The Journal of School Nursing2024, Vol. 40(4) 380–390© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405221111567journals.sagepub.com/home/jsn
Abstract
This study aimed to describe the profile and practices of school nurses working at a network of educational centers in Spain. This was a descriptive study of the documented actions of 107 school nurses between September 2018 and June 2021 in 54 educational centers (55.6% private and 44.4% subsidized). The profile of the school nurses was young (average age 33.8 [standard deviation (SD) = 7.7] years) and predominantly female (91.6%) with a diverse and multidisciplinary education, primarily at the postgraduate level (specialized mainly in emergency care, nursing/school health, and pediatrics/neonatology). They carried out 256,499 interventions. The most frequent types of incidents they treated were accidents (30.4%) and disease-related episodes (22.2%). The interventions were usually brief (average time 7.7 min) and were resolved by the school nurse (99.1%), and the main recipients were students (87.3%). The highest incidence of interventions occurs during breaks between classes. Acute interventions occupied most of the school nurses’ time, leaving little opportunity for health education (0.3%). School nurses played an important role in preserving and promoting the health of school populations and cost-savings to healthcare systems with the actions that they performed. Descriptions of these actions are essential when advocating for the continuation and expansion of school nursing services.
Keywordsschool nurse practice, school nurse profile, school health, health education, workload
School is a space for socio-educational training that contributes significantly to the development of children and adolescents (Mori et al., 2018) and transmits the learning and values that are considered necessary in the community and that encourage students to use and improve their capacities for the benefit of both society and themselves (Crespillo Álvarez, 2010). It is the ideal environment in which health can be promoted by offering easy access to health education for developing individuals and their families. The promotion of health in the educational environment favors the acquisition of healthy habits early in life, which facilitates the internalization and acquisition of healthy skills and behaviors (Mori et al., 2018). Among the rights of children are access to education and comprehensive health, and competent entities have the responsibility to grant such access. Including a specialized professional in educational centers facilitates a cross-sectional approach to health. The school nurse is the ideal figure to promote and guide healthy lifestyles in the educational environment (Mori et al., 2018). The competencies of the school nurse also include caring for acute pathologies and monitoring schoolchildren with chronic pathologies, as well as supporting the needs that arise in the different stages of life and accompanying children in their physical, mental, and emotional maturation (Consejo General de Colegios Oficiales de Enfermería de España, 2018). Therefore, they represent an investment in health for schools.
The reality of school nurses varies widely by country. While the image of this professional figure is well established in countries such as the USA, Sweden, the United Kingdom, and France, it is still developing in other countries such as Spain. Additionally, studies reveal considerable differences in the training and organization of school nursing services among countries (Consejo General de Colegios Oficiales de Enfermería de España, 2018; Encinar Casado, 2015; García Blanco, 2017; Helleve et al., 2022).
The functions of a school nurse can be framed in terms of directing, evaluating, and providing nursing care. Additionally, they contribute to the promotion, maintenance, and recovery of health and the prevention of diseases and disabilities (American Academy of Pediatrics, 2008; Encinar Casado, 2015; Jefatura del Estado, 2003). Furthermore, they have developed care, research, management, and teaching functions (Encinar Casado, 2015; Ministerio de Sanidad y Consumo, 2001). These professionals advocate applying changes in policies and practices to improve students’ health, safety, and school attendance (Gormley, 2019). To perform these functions, school nurses must collaborate with members of the educational center to design, implement, and evaluate feasible programs that reach the entire community (Bejster et al., 2020).
Empirical data support the need for school nurses and their impact on the health of children, and several studies at the international level show that school nurses’ contribution to health is significant in cases of children with chronic or allergic diseases and for health promotion and education programs for children (Anderson et al., 2019; Best et al., 2018a; Darnell et al., 2019; Weismuller et al., 2007).
However, research on school nursing should be strengthened with more solid study designs that focus on school nursing interventions and how they affect educational and health outcomes (Endsley, 2017; Weismuller et al., 2007). In addition, more research is needed on the effectiveness of school nursing interventions to guide the practices of school nurses (Bejster et al., 2020; Best et al., 2018b; Yonkaitis, 2018).
In Spain, studies on the characteristics and role of school nurses working at educational centers are limited. Therefore, the objective of this study was to describe the practice of school nurses in a network of educational centers in Spain and to describe the profile of these nurses and the centers where they work.
