The Journal of School Nursing2025, Vol. 41(6) 679–688© The Author(s) 2024Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405241264732journals.sagepub.com/home/jsn
Abstract
School nurses and pediatric nurses play vital roles in providing healthcare for children and adolescents in educational and healthcare settings. School nurses operate within educational institutions, serving as caregivers and facilitating communication between the school, families, and the healthcare system. These professionals closely collaborate with pediatric nurses. The primary objective of this study was to examine the state of school nursing in Spain. The research comprised 27 nurses, including 18 school nurses and 9 pediatric nurses, chosen through theoretical sampling. These nurses participated in in-depth interviews as part of the data collection process. Grounded theory, following Charmaz’s process, was employed for data analysis. The findings underscore the nurses’ call for their mandated presence and regulation in all Spanish educational institutions to address contemporary health challenges and ensure inclusive education.
Keywords
child health, chronic disease, educational needs assessment, grounded theory, pediatric nursing, school nursing
In educational settings such as Early Childhood Education, Primary Education, Compulsory Secondary Education, Baccalaureate, or Vocational Training, students aged 3 to 18 may require nursing interventions for special educational needs related to physical, emotional, or social health, highlighting the need for constant nursing support during the school day (Álvarez et al., 2018). Despite the recognition of various nursing specialties by the Spanish Royal Decree 450/ 2005, school nursing is not officially accepted as a specialty, unlike pediatric nursing, which is practiced in healthcare settings (Arrue-Gerra et al., 2024). The National Association of School Nurses (NASN) highlights the role of the school nurse in safeguarding students’ health, fostering development, and promoting academic success (McCabe et al., 2019; McDermott et al., 2018). The Madrid Association of Nursing in Educational Centers (AMECE, 2010) underscores the necessity for school nurses to be proficient in pediatric and family/community nursing, stressing comprehensive care provision and effective communication with students, teaching staff, and healthcare professionals (Ayuso et al., 2019a).
School nurses play a crucial role in delivering comprehensive care to students, overseeing health management within schools, and developing teaching, research, and interprofessional skills. They routinely identify students with specific needs and intervene early to prevent health issues from impacting academic success. Through individualized assessments, they determine optimal support and appropriate educational approaches (Ruiz & Ruiz, 2022). According to a Health Survey conducted by the Spanish National Institute of Statistics (INE, 2022), 57,718 students aged 0 to 14 experienced health problems or chronic diseases in the last year. Common conditions included chronic allergies, asthma, diabetes, tumors, epilepsy, behavioral and mental disorders, and permanent injuries. Approximately 15% of schoolchildren in Spain face chronic health issues, highlighting the need to integrate health into schools (Rodríguez-Almagro et al., 2018). The role of the school nurse is of paramount importance in caring for students with chronic diseases, given the imperative to provide specialized care in evolving educational settings (Lack & Kinser, 2020). Medical requirements may affect students’ attendance and academic performance, impacting their interactions with teachers and peers (Rodríguez-Almagro et al., 2018; Yoder, 2020). Thus, nurses play a vital role in developing self-management skills in students with chronic diseases throughout the educational stages (Charlucien-Koech et al., 2024).
The school nurse serves a vital function in improving students’ well-being, especially those with chronic conditions like diabetes and asthma (An et al., 2022; McCabe et al., 2019). They adapt to diversity, provide consistent care, and focus on anticipatory guidance (Oliveira et al., 2018). Following standardized protocols like the Clinical Practice Guidelines is essential, with nurses collaborating with other health professionals to develop and implement them (McCabe, 2020). Moreover, school nurses facilitate family reconciliation, acknowledging the challenges families face in balancing work and caring for their children (Gathercole, 2019). Their role is highly valued not only by families of chronically ill children, but also by those who appreciate the safety they bring to the classroom. Parents consider school nursing indispensable when enrolling their children, recognizing its significance in ensuring student well-being (Martínez-Santos et al., 2019).
