The Journal of School Nursing2024, Vol. 40(2) 200–207© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211064146journals.sagepub.com/home/jsn
Continuing education (CE) can help school nurses achieve the unique competencies required for the challenges of an academic health setting. A comprehensive understanding of school nurse learning needs is necessary to guide CE development. The purpose of this study was to describe school nurse perceptions of their learning needs according to the Framework for 21st Century School Nursing Practice ™. The researchers analyzed data from 24 interviews with practicing school nurses using descriptive coding to identify perceived learning needs. Learning needs relevant to all areas of the framework were identified, with clinical judgment and team development emerging as priority areas for CE. These results illuminate school nurse perceptions of their own learning needs and can help guide the development of meaningful CE opportunities.
school nurse education, continuing education, community, school nurse knowledge/perceptions/self-efficacy, Framework for 21st Century School Nursing Practice
School nurses fulfill a vital role in school health services by preventing illness and promoting health at the individual and population levels. The school nursing role supports health and academic achievement through a unique set of specialty practice competencies related to care coordination, community/public health, leadership, and quality improvement, along with standards of practice (National Association of School Nurses, 2016). Continuing education (CE) is an important means to achieving the competencies required for this specialty; however, a clear understanding of how school nurses perceive their own learning needs is needed to guide CE development.
School nurses have complex roles that require adaptation to the evolving needs of students, schools, and communities. Evidence indicates that school nurse presence is associated with better management of chronic health conditions (Baisch et al., 2011) and that school nurses are a costeffective public investment (Wang et al., 2014). The school nursing role is unique and encompasses a distinct set of activities identified in the Framework for 21st Century School Nursing Practice ™ (National Assocation of School Nurses, 2016). CE can help nurses develop the skills needed for success in environments outside of the acute care system (Padilla, 2021) and may help school nurses achieve the skills and competencies required for the school health setting.
Evidence indicates that CE is a useful nursing workforce intervention, but a clear understanding of workforce educational needs for school nurses specifically is lacking. CE can improve nursing workforce outcomes in areas such as behavior change and knowledge growth (Krugman & Warren, 2011), and evidence indicates that CE can be a valuable intervention in areas such as student advocacy and mental health care (Bohnenkamp et al., 2019; Gormley, 2019). Although CE has been shown to be useful, most evidence describing school nurse CE needs is in the context of topic-focused needs assessments (Bogale et al., 2022; Carlisle et al., 2010; Garbers et al., 2018). A comprehensive understanding of school nurse learning needs is needed to guide CE development that supports the full scope of the school nursing role. The purpose of this study was to identify perceived areas of needed continuing education for school nurses according to the Framework for 21st Century School Nursing Practice ™ (National Assocation of School Nurses, 2016).
The research team analyzed interview data in this qualitative descriptive study. The principal investigator (PI) conducted all interviews in this study, and three additional research team members assisted with the analysis. This study received ethics approval from the Medical University of South Carolina Institutional Review Board. The data for this study was collected simultaneously with data for a separate research question regarding how school nurses engage in CE. Methods are summarized here but also described elsewhere (Jordan et al., 2022). Notably, data was collected in the spring of 2020 as the COVID-19 pandemic was beginning to emerge in the United States.
This study was conducted in the state of South Carolina (SC), which is in the southeastern United States. Convenience samplingwasusedtoidentifyparticipants. Leadership in a state-level school nursing organization emailed members information about the study, and the first 24 participants who expressed interest and met inclusion criteria were invited to participate. The sample size of 24 was selected as likely to achieve data saturation, with the opportunity to recruit more participants if needed. The email provided the PI’s contact information, and interested potential participants were invited to contact the PI. When contacted by a potential participant, the PI verified inclusion criteria and arranged an appointment for a telephone interview at a time that was convenient to the participant. Telephone interviews were chosen as a cost-effective way to include participants throughout the state. Participants met inclusion criteria if they were licensed as a registered nurse (RN) and employed as a school nurse in a public school. Participants who completed the interview were given a $25 digital gift card.
A semistructured interview guide was used to fully explore learning needs according to the Framework for 21st Century School Nursing Practice ™ while allowing the PI to explore concepts as they emerged. The portion of the interview guide relevant to this analysis can be found in Table 1. The guide incorporated questions about relevance, areas of strength, and areas for improvement in each of the five major areas of the framework (see Table 1). Before discussing each aspect of the framework, the researcher explained the concept by providing examples provided by the framework developers (NASN, 2016). Interviews lasted between 38 and 78 min and were recorded with verbal consent of the participants. All interviews were completed before data analysis began. Interviews were transcribed by a professional transcription company for analysis.
