The Journal of School Nursing
2022, Vol. 38(2) 161–172
© The Author(s) 2020Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840520918310journals.sagepub.com/home/jsn
Adolescents with type 1 diabetes (TID) and their parents depend on school nurses to keep students safe in school. Parent satisfaction with T1D care is impacted by school factors including school nurse presence. The purpose of this study was to determine the relationships among parental satisfaction with diabetes care in school, parental report of diabetes-related safety, adolescent report of school nurse helpfulness, and school nurse presence represented by school nurse to student ratios. The sample consisted of 89 parent–adolescent dyads. Adolescents 10–16 years old with T1D completed a questionnaire that included perceptions of school nurse helpfulness. Parents completed a questionnaire that included perceptions of T1D safety and satisfaction. Diabetes-related safety was positively correlated with parental satisfaction and school nurse helpfulness and inversely correlated with age and school nurse to student ratios. Findings validate the importance of school nurse presence to adolescents with T1D and their parents with implications for school nursing policy, practice, and research.
adolescents, parental, safety, satisfaction, school nurse, type 1 diabetes
As the prevalence of type 1 diabetes (T1D) in children continues to rise (Mayer-Davis et al., 2017), it is incumbent upon school nurses to maintain a comprehensive knowledge base in order to provide safe and effective T1D care based on best evidence. Not only is it a moral imperative but a legal one as well. School nurses are charged with understanding and following oftentimes complex federal and state laws in order to provide minimum safe T1D care in the school setting. Yet, despite these enacted legal protections, students with T1D continue to experience discriminatory practices at school which interfere with optimal T1D self-management (Jackson et al., 2015; MacLeish et al., 2013).
Adolescents with T1D are at risk of poor glycemic control (Datye et al., 2015), and critical benefits such as improved T1D outcomes may be gained when school nurses have the resources available to meet the needs of this population. Students with T1D frequently encounter institutional barriers to T1D self-management, such as restricted access to diabetes supplies and blood glucose monitoring (BGM); inadequate training of school nurses and staff, restrictions on after-school activities, sports, and field trips; and lack of a daily presence of a school nurse (Lewis et al., 2003; Skelley et al., 2013). Removal of these unnecessary barriers promotes optimal self-management in students and improved glycemic control (Edwards et al., 2014), which can mitigate the risk of developing future T1D complications (Jackson et al., 2015) as well as contribute to better academic performance (Edwards et al., 2014; Tonoli et al., 2014). School nurses can contribute to the development of a supportive and unrestricted environment through the coordination and implementation of a customized Diabetes Medical Management Plan, which addresses the specific needs of the student with diabetes (Jackson et al., 2015).
In addition to managing the deleterious acute and longterm effects of hyperglycemia, such as diabetic ketoacidosis, school nurses are instrumental in preventing and managing severe hypoglycemia, a medical emergency in which the student may be incapable of diabetes self-management from an impaired motor or cognitive function (National Association of School Nurses [NASN], 2017). Alaqeel (2019) reported higher frequencies of both hypoglycemic coma and lack of insulin administration in Saudi Arabian public schools without nurse or physician health care providers than in private schools with nurse or physician health care providers, both of which can have catastrophic effects for students with T1D.
Students with T1D and their parents rely on school personnel to foster a supportive and safe environment by keeping abreast of state-of-the-art diabetes knowledge and implementing established diabetes standards, protocols, and practices. Parents of students with T1D face many challenges while navigating the educational system, of which safety is a priority concern (Johnson & Melton, 2014; Kise et al., 2017). In the United States, parents cite the following factors that contribute to safe T1D care in school: the presence of a school nurse, access to diabetes supplies and BGM, education of school nurses and school personnel, and accommodations for field trips and after-school activities (Driscoll et al., 2015; Jacquez et al., 2008; Johnson & Melton, 2014; Schwartz et al., 2010). Similarly, parents of students with T1D throughout Europe (Amillategui et al., 2007; Kime, 2014; Pinelli et al., 2011), Canada (Nurmi & Stieber-Roger, 2012), Taiwan (Lin et al., 2008), and Australia (Marks et al., 2014) echo parallel safety concerns, demonstrating that this is a worldwide concern.