Despite the reality of students’ needs, it is noteworthy that teachers, who lack formal training or expertise in this domain, are often tasked with providing healthcare in mainstream schools (Rodríguez-Almagro et al., 2018). Teachers highlight that the training they have received falls short of preparing them to address the health needs of the student population, both healthy minors and those with illnesses (Pestaner et al., 2022). In the study conducted by Rodríguez-Almagro et al. (2018), it was emphasized that 56.6% of teachers expressed concerns regarding the wellbeing of students suffering from chronic diseases. Furthermore, it was observed that over half of these educators had not undergone any health training and deemed the presence of a school nurse in educational institutions as crucial. According to the teachers, more than 60% of students had encountered dizziness and trauma necessitating health care intervention (Rodríguez-Almagro et al., 2018). Additionally, in Lack and Kinser (2020) study, teachers revealed instances of students with chronic health issues in their classrooms. The primary apprehensions voiced by teachers included assuming additional responsibilities and concerns about causing harm to students (Gathercole, 2019). Teachers are ill-equipped to handle technical responsibilities such as medication preparation and administration, and they lack the expertise to address students’ day-to-day health needs (Pestaner et al., 2022). Students with chronic illnesses require the attention of qualified professionals capable of assessing, monitoring, and treating their health conditions (Gathercole, 2019). It is recommended that nurses take on the task of educating teachers and students on health-related topics, encompassing wound care, vaccination, first aid, mental health, substance abuse, sex education, and dietary habits (Charlucien-Koech et al., 2024).
Health education (HE) emerges as a strategy for improving students’ lifestyles by fostering a school environment dedicated to promoting healthy habits (Gathercole, 2019; McCabe, 2020). This approach contributes to students and families adopting and managing healthy habits within educational settings, and establishing vital connections among the health system, educational institutions, and minors’ environments throughout their schooling (Rodríguez-Almagro et al., 2018). According to the World Health Organization (WHO, 2023) and the Spanish Youth Institute (INJUVE, 2019), there has been an increase in health problems among young people, affecting their quality of life. These problems include accidents leading to disabilities, violence, mental health disorders, substance abuse, sexually transmitted diseases, unplanned pregnancies, nutritional deficiencies, and lack of physical activity (INJUVE, 2019). Despite the significance of these findings, resources in Spain are not adequately allocated to instill healthy habits addressing societal health problems. Studies in Spain, such as those by Arrue-Gerra et al. (2024), Martínez-Santos et al. (2019), and Rodríguez-Almagro et al. (2018), underscore the necessity of teaching these healthy habits and starting them early, utilizing active methodologies that connect educational centers with the community and the health system, rather than relying solely on theoretical seminars (Hopkinson & Petty, 2023).
Despite efforts to incorporate HE across various subjects, the transversal approach has proven ineffective in delivering comprehensive training and promoting healthy practices (Arrue-Gerra et al., 2024). The primary challenges arise because these interventions are sporadic, are isolated from other curriculum elements, are perceived by teachers as irrelevant to the curriculum, face constraints of time and resources for effective instruction, and are often facilitated by unqualified professionals (Martínez-Santos et al., 2019; Rodríguez-Almagro et al., 2018). INJUVE (2019) reports that 50% of STI diagnoses occur in individuals aged 15 to 24, with high rates of gonorrhea, chlamydia, and HIV. Additionally, 300,000 youths suffer from eating disorders starting before age 14. Globally, 1 in 6 adolescents aged 10 to 19 is overweight, while over a quarter of 15- to 19-year-olds engage in heavy episodic drinking, and 4.7% of 15- to 16-year-olds use cannabis (WHO, 2023). Currently, attention to mental health, particularly self-esteem and affective relationships, is crucial for emotional wellbeing (Macyko, 2022). WHO (2023) notes that over half of adult mental health issues begin around age 14. Efforts should focus on comprehensive, integrated HE programs to address these multifaceted health challenges effectively. In Spain, while various regional initiatives exist, there is no permanent regulation established requiring HE in educational centers, except for special education needs centers where students require more acute healthcare akin to nursing homes (Ayuso et al., 2019a). In contrast, school nursing has been firmly institutionalized in several Eurozone countries for over 50 years, contributing significantly to enhanced school health plans (Martínez-Santos et al., 2019).
