The Journal of School Nursing
2021, Vol. 37(3) 146-156
© The Author(s) 2020
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DOI: 10.1177/1059840519899439
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School nurses are instrumental in delivering health services to children in schools. This study addresses the gap in school nurse health services data, examining patterns in health services and programs provided by school nurses between 2006 and 2016 for students in North Carolina public schools. This study focused on services and programs related to asthma and diabetes, two health conditions that affect millions of children in the United States. Over 1.46 million children attend North Carolina public schools. In 2006, the average school nurse-to-student ratio was 1:1,340. By 2016, the average school nurse-to-student ratio decreased to 1:1,086, a 19% improvement. Over the 10-year study time period, there were statistically significant increases in the rate of occurrence of all health conditions that students received health services for (p < .001), asthma (p < .001), type I diabetes (p = .0003), orders for all health-care procedures (p = .01), all school nurse–led health counseling (p = .004), and diabetes health counseling (p < .01).
school nurse, children, school health services, asthma, diabetes
School nurses intervene with students, families, and school staff each day to maintain or improve the health and academic success of students (Leroy et al., 2017). Evidencebased practice for school nurses includes providing students with acute/emergency and preventive care, care coordination, as well as assisting students with management of chronic health conditions (Centers for Disease Control and Prevention [CDC] Healthy Schools, n.d.-b). There are 51 million children who attend public schools in the United States (National Center for Education Statistics, n.d.). The 2017 National School Nurse Workforce Study of 1,062 public schools found an estimated 25.2% of the schools included in the sample did not employ a school nurse, and 55.9% of school nurse respondents were responsible for providing school health services in two or more schools (Willgerodt et al., 2018).
School nurses are viewed as the school-based manager delivering health services to school-aged children (Maughan et al., 2016), with the vital role of supporting all facets of student health, including physical, emotional, mental, and social well-being (American Nurses Association and National Association of School Nurse [NASN], 2017). They coordinate and provide services that support improvement and maintenance of student health and academic success. This is accomplished through direct care, program and policy development, education for school staff and students, health promotion and prevention, care coordination between student, family, school, and home, as well as quality improvement activities (e.g., data collection, documentation, measuring meaningful outcomes; NASN, 2016b).
School health services can positively impact student health outcomes, such as quality of life and symptom days, as well as education outcomes, including attendance and grades. School nurse–led student counseling has been associated with improved quality of life (p < .05; Pbert et al., 2013, 2016) and increased asthma symptom-free days (p < .001; Halterman et al., 2011). Case management programs implemented by school nurses have been associated with improved education outcomes for students diagnosed with asthma and diabetes. Moricca et al. (2012) found that students’ average days missed due to asthma decreased from 5.8 days to 3.7 days (p = .003) through school nurse case management, while Engelke et al. (2011) found that 69% of 42 students with diabetes met their goal to decrease the number of health-related absences.
A recent integrative review of empirical research in the United States explored school nurse interventions and activities and how they impact student outcomes (Best et al., 2018). In that review, 55% (36 of 65) of included studies focused on care coordination–related school nurse interventions and activities (Best et al., 2018). School nurses implement care coordination health services in their daily practice, including school nurse–led case management, chronic disease management, collaborative communication with other school and medical professionals, counseling, education, and student care plans. Only 26% of the included studies explored links between school nurse interventions and student health and education outcomes. There was also a lack of standardization in how school nurse interventions were identified and student outcomes measured (Best et al., 2018).
