The Journal of School Nursing2023, Vol. 39(3) 262–271© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840520984448journals.sagepub.com/home/jsn
Rural school nurses are on the front lines of providing health care for children and families in rural Colorado, but there is little research from their perspective. To fill this gap, a descriptive phenomenological study examined the experiences of nine rural school nurses through in-person audiotaped interviews. Analysis of data revealed three main themes: (1) rural school nurses’ efforts to meet students’ extensive physical and mental health issues, (2) school nurses struggle to help rural students in extreme poverty, and (3) communication challenges experienced by rural school nurses. The findings of this study give voice to the experiences and challenges faced by rural school nurses in southern Colorado.
Keywords
rural poverty, unmet students’ needs, rural school nursing, qualitative research
Rural school nurses play a significant role in supporting the health of students and families in rural Colorado communities. School nurses are essential health workers and interact with parents, teachers, and other health professionals to address rural health needs. Colorado faces many of the same challenges that other rural areas face in the delivery of public health services including low population density, transportation issues, lack of access to grant funding, lower public funding levels for rural services and programs, difficulties in recruiting staff, and potential fragmentation of scarce resources (Phillips & McLeroy, 2004; Colorado Rural Health Center, 2016). Many rural areas, including those in Colorado, are undergoing demographic changes that impact community health needs and influence the ability of providers to provide effective care (Phillips & McLeroy, 2004; Colorado Rural Health Center, 2016). In rural areas with limited health care providers, school nurses are often the health professionals most consistently involved in dealing with the health needs of school-aged children (Guttu et al., 2004; National Association of School Nurses [NASN], 2017). As physicians and nurse practitioners are scarce in some rural areas, the school nurses are often the most accessible health experts (Rural Health Information Hub, 2018).
There are 500 school nurses serving the state of Colorado (Colorado Department of Education [CDE], 2016). The minimum educational requirement for school nurses is an associate degree. However, a bachelor’s degree in nursing is preferred. The nurse must hold a current license as a registered nurse (RN). Primary responsibilities include monitoring and maintenance of records of immunizations, conducting required vision and hearing screenings, emergency care and disaster planning, student safety, management of chronic health conditions, and legal reporting of child abuse and neglect (CDE, 2016; NASN, 2017). The assignment of school nurses in rural schools is directed by school administrators who decide which schools the nurses serve and for what amount of time. Nurses in this geographic area often travel between schools and may serve several in a day as directed by school administrators. This is not uncommon in areas that cannot afford a full-time school nurse for each school (Sorg, 2020).
Geographic areas of less than 99 persons per square mile are considered rural (Rural Health Information Hub, 2018). School nurses who serve rural communities face critical health issues impacting children. Rural school nurses assist families with accessing health care services and healthy food (Mills et al., 2007; Ramos et al., 2014; Rew et al., 2015). Twenty-three percent of rural children in Colorado live in poverty, and 24% of families in rural Colorado are single-parent households (Colorado Rural Health Center, 2019). Other issues affecting rural Colorado are an elevated rate of suicide and mental health problems (Karlik, 2020). The United Health Foundation (2020) reported that Colorado had the highest increase in teen suicide rates in the United States since 2016. Additionally, nine of the 10 Colorado counties with the highest drug overdose death rates were rural (Colorado Rural Health Center, 2019). Many workers new to Colorado are poor and homeless with underlying behavioral and chronic health issues such as uncontrolled diabetes, asthma, obesity, lack of adequate nutrition, and housing (Centers for Disease Control and Prevention, 2017; Clausson et al., 2015; Cornish et al., 2016; Peterson et al., 2010; Rew et al., 2015). Compounding these problems is a lack of available health care and transportation services in rural Colorado, which requires families to travel long distances to access food sources and health services (Parasuraman & Shi, 2015).
Although school nurses are on the front lines of providing health care to children and families in rural areas, there is little research from their perspective (Ramos et al., 2014). Studies on the perspective of rural nurses are limited to specific diagnoses or community issues. In three rural schools in the Northeastern United States, Haley et al. (2013) researched condom use among teenagers and the students’ understanding of birth control and sexually transmitted diseases. A study from an unidentified rural area showed that school nurses were in positions to identify, evaluate, and report physical abuse and sex trafficking of youth (Grace et al., 2012). It was also found that students in rural Pennsylvania and South Carolina were willing to trust school nurses with issues of depression, homelessness, and vulnerability and look to the nurse as a point of contact into the mental health system (Puskar et al., 2011; Villalba, 2011; Wilson & Usher, 2015). Canfield (2014) and Ramos et al. (2014) studied the increase of behavioral issues and mental health among rural and highly mobile, homeless children in rural New Mexico. Ramos et al. (2014) and Rew et al. (2015) highlighted complications from uncontrolled diabetes, asthma, and obesity as being more common in rural children, partly due to lack of access to health care. These studies were limited in scope and were quantitative survey studies that identified student issues but not the experiences of rural school nurses.