A descriptive study was conducted of the documented actions of school nurses in educational centers.
The study was conducted in schools throughout the national territory of Spain that had a school nurse who belonged to the SchoolNurses® association between September 2018 and June 2021 (academic years 2018–2019, 2019–2020, and 2020–2021). The demographics of these schools were varied, with boys and girls aged from 2 to 19 years (nursery school, kindergarten, primary education, secondary education, high school, and vocational training) and with different sociocultural backgrounds. Their sizes also vary, and the average number of students in the centers is 1,000. The average nurse: student ratio in these schools is approximately 1:1,000, which is quite similar in the different centers, but can vary from 1:800 to 1:1,200.
SchoolNurses® is the registered trademark of Health Education SL. It is a private company with unified social objectives dedicated to professionally supporting school nurses. The company promotes the provision of health education by school nurses as a school subject. SchoolNurses® also researches the care provided and studies the importance and impact of investing in prevention, care, and early detection at an early age and in schools (School Nurses, 2020b).
All actions performed by the school nurses were studied in the educational centers and were registered with the SNapp® electronic (School Nurses, 2020a) platform during any of the three academic years of the study period.
Data were collected by the school nurse through the SNapp® electronic platform created by SchoolNurses® to facilitate the management and storage of data from school nursing services and fulfills the function of an electronical medical record in schools. It has been considered as a standardized and reliable source of data collection because is based in blockchain technology. The information is stored in the cloud by user profiles with different levels of access. It is mainly accessed by nurses or health personnel, but also parents or legal guardians of the students and course tutors or school directors can access as well. Only health personnel are authorized to register or edit health interventions, validate medication or care plans, and this information is recorded with a set of codes (School Nurses, 2020a).
This tool allows school nurses to record the characteristics of the actions they perform during their daily work in a standardized and protocolized way and is helpful in understanding the school nurses’ activities and presenting a robust picture of school nurse practice (School Nurses, 2020a).
The studied variables were related to the school nurse activity performed in the centers (the academic year during which the action is carried out, location of the action, time period of the action, duration of the action, type of action, type of patient attended, and whether a referral was required), as well as data related to the sociodemographic characteristics of the nurses who performed the interventions (gender, age, country of origin, and training) and the educational center where the interventions were provided (location and type of center).
A descriptive univariate analysis of each variable was performed. After the normality of the sample was determined, frequencies and percentages were determined for the qualitative variables, and the mean (standard deviation [SD]) was determined for the quantitative variables. For the analysis, the statistical software IBM SPSS Statistics version 25 was used.
The study received a favorable report from the Ethics Committee of Camilo José Cela University, and the current legislation on data protection was respected at all times. We worked with a dissociated and anonymized database provided by the company SchoolNurses®. This study was approved by SchoolNurses® and met the requirements of its internal regulations, which regulate the confidentiality of the personal data of nurses, centers, and students and through which all of them agreed to the use of the data recorded in SNapp® for research purposes.
A total of 54 centers with school nurses were described during the study period; most of them were located in the Community of Madrid (63%), followed by the Canary Islands (11.1%) and the Valencian Community (7.4%).
In the 2018–2019 academic year, school nurses were present in 18 (33.3%) educational centers; in the 2019–2020 academic year, they were present in 31 (57.4%); and in the 2020–2021 academic year, the number of centers with school nurses was 47 (87%).
All the described educational institutions were private (55.6%) or subsidized (44.4%) centers. The characteristics of the educational centers are shown in Table 1.
Of the 107 nurses who worked in these 54 educational centers, 91.6% were women. Their mean age was 33.8 (SD = 7.7) years, and only 3.7% of the nurses were 50 years of age or older. Regarding origin, 96.3% of the nurses were of Spanish origin, and the rest had different nationalities. In terms of training, 36.4% of the nurses had only a nursing degree or diploma, 37.4% had completed at least one postgraduate degree, and 22.2% had completed several postgraduate degrees in different specialties. The most frequent postgraduate degrees were in emergency and critical care (27.1%) and in nursing/school health (25.5%), followed by pediatrics/neonatology (18.7%). A total of 6.5% of the professionals had been trained in family and community nursing. The data related to the profile of school nurses globally and by academic year are shown in Table 2.