Although recognized as the health expert in school, measurement of the school nurses’ impact on student health and success is challenging, in part because school nurses collaborate with others to care for school children, and it is difficult to measure improved health of students from school nurse leadership, care coordination, advocacy, and mitigation of various barriers to health (NASN, 2018). School nurses must identify school nurse–sensitive outcome measures that distinguish the effect of school nursing interventions from effects of family and community on student, family, and school community outcomes (Bergren, 2011). Examining the impact of school nurses on student health and education outcomes is necessary to illustrate the impact on the student educational process, the need for students to have access to a school nurse each day, and to direct planning and resources for the types of services needed. There is a gap in the availability of data in current national data sets that capture health care provided to students in school (Bergren et al., 2016). To address the gap in school nurse health services data, this study focuses on services that are related to two chronic conditions that are now significantly affecting children, asthma and diabetes. Asthma is a leading chronic condition that affects over 6 million children in the United States and one of the leading causes of school absenteeism (CDC National Center for Chronic Disease Prevention and Health Promotion [CDC NCCDHP], 2017; Engelke et al., 2014; McClanahan & Weismller, 2017; National Association of Chronic Disease Directors [NACDD], 2016). In the 2017 National Health Interview Survey (NHIS), researchers found an 8.4% prevalence rate for asthma in children aged less than 18 years, an increase from 8.3% in the 2016 NHIS (Centers for Disease Control and Prevention National Center for Environmental Health [NCEH], n.d.-b.). In a longitudinal study (2002–2012) of diabetes across five study centers, researchers found incidence rates had a relative annual increase of 1.8% for type 1 and 4.8% for type 2 diabetes in children aged 0–19 years (Mayer-Davis et al., 2017). In 2015, about 193,000 youth under 20 years of age were diagnosed with diabetes (CDC, 2017).
While data on school nurse health services do exist, the data sets are disparate, not collected in a standardized format, and do not describe school nurse health services and student outcomes over time. North Carolina, however, is a leader in data collection (Johnson et al., 2017). Since the 1996–1997 school year, the North Carolina Division of Public Health has collected data submitted by school nurses based on their records of health services provided in assigned schools. These data that represent a large, longitudinal data set about school nurse health services in North Carolina were analyzed for this study.
The purpose of this annual data survey has remained the same since its inception in 1996 (North Carolina Department of Health and Human Services, 2018, p. 2):
The aim of this study is to describe patterns in health services and programs provided by school nurses. This study focuses on the major health conditions of asthma and diabetes of elementary, middle, and high school students in North Carolina public schools between 2006 and 2016.
The study design was a longitudinal repeated measures analysis of school health services data as reported to the Children and Youth Branch of the North Carolina Division of Public Health. Project data were collected during school years 2006–2007 through 2015–2016. School nurses representing all 115 North Carolina public school districts reported data each school year. While these data are representative of students enrolled in public elementary (K–5th grades), middle (6th–8th grades), and high (9th–12th grades) schools who received nursing services, other student-specific data, such as demographic data, are not collected. This study was determined to be exempt by the University of North Carolina at Chapel Hill institutional review board (17-0069).
This study used data from the North Carolina Annual School Health Services Report Survey, developed and managed by data specialists and the School Health Nurse Consultant Team in the Children and Youth Branch of the North Carolina Division of Public Health. The team consists of the State School Health Nurse Consultant and six Regional School Health Nurse Consultants, directly managed by the state position. Although further developed over time, the report survey process has been in place since 1996 and is regarded as an agency priority. Prior to each school year, the survey questions, collection, feedback from stakeholders, and the previous year’s data are reviewed to inform needed revisions in the instruments, process, or definitions. District lead nurses/nurse supervisors receive the current year instruments at the start of the school year with a review and discussion of issues and changes at a regional meeting. Additional data collection instruments are available for daily school nurse use, and assistance is provided through the school year in assuring the integrity of the data at the local level. Data are collected and aggregated at the district level prior to submission. During the course of the study years, the survey changed from hard copy submission of data to electronic submission. The regional nurse consultants maintain a close relationship with each school district that provides access for questions and detailed knowledge of district services. Submitted data are reviewed and revised through a four-step process completed by the nurse consultant team and the data manager. The survey includes instructions with standardized definitions that assist with collecting and reporting the data accurately. The nurse consultant team and data manager are available for assistance throughout the school year.