Lavalley (2018) asserts that rural schools are largely left out of research and policy discussions, perpetuating poverty, inequity, and isolation. Given the critical role that school nurses play as frontline caregivers for children, there is insufficient research that addresses the range of services school nurses provide and the effectiveness of the services (NASN, 2017). There is a need for research that targets rural school nurses and explores demographic trends, outcomes, and work environments. There is specifically a need for qualitative studies that give the perspectives of frontline rural school nurses. For that reason, the purpose of this study was to explore the experiences of rural school nurses who work with children and families in southern Colorado. The study gives insights into the support and services needed by school nurses in providing care to this rural school-aged population.
In this study, researchers used a qualitative method to explore experiences, feelings, and emotions that are difficult to explore with quantitative methods (Broussard, 2006). A descriptive phenomenological design was used to achieve a deeper understanding of the experiences of nine rural school nurses through face-to-face interviews (Barua, 2007). To achieve objectivity, the researchers acknowledged their biases at the beginning of the study. Data were collected in the fall of 2018. A semistructured interview guide was used with open-ended questions. The primary research question was: What is the experience of working as a rural school nurse with children and families in southern Colorado? Subquestions used to expand participant responses included: Describe the children and families you care for, describe types of health care issues you deal with, and describe your activities as a rural school nurse on a typical day. Interviews were 45 min to 1 hr in length and were digitally recorded. The researcher took notes and made observations throughout the interviews as part of an audit trail. Interviews were transcribed and put into Word files.
The study was given exempt status in summer 2018 following submission to the Regis University’s institutional review board.
This study used a purposive sample of rural school nurses in a medically underserved region of six counties in southern Colorado (San Luis Valley Area Health Education Center, 2020). These counties contained 14 school districts with a total student population in the 2015–2016 school year of 7,723 students from kindergarten to 12th grade (CDE, 2016). Thirteen nurses served the schools. Inclusion criteria included nurses who served at least one school in the assigned school district. Associate, bachelors, or masters prepared nurses of any gender with a current RN license were eligible.
Recruitment of participants began by contacting school administrators who were required to approve the study. Each school administrator provided a letter of permission and authorized access to nurses’ email addresses. Nurses were contacted individually by email and invited to in the study. The study intent, the interview process, and risks were explained in the initial email. In-person, interviews were scheduled for those who agreed to participate at times and places convenient to the participants. Interviews were conducted at sites away from the workplaces for five of the participants. Four were interviewed at their school workplaces. Written informed consent was signed by participants to give permission to audiotape the interviews.
The final study sample was composed of nine rural school nurses (n = 9). Seven of the nurses were bachelor or master prepared and two were associate degree nurses. Years working as a school nurse varied from 2 months to 37 years, with the majority having worked 2–3 years in school nursing. Overall nursing experience varied from 3 to 39 years. The number of schools served by each nurse included: three nurses covered one school each, one nurse covered two schools, one nurse covered three schools, three nurses covered four schools, and one nurse covered five schools.
The data analysis was achieved by grouping responses to each question into single Word files. Researchers independently read the files multiple times making notes about impressions and concepts. Investigators met together multiple times and completed line-by-line coding as per Creswell’s (1998) process of open coding. Codes were combined and refined, and a consensus was reached. Saturation was reached when no new descriptive data were obtained from additional participants. Major themes and subthemes emerged through a process of constant comparative analysis (Patton, 2002). Trustworthiness was addressed through peer review by an experienced qualitative researcher not involved in the study. Participants were provided with transcribed interviews for member checking. They confirmed the accuracy of their responses. Confirmability and transferability were met through a detailed audit trail consisting of notes, impressions, and files documenting data analysis (Lincoln & Guba, 1986).
Three major themes emerged from data analysis: (1) rural school nurses’ efforts to meet students’ physical and mental health issues, (2) rural school nurses struggle to help students in poverty, and (3) communication challenges experienced by rural school nurses. Subthemes are organized under the primary themes. See Table 1 below.
The theme of rural school nurses’ efforts to meet students’ extensive physical and mental health issues included three subthemes: students’ physical health issues, students’ mental health issues, and effects of family issues on students’ health. Rural school nurses reported a multitude of physical and mental issues present in the community and students’ families. Nurses expected and were prepared to deal with common physical issues. These included typical childhood illnesses and injuries of which were identified as: “flu-like illnesses,” “nausea, vomiting, and headache,” “fractures,” “impetigo and pinkeye,” “concussions,” “lice,” “bedbugs,” and “coughs [and] colds.” The nurses also observed that children had chronic illnesses. They reported having to manage “asthma [and] asthma care plans” including helping children with “inhalers” and dealing with parents who did not “ ...want to ...divulge it or say that their child had asthma.” Other students had common chronic illnesses such as diabetes. One nurse stated:
I have one diabetic kid that’s pretty out of control, so I see her quite a bit ...She’s the one that can’t get to Children’s [Hospital], so we’re trying to help her manage locally, and it’s, it’s been a struggle.
Other chronic illnesses that nurses managed included “migraines,” “seizures,” “spina bifida,” “congenital issues,” “severe hearing deficits,” “morbid[ly]obese,” “cerebral palsy,” “partial blindness,” “thrombocytopenia,” and “autism.” Children were also noted to have a variety of allergies to “foods,” “peanuts,” and “tree nuts,” and some were reported to have had “anaphylactic” reactions. School nurses also reported that they were responsible for students who required “tube feedings” and to be “cath’d.” Some students had “ADD [Attention Deficit Disorder” and “ADHD [Attention Deficit Hyperactivity Disorder] and were given meds at school.”