Research on parental satisfaction with T1D care in the school setting is scarce, but some of the primary causes of parental dissatisfaction reported are the aforementioned barriers (Lewis et al., 2003; Skelley et al., 2013). Parental satisfaction with T1D care in schools has been specifically associated with the ability to conveniently perform BGM in school, which strongly correlated with participation in all school activities (Skelley et al., 2013). Although T1D care in Saudi Arabian schools differs from that of the United States, a recent study of 411 parents of students with T1D reported that 47.7% of the parent sample had no confidence in the school’s ability to manage T1D (Alaqeel, 2019). This study explicated barriers to safety in students with T1D in public and private schools, such as the lack of glucagon availability (78.6%), lack of trained staff for glucagon injection (72%), and lack of a person identified as responsible for T1D management in school (17%). A significant negative outcome identified in the study was the occurrence of hypoglycemic coma (n = 52, 12.7%). Parents’ confidence was significantly higher in private schools than in public schools (p = .01), which is note worthy in that 6 (5.7%) of the 106 private schools and none of the public schools employed a nurse or physician as health care provider.
From the scarce data available, research on school nurses’ and personnel’s T1D knowledge suggests that it is insufficient to expertly care for students with T1D in the school setting, particularly in the areas of detection of hypoglycemia, access to diabetes supplies and snacks, and convenient BGM (Hayes-Bohn et al., 2004; Schwartz et al., 2010). Wright and Chopak-Foss (2018) reported that nonmedical school personnel not only had low levels of diabetes knowledge related to symptoms and treatment of diabetes emergencies, but they rated themselves low in diabetes management skills, such as BGM, insulin administration, and recognition and treatment of hypoglycemia and hyperglycemia. School nurses themselves cite inadequate T1D knowledge (Wang & Volker, 2013). In a pilot study of 43 school nurses, 29% perceived their T1D knowledge to be low to average, citing barriers to knowledge as time constraints and lack of access to educational materials, training, and updates (Joshi et al., 2008).
Little empirical data exist from the student’s perspective on the relationship with the school nurse. Oftentimes, researchers use the term school personnel, a blanket term that encompasses school nurses, teachers and aides, health office aides, sports coaches, school counselors, bus drivers, and administrators in varying combinations (Driscoll et al., 2015; Wright & Chopak-Foss, 2018). This is necessary in states and districts without the presence of a full-time school nurse in order to describe caregivers of students with T1D; however, the term creates confusion when interpreting study results, making it difficult to draw accurate conclusions.
Perceptions of helpfulness of the school nurse vary; some children found the school nurse helpful (Lehmkuhl & Nabors, 2008; Sullivan-Bolyai et al., 2014), while others found the school nurse unsupportive in their T1D care (Wang et al., 2013). Likewise, perceptions of the school nurse’s knowledge of T1D differed; some children reported that the school nurse was knowledgeable (Hayes-Bohn et al., 2004) while others reported that additional education was warranted (Nabors et al., 2003). Compared to older children, younger children tended to establish closer relationships with school nurses as well as need more support from school nurses (Nabors et al., 2003; Reitblat et al., 2016). Importantly, children’s satisfaction with school support in general was significantly associated with lower HbA1c levels (Lehmkuhl & Nabors, 2008) and better self-care, dietary practices, and BGM (Tang et al., 2013).
Parents report that school nurse presence is important for safe and effective TID management in the school setting (Johnson & Melton, 2014; Kime, 2014; Marks et al., 2014; Skelley et al., 2013). The American Academy of Pediatrics (2016) recommends a minimum of one full-time school nurse in each building; likewise, NASN (2015) endorses using a multifaceted approach that includes care based on acuity and social determinants of health and a school nurse workload that affords students direct access to a school nurse. Further, it is NASN’s position (2019) that a school nurse be present in school all day every day in order to promote student health, safety, and learning, yet fiscal constraints often impede the achievement of this goal. While school nurse to student ratios are no longer recommended as a guideline for staffing, they are representative of school nurse presence and, therefore, are used in this study.
The school setting is an important opportunity for school nurses to positively impact T1D management and build supportive relationships with students and families. To date, there is no research that examines the relationships among parental satisfaction with T1D care in school, parental report of T1D-related safety in school, adolescent report of school nurse helpfulness, and school nurse presence represented by school nurse to student ratios. The purpose of this study was to determine whether a relationship exists among these variables.