The overarching objective of the study was to assess the state of school and pediatric nursing in Spain. The specific objectives were: (a) to investigate the views of school and pediatric nurses regarding their abilities and responsibilities; and (b) to gain insight into the healthcare services offered by school nurses within educational settings. The research inquiries formulated were: What is the present state of school nursing in Spain? What healthcare services are available to minors within educational institutions? How are the educational and healthcare requirements of children and adolescents addressed within the educational setting? What kind of care do students receive within educational facilities throughout the school day?
The chosen design is rooted in the constructivist approach of grounded theory (Charmaz, 2005, 2006). According to this methodology, individuals actively shape both the phenomenon under investigation and the research process through their actions. Additionally, the design acknowledges the impact of historical, social, and situational conditions on these actions, along with the researcher’s active involvement in data collection and analysis (Charmaz et al., 2018).
Interviews were conducted with 27 Spanish nurses utilizing “Theoretical Sampling” in alignment with the research’s objectives. The inclusion criteria were defined as school and pediatric nurses. This selection was guided by the observed variation in the presence of school nurses across various autonomous communities (CGE, 2021). Furthermore, participants were required to be actively engaged in Spain and involved in the social and health care of minors during the data collection phase. To ensure confidentiality, an alphanumeric code replaced the names of all participants. It was crucial to assess the clinical experience of nurses in caring for minors across various professional roles to comprehend their caregiving responsibilities and their interactions with the educational team.
After receiving an affirmative report from the Ethics Committee of the University of Burgos (No. 071/2020), the authors gathered data through in-depth interviews. These interviews were facilitated by an online recruitment advertisement posted on the Official College of Nursing and the bulletin board of the Madrid Association of Nursing in Educational Centers (AMECE) from October 2022 to October 2023. The interviews took place at participants’ chosen times, utilizing Microsoft Teams or Zoom, with a preference for written communication and face-to-face interactions when feasible. Conducting direct interviews enhances communication with the interviewee. Nevertheless, considering the context and the convenience of providing interviewees with greater temporal flexibility through written responses, we have opted, based on the preference of the majority of participants (Amri et al., 2021), to carry out a combination of written and oral interviews. While this written data collection method has limitations in capturing nonverbal and paralinguistic cues, these drawbacks will be offset by the benefits of spoken interviews (Gül et al., 2022).
Participants provided consent for audio recording during interviews. We employed semi-structured, open-ended questions aligned with existing literature (Martínez-Santos et al., 2019; Oliveira et al., 2018; Rodríguez-Almagro et al., 2018). An interview guide was crafted to assess the present state of Spanish school nursing. This guide encompassed the following sections: (a) Demographic information; (b) Regulations and work competencies of school nurses; (c) Professional performance in the school context; and (d) Professional recognition and obstacles. Field notes were meticulously recorded throughout the interviews. The duration of the interviews ranged from 45 to 70 minutes. Data were collected until theoretical saturation was reached, indicating that no new categories or themes emerged. According to Hennink and Kaiser’s (2021) research, thematic saturation is typically achieved with 9 to 17 interviews. In our study, saturation occurred within the first 14 interviews with the foundational elements for the categories evident by the tenth interview. However, additional cases were examined to enhance the development of concepts and theoretical propositions. One of the authors transcribed the recordings, and the other two authors cross-checked them with the transcripts.