In total, 107 school nurses performed 256,499 actions. In the 2018–2019 academic year, 63,097 (24.6%) actions were carried out by 26 school nurses; in 2019–2020, 72,215 (28.2%); were carried out by 45 school nurses and in the 2020–2021 academic year, 121,187 (47.2%) actions were carried out by 80 school nurses. The total average number of actions per day in all schools was 340.2 (SD = 291.4), representing a total of 7,544 (SD = 2,748) activities per month and 85,500 (SD = 31,240) over the course of a school year. A total of 57.4% of the actions took place in Madrid, followed by 24% in the Canary Islands.
Regarding the schedule of care, 83.6% of the actions were performed between 10:00 in the morning and 16:00 in the afternoon, 15.9% were performed between 11:00 and 11:59, and 16.7% were performed between 14:00 and 14:59. The duration of the actions ranged from 1 to 300 min, with an average time of 7.7 min (67.7% lasted between 1 and 5 min, and 17.6% lasted between 5 and 10 min). The data related to the place and temporality of the activities performed by the school nurses globally and by academic year are shown in Tables 3 and 4.
The most frequent reasons for which school nurses provided care were accidents (30.4%), illness (22.2%), and administering cures or treatments (21.1%). Health education accounted for 0.3% of the total activities. With respect to the type of patient who required the intervention, 87.3% of the actions were directed toward students, and 4.8% were directed toward center staff. Students’ relatives were very rarely recipients of care (0.02%). Of all the actions described, only 2,294 (0.9%) required referral. The data related to the types of actions and patients treated by the school nurses globally and by year are shown in Table 5.
The most frequently covered health education topics were hygiene (29.4%), COVID-19 (16.6%), first aid/cardiopulmonary resuscitation (12.6%), and healthy eating (12.5%). Physical exercise (0.9%), postural hygiene (0.9%), and drug prevention (1.4%) were the less frequently developed topics in health education. An average of 30 (SD = 56.8) students participated in these activities, which had an average duration of 46 min (SD = 32.2). The characteristics of the health education actions carried out by school nurses globally and by year are shown in Table 6.
A large number of educational centers approach the SchoolNurses® company seeking a school nurse, and more centers employ a nurse each year, which shows exponential expansion based on the lack and growing demand for these professionals (Consejo General de Enfermería et al., 2022). This growing demand is reflected in recent literature that recognizes the important role that school nurses play in promoting health and well-being and in caring for children in the school environment (American Academy of Pediatrics, 2008; Bergren, 2017; Maughan et al., 2016).
Although school nurses are present in all types of centers internationally (Best et al., 2018a), as reported in our study, other studies in the Spanish literature consider only private or subsidized schools (López Gutiérrez, 2014). Other studies have also been found that refer specifically to school nurses in special education centers, but school nurses seem to be less common in public schools in Spain (López Langa, 2010; Ruiz Alcalá et al., 2012), possibly because in public educational centers, municipalities and regional governments have legislative frameworks that focus on professionals in primary and community healthcare centers without considering school nurses (Salvador & Merino, 2009). In contrast, school nurses are employed in special education centers because the health status of students with special needs makes access to health professionals relevant (Consejo General de Colegios Oficiales de Enfermería de España, 2018).
As is typical in nursing, most school nurses were women; women accounted for an even higher proportion of school nurses than registered nurses (Instituto Nacional de Estadística, 2019). The school nurses were mainly under 35 years of age, indicating that a young profile prevails among school nurses; the average age of the school nurses was even younger than that of registered nurses (Instituto Nacional de Estadística, 2019). In terms of their nationality, the majority were Spanish, which is consistent with ministerial data showing that in nine autonomous communities, foreign nurses accounted for only 0.2% of the total (López Blanco et al., 2012).
The most common form of training was postgraduate studies in urgent, emergency, and critical care, followed by nursing/school health and pediatrics and neonatology. The predominance of these training forms may be a result of postgraduate training in Spain not being required for nurses to work in the school environment, enabling each professional to follow a free and unrestricted career path. Notably, between the 2019–2020 and 2020–2021 academic years, an evident increase in nurses with training in nursing/school health was observed, which may be related to the increase in postgraduate degrees aimed at training school nurses in Spanish universities, which has increased the visibility of the profession in recent years. Despite the increase in training available in the field of school nursing/health in Spain, at present, no qualifying postgraduate degree is available for these professionals. In schools, a considerable variety of events can take place, and nurses must be well trained to respond to them, which explains the high percentage of nurses with one or more postgraduate degrees. This finding is consistent with the literature, which proposes that despite the difficulties of finding specific training in school nursing, school nurses should have extensive training and knowledge of evidence-based practice to expand their knowledge and experience and thus reinforce their autonomy (Ilgaz, 2022; Maughan et al., 2016; Yonkaitis, 2018).