Data for this descriptive correlational study were collected from a pediatric endocrinology practice at a large academic medical center in the Northeastern United States. Institutional review board approvals were obtained from both Seton Hall University and the academic medical center.
A convenience sample of 89 parent–adolescent dyads was recruited for this study. A full description of participants and recruitment has been previously described (Wilt, 2019). Parents provided demographic and diabetes-related data. Adolescent inclusion criteria were students diagnosed with T1D, between 10–16 years old, able to speak English, enrolled in public or private school, and able to read and understand grade-level material.
Two methods of participant recruitment were utilized. First, a blind-copied email announcing the study with the researcher’s contact information was sent by the participating endocrinology practice to 418 parents of adolescents aged 10–16 years old. Fifty-three (12.7%) completed packets were returned via postal mail to the researchers. Second, in-person recruitment took place in the waiting area of the endocrinology practice. The researcher approached 44 parents and 36 (81.8%) completed study materials, generating a total sample size of 89 parent–adolescent dyads. This number of participants met the minimum number of 84 participants required based on an a priori power analysis for a bivariate correlational analysis to achieve a power of .80 with an effect size of .30 and a significance level of .05 (Faul et al., 2009).
A letter of solicitation explaining the confidential and voluntary nature of the study was given to all interested parents. Adolescents were approached if their parents were interested. Prior to participating, written parental consent and written adolescent assent were obtained. Upon completion of the study questionnaires, each parent and each adolescent received a $10 Target gift card as a token of appreciation either in person or via the postal mail.
Parent questionnaire. A 42-item researcher-generated parent questionnaire (PQ) was constructed to obtain demographic information including the adolescent’s age, gender, last HbA1c level, and school of attendance. Using a 5-point Likert-type scale, parents responded to two questions related to their satisfaction with T1D care in school and their feelings about T1D-related safety in school (0 = not at all safe/not at all satisfied and 4 = very safe/very satisfied). An open-ended question asked parents what, if anything, they learned from the school nurse that influenced their ability to care for their adolescents’ diabetes.
Adolescent questionnaire. A 7-item researcher-generated adolescent questionnaire was constructed that asked about diabetes-related activities performed in school. Using a 5-point Likert-type scale, adolescents responded to one question related to their perception of the helpfulness of the school nurse (0 = not at all helpful and 4 = very helpful). An open-ended question asked adolescents what, if anything, they learned from the school nurse that helped them take better care of their diabetes.
Descriptive statistics were computed for main study and demographic variables using IBM SPSS Statistics (Version 25). Continuous and ordinal variables were described as frequencies, means, and standard deviations; categorical variables were described as frequencies and percentages. Pairs of continuous variables were analyzed using Pearson product–moment correlation coefficients. Spearman’s rank order was used to analyze pairs of categorical variables, pairs of categorical and continuous variables, and pairs of ordinal and continuous variables. An independent samples t test was performed to determine whether there were gender differences in the variables of parental satisfaction with T1D care in school, parental report of T1D-related safety in school, and adolescent report of school nurse helpfulness.
School nurse to student ratios were defined as the number of full-time equivalent (FTE) school nurses in the academic setting accessible to the total number of students enrolled for one academic calendar year. Calculation methods for FTE status and school nurse to student ratio have been previously described (Wilt, 2019). Enrollment data for one academic calendar year were acquired from the state department of education for all participant schools to obtain the most accurate data. Participants’ schools of enrollment were identified on the demographic portion of the PQ. Level of school was identified from the PQ and coded as either elementary/middle (Grades K–8) or high school (Grades 9–12).
Table 1 provides the frequencies, means, and standard deviations of the study variables. Most of the adolescent sample was predominantly male. No statistically significant difference (p = .798) was noted between the ages of males (M = 13.39, SD = 1.85) and females (M = 13.49, SD = 1.75). Mean HbA1c levels as reported on the PQ was 8.12% (SD = 1.37) with no statistically significant difference (p = .559) between males (M = 8.05, SD = 1.40) and females (M = 8.22, SD = 1.36). Mean diabetes duration was 5.23 years (SD = 3.19). The parent sample was predominantly female (n = 79, 88.8%) and well educated; nearly two thirds held baccalaureate degrees or higher (n = 60, 67.4%). Ethnicity, socioeconomic, and household structure data were not collected for this study.