The data were analyzed by three authors who are university lecturers with diverse educational backgrounds, specializing in nursing, therapeutic pedagogy, and social education. The intention was that the qualifications and experiences of the researchers would enhance communication with the nurses and contribute to enriching the data analysis process (Gül et al., 2022). The data analysis method comprised three stages: initiation, focus, and theory, as outlined by Charmaz (2006, 2008, 2017) and Charmaz and Thornberg (2021). In the first phase, the researchers formulated an initial coding framework through reflection on the collected dataset. The data underwent analysis, with a focus on identifying similarities and differences. The coding process involved capturing the first concept that surfaced during the procedure, continuously comparing it with the posed questions, and scrutinizing how it was expressed, by whom, and for what reasons. In the second phase, we established categories based on the most significant codes identified in the initial stage (Charmaz, 2006, 2017). Subsequently, during the final stage, codes were conceptualized, and themes were derived through continuous comparisons of codes, categories, and data annotations (Charmaz & Thornberg, 2021). The primary focus of this analysis centered on the role played by nurses in juvenile care within school settings, contributing significantly to the enhancement of the health of young individuals throughout their academic years. Upon identifying the final four themes, rigorous reviews were conducted, and the researchers collaborated to define, name, and reach a consensus, striving to uphold criteria such as credibility, originality, resonance, and usefulness (Charmaz, 2005, 2006).
To enhance the diversity of participant experiences and enrich the data, the sample comprised 18 school nurses and 9 pediatric nurses from distinct autonomous communities in Spain. The mean age of participants was 39.6 years, with an average of 8.3 years of work experience in the care of minors (refer to Tables 1 and 2).
During the interviews with school nurses (SN) and pediatric nurses (PN), the following topics were addressed: (a) professional profile; (b) intervention with families and students; (c) professional recognition and assessment; (d) facilitators and obstacles to implementing nursing practices in educational centers. The research objectives and questions posed were successfully addressed, and the main results are subsequently presented. To access the Spanish translations, please refer to the Supplementary Materials.
All school nurses unanimously acknowledge their responsibility for various types of care within educational institutions. The primary functions they reported undertaking included assistance, management, research, food control, HE, and the monitoring of students, with a particular focus on those with chronic diseases. They strive to deliver comprehensive and individualized care, consistent with the inclusion principle:
“There are various functions to oversee, notably the management of allergic children, a demographic that is particularly prevalent in the realm of cooking and, dietary considerations. Responsibilities encompass monitoring prescribed medications and, emergency medication for children undergoing chronic treatment. Your role extends to health education and conducting workshops focused on nutritional labeling. I provide direct assistance to children who come in when they are unwell, and I also manage the care of chronic patients. I engage in conversations with families, coordinating support for chronic patients to promote their maximum self-care and independence while at school. Together with families, we ensure that the child does not perceive themselves solely as a chronic patient, but rather as an integral part of the school community” (SN).
Families and teachers lack knowledge regarding the nurse competencies:
“It’s regrettable that the broader public is unaware of the valuable contributions made by nurses, and I’m not referring solely to school nurses. The dearth of awareness results in schools placing greater emphasis on directives from public authorities rather than heeding the expertise offered by the nurses working with institutions” (SN).
Pediatric nurses provide care for infants and children from the newborn stage through adolescence or puberty, up to the age of 16 years.
“We oversee health check-ups for well children. During these examinations, we conduct weight and height measurements to ensure proper growth. Additionally, for younger children, we provide health education to parents, and as the children mature, we extend this education directly to them. Not only do we focus on preventing illness, but we also prioritize health promotion, proper nutrition, cultivating healthy lifestyle habits, accident prevention, mitigating digital technology addictions, promoting oral health, and preventing obesity. Additionally, our clinic provides comprehensive sex education from a young age, fostering awareness that empowers individuals to understand and take ownership of their bodies. Furthermore, we implement a program dedicated to identifying and addressing child abuse or mistreatment. Our services extend to emergency care and pathology, collaborating closely with pediatricians” (PN).
Regarding to the legal regulations governing the profession, a school nurse elucidated the challenges involved in coordinating efforts among the relevant Ministries involved in this healthcare, including the Ministry of Health, Ministry of Education and Vocational Training, Ministry of Social Rights and Agenda 2030, Ministry of Inclusion, Social Security and Migration, and the Ministry of Equality. The uncertainty of employment within the sector, as emphasized by school nurses, amplifies feelings of being undervalued and unsupported by relevant entities. Additionally, a school nurse pointed out that school nurses are present during students’ school hours, providing crucial support for their academic performance. According to a school nurse, in the past, community and pediatric nurses attended to children with chronic illnesses, but their services were limited to Health Centers and homes.