All 115 school districts submitted data for each school year included in the study (2006–2016), yielding a 100% return rate. Not all questions were relevant to each school district; if the district did not provide all services and programs, or collect all the data included in the survey, some questions were not applicable. Due to this, each question did not have a response from all school districts. Throughout the 10-year study period, various questions were deleted or added to the survey, based on North Carolina school nursing policy or program changes. As such, results were not available for each variable for all school years. Through a data use agreement, the North Carolina Division of Public Health/School Health Unit provided existing aggregated data by school district, and all school nurse identifiers were removed prior to obtaining the data. Publicly available data from the North Carolina Department of Public Instruction were used to obtain annual summaries of North Carolina public school information (e.g., number of schools, number of students).
Sample characteristics. School district information included number of public schools and number of students in school each school year (available for 2006–2016). School district information did not include charter or private schools. School nurse information included highest degree earned and national school nurse certification (available between 2006–2009 and 2013–2016). Average school nurse/student ratios were based on full-time equivalents (FTE positions budgeted for school nurses) employed in the school districts.
Identified health conditions. For years 2006–2016, school nurses reported the number of students identified with health conditions (e.g., asthma, cystic fibrosis, diabetes) that required action at school (e.g., available medication, health-care plan, accommodations). History of health conditions without needed action in school was not reported. The rate of occurrence of all health conditions receiving services, and specifically asthma, type 1 diabetes, and type 2 diabetes was analyzed. For the purposes of this study, rate of occurrence for a health condition is the number of students diagnosed with the health condition that received services for that condition at school. As stated previously, asthma and diabetes are of interest particularly due to their increased national incidence rates and effect on educational outcomes such as increased school absenteeism rates and poor grades (NASN, 2017).
Health education presentations and programs. For years 2006–2016, school nurses reported number of times group presentations (e.g., alcohol and drug abuse, allergies, dental health) were provided and what health topics the education addressed. School nurses also reported number of asthmaspecific staff and student asthma education programs, staff generalized (training for all school staff) and intensive training (detailed training for at least two school staff) on diabetes care.
Health counseling. The overall measurement of counseling sessions was available for the entire 10-year study period. However, asthma and diabetes counseling were added to the survey starting in the 2009–2010 school year and counseling for injuries that began or occurred outside of school was removed from the survey in the 2013–2014 school year. School nurses served as health counselors and worked on a one-to-one basis with students to address a variety of health needs (e.g., asthma, depression, diabetes, injury, puberty/reproductive health). One-to-one counseling included a formal discussion and documentation of the encounter. This section did not include group or classroom education. School nurses reported the total number of counseling sessions. Rates of occurrence of all health counseling sessions, regardless of type, asthma health counseling, and diabetes health counseling were analyzed.
Health-care procedures. The number of students with healthcare procedure orders was available for years 2006–2016, with the exception of glucagon injection (2006–2014) and pulse oximeter (2009–2016). School nurses reported the number of students with health-care provider orders for specialized care procedures (e.g., clean intermittent catheterization, dressing change, tube feeding) that were performed in the school setting. Rates of occurrence of orders for any procedure, asthma-related procedures (nebulizer treatment, pulse oximeter), and diabetes-related procedures (blood glucose monitoring, glucagon injection, insulin injection, and insulin pump) were analyzed.
Descriptive statistics (means, standard deviations, frequencies, proportions) were computed for all health services and programs, nurse demographics, and school district characteristics at the different time points and overall. Next, longitudinal graphical displays (mean profiles, histograms of the counts) were created to identify patterns in the health services and programs data and to inform subsequent modeling decisions. Differences in health services and programs were evaluated by grade level and school year by a generalized linear model for longitudinal data analysis using a generalized estimated equations approach (Diggle et al., 2002). A separate Poisson regression model was fit with the log link to each nonnegative discrete (count) health services and programs variable. These models included time (entered as a categorical variable) and grade (when collected) as fixed effects; an exchangeable correlation structure was assumed. Each Poisson model was evaluated for overdispersion. When it occurred, overdispersion was managed by applying a scaling factor to the covariance matrix. All analyses were performed in SAS software Version 9.4 (SAS Institute, Inc., Cary, NC). Tests of hypotheses were two-tailed, and a p value ≤ .05 was considered statistically significant. No adjustment was made for multiplicity.