The results of this study show how the activities of the school nurse have increased considerably with each school year. This boom in the activity of school nurses may be due to the increase in centers that employ nurses and the consolidation of school nursing. This consolidation was further reinforced by the COVID-19 pandemic, which required a coordinator who served an essential role in facilitating communication between public health services and schools to ensure prevention—and, where appropriate, action—in the event of suspected or confirmed cases of COVID-19 in the educational center (Consejería de Sanidad, 2021).
The analysis conducted in this study shows that each day, approximately 340 actions are carried out in all schools that employ a nurse from the SchoolNurses® company. The differences in the characteristics of the nurses’ professional activities in terms of the workday, the time period, and the type of schoolchildren they serve make comparisons difficult.
Although these differences preclude comparisons of our data with those from other studies, we think that the data available from SNapp® represent real-world information reflecting the first-time interventions performed by school nurses and a profile of the school nurse and her actions in Spain. These findings show that school nurses perform many interventions in different schools, and their activity increases with each academic year.
However, we can highlight the results of another national study (López Gutiérrez, 2014) that registered an average of 30.4 nursing actions, which is a high number of actions performed by the school nurse. International studies show how demand could increase, reporting that on a normal day, school nurses can attend to an average of 43.5 students (Bergren, 2016).
The greatest number of actions took place during breaks between classes, such as recess or lunchtime, possibly because of more opportunities for accidents or because nurses try to respect school hours and schedule control efforts and medication administration outside of instructional time. Most of the actions were brief since they correspond to caring for acute/chronic illnesses or administering medications/treatments (Maughan et al., 2018). These processes are usually simple actions that are resolved quickly and efficiently with the appropriate care. This finding is similar to those of other studies reporting that most actions performed by school nurses are of short duration (Bergren, 2016).
The most frequent reason for nursing actions was accidents, which is consistent with a study stating that the most common emergencies are choking, asthma attacks, seizures, or cardiac arrest (López Langa, 2010). The second most frequent category of action was consultations for illness. Increasing numbers of children have chronic pathologies; therefore, educational centers should provide a qualified health professional to meet the needs of these children, ensure inclusive schooling, and improve the students’ quality of life. According to various studies, the ideal professional for this role is the school nurse (Maughan et al., 2016; Rodríguez Soriano et al., 2013). The data obtained in the present study support the need for school nurses, since, in their absence, most actions fall on teachers who do not have health training (Hill & Hollis, 2012). One study quantifies that in 59.3% of schools, teachers have been forced to treat acute or chronic health problems on some occasion (Araujo, 2013). The third most frequent type of action was cures/treatments, which is similar to findings reported by Bergren (Bergren, 2016) but much lower than observations reported by Araujo, who indicated that 65.6% of children needed to receive some type of medication during their time in school (Araujo, 2013).
The largest group of patients, was students, since 87.3% of actions were directed toward them. However, the staff of the center also benefited directly and indirectly from access to school nurses. On the one hand, almost 5% of the actions are directed toward center staff, and on the other hand, access to school nurses prevents the need for teachers to take health-related actions (Araujo, 2013). Families also received some type of assistance on occasion, although very rarely.
Notably, only 0.9% of the actionable cases required referrals, while the rest were treated and resolved in situ, allowing the student to return to class and avoiding an increase in health expenditures and absences from school and work for students and their families, which is consistent with other studies (Gormley, 2019). The data reveal a clear decline in referrals over the study years. In the 2018–2019 academic year, they accounted for 2.5% of actions; in the 2020–2021 academic year, this proportion dropped to 0.3%.
These referrals were related to accidents or illness in most of the cases, and the patients were referred to the nurse or pediatrician from the health center as well as to the emergency department. Generally, the return to class rate is higher, with more educated health care professionals assessing illnesses or injuries and providing appropriate interventions.
