The Journal of School Nursing
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DOI: 10.1177/1059840520946833
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2022, Vol. 38(3) 287–298
Many school districts rely on caseload or student to school nurse ratios that are not grounded in evidence-based research. There is a need for a comprehensive workload instrument to describe the work of school nurses that incorporates the complexities of the role and includes acuity, care processes, and social determinants of health. The purpose of this qualitative study was to identify workload activities from a previous Delphi study that can be empirically measured as items for a workload instrument. A nationally representative sample of 27 school nurses participated in four focus groups, describing activities important to the measurement of workload. Focus group input resulted in identification and confirmation of workload activities that impact school nurse workload. Use of the National Association of School Nurses’ Framework for 21st Century School Nursing Practice™ was integral in capturing gaps and important workload activities for a potential workload instrument.
workload, school health nursing, instrument development, school nursing organization and administration, evidence-based practice, qualitative research, role promotion/development
School nursing workload is usually defined by a caseload number, the number of students assigned to a registered nurse. A commonly cited reference point is one school nurse for every 750 students (National Association of School Nurses [NASN], 2015). However, there is a lack of research-based evidence to support this workload model (Combe et al., 2015; Jameson et al., 2018). A caseload ratio as a measure of school nursing resource consumption does not take into account variance in the length of time a student spends with the school nurse; the services provided; and the amount of time spent on documentation, phone calls, and developing care plans.
School nursing is a unique specialty, grounded in community/public health (Schaffer et al., 2016). The role of the school nurse is complex and includes care coordinator and case manager, reviews and evaluates school health services, follows communicable disease control procedures, and serves as the health team leader and resource person to the school and community regarding health issues (NASN, 2016). The school nurse professional role is guided by tenets of the scope and standards of practice (American Nurses Association [ANA] & NASN, 2017) and the Framework for 21st Century School Nursing Practice™ (the Framework™; Maughan et al., 2016).
The work nature and administrative hierarchy of the school nurse’s work environment differs greatly from other health care settings. School nurses regularly practice alone in the school building and are often the only person onsite with health-related skills. The direct supervisor of the school nurse is often a school administrator who has little or no understanding of health care, the role of school nurses, scope of practice, or the legal implications of professional licensure (C. R. Davis, 2018). Commonalities exist among various nursing specialties; however, current information related to nursing workload is largely focused on acute care nursing.
Understanding and defining nursing workload is a complex task. No published definition of school nurse workload was identified at the time of this article. Therefore, we examined workload definitions specific to nursing in general. No one consistent definition of nursing workload was located in the published literature. Two recent acute care nursing workload concept analyses were discovered in the literature (Alghamdi, 2016; Swiger et al., 2016). Both researchers reported the definition and the concepts used to quantify workload are inconsistent and at times contradictory. For example, the terms used in the definition include nursing work, nursing workload, patient dependency, and nursing intensity. The authors also noted that nursing workload includes non-patient-specific activities or concepts that are difficult to measure, such as documentation, case management, professional development, and patient education.
Alghamdi (2016) concluded that the attributes or activities of nursing workload could be described through five categories: the amount of nursing time, the level of nursing competency, the weight of direct patient care, the amount of physical exertion, and complexity of care. Alghamdi (2016) proposed that “Nursing workload is the amount of time and care that a nurse can devote (directly and indirectly) towards patients, workplace, and professional development” (p. 455). Similarly, Swiger et al. (2016) proposed that nursing workload is influenced by nurse, patient, unit, and organizational variables that can promote or hinder the delivery of highquality patient care. The authors proposed that “Nursing workload is the amount of time and physical and/or cognitive effort required to accomplish direct patient care, indirect patient care and nonpatient care activities” (p. 252).
The workload indicators for school nursing must include student-specific activities; indicators that benefit students, families, and community/population health but do not involve face-to-face care or contact; and be distinct to the school nurse environment. Additionally, the workload indicators must be consistent with the scope and standards of school nursing practice. Autonomous practice, individual and community health wellness and health promotion, advocacy, participation in research, contributing to school health policy development, and professional leadership are key components of the school nurse role (ANA & NASN, 2017). Items to be included should also address the five key principles from the Framework™: standards of practice, care coordination, leadership, quality improvement, and community/public health (Maughan et al., 2016).