The study sample included 115 school districts. Between 2006 and 2016, the number of public schools across all school districts increased from 2,304 to 2,434, a 5.6% increase. The number of students who attended public schools in North Carolina increased by 5% from 1.39 million to 1.46 million, with more students in Grades K–5 (∼680,000), than Grades 6–8 (∼340,000) and 9–12 (∼435,000). Trends for nurse-to-student ratios and school nurse FTEs can be seen in Figure 1. The number of school nurse FTEs increased from 1,034 to 1,318, a 27% increase. The average school nurse-to-student ratio decreased from 1:1,340 to 1:1,086, a 19% improvement. Between 2006 and 2016, the percentage of school nurses with at least a Bachelor of Science in Nursing increased from 65% (554 of 854 nurses) to 75% (1,018 of 1,357 nurses). The number of school nurses that held national school nurse certification increased from 474 to 699; however, the overall percentage of certified school nurses decreased (56–52%).
Between 2006 and 2016, asthma, attention deficit disorder/attention deficit hyperactivity disorder (ADD/ADHD), and severe allergies were the most common health conditions in students who received health-care services in school (Table 1). Over time, there were statistically significant changes in the rate of occurrence of all health conditions (p < .001). Compared to the 2006–2007 school year, there was a decrease in the rate of occurrence of health conditions from 2007–2008 to 2009–2010 and the 2015–2016 school year, while the rate of occurrence of health conditions increased from 2010–2011 to 2014–2015.
There were also statistically significant changes for the chronic conditions of interest: asthma and type 1 diabetes. Compared to the 2006–2007 school year, there was an increase in the rate of occurrence of asthma in all school years (2007–2008, 2009–2010 through 2015–2016) except the 2008–2009 school year (p < .001). For type 1 diabetes, compared to the 2006–2007 school year, there was a decrease in the rate of occurrence from 2007–2008 to 2009–2010 and an increase from 2010–2011 to 2015–2016 (p = .0003). There was no significant change over time in type 2 diabetes.
There was also a significant difference between grades. Elementary school students experienced a higher rate of occurrence of all health conditions and counts of asthma than middle and high school students (p < .001). High school students experienced a higher rate of occurrence of type 1 and type 2 diabetes than elementary and middle school students (p < .001).
The mean number of group presentations school nurses taught in all school districts decreased from 232 (SD 490.9) in 2006 to 212.8 (SD 331.0) in 2016. Even though the counts of asthma increased, the number of school districts for which school nurses provided asthma education programs for school staff decreased from 49 (43%) in 2006 to 38 (33%) in 2016, and asthma education programs for students decreased from 53 (46%) school districts in 2007 to 30 (26%) school districts in 2016. Since 2007, 94–99% of school districts have offered group diabetes management presentations. Generalized and intensive diabetes trainings for school staff were reported from 2009 to 2016; during that time, the number of school districts that offered generalized diabetes training programs increased from 105 (91%) to 114 (99%). School districts with at least two school staff intensively trained on diabetes care increased from 111 (97%) to 114 (99%).
Between 2006 and 2016, the most common one-to-one health counseling was injuries that began/occurred outside of school, asthma, and diabetes (Table 2). Over time there were statistically significant changes in the rate of occurrence of all health counseling sessions (p = .004). Compared to 2006–2007 school year, there was an increased rate of occurrence of all health counseling sessions from 2007–2008 to 2009–2010 and a decrease from 2010–2011 to 2015–2016. There were also statistically significant changes for diabetes-related health counseling sessions (p < .01). Compared to 2009–2010, there was a decrease in the rate of occurrence of diabetes health counseling sessions from 2010–2011 to 2011–2012 and an increase from 2012–2013 to 2015–2016. There was an increase in the rate of occurrence of asthma health counseling sessions; however, it was not significant.