Table 2 provides a description of participants’ school characteristics. Most of the adolescent sample attended elementary or middle school in public institutions. Nearly all participants (n = 85, 95.4%) attended schools with a minimum of one FTE school nurse; the remaining participants (n = 4, 4.5%) attended nonpublic schools with less than one FTE school nurse. Just over two thirds of adolescents (n = 60, 67.4%) attended schools with enrollments between 84 and 1,000. More than one quarter (n = 24, 27%) attended schools with school nurse to student ratios of greater than 1:751, and half of this subset (n = 12, 13.5%) attended schools with ratios greater than 1:1,001.
Parent perspective. Correlations among pairs of study variables are presented in Table 3. Moderate, significant inverse relationships among parental report of T1D-related safety were found with age, school nurse to student ratios, and level of school, indicating that parents felt their adolescents were less safe when they were older, attended high school, or attended schools with larger school nurse to student ratios. Also noted was a strong positive correlation between T1D-related safety and parent report of T1D-related satisfaction and a moderate positive correlation between T1D-related safety and adolescent report of school nurse helpfulness, indicating that parents felt their adolescents were safer when they were satisfied with T1D care and when their adolescents perceived the school nurse as helpful. An overwhelming majority of parents felt their adolescents were either very safe or somewhat safe (n = 85, 95.5%) in school (see Table 4).
Similar to T1D-related safety, T1D-related satisfaction was significantly moderately and inversely correlated with age, school nurse to student ratios, and level of school, indicating that parents were less satisfied with T1D care in school when their adolescents were older, attended high school, or attended schools with larger school nurse to student ratios. A strong positive correlation with adolescent report of school nurse helpfulness was noted, indicating that parents were more satisfied with T1D care when their adolescents reported the school nurse as helpful. This variable also showed a significant weak association with gender; parents of males reported higher levels of satisfaction than did parents of females. Similar to the parent report of safety, a large majority of parents reported they were either very satisfied or somewhat satisfied (n = 79, 88.8%) with diabetes care in school (see Table 4).
Parents were asked, “What, if anything, have you learned from the school nurse that influenced your ability to care for your son or daughter’s diabetes?” Fifty-four parents (60.1%) responded to this question, many reporting positive encounters with the school nurse. Seven parents reported that the school nurse was well educated about diabetes. Some parents appreciated that the school nurse attended insulin pump classes with them and participated in continuing education activities. Parents stated they learned carbohydrate counting, documentation, making healthy nutrition choices, and treating high and low blood glucose. Parents commented on the psychosocial aspects of T1D management; several learned that their adolescents were more prepared for independent T1D self-management than they believed while one learned that her adolescent was not yet ready for full independence. One reported the school nurse taught her that by trusting in her daughter’s capabilities, a school team would be created, thereby helping the parent shoulder the responsibility for T1D care. Another reported that due to the security she felt with the school nurse’s T1D knowledge, she was able to work full-time. Another stated the school nurse was a “lovely, supportive and caring lady. We admire her and cherish her support.” Parents described their adolescents’ school nurses as caring, reassuring, lovely, supportive, amazing, helpful, and knowledgeable.
The majority of comments were positive, but parents reported more negative responses than did adolescents. Sixteen of 54 (29.6%) parents responded “none” or “nothing” learned from the school nurse. Seven parents stated that the school nurse needed more T1D education, and seven parents reported it necessary to educate school nurses rather than be the recipients of education by the school nurse. Several described insufficient numbers of school nurses to care for the number of students with T1D, stating that the school nurse had difficulty managing eight students with T1D in a school with more than 800 students. One parent stated, “Too many kids. Not enough nurses. I’m frightened all the time.” Yet another reported she needed to speak with administrators because the school nurse was not adhering to the guidelines for the “Safe at School” program. Another reported needing to come into school several times weekly because the school nurse was not insulin pump trained. Due to this lack of school support, the adolescent was unable to continue on the insulin pump and transitioned back to multiple daily injections.
Adolescent perspective. Adolescent report of school nurse helpfulness was significantly moderately and inversely correlated with age and level of school, indicating that older adolescents and those attending high schools felt the school nurse was less helpful. Unlike parent report of T1D-related safety and satisfaction, adolescent report of school nurse helpfulness was not associated with school nurse to student ratios. As with T1D-related satisfaction, a gender difference was also noted; males reported higher levels of school nurse helpfulness than did females. Lesser numbers of adolescents reported the school nurse as either very helpful or somewhat helpful (n = 70, 78.7%) than the number of parents reporting positively on safety and satisfaction with T1D care. School nurse ratios were also strongly and positively correlated with age and level of school, meaning that higher ratios were associated with older adolescents and high schools.