For the purposes of this study, a broad workload definition that covers the complex array of individual and populationlevel services school nurses provide was required. Therefore, we chose to use the workload definition from Bowling and Kirkendall (2012). The authors define workload as “an allencompassing term that includes any variable reflecting the amount or difficulty of one’s work” (p. 222).
Difficulties reported in measuring nursing workload research indicated the complexity of the concept. It is apparent that one size does not fit all. Researchers cited multiple issues with measuring workload. Several examples included failing to include certain nursing activities such as not considering staffing mix and lacking in account of mental workload expenditure (Bowling et al., 2015; Mohammadi et al., 2015; Moloney et al., 2018). Other researchers reported that the workload tools lacked theoretical foundations, psychometric measures were not described or analyzed, and little incorporation of evidence-based practice components into the instrument (Griffiths et al., 2020; Meyer et al., 2020; Myny et al., 2014).
There is a vast amount of acute care nursing workload research available containing useful information for school nursing workload instrument development. Endsley (2017) conducted a scoping literature review of acute care, mental health, and community health nursing with the goal of understanding themes and concepts that may be applicable for school nursing workload research. Endsley identified workload themes that impact workload and were also applicable to school nursing: (a) missed nursing care, (b) unlicensed assistive personnel, (c) patient classification systems, (d) environmental factors, and (e) nurse satisfaction. Endsley concluded that although the work environment of the school nurse is a different clinical context than inpatient care, principles of quality care and patient (student) safety are paramount.
A review of the published literature discovered one workload instrument that was specific to the school nurse specialty practice environment, the School Health Intensity Rating Scale (SHIRS; Burt et al., 1996). Jameson et al. (2018) examined the SHIRS in their exploration of indicators related to school nursing workload. The scale was developed in 1996 and based on the Community Health Intensity Rating Scale (Burt et al., 1996; Peters, 1988). The SHIRS uses the foundational base of four main domains with classifications developed from community health research performed by Peters (1988): environmental, psychosocial, physiological, and health behaviors. Within each domain are sub parameters. Levels of intensity are applied to the sub parameters ranking the intensity based upon participatory involvement: Level 1 indicates participates in health care maintenance, Level 2 designates sporadic attention to health maintenance, Level 3 indicates responds to health crisis only, and Level 4 there is no interest in or lacks involvement ability. The instrument was piloted in 12 Midwestern school districts.
The last known use of the SHIRS is unclear. Klahn et al. (1998) used fictitious elementary age charts to establish inter-rater reliability. Karsting (2002) was the last published article found using SHIRS. The author continued to work with the SHIRS and applied some social adaptations to account for “student mobility” and trends in chronic diseases. The author reports that it was useful in supporting the need for additional nursing services. A lack of documentation of student mental health needs, an emerging trend at the time, was noted as a limitation of the tool. No psychometrics were reported.
The SHIRS, if adapted, may be useful for school nursing. However, school nursing roles and responsibilities have changed since the tool was last used. SHIRS was focused only on the intensity of care categorization of the students’ disease or illness and does not incorporate social determinants of health (SDOH). We do not know if the indicators are still appropriate 20 years later. The intensity rating scale requires psychometric testing.
Literature from school nursing supports the impact workload and staffing have on student outcomes, nurse outcomes, and organizational outcomes (Daughtry & Engelke, 2017; Duff, 2014; Hill & Hollis, 2012; M. J. Lineberry & Ickes, 2015; Wang et al., 2014). The American Association of CriticalCare Nurses (2016) considers appropriate workload and staffing as one of the six essential attributes necessary for a healthy work environment along with skilled communication, true collaboration, effective decision making, meaningful recognition, and authentic leadership. The consequences of a heavy nursing workload adversely affect job satisfaction, increase burnout, and contribute to poor patient outcomes (Jameson & Bowen, 2018; Liu et al., 2018; Van Bogaert et al., 2017).
