The Journal of School Nursing2025, Vol. 41(4) 418–425© The Author(s) 2023Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405231184387journals.sagepub.com/home/jsn
Abstract
We investigated school nurses’ experiences, perceived government support, school nurses’ acceptance of responsibility for medication administration, perceived stress, and perceived competence of medication administration and analyzed factors associated with perceived competence. In this cross-sectional study, from February to April 2023, we conducted an online survey of 269 school nurses serving at K-12 schools in Taiwan. The results revealed that although 71% of the participants had prior experience with medication administration, they reported low competence and high stress in areas such as drug interactions, adverse drug effects, and referrals. The school nurses’ disagreement with responsibilities for medication administration emerged as the only factor to be significantly associated with perceived medication administration competence, accounting for 22.8% of the variance. We recommend implementing continuing training programs to provide school nurses with up-to-date medication information. Additionally, the development of practice guidelines is suggested as a means of enhancing nurses’ competence and reducing their stress levels for the administration of medications.
Keywordscompetence, stress, medication administration, school nurse, K-12
With the increasing prevalence of chronic health conditions such as asthma, type 1 diabetes, mental health issues, and other complex health needs among students, school nurses are expected to possess advanced knowledge, skills, and expertise (Best et al., 2021; Davis et al., 2021). Medication management in school is an essential component of chronic disease management, offering children with chronic health conditions the opportunity to engage fully in educational activities, recreational play, and social interactions (Butler et al., 2020). With the increasing amounts of medication being administered in schools, ensuring safe medication administration relies on collaboration between school nurses and faculty members, supported by policies (Lowe et al., 2022).
School health systems vary worldwide, including different types of providers and services (Baltag et al., 2015). The presence of a qualified school nurse in every school could improve the health, wellness, and safety of children and adolescents (American Academy of Pediatrics, 2016; Morse et al., 2022). In Taiwan, the Ministry of Education oversees school health per the School Health Act. Every school in Taiwan, regardless of the number of students, is required to have at least one licensed nurse. If there are more than 40 classes, at least two nurses are required (Taiwan Ministry of Education, 2002). As a result, responsibilities related to health care in schools are considered the duty of the school nurse alone. During the school nurse’s absence, a licensed nurse must be appointed as a substitute (Lee, 2020).
Globally, medication administration is the responsibility of registered nurses. However, the management of medications in the school setting, as a non-healthcareoriented institution, is complex. In a national survey of school nurses, the proportion of students receiving prescription medications had increased, along with a wider range of medications administered in schools (Maughan et al., 2018). The responsibility and division of duties for medication administration in the school setting may vary by country/state regulations (Lowe et al., 2022; Maughan et al., 2018). In the US, 60–70% of medication administration was delegated to unlicensed assistive personnel supervised by licensed school nurses (Maughan et al., 2018; McCarthy et al., 2000). In Taiwan, medication administration is not explicitly listed as a school health activity. Although school nurses are asked to administer medications, the supervisory authority states that the final decision is based on school nurses’ judgment (Lee, 2020). However, there have not been evidence-based studies on this topic other than in the United States (National Association of School Nurses, 2022).
Registered nurses are required to possess the competence to effectively manage medication administration as mandated by their profession (Luokkamäki et al., 2021). School nurses often come from different clinical units and may not necessarily have experience in pediatric care. Hence, many of them may not be familiar with the standards of pediatric nursing and medication management in school (National Association of School Nurses, 2022). Even pediatric nurses may not be competent in performing medication dosage calculations for children (Ridling et al., 2016).
Administering medications in schools is a growing concern and presents a variety of unique issues that need to be addressed. However, limited studies have been conducted on the experience and competence of school nurses in medication administration, especially regarding the policy of having one school nurse per school in Taiwan. Our aim is to examine the demographic factors, experience in medication administration, government support, acceptance of responsibility for medication administration, perceived stress, and perceived competence in medication administration of school nurses. Moreover, by clarifying the factors associated with perceived competence, our study can serve as a reference for other countries with similar systems.
We adopted a cross-sectional design targeting the national sample of school nurses. The minimum sample size was determined to be 129 using G*Power 3.1.9.2 (using linear multiple regression: fixed model, with an effect size of .15, power of 0.95, and alpha of .05) (University of Cambridge, 2021). To account for a potential response rate of 33% based on a previous online survey of school nurses (Pietz et al., 2021), 391 participants were needed.
A probability proportionate-to-size technique was used to calculate the sample size for 49 high schools (12.5%), 91 junior high schools (23.2%), and 251 elementary schools (64.3%). Subsequently, at different school levels, the probability proportionate-to-size technique was again used according to the proportion of schools in the four regions (i.e., north, west, south, east, and outlying islands) and school size to calculate the number of schools in each region. Finally, we made a selection according to a random number sampling method by proportion from all 4,299 schools from the Ministry of Education’s list based on sample sizes determined for each region.