Adolescents were asked, “What, if anything, have you learned from your school nurse that has helped you take better care of your diabetes?” Most of the adolescent sample (n = 67, 75.3%) responded to the question. Overwhelmingly, the comments were positive and involved daily T1D management and reminders such as counting carbohydrates and administering insulin, changing lancets, checking blood glucose frequently, and recording blood glucose and carbohydrates. One reported that the school nurse showed him how to administer insulin in a site that usually requires two people. Adolescents reported that they learned better hypoglycemia management, how to balance physical activity with safe blood glucose levels, better nutrition, how to handle parties and field trips, and how to plan for T1D emergencies. Some reported that the school nurse taught them T1D self-care in order to prevent long-term complications. Some reported the school nurse provided emotional support and reassurance; the school nurse encouraged responsibility and independence with T1D care as well as maintaining a positive attitude. One adolescent wrote, “she cares about me more than the old one did. She’s interested in learning more.” Another wrote, “She reinforces things I already know in a kind manner. She advocates for me, especially with the gym teacher.”
Eighteen of the 67 (26.9%) adolescents reported “none” or “nothing” learned from the school nurse. Some stated that the school nurse knew “little to nothing about diabetes” and that adolescents taught the school nurse instead of the opposite.
To the author’s knowledge, this is the first study that demonstrates a correlation between school nurse presence and parent reports of satisfaction and safety regarding T1D care in the school setting. There is a paucity of quantitative research on parents’ reports of T1D-related satisfaction and safety in the school setting. In this study, parental report of T1D-related satisfaction was high, with the majority reporting being very satisfied or somewhat satisfied (88.8%). This is higher than that reported in previous studies. Lewis et al. (2003) reported 21.2% of parents as dissatisfied; Schwartz et al. (2010) reported that 61% of parents rated the adequacy of care and school support as either above average (24.4%) or excellent (36.6%); and Skelley et al. (2013) reported an overall satisfaction rate of 83.1%. It should be noted, however, that in these studies, a daily school nurse presence onsite was lacking, and the composition of school personnel caring for children in these studies is unknown. As parent satisfaction was correlated with school nurse to student ratio in this study, and therefore school nurse presence, it may be reasonable to infer that satisfaction rates would increase in these schools with a daily school nurse presence.
Parent report of T1D-related safety was also high in this sample; the majority of parents reported feeling very or somewhat safe (95.5%). This is slightly higher than the 92% reported by Hellems and Clarke (2007). Although 92% of that parent sample reported that their children with T1D were safely cared for at school, parents of younger children in the sample stated that they themselves were responsible for their children’s T1D care in school. Importantly, parents of 95% of children in the Hellems and Clarke’s study reported that a school nurse was assigned to their child’s school, although only 69% reported that the school nurse was full-time.
In this study, more than three quarters of adolescents reported the school nurse as very or somewhat helpful. In a qualitative study of 10 teens (Sullivan-Bolyai et al., 2014), all teens found the school nurse helpful, stating that the school nurse avoided lecturing them about diabetes management. Participants in Lehmkuhl and Nabors (2008) rated their satisfaction with the help received from the school nurse as 3.58 (SD = .65) on a scale of 1–4 (1 = poor and 4 = very good). This study used a 5-point Likert-type scale rather than a 4-point; therefore, a comparison between means would not be equivalent.
The findings of an inverse association between school nurse to student ratios and the variables of parental satisfaction with T1D care in school and parental report of T1D-related safety in school in this study are further supported by open-ended responses from parents. Several parents stated that, overall, the school nurse cared for too many students as well as too many students with diabetes, thus creating an unmanageable and unsafe situation. When school nurses are burdened by caring for too many students, many of whom have chronic illnesses, there are lost opportunities for developing important relationships with both adolescents and their parents. Adequate T1D parent education is often lacking, such as in the areas of target HbA1c levels (Jaacks et al., 2014), knowledge of federal laws (Jacquez et al., 2008), and handling developmental transitions (Smaldone & Ritholz, 2011). School nurses can provide valuable T1D information, especially to newly diagnosed adolescents and their parents. While some parents in this study have reported that they taught the school nurse, there were many who characterized the school nurse as indispensable to their own T1D education. School nurses must continue with advocacy efforts for increased numbers of school nurses in order to educate parents and promote optimal T1D management in adolescents.