The nurses also cared for children who had rare illnesses. Many nurses reported that health issues are related to children living in impoverished family conditions. A nurse reported that families unable to afford heat were using gas heaters in enclosed areas.
Children’s mental health issues were reported by many participants. Nurses often reported dealing with diagnosed and undiagnosed children’s mental health issues. Students had “diagnosed depression,” “schizophrenia,” and “bipolar disorder.” There were many students with “behavior issues” and “a lot of anxiety.” One nurse stated: “ ...I say mental illness is an underdiagnosed problem in the schools.” The nurses also described children with serious mental health issues related to abuse. There were reports of children being “totally neglected” both physically and mentally. A concerned nurse stated:
...[abuse] is a huge problem, and [it is not] just the kids that we have identified or that have come forward with stories of abuse, ...[it] makes me think about all the kids that aren’t saying anything.
Nurses reported awareness of students going through difficult situations at home. A nurse said: “I know a lot of them have some rough stuff going on at home and sometimes they just need a break,” and “they just lack really good coping skills.” There were reports of divorce, homelessness, and severe family issues. One nurse reported serious family issues including:
...some serious mental illness involved ..., and addiction, a lot of addiction, a lot of abuse, and just drug abuse and alcoholism, domestic violence, you know, that come along with that.
Addictive behavior by parents was of concern to nurses due to the effect on children. Not only were parental drug problems evident from their behavior, but children were reportedly “coming to school smelling like pot.” One nurse reported that:
Starting in fourth or fifth grade, [teachers say] they can’t even start teaching their lessons until the afternoon when the pot wears off from the night before ...but it’s hard to address [the issue with the students] because their parents are growing [marijuana] and their parents are promoting it.
The second theme rural school nurses struggle to help students in poverty had two subthemes: lack of necessities and efforts to assist students. Nurses described extreme cases of poverty in their school districts and how they made efforts to respond and help. One stated: “I think we [the school district] are [dealing with] around the range of 40% poverty ...so, we have a lot of kids with a lot of needs.” Another stated: “I mean the economy is booming but not for these families.” A nurse corroborated this by saying: “ ...there’s at least 30% of our kids here that still deal with hunger issues and money issues and need extra resources ...” Another nurse pointed out that, “We have 100% free and reduced lunch rate.” The viewpoint of the participants was summed up by one nurse that stated: “When children don’t have their basic [needs such as] shelter, food, water, those kinds of things ...I think it makes learning incredibly difficult.”
Nurses reported that homelessness impacted rural children having necessities. A nurse described a common situation where students were “using a bucket for toilet facilities and ...kids show up at school covered in bed bugs.” Others were aware of children who were “actually sleeping in a tent,” “some ...sleep on whoever’s couch,” and “[they] live in a camper in the trailer park ...so they are considered homeless.” One nurse stated:
We have some kids that are like poor, poor, poor, that don’t have coats, you know. All of our kids get free lunch and breakfast ...those are the kids that we see, that actually shower at school.
Other nurses reported problems with students’ hygiene stating:
...“we’ve literally had classes on how to shower. And that’s, that’s kind of sad in America” and “[we] have a lot of kids who shower at school because they don’t have running water at home.”
Children also were described coming “to school with no coats, ...they don’t have proper clothing, [or] proper shoes.” Another nurse described a child whose footwear was extra large. She said the “little girl ...has a pair of boots that I think are her sister’s.”
School nurses working with children in difficult circumstances became creative in assisting rural children. A participant stated:
...this one little girl, it took me an hour to get the knots out of her hair the first time I did her hair. So now she comes in every morning and I do her hair ...I’m working on getting [her] a haircut because I don’t know the last time she had a haircut. So, her hair is really frayed.
Statements by the participants confirmed how nurses provided services to children at school such as “doing their laundry.” The nurse elaborated:
“I asked for a washer and dryer in my office so that I can wash clothes for the kids,” ...[the kids are] left to depend on the school to help them eat and shower and learn basic hygiene.
Nurses along with teachers contributed their own funds to assist families in the care of children in poverty. A nurse stated:
A group of us got together and donated a bed to a family, then [when] we went on a home visit [to deliver the bed, we found] they didn’t even have [one] bed in the house.
A final theme of communication challenges experienced by rural school nurses had three subthemes: student challenges, parental challenges, and paraprofessional and administrative challenges. Rural school nurses had the responsibility to communicate with a variety of stakeholders as part of their jobs. Within the schools, they communicated with students, teachers, and paraprofessionals who were teachers’ aides and school secretaries. Outside the school, they communicated with parents and administrators. Communication challenges with rural students included not only careful attention to their physical health issues but also mental health issues. One nurse described the nurse’s office as “ ...a safe place to unload things.” Another stated: “I feel like the nurse’s office is a place for kids when they are having a bad day or when they’ve got something else going on.”