Existing measures in other nursing practice environments do not adequately capture the complexity of the school nurse practice environment. This study builds on a previously conducted Delphi study that asked school nurses to describe and rank workload indicators that were generated from a comprehensive literature review and expert school nurse input. Four dimensions were identified: health condition and needs of the students, SDOH, characteristics of nursing staff, and characteristics of school community (Jameson et al., 2018). See Table 1 for the list of workload indicators from the Delphi study.
Therefore, this qualitative research study is proposed as a means to contribute to addressing the gaps in knowledge by examining activities that contribute to the workload of the school nurse in the practice setting. We are proposing to accomplish this purpose with the following specific aims: Study Aim 1: identify workload indicators from the Delphi study that can be empirically measured as items for a workload instrument. Study Aim 2: seek confirmation that the items generated from the Delphi study cover the range of workload indicators that school nurses experience.
A qualitative descriptive design was used to identify and describe activities (environmental and personal) that school nurses perceive as important to the measurement of workload, with the goal of construction of the initial indicators for a school nursing workload measurement tool. This study utilized one in-person and three online focus groups. Online focus groups were used to allow participants from various geographic locations, with different levels of education and school nurse experience to participate with a minimal cost for travel and time. Online focus groups have been found to be effective in research; literature suggests that the optimal number is 6–12 participants per focus group to reach data saturation, the point where further data collection does not provide any new insights relevant to the research questions (Boateng & Nelson, 2016; Tuttas, 2015). Data were collected under a protocol approved by the Rutgers University Biomedical and Health Sciences Institutional Review Board.
The participants sought were practicing school nurses and school nurse administrators. The goal was to identify a group of at least 25 school nurses using purposive sampling to participate in approximately four to six focus groups. Twentyseven school nurses ultimately participated in the focus groups. The inclusion criteria for participants was a minimum of 1 year of work experience as a school nurse in the United States. Individuals from varied roles in school nursing (elementary, middle, and high school), age, geographic location, and position (frontline nurse, school nurse administrator) were included to obtain representation throughout the United States. Regional divisions used by the U.S. Census Bureau (2018) formed the four geographic areas created for the focus groups. The school nurses responded to the call for participants by completing an online demographic data form including their name, email contact address, and identifying characteristics related to experience, location, and background. This information was used to stratify participants to ensure sample variety and geographic representation.
Participants were recruited through NASN members via the online weekly digest in January 2018. The NASN digest subscription is delivered to NASN members’ email and is a benefit of membership but also is available open access on the NASN webpage. NASN funded the research but had no input into recruitment or selection of the participants. Approximately 16,000 school nurses subscribed to the digest at the time of the call for participants. Three hundred eightynine individuals responded to the call for participants. Responses that were incomplete were removed, leaving the number of potential participants at 315. Participants were stratified by region and demographics to form representative groups. When dates and times were set for the regional focus groups, the number of individuals who were available resulted in approximately 10–15 per region. It is not known if any of the participants were part of the previous NASN Delphi study. The unit of analysis was the focus group, not the individual participants (see Figure 1).
This article focuses on responses to questions in the Workload Indicators section of the interview guide (Table 2). Each focus group was conducted by at least two members of the study team. The first focus group was considered a pilot focus group. It was held in-person in central New Jersey, and the methodology was consistent across subsequent focus groups. Three focus groups were held online using Skype for Business 2016 software. For each focus group, participants were emailed a link to complete the informed consent, the audio-recorded informed consent, and the demographic data form. Prior to the meeting, instructions for downloading the online meeting software, an overview of the online focus group process, and a copy of the workload indicators identified in the previous Delphi study were sent. Each group was approximately 60–90 min in length.
Focus groups were conducted between February 2018 and May 2018. Each was audio-recorded, and field notes were taken during the interviews. Identities of the participants were coded, and all results reported as aggregate data to maintain confidentiality. All subject information including audio-recordings, consent forms, demographic data forms, subject emails, and transcribed interviews were kept on a password-protected computer. There was no cost to the subject to participate in the study. Participants received a US$25 VISA gift card incentive.