The research team met weekly for six weeks, with the entire team reading four transcripts each week before the group discussion. Manifest content analysis, which addresses what the transcript text states directly (Graneheim & Lundman, 2004), was primarily used to identify codes. Latent content analysis was also used when examining personal stories from participants, as the team considered the meaning behind what is stated in the transcripts (Graneheim & Lundman, 2004). During weekly meetings, the researchers identified codes describing perceived areas of CE need. These preliminary descriptive codes were developed within each area of the framework and compared and amended each week. Data saturation (Fusch & Ness, 2015) appeared to be achieved at 16 transcripts, but all 24 transcriptions were coded to confirm. After the initial descriptive coding scheme was collaboratively developed, the PI used the software MAXQDA Analytics Pro 2020 (MAXQDA, 2021) to apply the codes to all transcripts. After codes were applied, the research team reconvened to discuss and finalize the analysis.
Trustworthiness criteria were achieved in this study (Lincoln & Guba, 1985). Thick description was developed through a large number of interviews and a semistructured interview guide that allowed exploration of concepts as they emerged (Morse, 2015). Thick description and transferability were achieved through the use of a diverse geographic sample (Nowell et al., 2017). Credibility was enhanced by utilizing a team approach to data analysis, with attention to reflexivity and conversation about how personal experiences influence perceptions of the data.
Twenty-four female school nurses participated in this study, representing positions based in elementary schools (46%), middle schools (8%), high schools (17%), other types of schools, such as K-8 schools (21%), and district-based positions (8%). Urban, suburban, and rural area schools were included. Participants reported practicing school nursing between one and 33 years, with an average of 9.7 years of school nurse experience. The sample included registered nurses at both the Bachelor prepared nurse (58%) and the Associate degree level (42%).
Analyses resulted in descriptive themes that summarize participant perceptions of their own learning needs according to each area of the framework. A summary of themes developed can be found in Table 2. The categories “clinical judgment,” within the domain of standards of practice, and “team development,” within the domain of leadership, were the most commonly reported topics where more education was desired.
Clinical Judgment. Support for clinical judgment was one of the largest subthemes identified in this study, with 23 participants describing learning needs fitting this category. Clinical judgment is defined here according to the National Council of State Boards of Nursing (NCSBN) as the “observed outcome of critical thinking and decisionmaking,” including both assessment and decision-making (Currier, 2019). School nurses described the importance of taking the best action in each clinical situation and a desire for help evaluating the outcomes of their decision-making. Many discussed changes in understanding their clinical judgment when comparing their previous work environments, where they worked with a healthcare team, and their current position, where they often made decisions independently. One nurse described her concerns about maintaining appropriate clinical judgment by saying:
Even though we do it every day, just a refresher to make sure we are still on the same wavelength and still doing the things that are expected of us. You really don’t have anybody behind you because the people that are actually doing your competencies or doing your evaluations really have no medical background. It will just be nice to be refreshed in that to make sure that you are still doing what you need to be doing.
Continued support in this area was highly important to both experienced and novice nurses. One nurse described uncertainty related to professional expectations related to her decision-making in school settings by stating, “it would be good to have some type of continuing ed not to raise the bar, but—so nurses understand what the bar is.” Some nurses pointed out that while learning about medical diagnoses was helpful, it was often more valuable to attend learning experiences that discussed judgment from the perspective of how students or faculty may present to the school nurse’s office (such as headache, stomachache, or anxious thoughts) or in the classroom. One nurse described the challenge of determining appropriate action in the school setting by stating:
Giving school nurses more information about it at least what we’re seeing here, behavior issues and how to deal with that and how to help the people that are teachers that are in the front lines… chairs being thrown across the room in a five-year-old kindergarten classroom and stuff like that.
A list of specific topic areas related to clinical judgment is described in Table 3.
Skill Development. Skill development was another commonly reported learning need among school nurses, with 18 participants describing learning needs related to this theme. Desired skills included nursing procedures, assessment, teaching, and screening. One participant described the experience of searching for trustworthy skills education this way:
The first time I went over to do the in and out cath for him, I was anxious again. So I went to YouTube and I watched that video again, and I’ve read again about how to do in and out cath. And I, you know, I felt sure I could do it, but it was just one of those things that I just wanted to just make sure I was doing the right thing.
The respondents mentioned skills including emergency procedures, such as the administration of Narcan and responding to precipitous childbirth. Respondents identified a need to maintain and improve high-quality assessment skills. Skills related to students experiencing mental health conditions were also mentioned, such as therapeutic responses for students with acute anxiety. Fourteen participants described teaching skills as important areas of development, particularly related to teaching groups of school-age children and adolescents.