To assess school nurses’ experience, perceived competence, and perceived stress of medication administration in schools, we developed a 25-item questionnaire mainly based on the School Nursing Evidence-Based Clinical Practice Guideline: Medication Administration in Schools (National Association of School Nurses, 2022). The questionnaire included the following.
Demographic Characteristics. Data on age, marital status, educational level, practice setting, years of experience as a school nurse, and number of students and nurses at school were collected.
Experience with Medication Administration. We collected data on experience with medication administration, routes of administration, and types of injection medications.
Government Support. We assessed the perceived degree of government support including clarifying the responsibility of medication administration in schools or collaboratively engaging in discussions with relevant government departments and organizations to develop guidelines. We used a five-point Likert-type scale for scoring (1 = limited support, 5 = much support), with higher scores indicating greater support.
Perceived Competence in Medication Administration. Perceived Competence in Medication Administration was explored through six dimensions: medicine and dose (medication names, pharmacological mechanisms, and dosage calculations), stocking of medications (conditions for medication storage), identifying drug interactions (the effect that occurs when two or more medications or substances interact with each other), skill in administering medication (to perform drug administration through any route), identifying prescriptions (to interpret physician-prescribed medications), and adverse drug effects and referrals (observing medication side effects and having a community referral system). A fivepoint Likert-type scale was used for scoring (1 = 0% competence, 5 = 100% competence), with higher scores indicating higher perceived competence in medication administration.
Perceived Stress of Medication Administration. Perceived Stress of Medication Administration was explored through the same six dimensions described above. A five-point Likert-type scale was used for scoring (1 = not stressful, 5 = highly stressful), with higher scores indicating higher perceived stress.
Acceptance of Responsibility in Medication Administration. We evaluated school nurses’ acceptance of responsibility for medication administration with the statement “The school nurse should be responsible for medication administration in school.” A five-point Likert scale was used (1 = completely disagree, 5 = completely agree). Higher scores represented greater agreement.
The questionnaire underwent content validation by five experts in the fields of school health nursing, including three senior school nurses, one nursing professor in school health, and one physician in pediatric medicine, resulting in a content validity index of 0.85. Additionally, reliability testing with 20 school nurses demonstrated an internal consistency of Cronbach’s alpha = 0.89.
We conducted an online survey via Google Forms which was sent via email to the selected schools. A total of 391 school contacts were invited to participate (Taiwan Ministry of Education, 2023). Prior to answering the questionnaire, school nurses were presented with the research purpose and subject rights and asked to read the study description carefully. The questionnaire took approximately 10 min to complete, and data were collected from February to April 2023.
The research proposal and survey instrument were reviewed by the Institutional Review Board of Chang Gung Hospital (IRB number: 202300163B0). Participants could withdraw from the survey at any point. No personally identifiable data were collected, and the data were analyzed as a whole rather than individually. Electronic data were stored separately on a locked computer to protect the privacy of the participants.
We exported the online questionnaire data to MS Excel for comparison and debugging. Statistical analyses were performed using SPSS Statistics for Windows 25.0 (IBM Corp., Armonk, NY, USA). Descriptive data are reported as mean and standard deviation (SD) values unless otherwise specified. We conducted bivariate and multiple linear regressions to examine the factors associated with school nurses’ competence. Multiple comparisons were adjusted using the Bonferroni post hoc test to correct for type I error inflation. The level of significance was set at <.05.
The data of 269 female school nurses were analyzed with a 68.79% response rate. The average age was 48.12 (SD = 6.88) years. Nearly 88.1% were married, and 58% had graduated from an undergraduate program. The majority (59.9%) worked in elementary schools, followed by junior high schools (24.5%) and high schools (15.6%). The average number of years of school nurses’ experience was 12.97 (SD = 8.21). The average number of students was 812.86 (SD = 777.48), with 50.2% of schools having fewer than 500 students and 36.8% of schools having more than 10,000 students. Regarding the number of nurses, 64.3% of the schools had one nurse, and 35.7% had two (Table 1).
Most participants (71%) reported having experience with medication administration, whereas 29% did not (Table 2). Eye drops were the most commonly administered medications (72.3%), followed by asthma inhalers (45.5%). Of the school nurses, 29.3% administered injections for chronic diseases. Insulin injections were the most common type of injection medication (92.3%), and 9% of the participants had administered glucagon. In terms of agreement regarding whether medication administration was a school nurse responsibility, 22.7% disagreed/completely disagreed and 41.6% held a neutral opinion (Table 2). Of the sample, 54.3% perceived government support for the definition of medication administration.