“Prior to the existence of nurses, children who were seriously ill died earlier and died at home. Nobody considered that they had the right to attend a school” (SN).
Interviewed nurses stressed the need for regulations defining pediatric school nurse’s duties as primary healthcare provider.
“The presence of a pediatric school nurse is essential, as they have much to contribute to every school. Currently, however, such a role does not exist. Right now, since the school nurse does not exist as such, if a school nurse had to go to the school to visit a child, the nurse assigned to that child would go. The figure of the school nurse would be very important, the children with pathologies would be better attended and the teachers would not find themselves in the situation of assuming responsibilities that are not theirs. Finally, we take care of pediatric children who require intermediate or intensive care. My duties do not fall under those of a school nurse” (PN).
“Another obstacle is that we are not covered at the legal level and of course if we do not do them so that nothing happens to us, then we do nothing. This is unregulated and it is a disaster” (SN).
Frequent and seamless communication is maintained with families. Pediatric and school nurses are aligned on the need for exemplary communication and coordination. The school nurse is highly regarded by family members within educational settings, fostering a relationship of trust. The physical presence of school nurses within the center enhances accessibility for families, allowing for proposed interventions that are deemed beneficial for students. Conversely, pediatric nurses offer individualized care, addressing specific cases during consultations at health centers. Group interventions led by pediatric nurses typically arise from center requests rather than direct appeals from family members.
“I have successfully forged strong connections with those families, a bond rooted in utmost trust. I firmly believe that establishing such trust is the key to ensuring parents’ peace of mind and, in turn, imparting that sense of security to their children. Yes, I actively engage in the school for mothers and fathers whenever they request my involvement. Additionally, when it becomes essential to address a significant topic on an individual basis, I arrange meetings with the families alongside the tutor. I am also responsible for creating informative guides for specific scenarios, such as dealing with obesity or providing guidance on nail care. I collaborate with them comprehensively, assisting to enhance the well-being of their children” (SN).
“Typically, children with chronic conditions necessitate specialized care administered by their parents. When admitted to my unit, they often find themselves in situations requiring either intensive or palliative comfort care. Our usual approach involves collaborative teamwork with the parents, providing guidance, and accommodating their preferences, while also respecting their routines and habits” (PN).
Pediatric nurses emphasize that their responsibilities encompass therapeutic treatments administered in clinical settings. These treatments, which may be deemed invasive and non-ambulatory, could necessitate the hospitalization of children. Such interventions can heighten the complexity of decision-making regarding the child’s health in relation to the severity of their condition, as highlighted by a pediatric nurse. Consequently, these challenges may impede the bonds with family members.
“Indeed, we acknowledge that there are times when others associate us with unpleasant situations and may not agree with our approach” (PN).
The school nurses affirm that their presence and intervention provide reassurance to family members, as they themselves convey. Moreover, school nurses elaborate on the enduring nature of care, emphasizing that therapeutic treatment can evolve into a prolonged relationship throughout the entire school stage. The responsibilities of the school nurse are consistently oriented within the educational center, encompassing preventive measures, the promotion of healthy habits, emergency care, and the treatment of students requiring special attention. Should a more specialized intervention be necessary, this professional will be responsible for referring individuals to the corresponding specialist.
“Performing this task for the well-being of their children is akin to the role of a teacher, instilling a sense of reassurance in them by placing us at the forefront” (SN).
School and pediatric nurses assert that both families and teachers greatly appreciate their work, particularly in supporting students with chronic diseases. However, they also highlight the absence of economic stability and professional recognition. This issue disproportionately impacts school nurses compared to pediatric nurses. This is because the field of pediatrics enjoys recognition among nursing specialties, while school nursing lacks similar acknowledgment (Pediatric nurses said).
“Generally, I believe that families appreciate my work in a positive manner, particularly those with students facing chronic illnesses, as they experience a heightened sense of security when their children are at school” (SN).