Elementary school students received a higher rate of health counseling sessions for all topics (p < .001), asthma-related health counseling sessions (p < .001), and diabetes-related counseling sessions (p = .003) than middle and high school students.
Between 2006 and 2016, the three most common orders for health-care procedures were all related to diabetes care: glucose monitoring, insulin injections, and glucagon injections (Table 3). Over time, there were statistically significant changes in the rate of occurrence of orders for health-care procedures. Compared to 2006–2007, there was a significant increase in the rate of students with orders for all health-care procedures for all years (2007–2008 to 2013–2014, 2015–2016) except 2014–2015 (p = .01). There was also an increase in the rate of occurrence of orders for glucagon injections (p < .001) and insulin pumps (p = .01) for all school years. Although nonsignificant, over time there was an increase in the rate of occurrence in orders for glucose monitoring and insulin injections and a decrease in the rate of occurrence in orders for nebulizer treatments and pulse oximeter checks.
Elementary school students had a higher rate of orders for all health-care procedures, glucagon injections, and nebulizer treatments (p < .001) than middle and high school students. High school students had a significantly higher rate of orders for insulin pumps, glucose monitoring, and insulin injections (p < .001).
The purpose of this study was to describe the health services and programs provided under the direction of school nurses in North Carolina’s public schools between 2006 and 2016, concentrating on asthma and diabetes as chronic conditions.
In 2004, the North Carolina State Board of Education set a goal to reach a 1:750 school nurse-to-student ratio by 2014, which has been the historically acknowledged ratio recommendation (NASN, 2015). In the 2006–2007 school year, 31 (27%) school districts in North Carolina met this goal. By the 2015–2016 school year, 46 (40%) school districts met the 1:750 goal, while the average school nurse-to-student ratio in North Carolina was 1:1,086 (North Carolina Department of Health and Human Services, 2007; North Carolina General Assembly/Program Evaluation Division [NCGA/PED], 2017.) This is slightly above the national ratio of 1 nurse to 924–1,072 students reported in the 2015 NASN School Nurse Survey (Mangena & Maughan, 2015).
While the recommendation for school nurse to student ratios was 1:750, this universal ratio used to determine a school nurse’s workload based on number of students and schools in a district does not consider the complex health concerns of students, nor the environment in which they live (NASN, 2015). The NASN, National Association of State School Nurse Consultants, and American Academy of Pediatrics (AAP) no longer support a 1 school nurse to 750 students ratio. It is now recommended that every student has daily access to a school nurse (AAP Council on School Health, 2016; Combe et al., 2015; NASN, 2015). This approach takes into account not only nurse ratios but also social determinants (e.g., access to care and healthy food, safe and healthy neighborhood), student achievement, and collaboration with families, health-care providers, and school staff (Combe et al., 2015). In the 2015–2016 school year, 5 of 115 (4%) of North Carolina’s public school districts met this recommendation. To provide one nurse in every North Carolina public school will require substantial local and state investment to hire an additional 1,100þ nurses, which the Program Evaluation Division of the North Carolina General Assembly estimates will cost up to US$79 million each year (NCGA/PED, 2017).
There were statistically significant increases in all health conditions receiving services between 2006 and 2016, which include but are not limited to asthma, diabetes, ADD/ADHD, and severe allergies. Previous studies conducted in the United States found a steady rise in chronic health conditions such as asthma, diabetes, attention deficit disorder, and obesity (Miller et al., 2016; Perrin et al., 2014). The high number of health conditions is concerning because chronic conditions put students at risk of increased absenteeism, poor grades, and poor health that can persist into adulthood (NASN, 2017).
This study identified asthma as the health condition dealt with most frequently by school nurses. On average, each year 94,000 students were identified with receiving health services for asthma. This result is consistent with national findings. With a national prevalence rate of 8.4%, asthma is one of the leading chronic conditions and top cause of school absenteeism in the United States (CDC NCEH, n.d.-b; NACDD, 2016).