Research confirms that full-time school nurse presence is of vital importance to parents of students with T1D (Jacquez et al., 2008; Kise et al., 2017; Schwartz et al., 2010). Although the health care provider’s FTE status was not noted, Alaqeel (2019) reported that students with T1D attending the six private schools with medical health care providers received better diabetes care on the following indicators: availability of glucagon and trained staff for administration, accessibility of a health care provider during school, nurses responsible for T1D care, a diabetes management plan from the physician, and parental confidence in the school.
When school nurses are not present, the burden of diabetes care in school falls to other nonmedical school personnel or the parents themselves. At a minimum, this is disruptive to school personnel and parents who either forego employment or leave their places of employment and travel to school to manage episodes of hypoglycemia and hyperglycemia (Johnson & Melton, 2014; Schwartz et al., 2010; Skelley et al., 2013). In this study, one parent commented that she was able to work full-time solely because of her security with the school nurse’s T1D knowledge. School personnel are often unable or reluctant to help students with T1D in the absence of the school nurse (Johnson & Melton, 2014; Kime, 2014), finding the responsibility quite burdensome, thereby jeopardizing the safety of students with T1D. Utilizing NASN’s position statement on delegation in the school setting (2019) as a blueprint, the school nurse then has the responsibility to appropriately train nonmedical school personnel to recognize hypoglycemia and act accordingly, putting school nurses and other school personnel in situations that are neither desired nor comfortable (Lineberry et al., 2019; Schwartz et al., 2010).
As school nurse to student ratio and the variables of age and level of school were positively correlated in this study, high school nurses were generally responsible for greater numbers of older students than elementary or middle school nurses. This relationship between age and level of school explains the following inverse relationships between age and parental satisfaction with T1D care, age and parental report of T1D-related safety, level of school and parental satisfaction with T1D care, and level of school and parental report of T1D-related safety. This is of great importance for school nurses in elementary or middle schools with higher school nurse to student ratios, as younger students may be less independent or confident in T1D self-management than those attending high school. Conversely, while some adolescents in high schools may have higher levels of independent T1D self-management, particularly those with longer diabetes duration, newly diagnosed adolescents require more supervision, guidance, and support from school nurses. Recent studies have shown that adolescents lack vital knowledge in key areas such as insulin administration, BGM, prevention of complications, treatment of hypoglycemia (Flora & Gameiro, 2016), and math literacy (Rankin, et al., 2018). Therefore, school nurses must be mindful of the developmental stage as well as individual capabilities of their students with T1D to ensure they are providing adequate support and education.
Each of the variables of parental satisfaction with T1D care in school, parental report of T1D-related safety in school, and adolescent report of school nurse helpfulness were positively associated with each other. Interestingly, both adolescent report of school nurse helpfulness and parent report of satisfaction with T1D care in school showed gender differences. Male adolescents found the school nurse more helpful than did females and parents of males were more satisfied with T1D care in school than were parents of females. It is unclear what may account for the gender differences in these variables, but it is well-documented that adolescent brain development differs between males and females (Paus et al., 2017). Notably, previously published data from this study (Wilt, 2019) revealed that males had significantly lower diabetes self-efficacy scores on the Self-Efficacy for Diabetes Self-Management Scale (Iannotti et al., 2006) than did females. It is therefore feasible that males need more assistance than females from the school nurse and may have increased interactions that create a closer bond. This sense of security with the school nurse may also contribute to parental feelings of safety with T1D care in school and therefore greater satisfaction. It is likely that when adolescents and school nurses have a good relationship, adolescents may visit the school nurse more frequently, which can positively impact their understanding and T1D self-management. In a qualitative study of parents of adolescents with T1D, Nurmi and Stieber-Roger (2012) noted that “the amount of risk a parent took depended on his or her level of trust in those providing supervision” (p. 535). School nurses should be mindful that there may be gender differences in cognitive ability, communication, and overall perception of the school nurse’s helpfulness.