Importantly, health education accounted for only 0.3% of the actions performed. SchoolNurses® staff are asked to create a health education plan in advance for each course and grade in coordination with directors and based on a guide provided by SchoolNurses® containing suitable themes for each age, but this approach remains reactive rather than proactive or planned and is not based on preanalyzed or focused strategies. In reality, most schools only delegate their nurses to carry health education once a slot becomes available, a teacher cannot attend classes, or an urgent disease or case arises at school. In other centers, school nurses carried out little or no health education due to their workload of assisting in emergencies or medication administration, leaving little time that could be spent developing workshops. The themes range from workshops on hand washing, first aid, and prevention to drug abuse or sexually transmitted disease prevention, and health-trip documentation is shared with students and school communities to educate them about different aspects of health or diseases.
Although the care burden is high, the school nurse should place more emphasis on health education, as recommended in both Spain and Europe, given its long-term importance
(Salvador & Merino, 2009; Vilaça et al., 2020). This recommendation can be explained because, on the one hand the action of health education selected only when the nurse is actually holding a class. On the other hand, because in Spain, health is not a compulsory subject within the school curriculum. However, the importance of health education and the need for it in the classroom have been clearly demonstrated. In addition, a tendency to favor caring for diseases over health promotion is evident, since the role of the school nurse in Spain originated in part from the need to address social demands related to caring for childhood pathologies. Finally, the lower proportion of school nurses who are trained in health promotion compared to other areas, such as emergency care or pediatric pathology, may also influence these results, as was clearly observed in our study.
During the 2018–2019 academic year, the contents of health education workshops were more heterogeneous, but in subsequent years, a clear influence of the COVID-19 pandemic was evident. Hygiene-related actions were redoubled, and prevention and action workshops began to be held to increase awareness of COVID-19 and reduce its spread. Consequently, other equally important issues, such as physical exercise, affective sexual education, and mental health, have been neglected. Therefore, the COVID-19 pandemic has undeniably had a marked impact on health education. School nurses have focused their efforts on the control and prevention of acute disease, which has disadvantaged the acquisition of healthy lifestyle habits, accentuating the deficiencies in the comprehensive care of schoolchildren. Notably, one of the topics that has been most neglected is mental health, and in the study, the provision of workshops related to emotional management was observed to have progressively decreased. Since the beginning of the pandemic, social priorities have changed. Restrictive measures, fear, and uncertainty have negatively impacted the mental health of the population, including children and adolescents (Paricio del Castillo & Pando Velasco, 2020). According to Ministerial reports, well-being and mental health require more attention than is being provided (Martínez-Santos et al., 2019).
On the other hand, in the 2020–2021 academic year, addiction prevention workshops began to be implemented; this topic had not previously been addressed. This finding shows that despite the epidemiological situation, nurses continue to actively assess needs and incorporate new workshops into their activities.
The activity data for school nurses that were obtained in this study should confirm that these professionals are experts in health-related content within the school community and can play an even more important role in the development of effective and sustainable school health interventions (Bejster et al., 2020).
The knowledge, behavior, and health status of students improve after school nursing interventions. These professionals not only protect and improve the health of children (Ilgaz, 2022; Maughan et al., 2016), but they also help to decrease the school absenteeism and improve academic achievement.
Descriptions of the actions of school nursing are essential when advocating for the continuation and expansion of school nursing services (Weismuller et al., 2007).
Training in health promotion and the actions of school nurses related to this topic should increase given the importance of health promotion for maintaining long-term health and to avoid perpetuating a disease-based model and favoring a salutogenic approach.
On the other hand, the procedures performed by school nurses prevented hospitalizations and clinic or emergency visits. SchoolNurses® made an approximate calculation of the cost savings to healthcare systems achieved by the school nurse and resulted in cost savings of more than €2.4 million a year in Spain (Ruiz Janeiro, 2018).
In addition, the school nurse saves time and allows teachers to develop their full educational potential without having to assume functions and responsibilities beyond the scope of their training and that generate insecurity and stress and promote transversal projects where health can also be a component of other subjects.
Therefore, the school nurse, in addition to promoting health and academic performance in the children and preventing the absenteeism of parents and the loss of teaching hours, would mean considerable savings in health spending in the long term.
More studies of the important contributions of school nurses to preserving and promoting the health of school populations and cost savings to healthcare systems for the procedures performed by school nurses are needed.
Few studies on the activity of school nurses in Spain and the rest of the world are available; consequently, establishing comparisons with similar studies has been difficult. This is the first study in Spain to analyze the interventions performed by school nurses and present a profile of the school nurse and her actions. The findings provide new evidence for future research on the activities of these professionals.