Between 2006 and 2016, there was a significant increase in students receiving services for type 1 diabetes, but not type 2 diabetes. In comparison to asthma, the average number of students identified with diabetes was much lower. On average, each year 4,698 students were identified with diabetes, with more cases of type 1 (average 3,663) than type 2 (average 1,034). About 208,000 children 20 years and younger living in the United States are affected by diabetes (CDC NCCDHP, 2017). The SEARCH for Diabetes in Youth study (2002–2012) identified 11,245 children in five U.S. study centers with type 1 diabetes and 2,846 children with type 2 diabetes (Mayer-Davis et al., 2017). The researchers found that, after adjusting for age, sex, race, and ethnic group, the relative incidence of both type 1 and type 2 diabetes increased each year (Mayer-Davis et al., 2017). To help students with diabetes stay in school, healthy, and ready to learn, it is imperative they have access to health services while in school that help them manage their chronic health condition (CDC NCCDHP, 2017). School nurses have a pivotal role in supporting students with chronic conditions such as diabetes through direct care (blood glucose checks, insulin and glucagon injections), education (one-to-one counseling for self-management, group education for school staff and parents), and care coordination (coordinating with parents, health-care providers, teachers, counselors, coaches; CDC NCCDHP, 2017; Leroy et al., 2017; NASN, 2017).
Although more students were identified for needed services with asthma than diabetes, more school districts offered staff diabetes education (96%) than staff asthma education (37%). This may be explained by North Carolina state policy. The North Carolina state legislature enacted the Care of Students with Diabetes Act (North Carolina Session Law 2002-103/Senate Bill 911 and North Carolina Session Law 2009-563/Senate Bill 738) to address schoolchildren with diabetes. These laws required the North Carolina State Board of Education to adopt guidelines recommended by the American Diabetes Association. Adopted guidelines include staff training for teachers and other school staff to support students with diabetes and individual health-care plans after request by a student’s parent or guardian (North Carolina Session Law 2002-103, Senate Bill 911, § 115C-47; North Carolina Session Law 2009-563, Senate Bill 738, § 115C-375.3). This was a positive step to address the needs of students with diabetes. However, if meeting the statutebased requirements causes school nurses to be more focused on diabetes management than asthma management, school nurses and other school health stakeholders will need to create effective strategies for improving student and staff access to asthma education as well as other leading health conditions (NACDD, 2016).
The number of school districts that provided group asthma education presentations for students decreased over time from 53 (46%) to 30 (26%), an alarming finding in light of the impact of asthma on educational outcomes such as chronic absenteeism. Successful school-based asthma programs include administrative buy-in and building a team that includes a full-time school nurse to support the program, providing asthma education for students, school staff, parents, and families (CDC NCEH, n.d.-a).
An overall decline in one-to-one student counseling sessions appears to be attributed to the removal of counseling for injuries that began or occurred outside of school from the health counseling section of the survey in the 2013–2014 school year. In the 2012–2013 school year, this type of health counseling accounted for 207,175 sessions (of 506,664 total sessions). The School Health Nurse Consultant Team decided to remove injuries that began or occurred outside of school from the health counseling section based on school nurse feedback that they did not distinguish between seeing a student for something that occurred at home versus school. Also, encounters for injuries often were for provided health care, not health counseling.
One-to-one health counseling sessions represent less visible components of the professional school nurse role that are imperative for successful management of chronic health conditions in schools. They are inherent to the school nurse case management process and a component of higher level nursing service. Individual student counseling and education regarding living a life with a chronic condition is a necessary component for success.
Due to the increased rate of occurrence of students receiving services for asthma in the health conditions section of the survey, an increased rate of occurrence was expected for asthma health counseling sessions. Compared to the first school year asthma was included in the health counseling section of the survey (2009–2010), this was true for each school year; the increases, however, were not statistically significant.