Legal Risks and Expectations. The legal risks and expectations subtheme referred to knowledge relating to law and policy. Eighteen participants described learning needs related to this subtheme. Common areas of concern included legal aspects of appropriate documentation, issues related to student privacy, and exercising appropriate clinical judgment. School nurses described the importance of learning more than the broad tenants of policies such as the Nurse Practice Act, with value placed on experiences that teach application through case studies specific to the school nursing role. For example, one participant described concerns about meeting legal expectations for privacy in an emergency situation, “And then privacy as far as, like when we’re talking Diastat, you know, you’re going to administer on this whole bus with a bunch of people.” Other nurses expressed concern about meeting legal requirements associated with filing Medicaid claims. One nurse provided this example of her concern about meeting legal requirements:
My old school we dealt with Medicaid forever and all I had to do is make sure I had my ICD 10 codes and then I was good. Here I’ve got to be in charge of getting all the paperwork. I need to make sure that the ducks are in a row versus where I was before.
Competence with Technology. Twelve participants reported that ongoing education related to the use of new and emerging technology was an important learning need. All school nurses in this sample reported competence with basic computer skills. Still, many wanted education on how to further leverage the available technology to meet student needs, such as how student-assigned notebook computers could be used to promote health or how to use existing electronic health records (EHRs) to better capture health outcomes. Best practices related to student technology issues, such as social media, were also of interest. Other school nurses were interested in how to obtain emerging technologies, such as telehealth, to meet student needs. One rural nurse explained how a CE opportunity had helped her start the process of bringing telehealth to her school:
So, I think school-based telehealth is also on my to-do list. I did a webinar for that and I think, you know, that seems to be the best solution for rural communities.
Logistics/Time Management. Fifteen participants described a desire for educational experiences about managing the often-overwhelming needs and expectations associated with the school nursing role. One nurse described her frustration with the role expectations:
The biggest gap is understanding. Okay, so the biggest thing we need to work on, and I don’t even know if it’s educating nurses on how to do it, is understanding that even though we’re trying to individualize care, individualizing care for 630 children is impossible.
Another nurse discussed distress related to how to make decisions about where to spend time:
There’s not time. I always do try to make time to communicate with parents when I feel like I need to but I don’t always feel like it’s… a balancing act on where my time goes.
Many school nurses wanted guidance in decision-making related to time management and strategies to practice more efficiently.
Collaboration. Collaborating effectively with others was another major theme, with eighteen participants identifying this as a needed area for CE. Collaboration is defined in this study as purposeful partnering to support student outcomes and includes partnership with students, families, teachers, administrators, other school professionals, health care providers, and community leaders. Participants identified that effective collaboration was especially difficult because many potential collaborators, both within and outside the school setting, did not understand the school nursing role. A few participants even described being asked and declining to engage in activities that were unsafe or inconsistent with nursing scope of practice, such as administering unlabeled injections to school faculty. One nurse described how she felt that a marker of success in effectively collaborating was engaging in “uncomfortable conversations”:
An uncomfortable conversation where I always try to go in and make a teaching opportunity for… that person and a learning opportunity for myself. It is very much navigating the culture between education professionals and healthcare professional. So, if I can learn something and I can teach something… we have an understanding about each other.
While participants identified communication as an area of strength, it was also an area of great need. Nurses noted that a different type of communication was necessary than in acute care, particularly when working with school administrators. One nurse described this need by stating,
to communicate our roles and things like that with parents, with faculty and staff, with administration. I feel like we have so many people that don’t totally understand our role.
Nurses reported the need for strategic communication techniques to accomplish goals such as health-promoting policy changes in non-healthcare environments.
IEP/Section 504 Plans. Four participants reported learning needs related to supporting student success with Individualized Education Programs (IEPs) and Section 504 plans. This was a high priority to these participants, but also an area of frustration. IEPs and Section 504 plans are legal documents that guide educational accommodations in public schools. These participants wanted to be more involved in IEP or Section 504 meetings but expressed a need for training in how to communicate the potential benefits for student outcomes to other school professionals. One nurse described challenges engaging in Section 504 plans:
I’m lucky this year that I’m even invited to 504 meetings, because last year I was not. And it’s my understanding that the nurses before me were not. But I pushed for that, because, you know, a 504 is generally medical. And I feel like you ought to have your only medical person in there.
Some participants, especially those newer to school nursing, wanted to learn more about the IEP and Section 504 structures within schools.