Prior to the focus group meeting, the participants received a worksheet with the workload indicators identified in the previous Delphi study (see Table 1). Each participant was asked to review the workload indicator categories and be prepared during the focus group to rate the indicators on a scale of 1–10, with 1 being the lowest and 10 being the highest on their perceptions of (1) whether the item measured their workload activities and (2) is this data you collect and have access to. Each category had four to eight individual workload indicators. The participants were also asked, (1) Are the items appropriate for measurement in the school nurse office to assess workload? (2) Is the suggested data source for each item something you believe you can find and use for the indicators? (3) Is there anything missing? (4) What would you like to add?
The interview guide (Table 2) consisted of a series of questions and probes to guide the interview process. Participants were asked to describe their role and professional responsibilities, relate experiences from their school nurse job, and discuss the workload indicators. Examples of questions were “tell me about your workload,” “what challenges and barriers exist?” and “are the identified items appropriate for measurement in the school nurse office to assess workload?” Each workload activity was reviewed individually. The participants responded whether the item could be measured empirically, and whether they had access to the data or knew how to locate the data. They were asked to provide details on their perspectives of the workload indicators using the above questions as a guide. Each item on the worksheet (Table 1) was reviewed individually by asking how each participant rated the indicators and discussing any items that were rated below a 10. Group consensus was used to reach decisions to remove or keep each workload activity by asking the group to confirm a final vote of yes or no to keep the indicator.
The goal of the interviews was to obtain school nurse perspectives on the meaning and clarity of the items, including definitions, sources available to measure, and usefulness to school nursing. Transcribed audiotapes and interview notes were used to generate an item-by-item summary and included recommendations for item modifications. Three study researchers examined the content independently, and final decisions were made through consensus. These data interpretations were then verified by three school nurses from the focus groups. We returned synthesized and deidentified data results to review for accuracy and provide any comments. The school nurses reported accuracy of the data results and had no edits or suggestions for change. Data saturation was reached with the third focus group, and we held a fourth focus group to be certain that no new relevant knowledge was obtained from the new participants.
Twenty-seven school nurses participated in four focus groups in group sizes ranging from six to eight individuals. The participants were practicing school nurses and school nurse administrators. Study sample characteristics are presented in Figure 2. All participants were female and evenly represented each geographic area of the country with the most participants from the Midwest (n = 8, 30%). The majority were between 51 and 60 years of age (n = 12, 44%), 52% (n = 14) cared for 751 or more students, and 67% (n = 18) worked alone in one building.
The participants identified the workload indicators that could be empirically measured and described as an item for a school nurse workload instrument. Each workload activity from the Delphi study was presented to the participants. Each group was asked for consensus on the items as described in the Method section and outlined in Table 1. Four workload indicators were removed because they were considered not appropriate for measurement in the school nurse office or included data that could not be found; number of students without access to health care, number of students without health insurance, level of engagement (nurses’ dedication, vigor, and application of current Framework™), and school support (nurse supported and valued by administration, teachers, and staff for nursing care).
School nurses noted that there was not a measure for understanding the number of students without access to health care, and communication with parents did not always get the information they needed. Especially as one school nurse described, “we do not collect that information, parents may not say anything if I gave the child a referral. I don’t think anyone could even ask that, but we [school nurses] do know our communities. But to have this on every single student, no way.” Another stated this is a barrier that is encountered and may need further exploration, but again no information readily available: “We’ve had a couple of unexpected barriers that we found when it comes to accessing health care, the student had insurance, but they didn’t have transportation.”
Overall, the sense among the school nurses was that the number of students without access to health insurance data was not readily available, unless the students received Medicaid. The consensus was that these data were not readily available to the nurse to measure, and the resulting need to rely upon parent or guardian notification was problematic. Only some states require these data to be collected. However, the school nurses did talk about the number not being consistently reliable.
We’re not always made aware of that unless the parent shares that, that they lost their job, they lost their health insurance, or their student has a problem at school and then you call and say, well they need to go see a physician. And then the parents said, well we lost our health insurance.