The inverse association between adolescent report of school nurse helpfulness and the variables of age and level of school indicates that older adolescents in high school find the school nurse less helpful than younger adolescents in elementary or middle schools. This has implications for the prevention of long-term complications, especially given that older age has been correlated with higher HbA1c levels (Kristensen et al., 2018; Lansing et al., 2018). If this population perceives the school nurse as unhelpful, they may be reluctant to visit the school nurse, who is often in a position to offer valuable education, guidance, and advice, especially given the developmental changes rapidly occurring during adolescence. It is imperative then that school nurses develop positive relationships with adolescents with T1D so that they feel free to check in with the school nurse on a regular basis.
Although the vast majority of open-ended responses elicited from both parents and adolescents were favorable, there were troubling comments regarding the school nurse’s knowledge of T1D. Of the 54 parent responses, equal numbers commented that the school nurse was well educated (n = 7, 13%) or that the school nurse needs more education in T1D care (n = 7, 13%). A few adolescents wrote similar comments about teaching the school nurse about T1D. School nurses’ knowledge of T1D care is difficult to parse out in the literature when the term school personnel is used in studies. Research on adolescent and parent perspectives of school nurses’ T1D knowledge shows mixed results (Hayes-Bohn et al., 2004; Jacquez et al., 2008; Nabors et al., 2003; Smaldone & Ritholz, 2011; Wang et al., 2013). While parents’ and adolescents’ perspectives indicate that many school nurses are reportedly providing expert T1D care, the areas needing enhancement require administrative support. This is vital as school nurses are responsible for maintaining professional and educational standards in T1D management. This is typically made possible through the provision of time, as compensated or uncompensated, for school nurses to attend off-site workshops and conferences, webinars, inservices, or insulin pump training with students and their parents. Fiscal limitations on school districts are often challenging, leaving school nurses few resources to meet their educational needs, such as through grant funding and continuing education modules offered online and in scholarly journal formats. School nurses need to make T1D education a priority to provide evidence-based T1D care to their students.
Findings from this study are limited in generalizability as the homogeneous sample was recruited from a single large pediatric endocrinology practice. Although the findings from this sample are important, a more diverse socioeconomic and racial or ethnic sample could provide useful data, especially given the impact of these social determinants of health on T1D outcomes in youth (Chalew et al., 2018; O’Connor et al., 2019; Rose et al., 2018). The use of one recruitment method rather than two would enhance the rigor of the study. The low response rate of electronic recruitment may be explained by the reluctance of participants to ask questions when completing the study materials. The inperson data collection method provided the opportunity for participants to ask for clarification or questions as they completed the study materials and may explain the higher response rate of nearly 82%.
Self-report methods may be subject to response bias (Polit & Beck, 2020, p. 294). It was not possible to evaluate nonresponse bias as characteristics of nonresponders receiving the electronic recruitment method were unknown. The parent sample was well educated, and this may have influenced their questionnaire responses. Demographic data for the endocrinology practice were unavailable, so it is unclear whether this sample is representative of the practice’s population. Importantly, nearly all schools in the sample had at least one FTE school nurse, which is not representative of many other parts of the United States.
Study findings contribute valuable information important to the practice of school nursing with the adolescent T1D population, providing evidence that the relationships between parental satisfaction with T1D care in school and parental report of T1D-related safety in school are positively associated with school nurse presence. Further, it is estimated that 25% of children of ages 2–8 years (Centers for Disease Control and Prevention, n.d.) and one in four adolescents have a chronic illness (National Center for Chronic Disease Prevention and Health Promotion, n.d.), which requires increasing the numbers of school nurses. These data should then be used to advocate for increased funding in order to meet NASN’s recommendation (2019) for a school nurse presence in school all day every day with stakeholders such as parents, lawmakers, administrators, and boards of education. Research on school nurse workload can provide the best evidence on school nurse staffing patterns for safe and effective TID care (Jameson et al., 2018; Willgerodt et al., 2018).
T1D is a complex and challenging chronic illness; therefore, school nurses educated at the baccalaureate level holding state certification are the most appropriate personnel to care for this population (NASN, 2016). When delegation of T1D care is necessary and appropriate, school nurses must again engage stakeholders to support time and funding resources in order to provide training programs that facilitate safe and effective T1D care in school. Importantly, school nurses report that budget cuts prevent the filling of vacant positions and reduce the number of days and hours that school nurses work. This is most problematic at the start of the school year when school nurses are reviewing student records, planning for accommodations, and training school personnel for delegation (Lineberry et al., 2018). Administrators have an obligation to ensure student safety and must support school nurses as the designated stewards.