Team Development. The largest subtheme related to leadership was team development, which referred to the ability to develop a functioning team to meet health needs in the school environment. This is distinct from the previous subtheme, collaboration, which focused on partnering to address individual student needs. A total of 23 participants indicated that the ability to develop and sustain a group of supportive relationships in the school environment was an important learning need for the school nursing role. This was amplified for school nurses who functioned as the only health professional in their school environment, with many participants perceiving that their effectiveness in addressing school health needs was severely impeded by sustained isolation. One nurse described the necessity of team development by stating “At this school, I created the team here that I needed… And so I created the team of people around me. There are no other nurses.” Skill in effective communication, particularly with school leadership, was essential for implementing health-promoting change. One nurse discussed the challenge of developing relationships when other professionals did not understand the school nurse role when she stated, “learning how to show my value to people who may not see it would be a gap. And also just learning how to effectively present ideas to the administration.”
Policy Development and Change Management. Ten nurses described leadership related to school health policy change and development as important for school nurse CE. These nurses described challenges making changes to health policies that were inadequate, outdated, or absent and wanted education pertaining to policy development, implementation, and communication. One nurse described challenges when implementing a policy change that promoted best nursing practice by saying, “people grumble about it, and I was like, at the end of the day, it’s protection, protection for my life.”
Infectious Disease/Emerging Challenges. Eleven participants discussed learning needs related to emerging public health needs. These data were collected as COVID-19 was emerging in the state, and learning needs related to infectious disease specifically received more attention in later interviews. Participants, especially those who worked in schools or districts without robust school nursing infrastructure, were concerned about where to find evidence-based
Acute Conditions Headache Concussion Cough Dermatologic Conditions Ear Infection Orthopedic Injuries Viral Illness Influenza COVID-19 Chronic Conditions Diabetes Allergy Asthma Wound Care Seizure Mental Health Anxiety Attention Deficit Hyperactivity Disorder Substance Use/Abuse Student Behavioral Challenges Abusive Situations recommendations for emerging and current issues. One nurse described the challenge this way:
What’s new out in the community for us to be able to tap into. And then what… I’m thinking in my head coronavirus… what’s out there right now or what’s on the horizon that we need to be looking for.
Other topics related to community/public health also centered around keeping abreast of current recommendations and evidence-based programs, such as screenings, health promotion and education, emergency preparedness, and illness prevention.
Cultural Sensitivity. Twelve nurses described cultural sensitivity as important area for school nurse CE. Several nurses expressed a desire to learn Spanish in order to provide better care. This theme was often discussed in relation to collaboration, with an emphasis on partnering with community organizations to meet needs related to social determinants of health for diverse families. One nurse emphasized the importance of learning about community resources, “I really try to find a resource for them and I ask—if I don’t know a resource, I will find something. I will keep looking until I can find something that will help them.”
Documentation. Documentation was another frequently discussed concept among participants in this study, with 16 participants describing this as a learning need. Documentation was often discussed with the concept of legal risk, with many nurses reporting that the independence of the school nursing role required advanced documentation skills. One nurse described the challenge of moving from acute care to school health this way:
we’ve got nearly 1000 kids at our school… you can have 60 kids come in a day plus medications and you know staff… And I’m thinking, oh my goodness to do the kind of assessment I want to do and document how I want to it’s just almost not possible.
Outcome Measurement. Twenty-one participants described outcome measurement as an important learning need. Although some nurses expressed confidence in using data and utilized their electronic documentation systems to track outcomes of interest, many desired additional training in this area and related this skill to increased effectiveness in leadership and communication. Participants sometimes reported that they judged their success as a school nurse in informal ways, such as the quality of relationships with individual students, trust from school faculty, or a lack of complaints. Participants who did use formal measures such as tracking attendance, referrals, or illnesses sometimes reported inadequate infrastructure to confidently capture relevant population-level metrics. One nurse described challenges with outcome measurement this way:
In the hospital, the patient starts to get well and is discharged. So, you’ll see that what you’ve done has been successful. With kids in school, I don’t know how you’d know, I don’t know how you’d measure that other than maybe sometimes no news is good news. You know, if I don’t see the child again, I’m going to assume we’ve gotten better.