School nurses described wanting to include this item, but the most felt it should be removed due to the subjective nature of the indicators and the lack of this type of assessment or measuring within the school nurse work environment. The discussion also encompassed the use of rubrics for evaluating the school nurse, and what items are included. No school nurse in the focus groups reported that the application of the Framework™ was used in their formal evaluations. For example, one nurse stated, “What metric to use? NASN membership?”
School support was also removed due to the subjective nature of the activities and lack of this type of assessment in current use within school nursing. Nurses reported that feeling appreciated and recognized for their contribution to the student’s health was important, “I think it’s just a given, when you feel valued, you’re going to do your best work.” However, the consensus was that this is not an item that is routinely measured and would be difficult to obtain.
Several workload indicators did result in discussion regarding a uniform or common definition. For example, nurses indicated that the number of invasive treatments/procedures and the number of students needing care planning were important but not well defined. Could we come to a common definition of invasive procedures? “I didn’t know if that meant cathing a student as invasive, or a tube feeding type invasive, or simply doing a dressing change.” It was decided to keep these workload indicators and develop a consistent, uniform definition for use.
Participants were asked to fully consider workload indicators they determined should be removed within the context of a nationwide instrument. For example, one school nurse office did not have access to data on the number of students on free or reduced (FRL) lunch. After discussion within the group, it was decided that the number of students on FRL should remain on the list. The data point is readily available to some school nurses, but others described that the information may need to be requested, or there was a misunderstanding with office staff regarding access to those data. In addition, the participants were asked if there were items that should be added to the workload indicators. No participants recommended new workload indicators.
In summary, this study identified workload indicators from the original Delphi study that can be empirically measured as items for a workload instrument. We found when applying NASN’s Framework™ as a foundation for appraising the workload indicators that the items generated from the Delphi study did not cover the entire range of workload indicators that school nurses experience, and as a result, we identified additional indicators beyond the Delphi study to include in a workload instrument.
The results of this study point to indicators to include in an instrument to assess workload of school nurses. The contributions of the school nurses from across the country in confirming the workload indicators and providing context to the role and responsibilities within the context of workload advance the understanding and provide evidence-based support for a school nursing workload instrument.
Several items dropped out of the factor list because consensus determined that they were not measurable. These include indicators related to SDOH student characteristics of access to health care and health insurance, school nurse characteristics that can be described as the professionalism and engagement of the school nurse, and overall support of the school for the school nurse. Given the role expectation that school nurses are care coordinators and case managers, the ability to measure certain SDOH such as access to health care and health insurance is disappointing. While nurses are wellpositioned as care coordinators in schools, measuring, availability, and consistency in the data is a concern (Elias et al., 2019; Schroeder et al., 2018). Often, the number of students receiving FRL is used as a proxy for levels of poverty that would include health insurance and access to health care.
As shown in our results, some school nurses struggle with locating data sources. Locating, collecting, analyzing, and reporting accurate school health data is imperative, whether the information is for a workload instrument or demonstrating the impact of school nursing (Bergren, 2016; Sheetz, 2012). To overcome the challenge of locating and accessing health data, King et al. (2019) compiled an annotated list of federal data sets. Jameson et al. (2018) compiled a table specific for school nurses on commonly used data and sources, including FRL. However, FRL still does not account for the ability to know the actual specific students or the numbers in the school population who do not have access to health care or health insurance; particularly as the evidence related to education and health disparities demonstrates the importance of health and academic success to future adult health and productivity levels (Martinez et al., 2020; Terry, 2019). The deleted workload measurement indicators may in fact contribute to school nurse workload but that at this time group consensus stated there are either no data available or they would be difficult to measure.
Lastly, several of the indicators posed challenges in that they were not well defined, for example, the number of invasive treatments/procedures and the number of students needing care planning. The indicators were kept, but the need for clear definitions and examples will be an important next step in instrument development. Overall and other than these four indicators, nurses indicated that the rest of the original indicators were appropriate and measurable.