Elementary school students received more individual asthma health counseling sessions than middle and high school students. This was an expected finding due to the higher rate of occurrence of elementary students receiving services for asthma than middle and high school students. Also, because asthma symptoms often develop in children before 5 years of age, elementary school students are less likely to be independent at their young age and require more support from the nurse. Structured education focused on self-management, combined with group presentations and family involvement, is beneficial to controlling asthma symptoms (U.S. Department of Health and Human Services, National Heart, Lung, and Blood Institute [NHLBI], 2007, 2014). Asthma education has been found to improve quality of life, increase confidence in asthma self-management, and reduce health services utilization and days out of school (Cicutto et al., 2013; Guevara et al., 2003; McGhan et al., 2010). Managing chronic health conditions such as asthma requires students to develop a solid knowledge base and skill set, which can be assessed and developed during individualized health counseling sessions with the school nurse (Carpenter et al., 2013; NHLBI, 2007).
Elementary school students had more orders for nebulizer treatments for asthma than middle and high school students. This was an expected finding because significantly more elementary school students were identified with asthma than middle and high school students. However, considering the numbers of students identified for services with asthma, higher numbers of students with orders for nebulizers might have been expected. This finding may be due to asthma medication guidelines that recommend the use of inhaled corticosteroids as the preferred treatment for management of persistent asthma (Hsu et al., 2018). Because medications through nebulizer in school are most often for medications used to treat acute symptomatology when controller medications have failed, well-controlled students may not be prescribed them as often (Hsu et al., 2018; NHLBI, 2007).
Because more high school students than elementary and middle school students were identified with receiving services for type 1 and type 2 diabetes, there was an expectation that high school students would have more diabetes healthcare procedure orders (i.e., glucagon injections and insulin pumps). This was true for insulin pump orders, which provide a child with flexibility in meal times and how they administer insulin. Insulin pumps are also beneficial to a child’s quality of life and ease apprehension about hypoglycemic episodes (Abdullah et al., 2014; American Diabetes Association, 2013; Mueller-Godeffroy et al., 2009).
Strengths of this study include the use of a longitudinal data set that represents 1.5 million public school students in one of the largest school systems in the United States. These data provided a rich source of population-based information about school nurse health services provided to students enrolled in public elementary, middle, and high schools in North Carolina. The survey used for this study had a 100% participation rate by all 115 North Carolina school districts. This is the first study that has been conducted using this data set to describe trends in school nurse health services and programs provided to public school students in all 115 of North Carolina’s school districts.
This study is not without limitations. Although all school districts participated in the survey, not all questions pertained to each district, and some questions were not answered for other unknown reasons. This study does not include all school nurse health services provided by school nurses in North Carolina.
School nurses practice in schools throughout the United States, providing evidence-based health-care services for more than 56.6 million children in public and private schools (NASN, 2016b; NCES, n.d.). School nurses provide support to children, parents, families, and school staff and promote health through activities such as individual and group education programs, health counseling, and care coordination. This study provides insight into the changes over time of data collected by school nurses about health services they provide and health conditions identified in students who required action while they attended school, in particular asthma and diabetes.
First steps to being able to capture changes in the health of the student population and services school nurses provide include having command of the data about the students, school, and community (Begren, 2016). Understanding the demographic data of students and the community (school district) can provide insight into how social determinants impact students and families (Begren, 2016; NASN, 2016a). When considering interventions for students and families, school nurses can take demographic data into account, along with the types of health conditions with which students are diagnosed. Also, it is important for school nurses to collect and analyze data about the numbers and types of health conditions students have, the care they provide, and their impact on student health and education outcomes. It is imperative that these data are collected in a standardized form (e.g., using the same terms and definitions) so that data can be aggregated (Bergren et al., 2016) across state school districts and nationally.
North Carolina school nurses commit considerable time and effort to collect data about school health services to support school district quality improvement. However, this intended purpose has morphed into also using these data to tell an important story about school nurse health services. Often state agencies are limited in being able to develop this story; thus, it is essential that researchers enter into relationships with community partners. It is beneficial on both sides for researchers and nonacademic community organizations to work together to use data sets that may have not been created for the purposes of research but can be used to help both the researcher and community identify meaningful trends and more clearly understand challenges and resources in the community.