This study was only able to analyze the work of school nurses at private or subsidized centers. Studying their work at schools with different profiles, such as public centers for general education and special education, would be of interest for determining whether the activity of school nurses varies according to the type of center where they work.
The variability in the professional performance of the nurses who were studied complicated comparisons, and for future research, selecting a single profile of nurses who work full time and throughout the academic year could be useful to better approximate the daily workload and facilitate comparisons.
On the other hand, this study worked with real-world data, allowing an analysis of larger and more significant data samples. SNapp® information provides a very good approximation of the practices of school nurses but is not 100% complete, and some underreporting should be recognized since the coding of an action can vary according to the nurse who performs it. It was only possible to register one intervention per encounter, and the type of action recorded does not allow us to differentiate whether the managed or treated disease was acute or chronic. Similarly, only group workshops for students were registered in SNapp®, and the remaining online or offline communications (such as posters), one-to-one meetings with parents, or teachers’ health education have not been registered in this platform.
Finally, as records are completed by different professionals, information biases may have occurred in the form of errors in coding or lack of definition in actions carried out, which would limit the ability to measure real activity.
However, because the data were derived from the standardized and protocolized SNapp® registry, they are considered reliable, because they are based on blockchain technology. Nonetheless, it would be better that health-care practitioners could use an internationally accepted webbased system which establish standardization in documentation, automate clinical data handling, and monitor the quality of maintenance such as Omaha System (Bennett et al., 2021).
School nurses perform a significant number of interventions in subsidized and private schools, and their presence and activity have increased with each academic year. The profile is predominantly that of a young woman who is a native of Spain and generally has diverse and multidisciplinary postgraduate training.
The greatest workload takes place during breaks in the school day; encounters are usually brief, and the main recipients are students. The most frequent type of action is related to accidents, followed by consultations for illness and the administration of cures and treatments. Health education comprises a smaller than expected percentage of school nurses’ actions, and important aspects such as physical exercise or emotional management are neglected. The COVID-19 pandemic has exacerbated this situation by shifting the focus of school nurses’ activity to controlling acute disease. School nurses are autonomous and responsive, rarely making referrals to other sources of care.
School nurses played an important role in preserving and promoting the health of school populations and cost savings to healthcare systems with the actions they performed. Descriptions of these actions are essential when advocating for the continuation and expansion of school nursing services.
We thank the SchoolNurses community and the Camilo José Cela University professors in the Health and Education Faculty for all the support with this project.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Universidad Camilo José Cela, (2022 Grant for translations and publications).
Jaime Barrio-Cortes https://orcid.org/0000-0002-2582-0203
Supplemental material for this article is available online.
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Maddi Arrue-Guerra is a registered nurse working in Hospital Universitario Donostia and a school nurse with the Master in School Health of the Camilo José Cela University.
Jaime Barrio-Cortes is a PhD medical doctor, specialist in Family and Community Medicine, researcher in the Research Unit of the Primary Care Assistance Management and the Foundation for Biosanitary Research and Innovation in Primary Care in Madrid, director of the Master in School Health and associate professor of the Faculty of Health of the Camilo José Cela University.
Cristina María Lozano-Hernández is a registered nurse, specialist in Family and Community Nursing, researcher in the Research Unit of the Primary Care Assistance Management and the Foundation for Biosanitary Research and Innovation in Primary Care in Madrid and associate professor of the Faculty of Health of the Camilo José Cela University.
Jesús Ruiz-Janeiro is a computer engineer and CEO of School Nurses company.
Cayetana Ruiz-Zaldibar is a registered nurse and associate professor of the Faculty of Health of the Camilo José Cela University.
Montserrat Ruiz-López is a registered nurse and director of the Degree of Nursing in the Faculty of Health of the Camilo José Cela University.
1 Hospital Universitario de San Sebastián, Osakidetza, San Sebastian, Spain
2 Health Faculty, Camilo José Cela University, Madrid, Spain
3 Foundation for Biosanitary Research and Innovation in Primary Care, Madrid, Spain
4 School Nurses, Las Rozas, Madrid, Spain
Corresponding Author:Jaime Barrio-Cortes, Health Faculty, Camilo José Cela University, Calle Castillo de Alarcón, 49, 28692 Villafranca del Castillo, Madrid, Spain.Email: jbarrio@ucjc.edu