Figure 3 displays the remaining workload measurement indicators categorized by the Framework™ principles. The use of the Framework™ as a guiding structure for data analysis notably revealed that two of the key principles of the Framework™, leadership and quality improvement, were not reflected in the original list of indicators. The school nurse experts in the earlier Delphi study did not identify indicators explicitly related to leadership or quality improvement, and the focus group participants did not identify that those were missing elements in a workload instrument. This experience alsounderscores theutilityoftheFramework™ in identifying key principles and components of school nursing practice.
Indicators that may be an example of the leadership principle could include membership and leadership roles on local, state, and national committees and boards; membership in advocacy organizations; participation in continuing education opportunities; as well as some of the other harderto-measure indicators of professionalism, such as engagement. Other aspects of leadership within the school nurse’s role include creating or revising policies and procedures and being an effective change agent in their school community through advocacy at the school, school system, school board, county, and state levels.
The quality improvement principle may be indicated by the presence of a robust data collection mechanism, competency assessment of assistive personnel, and appraisal of the school nursing/health program. Continuous quality improvement is a proactive process for implementing ongoing improvements in care processes to provide quality nursing outcomes (American Association of Colleges of Nursing, 2020). It involves the nursing processes of assessment, identifying issues, developing plans, implementing plans, and evaluating outcomes.
These are the beginning steps of identifying indicators that impact and define the work of school nurses. Our research identified several implications for school nursing practice. First, connecting the Framework™ to school nursing workload instrument development is essential to moving forward. The workload measurement indicators identified in the Delphi study and reviewed in the focus groups did not represent the Framework™ principles of leadership and quality improvement. This finding is similar to D. Davis et al. (2019), who conducted a survey with current school nurses to examine the scope of practice in the context of the Framework™ principles. They identified two principles, quality improvement and community/public health, as the least practiced. The authors called for future studies to examine barriers to practice that may contribute to the differences.
Second, a workload instrument should reflect the scope and standards of school nursing practice (ANA & NASN, 2017). The lack of workload indicators reflecting the principles of leadership and quality improvement presented in our research suggests that school nurses may not be articulating the entire scope of practice in meaningful ways to other school stakeholders and administrators (Bergren, 2017; D. Davis et al., 2019; Weismuller et al., 2016). If school nursing practice is to utilize a school nurse–specific workload instrument, it is imperative that workload measurement indicators representing the missing principles of leadership and quality improvement are included. Like previous literature findings (Bergren, 2017; M. Lineberry et al., 2017; Weismuller et al., 2016), school nurses need training, resources, and support to effectively communicate the range of their roles and responsibilities.
A beginning foundation is formed with the inclusion of the school, student, and school community characteristics that reflect not only the demographics, but the SDOH and trauma-informed care. Research suggests other areas that may need consideration, such as cognitive/mental workload, physical work environment, and intrinsic nurse characteristics (Alghamdi, 2016; Endsley, 2017; Henderson et al., 2016; Moloney et al., 2018). Items can be weighted to reflect actual importance and contribution to school nurse workload.
Finally, indicators should not be discounted because they were removed from the list of potential indicators for the workload instrument. They may be moved back in as data and measures become available. It also does not mean that the workload indicators could not be used for other types of school nursing or school health research.
Certain study limitations must be acknowledged. Participants were stratified by region, roles in school nursing (elementary, middle, and high school), age, geographic location, and position (frontline nurse, school nurse administrator). The necessity of being available for a 2-hr time window on one particular evening may have limited participation. Thus, the resulting participants may not be reflective of U.S. school nurses.
The availability for the focus group interviews may have also contributed to a biased sample. Some characteristics of the focus group participants are not reflective of national school nurses. For example, 67% (n = 20) of participants workinonebuildingascompared to43.7% nationally (Willgerodt et al., 2018). One focus group consisted of all New Jersey school nurses (n = 7), the rest were distributed by region. The participants were subscribers to the NASN Weekly Digest. The study participants may differ from ways we do not know or cannot identify from school nurses who do not subscribe. Most of the focus groups were conducted online, which may impact participants’ attentiveness. Focus groups may discourage some people from participating. The method of focus group discussion may also discourage some people from trusting others with sensitive or personal information.