The participants’ self-perceived competence in medication administration was at a moderate to high level (3.64 ± 0.88) (Table 3). Among the six dimensions, participants had the highest level of competence in the administration of stock medications, while identifying drug interactions, adverse drug effects, referrals, and skill in administering medications ranked lowest.
The participants experienced a moderate to high level of stress in medication administration (3.56 ± 0.96). Among the six dimensions, participants experienced the lowest stress in the administration of stock medications, but the mean stress score was still high at 3.45. The highest level of stress was reported when identifying drug interactions, adverse drug effects and referrals, and medicines and doses (Table 3).
In the initial exploration stage, we used bivariate and multivariate linear regression analyses to identify significant correlates of self-reported competence. The results showed that participants who were older (β = .131, 95% confidence interval [CI] = 0.00–0.030), had experience in administering medications (β = .191, 95% CI = 0.141–0.600), exhibited high levels of agreement with being responsible for medication administration (β = .501, 95% CI = 0.339–0.571), and had lower perceived stress levels (β = .219, 95% CI = 0.308–0.593) reported higher scores for self-reported competence. Subsequently, multivariate linear regression analyses showed that agreement with being responsible for medication administration (β = .468, 95% CI = 0.304–0.496) was the only factor that was significantly associated with self-reported competence, accounting for 22.8% of the variance (Table 4).
The administration of medication in schools is vital for student health, chronic condition management, and emergency preparedness, necessitating further academic exploration. Our study provides valuable insights into perceived medication administration competence reported by school nurses, serving as a reference for establishing policies and continuing training in school settings.
Administering medications in schools has traditionally been seen as the responsibility of school nurses. Owing to increasing numbers of children with chronic diseases (Baltag et al., 2015; Vieira et al., 2022) and those requiring medication administration (Maughan et al., 2018; McCarthy et al., 2000) school nurses need to take more responsibility in administering medication for students than before. However, only 71% of our participants reported administering medications to students, lower than previously reported rates among school nurses in the United States (Krause-Parello & Samms, 2011; Maughan et al., 2018; McCarthy et al., 2006). This could be because of the discrepancy in prevalence rates of chronic illness among children and healthcare services across countries (Vieira et al., 2022). In Taiwan, school nurses, without sufficient medication information, assist children with medication needs through referrals to community resources instead of direct administration (Lee, 2020).
Nearly half of our participants (45.5%) administered asthma inhalers to children, whereas the vast majority (92.3%) administered insulin. These findings coincide with a report by the Taiwan Ministry of Health and Welfare (2022) that identified asthma and type 1 diabetes mellitus as two significant chronic diseases affecting primary and secondary school students in Taiwan. Moreover, the care management of asthma and type 1 diabetes mellitus in school has been established to provide clear medication administration instructions for school nurses (Health Promotion Administration, 2018).
The moderate to high levels of perceived stress in medication administration observed in this study were consistent with Lee (2020), who reported that no guidelines regarding medication administration have been established in schools, which has given rise to uncertainties and concerns among school nurses in Taiwan. However, contradicting the finding regarding the moderate to high levels of stress, school nurses reported moderate to high levels of self-assessed competence in medication administration. Our findings align with previous studies, indicating that nurses perceive themselves as having sufficient competence to administer medication, even when medication administration involves complex clinical judgment (American Academy of Pediatrics, 2016; Luokkamäki et al., 2021; Rohde & Domm, 2018).
School nurses reported high competence and low perceived stress in six domains of medication storage because of the clarity of the guidelines for medication storage in school health centers provided by the Taiwan Ministry of Education (2008). Clinical judgment regarding medication side effects or drug interactions relies on open communication channels between nurses and physicians to ensure the safe administration of medication to patients (Rohde & Domm, 2018). However, the school health system in Taiwan does not allocate funding to hire physicians as dedicated personnel in schools or at the county level. It is dangerous for school nurses to administer medications without receiving sufficient information from physicians (McCarthy et al., 2006).
We found that self-reported competency was higher in older individuals and in those with experience administering medications at schools. This finding was consistent with Yoon and Son’s (2021) finding that triage competency was higher in school nurses who were older and had emergency experience. Ridling et al. (2016) found that the accumulation of experience in the medication administration process would benefit the competence and performance of pediatric practitioners. Similar to Zakeri et al.’s (2021) finding that nurses with lower perceived stress could have higher perceived clinic competence to successfully carry out nursing tasks.
According to our results, the proportion of school nurses who agreed, disagreed, and held neutral opinions regarding taking responsibility-for medication administration was onethird each. This is explained by Bellis et al. (2017), who reported that the management of medicines varies across schools because of the diverse interpretations of policy guidance by school members. School nurses who perceive they are competent are more likely to agree to that medication administration (Maeland et al., 2023). This supports our finding regarding the significant role of acceptance of school nurse responsibilities for medication administration.