Participants identified the different roles they play when interacting with students. A participant described the different roles they assumed when communicating with students:
You are ...[a] primary person in these kids’ lives ...where you see everything. Like you’re there for their emotional parts. You’re there for their physical ailments ...and ...you’re a counselor, you’re a nurse, you’re [a] friend, you’re an educator.
Several nurses shared concern that they were sometimes expected to assess and make recommendations for children’s injuries and illnesses that they were not trained to handle. There was concern that nurses were expected in some situations to function beyond the extent of their education, license, and experience. A nurse noted that “ ...kids come to me [for help] and their parents use me as their primary care doctor ...” One nurse stated that the school nurse’s office is “ ...like a mini ER or mini urgent care.”
Communication with parents was particularly challenging for school nurses. Although many parents were attentive, there were a variety of difficult parental life situations that impacted communication. Problems related to homelessness, addiction, and poverty impacted parents’ ability to communicate. A nurse identified one particular problem contacting parents:
A lot of kids are staying with grandparents [and] that parents are out of the picture ...I think a lot of it is ...drug-related history for parents and so the grandparents are taking care of the kids.
Parents of rural students were often in difficult situations that affected their ability to be accessible when contacted by school nurses. Some parents were unable to leave work to pick up a sick child. One of the participants noted that many “both parents work, so if the kid gets sick, it’s a struggle to contact them and to have them leave work because if they leave work, they lose pay.” Parents’ cell phones were also a contributing problem. Phones often were not working or “they shared a cellphone with a family member.” Parental divorce also affected communication with rural nurses who struggled to know which parent the children were living with. One nurse stated:
[There are] a lot of split homes too, parents are not together anymore. They’re divorced so [the kids] go from one house to the other. Sometimes it’s hard to keep up with ...where they’re at, or their medications ...
Provider authorization for medical treatment was often delayed due to the parents not completing or returning paperwork. A nurse stated:
...it may take me a long time to just get that paperwork ...I just end up having to make do and ...sometimes that’s really stressful because it technically puts my license at risk and the liability of that. But sometimes, you know, if it’s between the child actually carrying their inhaler and not having the paperwork, you know, you just try to do what you can until you get it.
In some cases, nurses were discouraged and frustrated with the lack of response when they tried to contact parents in emergencies. Parents were sometimes unresponsive. A nurse reported trying to contact the parents of a student who experienced a food allergy. The nurse stated:
Nobody would answer, and we ended up having to call 911, and then the police had to drive over to his house to get his family. They were just home but they just weren’t picking up the phone.
School nurses described challenges in communicating with professionals and paraprofessionals in their daily routine. The role of rural school nurses included supervising and delegating tasks to unlicensed assistive paraprofessionals. The nurses communicated with teachers, teachers’ aides, and secretaries. Challenging conversations with stakeholders were often completed over the phone and occurred while traveling between schools. One nurse stated: “ ...she [the teacher’s aide] takes care of those problems when they arise and calls me. I am usually available by phone.” Another nurse said, “ ...our secretaries are all very helpful and jump in to see kiddos when we’re not here.” Nurses and paraprofessionals worked together to care for children. A nurse said, “because I’m not in every building all day, every school day, and so, you know, our secretaries, who are designated, ...health aides ...do a great job.” Nurses shared that teaching paraprofessionals were an important part of the nurses’ routine communication. A nurse noted:
...I do a lot of staff training as far as medication administration, emergency procedures like epi-pen use and, emergency seizure medication, what to do in the event of a diabetic emergency, [and] those types of things.
A major communication challenge occurred when school nurses were not physically present due to traveling between multiple schools and needing to maintain communication with staff while away. A nurse stated:
...so, I was gone ...which I’m regularly scheduled [to be] there on Tuesday mornings, and I was gone for about, a little over an hour. I get back to their school and they had had fourmajor incidences happen, and so it’s really stressful and I feel like I’m spread really thin.
Rural nurses also described challenges when communicating with administrators about needed resources for children. Children and families frequently requested resources that rural school nurses could not provide. One nurse described the feeling as “frustrating ...[when you have] poor families ...[with] a lot of social problems ...and you don’t really have anywhere to refer them.” Another nurse shared her frustration and distress by stating:
I’ve just had it, trying to get them [children] the medical help they need and the support they need, but there’s nothing in our community or our county that I can really refer them to.
School nurses expressed to the administration that they lacked monetary resources to help students. Nurses sought “grants for playground equipment,” “Medicaid reimbursement,” and “school-based health centers.” Several participants wanted to pursue networking relationships with local hospitals and specialty clinics in urban centers.
Many school nurses spoke of not having sufficient time to complete their work in each school and wanted to share this with school administrators. There was a wide variation in the reported number of hours that nurses worked in each school. A common theme was “I cover four different schools and I rotate [to each school] one day a week.” Another nurse reported that she was “ ...at the middle school for probably six hours per week.” Another stated: “[I am] in the district 20 to 25 hours per week.” There was consensus by nurses that time with students was an unmet need communicated to administrators. One stated: “There is just so much to do and it’s like never enough time.” Another participant stated: “I do think that the district would benefit from having a fulltime nurse in every school.”