In turn, school nurses, such as those designated as school nurses, emphasize the importance of recognition from the teaching staff. In many instances, educators may lack the knowledge on how to respond, feel uncertain, and may be unwilling to undertake nursing responsibilities within the school setting. This reluctance stems from the perception that such tasks fall outside their professional competencies, and they may not possess the qualifications for providing this care. Contrastingly, pediatric nurses do not highlight the recognition from teachers, as their interactions with educators are sporadic.
The nurses interviewed identified several key challenges, including burden of sole responsibility, time constraints, resource limitations, and legislative gaps as challenges.
“I find myself in solitude, often compelled to make life-and-death decisions due to the absence of a doctor or a colleague. This responsibility is immense, especially in the presence of individuals who lack proper hygiene and barely manage to avoid fainting when witnessing an epileptic seizure. The infirmary is a room within the school; however, it is not integrated or coordinated with any specific department” (SN).
“When you wish to collaborate with them, I comprehend that coordinating the transportation of children entails considerable effort. However, when engaging in activities that involve parents and children requiring visits to the health center, I believe it would be more convenient to conduct within an educational center. Not only individuals with chronic pathologies should receive education, but also others. Numerous interventions require delivery by trained professionals” (PN).
The school nurses believe that the standardization of protocols and adherence to good clinical practice guidelines in educational centers would enhance their effectiveness. Currently, there is a lack of protocols for action, making their work challenging.
“There are currently no protocols in place within the Navarre Department of Education or the Department of Health regarding the proper care of children with chronic illnesses and how to effectively coordinate with teachers. This issue requires regulatory attention” (SN)
Another aspect pointed out by pediatric and school nurses is the absence of a connection between the health and education systems, which complicated access to minor records. Furthermore, there is a significant disparity in resources between public and private schools, with the provision of school nursing services in private centers viewed as an enhancement in educational quality. However, due to the absence of regulation, funding is not allocated uniformly to all educational centers.
“To underscore the significance of the school nurse in public schools, it is noteworthy that private schools have long recognized the importance of this role” (PN).
“We possess limited information about children with pathologies; they are required to provide either the medical report or the vaccination schedule. […] It is imperative for this practice to be regulated in Spain, as it has been in place for many years in other countries” (SN).
Pediatric and school nurses emphasized the pivotal role of nursing professionals in clinical and school settings amid the COVID-19 pandemic, highlighting their importance to teachers and families. This accentuates social networks as vital for improving accessibility, dissemination, and knowledge transfer in school nursing.
“On my Instagram, I engage in comprehensive health education, addressing various pediatric subjects such as diseases, childcare, hygiene, development, nutrition, and sleep. I believe I contribute significantly to health education in these areas” (PN).
“A glaring example pertains to the past two years, wherein the monitoring of adherence to COVID prevention measures has been prominent” (SN).
The objective of this study was to assess the state of school and pediatric nursing in Spain, advocating for their inclusion in all educational institutions and recommending the establishment of regulatory measures designating them as specialized nursing roles. The results indicate that school nurses take on health care and health-related responsibilities within schools. These findings align with the results obtained by Arrue-Gerra et al. (2024) and the Spanish General Nursing Council (CGE, 2021), who highlight the diverse training profiles encompassing both general nurses and those specialized in emergency, school, community, and pediatrics. Nonetheless, similar to our study, Álvarez et al.
(2018) and Ayuso et al. (2019a) emphasize the importance of standardizing the professional profile of school nurses to ensure consistent care and safety for students in educational settings. To achieve this, as suggested by Ayuso et al. (2019b), it is imperative to establish legislation for the role of the school nurse, standardizing the training and competencies required for entry into this profession. Nurses devoted to school healthcare emphasize the existing legal gaps within their profession, as well as the disparities in recognition and allocated resources among autonomous communities.
A more detailed analysis shows school nurses prioritize family interaction, enhancing student benefits. Pediatric nurses assist schools selectively, emphasizing school nursefamily engagement. The results align with other research (Alvarez et al., 2018; An et al., 2022), indicating that school nurses primarily encounter accidents and isolated episodes of exacerbated chronic diseases (An et al., 2022). Nevertheless, Arrue-Gerra et al. (2024) emphasize that interventions are typically brief, resolved within the school setting in the presence of nursing, and predominantly occur during class breaks and recess. Furthermore, Hopkinson and Petty (2023) have demonstrated, as suggested by the nurses interviewed in this study, that the school nurse’s presence enhances the detection of health problems. Consequently, this leads to early interventions, thereby preventing the onset of health comorbidities, as indicated by pediatric nurses.