As North Carolina school nurses continue to improve models of care to better meet student health needs, future research should include examination of the data for possible links between school nurse-to-student workforce and workload ratios, health services and programs, and student health and education outcomes. The improvement seen in school nurse workforce factors, such as increased FTE and professional credentialing, is expected to result in a greater capacity to provide health services that impact student health and education outcomes.
Future studies are needed to determine which school nurse health services and programs, such as health office visits, medication administration, and school nurse case management for children with chronic conditions, may be most beneficial and cost efficient to students with asthma, diabetes, and other chronic health conditions. Future cost–benefit analyses studies are important to better understand the value of care coordinated by school nurses and how school nurses optimize overall health-care utilization (e.g., decreasing using of emergency rooms and urgent cares) by providing timely preventive care.
Future research can focus on school nurses working with community partners to address health behaviors and socioeconomic factors to build a culture of health that improves student, family, and community outcomes. Promoting health in the school environment is important, but where students live and play must also be taken into consideration. School nurses have a wealth of knowledge and experience in improving health outcomes (Leroy et al., 2017; NASN, 2017) and are well positioned to assess community needs, develop a plan (e.g., preventive health services, education programs that promote healthy eating and increasing physical activity), and evaluate outcomes (NASN, 2018).
This study captures factors related to the health of schoolaged children in North Carolina’s public schools and school nursing service trends and, in particular, services related to asthma and diabetes. Using data to understand what health conditions commonly require health services in a school can assist school nurses and community stakeholders at a local level and legislators at the state and national levels. This can help them target resources for students that may be at risk of particular conditions such as asthma or diabetes, while developing programs in a manner that is evidence-based and priority-driven.
The authors would like to acknowledge North Carolina school nurses who provided the reviewed services and shared their data. This work is possible only through their efforts.
All authors contributed to the overall concept of the manuscript and acquisition as well as analysis of the data involved. Nakia C. Best, Bosny Pierre-Louis, Sonda Oppewal, Debbie Travers, Anna E. Waller, and Meg Zomorodi drafted the manuscript. All authors were involved in the revision process, gave final approval, and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Nakia C. Best, PhD, RN https://orcid.org/0000-0002-4111-0527
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Nakia C. Best, PhD, RN, is an assistant professor at Sue & Bill Gross School of Nursing at The University of California, Irvine.
Ann O. Nichols, MSN, RN, NCSN, is the state school health nurse consultant at the North Carolina Division of Public Health.
Sonda Oppewal, PhD, RN, is a clinical professor at the University of North Carolina at Chapel Hill School of Nursing.
Bosny Pierre-Louis, DrPH, MPH, is a biostatistician at Novion Analytics.
Anna E. Waller, ScD, is a research professor in the Department of Emergency Medicine and Director of the Carolina Center for Health Informatics at the University of North Carolina at Chapel Hill.
Meg Zomorodi, PhD, RN, CNL, is an assistant provost for Interprofessional Education and Practice and Professor at the University of North Carolina at Chapel Hill.
Debbie Travers, PhD, RN, is an associate professor at the University of North Carolina at Chapel Hill School of Nursing.
1 Sue & Bill Gross School of Nursing, The University of California, Irvine, CA, USA
2 Children and Youth Branch, Division of Public Health, NC Department of Health and Human Services, Raleigh, NC, USA
3 School of Nursing, University of North Carolina at Chapel Hill, NC, USA
4 Carolina Center for Health Informatics, Department of Emergency Medicine, University of North Carolina at Chapel Hill, NC, USA
5 Office of Interprofessional Education and Practice, University of North Carolina at Chapel Hill, NC, USA
Corresponding Author:Nakia C. Best, PhD, RN, Sue & Bill Gross School of Nursing, The University of California, 120C Berk Hall Mail Code: 3959, Irvine, CA 92697, USA.Email: nbest@hs.uci.edu