Rural school nurses also experienced challenges in sharing their professional needs with school administrators concerning continuing education. They shared that their lack of continuing education was an unmet need that affected children at the schools they served. They wanted more access to information that addressed specific problems they experienced with children in the schools. One nurse expressed that “ ...there’s always something to learn, and ...the rules and regs are always changing.” They spoke highly of educational resources such as “the school nurse forum” and the “school nurse mentoring program” as possible options for them to obtain additional knowledge. A nurse stated:
What I would like to see is more support for [nurses in] rural areas as far as, ...workshops and things like that. I feel like everything is centered up north and you know it’s difficult for us [in the rural area] to be able to get to these trainings ...[you the nurse] don’t have somebody to fill in for you, it’s hard to miss work, you know, plus the travel and weather and different things like that and I feel like forever it’s been a problem.
Rural school nurses in this study identified efforts to meet the physical and mental issues of students in rural southern Colorado. They described a variety of chronic physical, mental, and behavioral health problems faced by rural students. These findings were consistent with statistics that show 20% of students enter school with serious chronic health conditions that require attention by school nurses (U.S. Health Resources and Services Administration [HRSA], 2020). Research supports that rural communities have higher rates of multiple chronic conditions and fewer resources to prevent and treat chronic diseases than urban communities (Rural Health Information Hub, 2018). Nurses in the study cared for rural children with rare conditions that required follow-up by medical providers not available in the local community. Fleming and Willgerodt (2017) emphasized the importance of school nurses coordinating care with other health care professionals outside of the school setting. Rural school nurses struggled to initiate connections with providers outside the local area. Parents encountered barriers such as transportation issues that limited their ability to reach the health care children needed. Nurses tried to find resources to help families.
A significant finding was that nurses described rural children in poverty. The area in which this study was conducted included four of the 11 poorest counties in Colorado (DataUSA, 2018). Many children utilized services at schools to meet their basic needs for food, clothing, and personal hygiene. Nurses stated that meeting students’ health needs often came at the expense of educational time. These findings were corroborated in the literature by Probst et al. (2018) who described poverty as particularly acute among rural children who live in environments characterized by economic deprivation and adverse long-term trends. Parental situations of divorce, homelessness, and addiction contributed to living in poverty and adversely affected children’s abilities to function in school and socially. This is corroborated by Melchior and Waerden (2016) who discussed the adverse effects of parental health on children’s mental health. Nurses expressed their frustration with trying to access resources to help impoverished and homeless children.
Rural school nurses also experienced communication challenges. When interacting with students, nurses often functioned as counselors and primary care providers, roles they were not trained for. Nurses were considered “safe persons” with whom students could discuss private issues. Baker et al. (2016) elaborated on the role of school nurses and stressed the school nurse was often a case manager who provided a “quasi-medical home” for students. Nurses stated that there were times they felt inadequate in counseling students.
Rural nurses also shared that they experienced communication challenges with parents. Nurses expressed frustration when parents would sometimes “just not answer” or “not return forms” when contacted. Many parents were unable to respond because of work-related issues, personal problems, or lack of transportation. Divorced parents were not always equally involved in the care of their children, also interfering with communication. These types of problems were noted by Fleming and Willgerodt (2017) who reported that school nurses often experience communication barriers with families when health history forms are not completed and returned promptly. Power et al. (2013) note that a lack of shared electronic health records impedes coordination of care between parents, school nurses, and health care providers in different health systems.
Communication challenges between nurses and paraprofessionals occurred when nurses were not present at schools or traveling between schools. Difficulties centered around the delegation of tasks and meeting students’ needs when nurses were unavailable. Rural school nurses reported frustration and delayed care of children when they were not present to make decisions. All participants in the study served multiple rural schools except for one. Willgerodt et al. (2018) confirmed that rural schools in the Western United States are more likely to have one nurse cover multiple schools or not have a school nurse at all. This problem of difficult communication highlighted the significance of the lack of full-time school nurses. Powell et al. (2017) found that school nurses experienced significant moral distress about not having enough time and resources to deliver care to children in their assigned schools. Nurses were also described as being unable to provide effective coordination of care for children with chronic illnesses without dedicated time to do so. The NASN (2017) recommends each school has a full-time nurse with a baccalaureate degree in nursing. NASN (2017) supports having nurses serve a single school full-time. When assigned to a single school, nurses form strong relationships with students and the community (Maughan, 2018). The consensus of nurses in the study was that more school nurses were needed in rural areas and that by improved staffing, nurses would have more time to address urgent student concerns.
A final communication challenge was between school nurses and school administrators. These discussions centered mainly on a lack of resources to meet the needs of impoverished students and the need for continuing education for nurses. Rural schools needed funds for a variety of purposes to help families and children. Children from lowincome homes experienced serious food, housing, and health insecurity. Nurses were aware of insufficient funding and often spent their own money to help students because school budgets for accessory needs were limited. Public Schools First (2020) notes that rural districts cannot make up the difference when state funding levels are insufficient and calls for new creative approaches to school funding to be addressed nationwide.
Nurses also requested rural access to professional continuing education. Updated information on medical diagnoses and treatments was needed as evidenced by the variety of children’s health issues. Nurses stated that they wanted to be informed of policy changes in a timely manner. Many voiced that e-learning would be an effective option.