School and pediatric nurses stress their vital roles but lament lack of state recognition and economic stability, underscoring school nursing’s non-specialty status. Gathercole (2019) and Lack and Kinser (2020) underscore that the school nurse is not only esteemed by families and teachers, but also plays a role in alleviating stress and anxiety. This results in a decrease in episodes of chronic diseases exacerbation, such as asthmatic crises, and permits the children’s participation in extracurricular activities. There are aspects highly valued for family members. Consistent with the narratives of interviewed nurses, Macyko (2022) emphasized that educational institutions supported by nurses in addressing bereavement due to the loss of family members during the COVID-19 pandemic witnessed enhancements in both students’ academic expectations and psychological well-being. However, Yoder (2020) pointed out that the presence of nurses is linked to reduced absenteeism and time away from class but does not necessarily correlate with academic performance. This perspective is nuanced, considering that the studies analyzed primarily focus on short-term academic outcomes.
Numerous studies have underscored that effective communication between teachers and school nurses enables the identification of student behaviors that may be indicative of underlying mental health needs. This collaborative approach also enhances connectivity, thereby promoting student safety (Pestaner et al., 2022). As revealed in these interviews, the role of the school nurse is evolving into that of an agent of educational innovation in health-related matters. These professionals employ active methodologies to impart knowledge in areas such as first aid, donation, and sexuality. Their practical perspective, derived from socio-health training, contributes to the development of more health-conscious societies (Martínez-Santos et al., 2019).
These findings align with previous studies conducted in the Spanish context, as indicated earlier (Arrue-Gerra et al., 2024; Ayuso et al., 2019b; Rodríguez-Almagro et al., 2018). Arrue-Gerra et al. (2024) highlights the limited opportunities for providing HE due to time constraints and insufficient support from the school team. It is noteworthy that, despite the absence of regulations in Spain concerning the role of school nurses, countries like the United States and the United Kingdom, where this practice has been established for several years, face similar challenges (An et al., 2022; Hopkinson & Petty, 2023; McDermott et al., 2018). In the process of establishing the role of the school nurse in Spain, it is imperative to consider these areas for improvement. This consideration is essential to prevent the recurrence of similar errors, thereby enabling an effective response to the challenges that may arise (Arrue-Gerra et al., 2024). Moreover, it is noted that school nurses have the potential to engage in more preventive tasks given their training and preparedness. They could play pivotal roles in facilitating the development of self-management skills during the pediatric health transition to adulthood. Nevertheless, the study by Charlucien-Koech et al. (2024) emphasizes that a significant number of school nurses fail to fulfill this function due to a lack of tools, connections with the health system, and appropriate spaces. Consequently, they often find themselves focusing on providing ad hoc emergency care.
School nurses are absent in Spanish schools despite a nationwide decline in healthy habits among children and adolescents (Rodríguez-Almagro et al., 2018). To resolve this issue, it is imperative to enact legislation establishing permanent regulations governing the presence of school nurses (Ayuso et al., 2019a). Charter and private educational institutions in Spain provide school nursing services to ensure student well-being and safety, a hallmark of quality that attracts families and boosts enrollment (Martínez-Santos et al., 2019). The benefits from the presence of school nurses are substantiated by data derived from continuous student health monitoring, which informs the development of Evidence-based School programs tailored to address health challenges (Ayuso et al., 2019b; Pestaner et al., 2022).