In-service training for school staff is important to establish consensus regarding responsibility in medication administration and maximizing the safe use of medications for all students (Lowe et al., 2022). According to the experience of medication administration revealed in our study, the importance of the guidelines established by the National Association of School Nurses (2022) is emphasized. The school nurses’ association in Taiwan needs to follow in the footsteps of the National Association of School Nurses (2022), continuously refining policies and establishing guidelines for medication administration through cooperative agreements across related professional associations.
Our study represents the first attempt, using a national sample, to examine the status of medication administration practices as well as the competence and perceived stress levels of school nurses in the administration of medications in Taiwan. However, our study had several limitations. First, although we investigated the status of medication administration by school nurses, we did not examine the prevalence or severity of chronic diseases among students, which may have limited the study’s capacity to fully elucidate the medication administration status in schools. Second, owing to the absence of an unlicensed assistive personnel system in Taiwan, we did not collect data on the procedure whereby schools respond to medication administration for children with chronic illnesses, which limits the explanations for nonmedication administration. Finally, future studies should include information on on-the-job education and training to clarify the factors that may influence school nurses’ competence in medication administration.
In this study, the identification and management of drug interactions and adverse drug effects, as well as making referrals, represented the lowest competence and highest stress areas in medication administration. Additionally, almost a quarter of school nurses did not agree that medication administration is a school nurse’s responsibility, which emerged as the sole factor to be significantly associated with perceived medication administration competence, accounting for 22.8% of the variance. Given the growing prevalence of chronic conditions among children, school health managers and school nurse associations must collaborate to develop national guidelines and design professional training programs that foster consensus on medication administration in schools and enhance the competence of school nurses. Such initiatives can optimize the provision of safe and effective care to students with chronic illnesses and promote adherence to legal and ethical standards in school-based health care delivery.
Owing to educational, legal, medical, and social factors, school districts have seen a substantial increase in children requiring complex nursing care. School nurses play a vital role in administering medications in school, and continuing training is an important element for them to fulfill their competence effectively. Training should include up-to-date medication information and legislation issues related to medication administration in schools that could enhance the competence in and decrease the stress of medication administration for school nurses. Moreover, developing practice guidelines could achieve consensus regarding school medication administration among school members.
The authors thank all the participants who engaged in this online survey.
Conceptualization: LCC; Data curation: HYY and LCC; Formal analysis: HYY and LCC; Investigation: LCC and CHH; Methodology: HYY and LCC; Project administration: HYY and LCC; Resources: CHH, LLL, and HLL; Validation: HYY, LLL, and LCC; Roles/Writing - original draft: HYY and LCC; Writing - review & editing: HYY and LCC.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical approval was granted by the Chang Gung Medical Foundation Institutional Review Board (approval number: 202300163B0).
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Li-Chun Chang https://orcid.org/0000-0002-6704-8995
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Hsing-Yi Yu, RN, Ph.D, Assistant Professor, School of Nursing, College of Medicine, Chang Gung University & Researcher, Department of Nursing, New Taipei Municipal Tu Cheng Hospital, New Taipei, Taiwan.
Chun-Hsia Huang, RN, Ph.D, Assistant Professor, School of Nursing, College of Medicine, Chang Gung University & Researcher, Department of Nursing, Linkou Branch, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.
Li-Ling Liao, RN, Ph.D, Professor, Department of Health Management, I-Shou University.
Hui-Ling, Lin, RN, MS, Supervisor, Department of Nursing, Linkou Chang Gung Memorial Hospital.
Li-Chun Chang, RN, Ph.D, Professor, School of Nursing, Chang Gung University of Science and Technology and Chang Gung University. Researcher, Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan.
1 School of Nursing, College of Medicine, Chang Gung University, Taoyuan, Taiwan, R.O.C
2 Department of Nursing, New Taipei Municipal Tu-Cheng Hospital, New Taipei, Taiwan, R.O.C
3 Department of Nursing, Linkou Branch, Chang Gung Memorial Hospital, Taoyuan, Taiwan, R.O.C
4 Department of Health Management, I-Shou University, Kaohsiung City, Taiwan, R.O.C
5 School of Nursing, Chang Gung University of Science and Technology, Tao-Yuan County, Taiwan, R.O.C
6 Taipei Medical University, Taipei
7 Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan, R.O.C
Corresponding Author:Li-Chun Chang, School of Nursing, Chang Gung University of Science and Technology, Gui-Shan Town, Tao-Yuan County, Taiwan, R.O.C.; Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan; School of Nursing, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan, R.O.C.Email: lichunc61@yahoo.com.tw