Importantly, these parent variables are linked to adolescent perceptions of the helpfulness of the school nurse. Although older adolescents can appear more independent and capable of T1D self-management, resulting in less frequent visits to the school nurse, school nurses need to strive for consistent communication as adolescents are an at-risk group for suboptimal treatment adherence (Hilliard et al., 2013; Rausch et al., 2012). Likewise, regular contact with parents, especially those of adolescents who may not go to see the school nurse, can increase both parental satisfaction with T1D care and feelings of T1D-related safety in school. Additionally, when adolescents consider the school nurse as helpful, it is more likely that they will check in and visit, which provides vital opportunities for new and reinforced education and skill mastery.
The relationship between parental satisfaction with T1D care and adolescent report of helpfulness of the school nurse should be important to all school nurses. These two variables have not been previously studied in a quantitative manner, but school nurses can increase parental satisfaction with T1D care by fully addressing the needs of the adolescent with T1D, including psychosocial needs, which were identified in this study as important to parents. The gender differences identified should remind school nurses to be mindful of developmental differences that may be present.
Findings from the open-ended question suggest that some school nurses need to have additional training and education in T1D management. School nurses have identified concerns with their own current state of diabetes knowledge (Fisher, 2006; Joshi et al., 2008; Wang & Volker, 2013). Although states have different legal requirements for diabetes management, delegation, and education of school personnel, federal laws require specific actions and provisions for the care of students with T1D in school, and school nurses must be familiar with them. Maintaining current knowledge using the best evidence is a professional responsibility as well as a significant safety factor. School nurses must be compensated for continuing education and maintenance of professional standards, including state and national school nurse certification.
Future research should include sampling and collecting data from a more heterogeneous population. Recent literature (Chalew et al., 2018; O’Connor et al., 2019; Rose et al., 2018; Skelley et al., 2013) has identified sociocultural disparities in access to care and treatment outcomes. As the majority of the sample was 13–16 years old, expanding the age range could further explicate ways in which the school nurse can educate parents and students of all developmental stages. Although nearly all students had at least one FTE school nurse in each building, a nationwide sample would provide more information on parent report of satisfaction and safety and helpfulness of all school personnel providing T1D assistance. It would be beneficial to query adolescents with T1D and their parents on what they desire from the school nurse to foster these variables of satisfaction, safety, and helpfulness. School nurses must continue to collect data that support and validate the critical role that school nurses play in T1D management in order to engage the support of stakeholders.
This was the first study to investigate the relationships among these particular variables, demonstrating that lower school nurse to student ratios are associated with increased parental report of T1D safety and satisfaction and increased adolescent report of school nurse helpfulness. It was also the first to report statistically significant gender differences in adolescent report of school nurse helpfulness and parent report of satisfaction with T1D care, which is important for school nurses to recognize that developmentally, males may require more assistance from the school nurse. Findings from this study add to the small body of knowledge about school nurse presence, parent report of satisfaction and safety, and adolescent report of school nurse helpfulness. The increased prevalence rate of diabetes (Dabelea et al., 2014) is a cause for concern, and it is incumbent upon school nurses to continue to generate data that demonstrate the role of the school nurse in T1D support and education of parents and students, particularly as it pertains to the prevention of T1D-related complications. School nurses should continue to engage stakeholders so that all students have access to a school nurse all day every day.
Lori Wilt contributed to the conception/design of the manuscript, acquisition as well as analysis of the data, manuscript drafts, and critical revisions and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Lori Wilt, PhD, RN, NJ-CSN, CNE https://orcid.org/0000-0001-7436-2918
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Lori Wilt, PhD, RN, NJ-CSN, CNE, is an assistant professor of nursing at Seton Hall University.
1 Seton Hall University, South Orange, NJ, USA
Corresponding Author:Lori Wilt, PhD, RN, NJ-CSN, CNE, Seton Hall University, 400 South Orange Avenue, South Orange, NJ 07079, USA.Email: lori.wilt01@gmail.com