The implications of this study carry significant consequences for nursing practices in Spain, particularly regarding school and pediatric nurses. Recognizing the distinct yet interdependent roles played by these professionals is crucial for optimizing healthcare delivery to children and adolescents. First and foremost, there is a compelling need to advocate for the mandatory presence of school nurses in all Spanish educational institutions. This advocacy represents a pivotal step towards ensuring comprehensive healthcare support for students, aligning with a holistic approach to well-being. Moreover, the study emphasizes the importance of recognizing school nursing as a specialized field. Integrating this recognition into healthcare policies and legal frameworks is vital, as it validates the unique skills and responsibilities of school nurses and promotes standardized practices. Collaborative efforts between school and pediatric nurses are critical for effective healthcare provision. Actively fostering and supporting collaboration between these two specialties, through the establishment of communication channels and protocols, are essential for enhancing the continuity of care. Additionally, the study underscores the necessity for formal regulation and mandates governing the practice of school nursing. Policymakers and relevant authorities should consider incorporating legal frameworks that define the scope of school nursing practice, ensuring clarity in roles, responsibilities, and standards. Finally, nurses and educators should collaboratively address contemporary health challenges within educational settings, promoting inclusive education and developing strategies that cater to diverse health needs. By implementing these recommendations, the school nursing profession can significantly contribute to enhancing healthcare services in educational settings in Spain.
In terms of the limitations of this study, it is essential to underscore those arising from the absence of a non-random sampling procedure. It is plausible that the attitudes of voluntary respondents might have been more favorable compared to those of non-participants. A potential avenue for further research could involve complementing the findings with longitudinal studies that elucidate the influence of nurses in the school environment. This could be accomplished by tracking the progress of both healthy students and those with chronic pathologies, assessing their personal development over time. Additionally, it would be pertinent to replicate the study and corroborate the information with input from nurses, teachers, and students who have availed themselves of these services, in order to discern the evolution of their roles and the educational and health impact thereof. In future studies, it would be interesting to explore the comparative benefits and drawbacks of different nursing models across all countries through interviews that provide valuable information about the role of school nurses.
It is essential to highlight that no comparable studies have been conducted to address these issues. The provided information presents a precise overview of the status of school nurses in Spain. School nurses warrant acknowledgment, appreciation, and national-level regulation. Their efforts not only lead to cost savings within healthcare systems but also play a pivotal role in upholding and fostering the health of the Spanish school population.
The authors express their gratitude for the active participation of all school and pediatric nurses who contributed with their professional experiences. Without their involvement, this study would not have been feasible. They also extend their thanks to the Spanish Official College of Nursing, especially to Burgos College of Nursing and the Madrid Association of Nursing in Educational Centers (AMECE).
All authors contributed equally.
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: The authors did not receive any financial support for this article, but had the support of the Spanish Official College of Nursing and the Madrid Association of Nursing in Educational Centers (AMECE).
Laura Armas Junco https://orcid.org/0000-0002-5263-7519
Laura Alonso Martínez https://orcid.org/0000-0001-5425-5090
María Fernández Hawrylak https://orcid.org/0000-0002-7222-587X
Supplemental material for this article is available online.
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Laura Armas Junco, PhD, is an Assistant Professor in the Area of Didactics and School Organization within the Department of Educational Sciences at the Faculty of Teacher Training and Education, University of Oviedo. She is a pedagogue and a social educator.
Laura Alonso Martínez, PhD, is an Assistant Professor in the Area of Nursing within the Department of Health Sciences at the Faculty of Health Sciences, University of Burgos. She is a nurse and a psychologist.
María Fernández Hawrylak, PhD, is Professor in the Area of Didactics and School Organization, part of the Department of Educational Sciences at the Faculty of Education, University of Burgos. She is a pedagogue and an educator.
1 Area of Didactics and School Organization, Department of Educational Sciences, Faculty of Teacher Training and Education, University of Oviedo, Oviedo, Spain
2 Area of Nursing, Department of Health Sciences, Faculty of Health Sciences, University of Burgos, Burgos, Spain
3 Area of Didactics and School Organization, Department of Educational Sciences, Faculty of Education, University of Burgos, Burgos, Spain
Corresponding Author: Laura Alonso Martínez, Area of Nursing, Department of Health Sciences, Faculty of Health Sciences, University of Burgos, Burgos, Spain. Email: lamartinez@ubu.es
