items as “lack of acceptance as a pro- fessional person, no definition of school nurse role, not accepted for more than routine first aid and screening, failure to use nurses’ training, communi- cation, superintendents’ lack of knowledge of school nursing, no interaction with public health nurse or other health professionals, lack of communication with agencies and lack of consensus regarding duties of a school nurse.” Although workload and salary were mentioned by two respondents each and other items, such as lack of a private office and adult edu-

S Sometimes N Never

cation by five others, many responses (n-23) were appropriate for recording into the categories related to teamwork, making i t the major problem area re- ported, and either supporting the notion that the level of collaboration reported in Table 2 is an over- estimate, or raising questions regarding the quality of the collaborative relationship.

Level of teamwork was also investigated in terms of frequency of participation in selected activities. Again, the categories, Frequently, Sometimes, and Never were used. Table 4 reports these results. The team activities in which most frequent partici- pation is reported by school nurses are: (1) with school staff in curriculum planning sessions; ( 2) with school staff in planned evaluation of school en- vironment concerning safety, sanitation, etc; and (3) in staff meetings to help others identify health needs and deviations. Least frequent include coun- selor-parent-nurse conferences, local school health

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Table 3 Reported Major Problem Areas of the School Nurse Position

(n=293)

Problem Area YES NO n To n 90

Relations with teachers/counselors* 16 5 277 95 Relations with School Admin. * 19 6 274 94 Relations with Parents’ 12 4 281 96 Minor, nonessential duties 106 36 187 64 Lack of over-all planning 77 26 216 74 Staff communication-teamwork breakdown* 78 27 215 73 Time and Workload 83 28 210 72 Lack of acceptance by school staff’ 28 10 265 90 Lack of community resources 48 16 245 84 Lack of facilities for nursing service 80 27 213 73 Divided admin. (health dept/school admin. ) 25 9 268 91 Lack of Supervision 32 11 261 89 Other* 66 23 227 77

*Regarded as indicative of problems in teamwork.

policy setting sessions with school administrators and others, and interpreting school health policies with school administrators and faculty to the new faculty. That the category Never was consistently avoided indicates some level of participation in all of the selected activities listed. In this regard, how- ever, Sometimes could represent an extremely in- frequent activity.

To determine whether or not there is a relation- ship between reported level of teamwork and job satisfaction, two scores were calculated by assigning values of 5 to Frequent, 3 to Sometimes, and 0 to Neuer, in each of the categories listed in Tables 2 and 3, and a Pearson product moment-coefficient of correlation was computed between these scores and the nine-point job satisfaction ratings. The correla- tion coefficients are 0.024 and 0.010 respectively, indicating a very small positive relationship between degree of collaborative activity reported and level of iob satisfaction. Since the correlation coefficients are not significant a t .05, i t is concluded that at this level, there is no significant relationship between level of teamwork reported by school nurses and their job satisfaction.

That general job satisfaction is high, regardless of whether team relationships exist to any large ex- tent or not, suggests the health team concept is not a central issue for most of the school nurses sur- veyed. Other job factors apparently negate the ef- fects one might expect a low level of collaborative relationships to have. The disparity between the

preparation recommended for school nurses and that held by the majority of respondents may be a fac- tor. Further study of this data is underway, in which the reported interactions and job satisfactions of two subsamples are being analyzed. The two samples are representative of the extremes of what might be termed professional orientation, ie, one subsample consists of the school nurses “scoring” highest in the areas of educational preparation, full-time em- ployment, activities in professional organizations, participation in continuing education opportunities, and reported readership of the current nursing and educational literature; the other consists of the school nurses “scoring” lowest in these areas.

Further research is also needed to measure more precisely the kinds of interaction among the school health team-quality, as well as frequency. In addi- tion, it would be useful to determine if the percep- tions reported by the school nurses are shared by other members of the school health team.

BIBLIOGRAPHY

Berg B, Fletcher M, Fordharn N, et al: In health related tasks, where does the school nurse function? J Sch Health 43:316-319, 1973.

Chen S-PC: Role relationships in a school health interdisciplinary team. J Sch Health 45:172-176, 1975.

Coleman J , Hawkins W: The changing role of the nurse: An al- ternative to elimination. J Sch Health 40:121-122, 1970.

Eidens CO: The Work of the School Nurse- Teacher as Perceived by Selected Public School Staff Personnel, dissertation. Teach- ers College, Columbia University, New York, 1963.

THE JOURNAL OF SCHOOL HEALTH 469

Table 4 Reported Participation by School Nurses

in Selected Activities (n 293)

How often do you feel you participate? F* S* "

n % n % n %

With community groups in health services in the school (e.g., TBC Assn., vision screening)

In interpreting your role to teachers, counselors, administrators and other staff members

With professional school staff in curriculum planning sessions

In staff conferences for case discussions of known health problems

In staff meetings to help others to identify health needs and deviations

With teachers in direct and indirept planning

In teacher-parent-nurse conferences

In counselor-parent-nurse conferences

With school staff in planned evaluation of school environment concerning safety, sanitation, etc.

With school administrators and others in local school health policy planning

With school administrators and faculty in interpreting health policies to new members of the faculty

50 17 243 83 0 0

17 6 276 94 0 0

108 37 185 63 0 0

38 13 255 87 0 0

20 7 273 93 0 0

53 18 240 82 0 0

16 5 277 95 0 0

9 3 284 97 0 0

57 19 236 81 0 0

11 4 282 96 0 0

13 4 280 96 0 0

F Frequently S Sometimes N Never

Hawkins NG: Is there a school nurse role? A m J Nurs 71:744-751, ,

Kelly HW, Bradshaw MC: A Handbook for School Nurses. New

National Council for School Nurses: School Nursing Monograph

school nurse. A m J Public Health 59:669-672, 1969.

1963. 1971.

York, MacMillan Co, 1918.

Tipple D: The school nurse as a counselor. Am J Nurs 63:110-113,

#1, Solutions to Critical Health Needs, American Association for Health, Physical Education and Recreation, Washington DC. 1969.

The author of this article is Barbara Thomas, PhD, Associate Professor, College of Nursing, The Uni- - _ .

Stobo EC: Trends in the preparation and qualifications of the versity of Iowa, Iowa City, I A 52242.

470 OCTOBER 1976 VOLUME XLVl NO. 8