A study strength was that face-to-face interviews were conducted by the researcher with school nurses in rural areas that involved extensive travel. This made it possible to gather data from a group of nurses who would otherwise not have been contacted. The study limitations were that the sample size was small and homogeneous. Participants were drawn from a limited geographic location in a high-poverty area. Further studies should include qualitative research that examines perspectives about the role and potential of rural school nurses by other rural stakeholders including educators, school board members, and school administrators.
A recommendation based on the findings of this study is to expand forms of assistance to rural families in poverty experiencing health problems. On the local level, funding sources need to be developed through local businesses, foundations, churches, and employers. Local rural schools should have axillary emergency funds available to school nurses to help families in emergencies. On the local level, families need help from nurses, social workers, and community members in applying for Medicaid, food stamps, and any programs to address poverty. As most rural schools now have interactive websites, it is recommended that school nurses utilize a specific section of the website to list community resources such as food banks, utility assistance programs, and service organizations that assist with costs for medical, vision, hearing, and dental services, as well as transportation.
There are also programs at the state and federal level that families should receive assistance in accessing. State programs include those through the Colorado Human Services Department, and Federal programs are available through the Federal Human Services Department (The National Advisory Committee on Rural Health and Human Services, 2014). Coordination of local, state, and federal services could be achieved at community centers, schools, or hospitals that are accessible to local families.
Nurses also spoke of struggling to assist parents in accessing health experts for follow-up care outside the rural area. Nurses needed connections with specialists in urban areas and major medical centers. Fleming and Willgerodt (2017) emphasize the importance of school nurses collaborating with other health care professionals outside the school setting. This includes working with primary care and/or specialty physicians, hospitals, and community health providers. A network of providers should be compiled for access by school nurses that includes types of specialties, phone numbers, and email addresses. Where internet is available, telehealth should be used to connect nurses with providers, which would be a valuable tool especially in a time of pandemics (Ramos et al., 2014; Sanchez et al., 2019). Facetime and ZOOM sessions could improve access and decrease travel. These technologies can assist nurses in connecting with experts to gain knowledge of rare and chronic conditions. Internet-based learning is described to be “as effective” as in-person training (Sinclair et al., 2016). E- learning can provide continuing education for nurses in rural areas. It is also recommended that nurses organize in groups for mutual support and networking to encouraging peer learning.
A final recommendation is that nurses support local, state, and federal policies that expand funding for full-time nurses in every school. The practice of having full-time nurses in schools is recommended by the NASN (2017). Studies support that nurses help students to manage health disorders resulting in improved school attendance and that school nurses’ interventions save educators’ time in addressing student health concerns (Baisch et al., 2011). Johnson (2017) describes school nurses as an important link in the care of children with chronic conditions and a critical component of illness prevention. Bergren (2017) states that nurses must view policy as important and work to make changes at the local, state, and federal levels.
On the local level, nurses should participate on boards of directors of public health departments, hospitals, nonprofits, and schools. Members of local boards benefit from the perspective of nurses who live and work in the communities and can translate the impact of social determinants of health (Johnson, 2017). Barriers such as the school district’s lack of understanding of the school nurse’s role must be addressed through policy development and advocacy.
Innovative approaches should be considered to fund fulltime school nurses on the local level. School districts can consider partnerships with school-based health centers, local health departments, and hospitals to fund school nurses. An increasing number of hospital systems collaborate with school districts to staff school nursing services (Johnson, 2017). Some school districts have come up with innovative ways to pool funding from multiple sources to support their nurses (Becker & Maughan, 2017).
On the state level, nurses should serve in state legislative office as advocates for school nurses and help attain resources that support nurses practicing at the full scope of nursing practice. There should be an outreach to organizations on the national level such as the Association of School Superintendents to inform about the role of the school nurse and make a connection between school nursing and positive health outcomes (Fleming & Willgerodt, 2017).
The findings of this study give voice to the experiences and challenges faced by rural school nurses in southern Colorado. The information informs stakeholders including nurses, educators, community members, and school administrators how school nurses enhance the health and well-being of rural children. Rural school nurses have important perspectives to offer in the care of children and families in southern Colorado. The perspective of rural school nurses is an untapped source to determine the health care needs of school-aged children in Colorado.
We warmly thank all of the participating school nurses.
A.M.B. and P.R.S. contributed to conception or design; contributed to acquisition, analysis, or interpretation; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. P.R.S. critically revised the article. A.M.B. drafted the article.
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.