School nurses in this study reported learning needs in all areas of the Framework for 21st Century School Nursing Practice ™ (National Association of School Nurses, 2016). Priority learning needs as described by the school nurses were identified (see Table 2). These data provide depth to previous research related to what content school nurses find relevant when choosing continuing education opportunities (Jordan et al., 2022). Participants readily described a variety of learning needs related to the areas of practice where they spent most of their time, such as giving direct care to students. However, nurses also identified a desire for CE to help them fundamentally change the way they practiced, with the goal of increasing positive outcomes for students. These learning needs ultimately reflected a much deeper desire for educational opportunities that promoted optimal decision-making, population-level influence, and the ability to create sustained change in school environments. Participants noted that the school nurse role’s unique nature required fundamentally different approaches than what worked in hospital settings, especially related to leadership and team development. These results highlight not only potential topics for continuing education programs according to different areas in the framework, but also the need for research to guide school and public health nursing practice. Models guiding leadership, particularly related to team development for innovation and change, relevant to public health nurse practice are needed for guidance in settings where nurses may be the only health professional in the organization.
While it is important to be attentive to the needs identified by the participating school nurses, it may also be useful to consider what was not mentioned in these results. Case management was notably lacking in much of the conversation about perceived learning needs, along with explicit mentions of other topics relevant to school nursing practice such as motivational interviewing and direct education. The topics identified primarily highlight learning needs that participants were aware of and challenged by on a regular basis. This awareness is partially driven by the social and political environments in which these nurses serve. Fewer mentions of high-impact nursing interventions such as case management do not indicate a lack of need for this type of education, but instead the importance of school policies that allow school nurses time and support to engage in the full scope of this role. It is important to consider what organizational and system changes are needed in the school environments to allow school nurses to practice in a way that maximizes their impact on health outcomes. Without accompanying changes to the school nurse work environment, the benefits of robust CE will be limited. This is consistent with previous evidence that indicates structural barriers such as workload, school and district expectations, and state regulations are critical barriers to practicing to the fullest extent of the scope of school nurse practice (Davis et al., 2021).
Similarly, many of the learning needs related to communication and team development were connected to misperceptions of the school nurse’s role by school faculty and staff, parents, and community partners. Evidence supports differences in perceptions of the school nursing role between school nurses and school leaders (A L-Dahnaim et al., 2013). Education can be a critical source of support for school nurses to advocate for their professional role. Still, increased visibility and awareness of the school nursing role are needed. Although the Covid-19 pandemic has brought attention to the importance of school nurses, sustained efforts to educate professionals, such as district superintendents, principals, and primary care providers, about the school nursing role may also ultimately promote positive student outcomes. CE interventions may help nurses champion stakeholder education in their school environments, but ultimately this must be addressed at the system level. State and district policies supporting school-nursing practice, interprofessional education for school-based professionals, and strengthening the nursing infrastructure in school systems are areas for future research.
This study has several limitations. The emergence of the COVID pandemic during data collection may have influenced the perception of learning needs, particularly related to emerging issues and infectious diseases. The qualitative design of this study is not generalizable. Finally, this study was designed to identify school nurse perceptions of priority areas of their own CE need, but other measures may identify different or additional educational needs.
These results can be used by school nurses, school nursing leaders, and continuing education planners in the development of robust CE opportunities for the school nursing workforce. The use of the Framework for 21st Century School Nursing Practice ™ (National Association of School Nurses, 2016) provides CE ideas that span a variety of components of school nursing practice. School nurses may use this information to reflect and compare learning needs in their own practice and identify new opportunities to seek out learning. School nurses may also find it valuable to identify CE opportunities relevant to areas of the framework that are less familiar in their practice and may represent opportunities for growth. Nurse leaders may benefit from data that support advocacy efforts for policies and expectations that allow school nurses to grow professionally, and researchers may benefit fromtheidentification of future areas of study to further investigate the topic of CE for school nurses. Finally, CE planners may use these results to identify areas for new CE opportunities.
School nurses in this study desired continuing education opportunities that would empower their practice to improve student health outcomes. Learning needs related to clinical judgment and team development were high priorities. The development of CE opportunities in all areas of the 21st Century Framework for School Nursing ™ (National Association of School Nurses, 2016) can support school nurses in their role.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The article was supported by both SCTR and TACHL: This publication was supported, in part, by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR001450 and by the Technology Applications Center for Healthful Lifestyles (TACHL). Additional support is provided by the South Carolina SmartState® Centers of Economic Excellence. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or TACHL.
Kasey Jordan https://orcid.org/0000-0002-8437-1823
KellyAnn Reese https://orcid.org/0000-0002-6203-9838
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1 College of Nursing, Medical University of South Carolina, Charleston, SC, USA
2 College of Health Sciences and Professions, University of North Georgia, Dahlonega, GA, USA
3 School of Education, Health, and Human Performance, College of Charleston, Charleston, SC, USA
Corresponding Author:Kasey Jordan, Medical University of South Carolina, 99 Jonathan Lucas Street, Charleston, SC 29425, USA.Email: jordakas@musc.edu