We propose that future workload tools align with NASN’s Framework for 21st Century School Nursing Practice™. Next steps in instrument development include development of definitions and examples of the indicators identified in this study. Pilot testing with school nurses to determine the impact of the workload indicators would include nurses specifying the extent to which the indicator affects their daily workload (weight) and the frequency of occurrence of this indicator in their daily work (frequency).
To support a workload instrument, researchers can use the workload measurement indicators to formulate data that compare student health and academic outcomes when the workload instrument is used to apply the appropriate staffing numbers and when staffing is not adequate. In addition, a further application of a workload instrument is in locations where there is no school nurse, or the school nurse is used as a case manager, not as direct care personnel, to compare health and academic outcomes.
Future studies should also examine the SHIRS (Burt et al., 1996) for usefulness and adaptation to 21st-century school nursing practice. In addition, location and evaluation of existing school nurse staffing and workload tools in existence that are not found in the peer-reviewed literature is necessary (Jameson et al., 2018). Compiling a listing of local district data resources or other measurement tools may capture health insurance status and access to care for a school community. Lastly, time studies of school nurse work activities will inform what affects workload and should be considered in planning staffing needs.
Quality of care and student safety are impacted by school nursing workload. This study (1) identified workload indicators from the original Delphi study that can be empirically measured as items for a workload instrument, (2) found when applying NASN’s Framework™ as a foundation for appraising the workload indicators that the items generated from the Delphi study did not cover the entire range of workload indicators that school nurses experience, and as a result (3) identified additional indicators of quality improvement and leadership beyond the Delphi study to include in a workload instrument. The collection of the data points that underlie workload indicators improves the ability of school administrators and school policy makers to understand the complexity of the school nurse role and responsibilities. Benchmarking of data can take place, enhancing the ability to look at trends over time. A workload measurement tool can support staffing decisions to ensure capacity and the ability to provide safe, quality, and efficient care for students.
This information can further inform multiple stakeholders interested in assessing population health through the school health needs of students and the school community. A valid and reliable school nurse workload instrument will provide insight into the need to focus school nursing resources on prevention and wellness. The use of workload indicators that go beyond the stereotypical task or caseload indicators to account for the community characteristics can lead to a preventive shift to a holistic, client-centered approach that involves the contribution of school administrators, school nurses, social workers, counselors, health care providers, policy makers, business organizations, faith-based organizations, and others. Resource allocation and utilization of proactive and predictive care solutions can and should be used in our schools, with school nursing as its pivotal entity, to intervene with an upstream approach. School nurses cannot be that entity unless we provide for the staffing and care needs holistically and as a community collaborative effort.
The authors gratefully acknowledge Dr. Erin D. Maughan (National Association for School Nurses) for comments on an earlier version of the article.
Jameson, B. E., Anderson, L. S., and Endsley, P., contributed to conception or design; contributed to acquisition, analysis, or interpretation; drafted the manuscript; critically revised the manuscript; 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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by a grant from the National Association of School Nurses.
Beth E. Jameson, PhD, RN, CNL https://orcid.org/0000-0003-0225-3741
Lori S. Anderson, PHD, RN, CPNP-PC, NCSN https://orcid.org/0000-0002-0248-6580
The supplemental material for this article is available online.
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Beth E. Jameson, PhD, RN, CNL, is an Assistant Professor at the College of Nursing, Seton Hall University.
Lori S. Anderson, PhD, RN, CPNP-PC, NCSN, is a Clinical Professor at the School of Nursing, University of Wisconsin–Madison.
Patricia Endsley, MSN, RN, NCSN, is a School Nurse at WellsOgunquit Community School District, Wells High School.
1 College of Nursing, Seton Hall University, Interprofessional Health Sciences Campus, Nutley, NJ, USA
2 School of Nursing, University of Wisconsin–Madison, WI, USA
3 Wells-Ogunquit Community School District, Wells High School, ME, USA
Corresponding Author:Beth E. Jameson, PhD, RN, CNL, College of Nursing, Seton Hall University, Interprofessional Health Sciences Campus, 340 Kingsland Street, Nutley, NJ 07110, USA.Email: beth.jameson@shu.edu