Alice M. Burch, DNP, RN https://orcid.org/0000-0001-7803-3804
Baisch, M. J., Lundeen, S. P., & Murphy, M. K. (2011). Evidencebased research on the value of school nurses in an urban school system. Journal of School Health. 81(2), 74–80. https://doi.org/10.1111/j.1746-1561.2010.00563.x
Baker, D., Anderson, L., & Johnson, J. (2016). Building student and family-centered care coordination through ongoing delivery system design. NASN School Nurse, 32(1), 42–49. https://doi.org/10.1177/1942602X16654171
Barua, A. (2007). Husserl, Heidegger, and the transcendental dimension of phenomenology. Indo-Pacific Journal of Phenomenology, 7(1), 1–10. https://doi.org/10.1080/20797222.2007.11433942
Becker, S. I., & Maughan, E. D. (2017). Descriptive study of differing school health delivery models. Journal of School Nursing, 33(6), 415–425. https://doi.org/10.1177/1059840517725788
Bergren, M. (2017). School nursing and population health: Past, present, and future. OJIN: The Online Journal of Issues in Nursing, 22(3). https://doi.org/10.3912/OJIN.Vol22No03Man03
Broussard, L. (2006). Understanding qualitative research: A school nurse perspective. Journal of School Nursing, 22(4), 212–218. https://doi.org/10.1177/10598405050220040501
Canfield, J. (2014). Examining perceived barriers and facilitators to school social work practice with homeless children. Children & Schools, 36(3), 165–173. https://doi.org/10.1093/cs/cdu/015
Centers for Disease Control and Prevention. (2017). Rural health. https://www.cdc.gov/ruralhealth/about.html
Clausson, E. K., Berg, A., & Janlov, A. (2015). Challenges of documenting schoolchildren’s psychosocial health: A qualitative study. Journal of School Nursing, 31(3), 205–221. https://doi.org/10.1177/1059840514543525
Colorado Department of Education. (2016). www.cde.state.co.us
Colorado Rural Health Center. (2016). The state of health in rural Colorado. https://coruralhealth.org/wp-content/uploads/2016/01/2016-Snapshot-CRHC.pdf
Colorado Rural Health Center. (2019). Snapshot of rural health in Colorado—2019. https://coruralhealth-wpengine.netdna-ssl.com/wp-content/uploads/2013/10/2019-Snapshot-FINAL.pdf
Cornish, D., Askelson, N., & Golembiewski, E. (2016). Reforms looked really good on paper: Rural foodservice responses to the Healthy, Hunger-free Kids Act of 2010. Journal of School Health, 86(2), 113–120. https://doi.org/10.1111/josh.12356
Creswell, J. W. (1998). Qualitative inquiry and research design: Choosing among five approaches. Sage. DataUSA. (2018). Colorado. https://datausa.io
Fleming, R., & Willgerodt, M. A. (2017, September 30). Interprofessional collaborative practice and school nursing: A model for improved health outcomes. OJIN: The Online Journal of Issues in Nursing, 22(3), Manuscript 2. http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-22-2017/No3-Sep-2017/Interprofessional-Collaborative-Practice-School-Nursing.html
Grace, L. G., Starck, M., Potenza, J., Kenney, P. A., & Sheetz, A. H. (2012). Commercial sexual exploitation of children and the school nurse. Journal of School Nursing, 28(6), 410–417. https://doi.org/10.1177/1059840514541855
Guttu, M., Engelke, M. K., & Swanson, M. (2004). Does the school nurse-to-student ratio make a difference? Journal of School Health, 74(1), 6–9. https://doi.org/10.1111/j.1746-1561.2004.tb06593.x
Haley, T., Puskar, K., Terhorst, L., Terry, M. A., & Charron-Prochownik, D. (2013). Condom use among sexually active rural high school adolescents personal, environmental, and behavioral predictors. Journal of School Nursing, 29(3), 212–224. https://doi.org/10.1177/1059840512461282
Johnson, K. (2017). Healthy and ready to learn: School nurses improve equity and access. Online Journal of Issues in Nursing, 22. https://doi.org/10.3912/OJIN.Vol22No03Man01
Karlik, M. (2020). State pushes rural suicide prevention resources. https://www.coloradopolitics.com/news/state-pushes-rural-suicide-prevention-resources/article_f32d68e8-9b7e-11ea-806d-03e404598ce6.html
Lavalley, M. (2018). Out of the loop: Rural schools are largely left out of research and policy discussions, exacerbating poverty, inequity, and isolation. Center for Public Education. https://cdn-files.nsba.org/s3fs-public/10901-5071_CPE_Rural_School_Report_Web_FINAL.pdf
Lincoln, Y., & Guba, E. (1986). But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. New Directions in Program Evaluation, 1986(30), 73–84. https://doi.org/10.1002/ev.1427
Maughan, E. D. (2018). School nurses: An investment in student achievement. Phi Delta Kappan, 99(7), 8–14. https://kappanonline.org/maughan-school-nurses-investment-studentachievement/
Melchior, M., & Waerden, J. (2016). Parental influences on children’s mental health: The bad and the good sides of it. European Child & Adolescent Psychiatry, 25(8), 805–807. https://doi.org/10.1007/s00787-016-0891-9
Mills, J., Francis, K., & Bonner, A. (2007). Live my work: Rural nurses and their multiple perspectives of self. Journal of Advanced Nursing, 59(6), 583–590. https://doi.org/10.1111/j.1365-2648.2007.04350.x
National Advisory Committee on Rural Health in Human Services. (2014). The intersection of rural poverty and federal human services programs policy brief. https://www.hrsa.gov/sites/default/files/hrsa/advisory-ommittees/rural/publications/2014-rural-poverty.pd
National Association of School Nurses. (2017). www.nasn.org
Parasuraman, S. R., & Shi, L. (2015). Differences in access to care among students using school-based health centers. Journal of School Nursing, 31(4), 291–299. https://doi.org/10.1177/1059840511556180
Patton, M. Q. (2002). Qualitative research and evaluation methods (3rd ed.). Sage.
Peterson, S., Scheffer, S., Long Roth, S., Bennett, P. A., & Lloyd, L. (2010). Noninvasive screening for risk factors of type 2 diabetes in young, rural, Caucasian children. Journal of School Nursing, 26(4), 301–309. https://doi.org/10.1177/1059840510366021
Phillips, C. D., & McLeroy, K. R. (2004). Health in rural America: Remembering the importance of place [Editorial]. American Journal of Public Health, 94(10), 1661–1663. https://doi.org/10.2105/ajph.94.10.1661
Powell, S. B., Engelke, M. K., & Swanson, M. S. (2017). Moral distress among school nurses. Journal of School Nursing, 34, 390–397. https://doi.org/10.1177/1059840517704965
Power, T. J., Blum, N. J., Guevara, J. P., Jones, H. A., & Leslie, L. K. (2013). Coordinating mental health care across primary care and schools: ADHD as a case example. Advances in School Mental Health Promotion, 6(1), 68–80. https://doi.org/10.1080/1754730X.2013.749089
Probst, J. C., Barker, J. C., Enders, A., & Gardiner, P. (2018). Current state of child health in rural America: How context shapes children’s health. Journal of Rural Health, 34(Suppl 1), s3–s12. https://doi.org/10.1111/jrh.12222
Public Schools First. (2020). The facts on rural schools. https://www.publicschoolsfirstnc.org/resources/fact-sheets/the-factson-rural-schools/
Puskar, K. R., Grabiak, B. R., & Ren, D. (2011). The life events of adolescents: Implications for rural school nurses. Online Journal of Rural Nursing and Health Care, 11(1), 8–16. https://wwwncbi-nlm-nih-gov.proxy.cc.uic.edu/pmc/articles/PMC3201748/
Ramos, M. M., Fullerton, L., Sapien, R., Greenberg, C., & Bauer-Creegan, J. (2014). Rural-urban disparities in school nursing: Implications for continuing education and rural school health. The Journal of Rural Health, 30, 265–274. https://doi.org/10.1111/jrh.12058
Rew, L., Arheart, K. L., Horner, S. D., Thompson, S., & Johnson, K. E. (2015). Gender and ethnic differences in health—Promoting behaviors of rural adolescents. Journal of School Nursing, 31(3), 219–232. https://doi.org/10.1177/1059840514541855
Rural Health Information Hub. (2018). What is rural? https://www.uralhealthinfo.org
Sanchez, D., Reiner, J. F., Sadlon, R., Price, O. A., & Long, M. W. (2019). A systematic review of school telehealth evaluations. Journal of School Nursing, 35(1), 61–76. https://doi.org/10.1177/1059840518817870
San Luis Valley Area Health Education Center. (2020). http://www.slvahec.org/
Sinclair, P. M., Kable, A., Levett-Jones, T., & Booth, D. (2016). The effectiveness of internet-based e-learning on clinician behavior and patient outcomes: A systematic review. International Journal of Nursing Studies, 57, 70–81. https://doi.org/10.1016/j.ijnurstu.2016.01.011
Sorg, M. (2020). School nurses should be leading the COVID-19 response, but many schools don’t have one. The Conversation. https://theconversation.com/school-nurses-should-be-leadingthe-covid-19-response-but-many-schools-dont-have-one-144793#:*:text=were%20already%20overwhelmed.The%20CDC%20recommends%20schools%20have%20one%20nurse%20for%20every%20750,nurse%20shared%20between 20multiple%20schools
United Health Foundation. (2020). America health ranking, health of women, and children. https://www.americashealthrankings.org/explore/health-of-women-and-children/measure/teen_suicide/state/CO
U.S. Health Resources and Services Administration [HRSA]. (2020). https://mchb.hrsa.gov/maternal-child-health-topics/children-and-youth-special-health-needs
Villalba, J. A. (2011). The impressions of school nurses and school counselors related to health disparities of Latina/o students in rural, emerging Latino communities. Hispanic Health Care International, 9(1), 32–40. https://doi.org/10.1891/1540–4153.9.1.32
Willgerodt, M., Brock, D., & Maughan, E. (2018). Public school nursing practice in the United States. Journal of School Nursing, 34(3), 232–244. https://doi.org/10.1177/1059840517752456
Wilson, R. L., & Usher, K. (2015). Rural nurses: A convenient colocation strategy for the rural mental health care of young people. Journal of Clinical Nursing, 24(17/18), 2638–2648. https://doi.org/10.1111/jocn.12882
Alice M. Burch, DNP, RN, is an assistant professor of Nursing at the Adams State University.
Pamella R. Stoeckel, PhD, RN, is professor emeretus in the Nursing Department at the Regis University.
1 Adams State University, Alamosa, CO, USA
2 Regis University, Denver, CO, USA
Corresponding Author:Alice M. Burch, DNP, RN, Adams State University, 208 Edgemont Blvd, Suite 2250, Alamosa, CO 81101, USA.Email: aliceburch@adams.edu
